A report to the Trafford Strategic Programme Board on the 16^th October 2013 and the Minutes of the meeting are attached.

The Joint Health Scrutiny Committee will be briefed on the following issues.

The Chair explained that the purpose of the meeting was to assess whether the concerns raised by the JHOSC about the New Health Deal for Trafford had been addressed, and to what extent.  It was noted that 23 professionals were in attendance from the NHS to deliver presentations and respond to queries and concerns.  Members were issued with supplementary information provided by the NHS which included print-outs of the presentations which would be delivered and letters of support and assurance from the local NHS Trusts.  Members were issued with supplementary information from the Committee Support Officers’ including  letters from Kate Green MP and Mike Deegan, Chief Executive, CMFT, the Secretary of State’s decision letter of the 11 July 2013, Cllr Newman’s notes of points to be raised at the 3 July 2013 meeting with Mike Burrows, and a note of that meeting.  

Mike Burrows, Director (Greater Manchester) of NHS England delivered the first presentation entitled ‘Greater Manchester Area Team Joint Health Overview & Scrutiny Committee’.  He drew members’ attention to the letters of support and assurance from the local NHS Trusts that were included within their packs.  He explained that the letters met four key assurances as outlined in the presentation.  Dr Nigel Guest, Chief Clinical Officer, Trafford CCG delivered the presentation entitled ‘Developing Integrated Services in Trafford’.  Dr Scott Pearson, GP with interest in Older People, Pennine Care and Gill Eccles, Pennine Care delivered presentations entitled ‘Integrated care in Trafford’.  Dr J Simpson, CMFT delivered a presentation entitled ‘Changing hospital services in Trafford’.

Mr Burrows talked members through the minutes of the Strategic Programme Board (SPB) held on the 16^th October that were contained within the supplementary agenda.  NHS Greater Manchester had agreed to the New Health Deal for Trafford proposals subject to 6 conditions and he advised that conditions 1, 2, 3a and 3b had now been met.  Condition 4 had been noted at the meeting but was not relevant for discussion this evening as it was not applicable at this time.  Conditions 5 and 6 had been met and best practice would be shared throughout the NHS in respect of the latter.  He explained that a significant piece of assurance work had taken place in order to achieve the conditions and noted the letters from the 3 acute hospital trusts, Greater Manchester West Pennine Care and the North-West Ambulance Service that detailed this.   

In respect of Accident and Emergency Department (A&E) performance Mr Burrows explained that the target required 95% of patients to be seen within 4 hours but that it was not further defined to be yearly, monthly or weekly.  Admissions fluctuated within the NHS by season and through the week and the regulator ‘Monitor’ considered a failure to occur where the target was not achieved across 3 consecutive quarters.  The Secretary of State had not provided any further definition than this in his response to the JHOSC referral in his wording “consistently meeting their waiting time standards”.  Mr Burrows explained that A&E waiting times were affected by many factors including how well individual departments were managed, how effective the flow of people was through the department, how well primary care worked and the ability to deflect patients where required, the resilience of GP out of hours services, and hospitals’ relationships with social care providers.  Members were assured that NHS England had overseen the establishment of urgent care boards nationwide and also held responsibility for the nationwide planning and delivery of A&E targets. 

Mr Burrows acknowledged that the forthcoming winter period would be a big challenge for the NHS generally due to population growth and budget challenges faced by social care partners.  In preparation for this a significant exercise had been carried out with South Manchester, Trafford and Stockport CCG’s to improve service flows and co-ordinate discharge arrangements.  He advised that contrary to popular opinion the most challenging month for A&E departments was April. 

It was explained that 12 CCG’s across Manchester had each contributed to a £19 million levy to support Trafford Services but that funding for this would run out within the next few weeks.  If the New Health Deal for Trafford proposals could not be implemented in a timely way a further £5.5 million would be required, specifically from Trafford CCG.  The Chair queried whether the implementation timetable was pre-determined and noted that staff consultation that had been carried out at Central Manchester Foundation Trust (CMFT).  Mr Burrows explained that he had a meeting the following day with Richard Barker the North of England Regional Director for NHS England and following the outcome of tonight’s meeting would make the decision when to proceed.  Darren Banks, Director of Strategic Development from CMFT advised that CMFT had been making preparations for major change for some time.  Since staff terms and conditions would need to change there was a statutory requirement to consult with staff to make sure the proposals were implemented in a safe and sensible way.  He assured members that two major changes had already successfully been carried out at the CMFT site.  Preparation needed to be carried out pending a decision; and implementation was being proposed within the 2 week period of 16-29 November.  The Chair questioned whether if the proposals were not implemented straight away that they would be delayed until the following year.  Officers advised this was not the case.

Discussion then focussed around the various conditions placed on the implementation by NHS Greater Manchester and whether the Committee could be assured that these had been met. 

1. The development of additional Integrated Care Services for some parts of the Borough, specifically the introduction of a community matron service and a consultant community geriatrician, before changes can take place to the Accident and Emergency service.

Members had received a lot of information regarding the development of Integrated Care Services in Trafford although noted that they would like more facts and statistics regarding this.  Members acknowledged that a community matron service and consultant community geriatrician had been introduced however queried the relationships between the community matrons and social care providers, as this wasn’t clear in the presentation provided.  They also queried whether all GP’s were signed up to the integrated care system, what the current situation was regarding out of hours GP access, and were concerned to hear that hospital discharges took place 7 days a week and during the night. 

The Chief Nurse for Trafford confirmed that community matrons had excellent relations with social care.  Community Matrons consisted of 3 fully funded multi disciplinary teams supporting both children and adults with some shared management and practices.  Ascot House provided joint health and social care services.  Matrons had access to rapid response from social care services.  Healthier Together developments would only support this in the future. 

Officers assured members that 7 day discharge was only to be used in appropriate scenarios; and that vulnerable and elderly patients were not discharged in the night. Nigel Guest confirmed all GPs were signed up to Integrated Care in Trafford since 2008 and that patients were fully supported.  Officers stressed that developments within the integrated care system had reduced demand for A&E services.  Members were not happy about Officers previous assertion that removing the A&E provision would reduce demand and felt that evidence of reduced demand was required prior to service removal.  Mr Guest advised that out of hours GP access had developed considerably in the past 2 years and the Healthier Together programme would be developing this further.  At a recent medical summit he attended it had been agreed in Trafford to offer slots for the A&E service directly to GPs; and to give people access to GP’s at weekends.  

2. The identification of appropriate pathways for those affected with Mental Health issues and who currently access services at Trafford General Accident and Emergency department at night and might be impacted by the potential changes.  These pathways should be identified before any proposed changes take place to the Accident and Emergency service.

In response to a query Gina Lawrence, Director of Commissioning and Operations, Trafford CCG explained that mental health services in Trafford were commissioned via Greater Manchester West meaning that Trafford residents would not unduly impact upon Manchester social care provision.  Greater Manchester West provided a high quality service to residents of Manchester, Bolton and Trafford and had close working relationships with the police.  The 136 suite at Trafford that was attached to the A&E Department and was specifically for mental health issues would continue admitting patients until midnight.  Only 8 patients in the previous 6 months had required access in the time period when the suite was planned to be closed.  Those people would in future be referred to UHSM instead. Members emphasised the importance of good communication between UHSM and social care providers within Trafford in order to ensure appropriate follow on care.  She explained that only 2 individual patients from Trafford were not Section 136 patients and these cases had been looked at by GMP and the NHS.  Members asked for further assurances and evidence to be provided that mental health services would be unaffected. 

3. a) Transport

The investment in a subsidy for local Link services, for access to alternative hospital sites when needed, should be made before any changes to Trafford hospital services are implemented

b) The health travel bureau should be substantially in place before any changes to Trafford hospital services are made

Members were told that Trafford CCG worked with local to implement an additional scheme in Partington which would be subsidised for those patients that did not meet the criteria for ring & ride.  Officers advised that when patients rang the hospital to find out information on transport and subsidised transport available they would be signposted to the new providers.  Pennine Care was using the new provider at present and the service was going well.  Members were unhappy about the ring and ride service generally advising that people complained it could take all day to reach their destination and didn’t pick them up when they wanted it to.  Officers advised they would look into this.

4. Prior to any service changes, an assurance process should be established to further ensure alternative provider capacity is in place and services can be safely moved.

Members challenged the loose definition for A&E performance targets which stated that patients of A&E’s had to be seen within a 4 hour maximum waiting time.  Members requested further information on this in particular they requested information to be broken down on a daily or weekly basis.  Members also challenged differing Trusts reporting mechanisms and questioned whether the use of Accident Medical Units (AMU’s) attached to A&E Department’s could provide misleading success rates.  They queried what the underlying factors were that resulted in hospitals not achieving their targets, and questioned whether demographics or the wider economy had any impact on A&E admissions. 

Officers noted that UHSM had just achieved its best performance in the previous quarter and said that this was a direct result of the work being carried out across the whole health economy of South Manchester.  Members questioned what guarantees could be made that the A&E services at UHSM could be maintained, particularly during the coming winter months.  A member representing Wythenshawe stated that local residents were concerned about the impact the Trafford closure would have on the performance of the A&E at UHSM.  Officers advised that it would not be possible to guarantee that A&E services could be maintained however, UHSM had provided assurances that additional services, beds and intermediate care was already in place.  Officers said the 7 day working model now being used across the NHS meant that patient flow could be better managed to increase capacity.  Also they stressed the work being carried out across CCG’s and Local Authorities to ensure a co-ordinated approach and the stability of urgent care services.

CMFT was managing Trafford A&E at the present time and Officers advised that if the current A&E service continued to be provided in Trafford then it would be difficult to guarantee it could be provided safely.  It was becoming increasingly difficult to sustain the levels of expertise.  Some units were very dependent on agency staff and locums.  Recruitment and retention of staff would become a safety issue the longer the unit remained open.  At CMFT approximately 300,000 people attended the A&E per year whereas only approximately 8,000 people attended the A&E at Trafford per year.  The NHS did not think such a small amount was sustainable in safety terms and its closure would not unduly impact on other A&E’s.

Members questioned which services would be affected by the proposals and Nigel Guest responded that this would be a complete reconfiguration.  All services outlined in the presentation would be subject to change within 2 years.

In respect of CMFT Jon Simpson, Clinical Head of Division Medicine and Community Services at CMFT advised that within the AMU 2 consultants were available from 8am-4pm and one from 1pm-9.30pm.  They provided a high quality service and did not have a culture of moving people from A&E to within the hospital: Manchester Royal Infirmary had one of the lowest conversion rates in the area.  Officers felt that A&E numbers should be condensed for the whole of the CMFT site.  They admitted that some days were more challenging but held the view that they had not failed for a quarter of a year.

Officers emphasised that specialisation of services at hospitals provided a better service for patients.  North West Ambulance Service was crucial in this respect and were transferring patients to the most appropriate A&E Department in the area for their needs. 

Members queried whether Trafford patients of the AMU would be disadvantaged if they required admission.  Officers advised that there would be a crash team at Trafford during the night and a consultant physician and registrar.  Those with complex health needs would be transferred by ambulance to the most appropriate alternative hospital for their needs, but for those without complex needs they could be dealt with at Trafford.  Trafford would receive a further 10 intermediate care beds. 

Following the presentations and questions session, the Chair then asked members to consider whether they had received sufficient assurance or whether they required further information or assurance prior to making a decision.  Each member summed up their thoughts on the discussion and acknowledged that it was a difficult decision with severe financial implications.  Members found it difficult to accept that no other funding was available to cover the £5.5 million that would be required and felt that the NHS should have a risk management strategy in place should the proposals not go ahead.  Members continued to have concerns in particular about the transport and mental health issues

The Chair asked the members to vote on whether they had received sufficient assurances that they felt the NHS proposals should go ahead or whether they were not confident and felt the proposals should be delayed.  A vote was taken with the outcome that 5 members agreed to the proposals going ahead and 4 against.

Decision

1. The Committee broadly accepts the assurances provided by NHS England that its concerns have been met sufficiently in order that the proposals can proceed

2. The Secretary of State has highlighted the role of the JHOSC in assurance and as such the JHOSC expects reports to be provided following the implementation to provide assurance that its concerns have been addressed

3. To consider waiting time standards at its next meeting