Representatives of Stockport Clinical Commissioning Group will attend the meeting to make a presentation to the Committee on proposals for the reconfiguration of health services across Greater Manchester as part of the ‘Healthier Together’ programme.
All members of the Council have been invited to the meeting for this item.
Further detail on Healthier Together can be found online at https://healthiertogethergm.nhs.uk/
Minutes:
The Chair welcomed those councillors who had attended the meeting to take part in the discussion on the Healthier Together proposals and introduced representatives from the Stockport Clinical Commissioning Group, Stockport NHS Foundation Trust and the Council’s Adult Social Care service and invited them to outline the key features of the Healthier Together Programme and the possible implications to their organisation.
Healthier Together (HT) referred to a programme of proposals to change the way health services were delivered in Greater Manchester which included improved access to primary care, greater focus on prevention and management of complex conditions, and reconfiguration of some hospital services.
Dr Ranjit Gill, Chief Clinical Officer, Stockport Clinical Commissioning Group
Dr Gill outlined the drivers for the development of Healthier Together, including the need to improve health outcomes across Greater Manchester (GM), which were currently amongst the worst in England; to reduce variation in outcomes and standards of care between different parts of GM and between different facilities; to improve diagnosis of treatable conditions to provide more appropriate care and management that might otherwise lead to avoidable deaths; to respond to changing demographic requirements.
Dr Gill emphasised that the Programme was clinically-led, with the decisions being taken by the GM Clinical Commissioning Groups acting in concert, and that the focus was on clinical outcomes. He further stressed that the proposals were not driven by financial considerations as the cause of the variations and poor outcomes were systemic and organisational and that these problems could not be overcome through resources and investment alone.
Clarity was also provided on the scope of the HT proposals with respect to hospital services which would include specialist services (rather than specialised or tertiary services commissioned by NHS England) such as Emergency Acute Medicine, Emergency and Elective Surgery - services for the ‘once in a lifetime’ events.
Ann Barnes (Chief Executive) and Dr James Catania (Clinical Director) Stockport NHS Foundation Trust
Ann Barnes outlined the role of the Foundation Trust (FT) in providing both Acute and Community Care services for Stockport, but also for a wider catchment that included High Peak, Glossop, Macclesfield (acute) and Tameside (community), as well having a key role in the integration of health and social care.
She further emphasised the distinction drawn in the HT consultation between Specialist and Local Hospitals, the former retaining those specialitist services commissioned by the CCGs (detailed above) while the former would not (although both may provide specialised/tertiary services). One of the assumptions of the HT programme was that the concentration of services in this two tier system would mean that all the hospitals would be better able to meet the national clinical care standards.
In the options set out in the consultation, the geographical distribution of specialist/ local hospitals assumed at least three of the former, while respondents were asked to give a view on whether a further one or two specialist hospitals should be designated, and these would be from a short list of existing facilities clustered in either the north or the south of GM.
As part of the development of the HT proposals, further consideration would be given to access and transportation issues, which was of particular concern for the FT because a significant element of its wider catchment population (not including Stockport) lived in areas that were not easily accessible via public transport.
The HT proposals also contained standards for ‘blue light’ journeys to specialist hospitals of no more than 45 minutes. Given the potential spread of these with either the four or five specialist hospital model, this would present particular challenges.
It was the view of the FT Board that it was important that Stepping Hill be designated as one of the specialist hospitals, and that the five model option in the HT consultation was to be preferred. The Board was also committed to working in partnership with other hospitals in delivering services.
Terry Dafter, Service Director (Adult Social Care), Stockport Council
Terry Dafter provided an overview of the efforts to integrate health and social care and the connections with the HT proposals. In particular, he emphasised the impact of changes to hospital services would have an impact on social care service users, but also that this presented an opportunity to reconsider the approach to community care.
He provided a brief overview of the Stockport One pilot and the work going on to build on the learning from this, including building a system around GP Practices; moving toward a preventative model working collaboratively to identify those most at risk; increased third sector engagement and involvement through ‘people-powered’ health to tackle a range of issues such as social isolation; harnessing the power of new technology; devolving budgets and empowering staff.
Gaynor Mullins, Chief Operating Officer, Stockport Clinical Commissioning Group
Gaynor Mullins emphasised the breadth of work taking place across the health and social care economy toward providing more integrated services. She also stressed that HT needed to be considered within the context of expanding primary care, both locally and across GM. The Clinical Commissioning Group had ambitious plans to expand opportunities for GP contact; to increase GP engagement with the integrated health and social care teams, which GPs had already expressed great interest in; greater focus on prevention and increased investment in Mental Health.
Councillors then asked questions and made comments about the proposals and the issues raised by the speakers [these, and any responses provided, are summarised below].
· The phraseology of the proposals contained in the consultation document was confusing and unhelpful, and may not be fully understood by the public. There was insufficient detail about all three strands in the HT Programme.
· The consultation was seeking the opinion of respondents to some questions that were more appropriately addressed through scientific and clinical evidence. The outcome of the consultation would therefore be poorer as a consequence.
· There was a danger that the public relations campaign of the hospital trusts won out over an evidence-based decision. In response it was stated that there was a great deal of clinical evidence available, but the purpose of the consultation was to seek the opinions of the public and stakeholders about whether to change services, or then if so, what to change to.
· Changes to front line service delivery was vital to ensuring meaningful improvement took place. In response it was stated that the Stockport One pilot had demonstrated that staff were enthusiastic and willing to change and welcomed the opportunities for integration.
· The Healthier Together website put greater emphasis on the hospital changes, rather than the other elements that were vital to the success of the overall proposals. In response it was stated that the consultation had to focus on hospital provision because that required more formal consultation. It was also emphasised that the evidence suggested that the type of hospital configuration being proposed would improve outcomes. Additionally, it was hoped that the more co-ordinated approach to hospital provision would encourage the best staff to come to GM where currently there were recruitment problems.
· Would the proposals for flexible GP appointments lead to additional capacity? GP appointments were a real concern for many people. In response it was stated that capacity was never likely to match the growing demand, but it was hoped that the flexibility proposed would improve the consistency of treatment for those with long term conditions in particular, and those who were most at risk of avoidable hospitalisation and acute interventions. There would be greater need in the future to make better use of the wealth of data available to the NHS to better target resources.
· There was a danger that the changes to hospitals would mean clinicians would be drawn away from the local/ general to the specialist hospitals. In response it was stated that the proposals would necessarily mean staff would be transferred between facilities to where most appropriately based, but the aspiration was for a single service model/ network approach so that staff from the specialist hospitals could be deployed in the local hospital for outreach work. The current model meant many hospital departments lacked resilience, so clinicians were supportive of this type of approach. Recruitment continued to be a challenge in some fields while there remained a lack of clarity about the outcomes of HT.
· How would the specialist locations be chosen? In response it was stated that should the decision be taken to go forward with the proposals, more detailed work and planning would be needed in the next year, but the process was set out in the supporting documentation. Ultimately the decision on the proposals would be taken by commissioners, currently CCGs.
· Travelling to hospitals for care was a real concern, including for carers and relatives. What was the risk to the HT programme if the travel arrangements were not in place? In response it was stated that travel was part of the balance between convenience and quality and would be factored into the final decision, but it was intended to have any required travel arrangements in place first. The GM Joint Scrutiny Committee had discussed these very points. It was also reported that the HT Team had arranged a series of events specifically in relation to transport. It was also commented that while the HT Programme was about acute medicine, it needed to be seen as the start of a process of change and that other service provision was likely to change in the future.
· Would the proposal, particularly the health and social care proposals, mean greater reliance on the third sector, and was the infrastructure resilient enough? What needed to be done now to make it so? In response it was stated that there would not necessarily be any greater demands, but that what was needed may change and they would work differently, particularly being more integrated into delivery. There was a greater role of the third sector in peer support type activity, as ‘people-powered health’ had proved very effective.
· Given the complexity of the interplay between the various strands of HT, what were the measures of success? In response it was stated that the outcome measures would be based on those outcomes where GM performance was worst. It was clarified that this stage of the HT Programme would take between 2 to 5 years to complete.
· What was the likely effect of the proposals on related services? In response it was stated that there was likely to be a ‘domino-effect’ where other services would be drawn away from local hospitals to the specialist centres.
· Were there plans for GPs/ Practices to work together more closely? In response it was stated that there were no plans to change the current process for choosing GPs, but is was hoped to enable Practices to be more flexible in how they deliver services, particularly in connection to working with the Integrated Health & Social Care Teams.
· There appeared to be a tension between the messages from the CCG about the limited scope of hospital change, and the message from hospitals themselves that suggested the start of a much bigger process. In response it was stated that the formal consultation was about the limited elements, but that there may be ‘knock-on’ effects of these changes. There was the possibility that the proposals would not be pursued.
· Was it likely that services would be centralised, and as a consequence some ancillary services? Would this mean the closure of hospitals? In response it was stated that there would be centralising of services but that there were no proposals to close any hospitals. It was the belief of the clinicians behind the HT proposals that the type of system needed was one where certain conditions were treated via a fully functioning primary care system and a state of the art tertiary system as the evidence showed that a primary/tertiary system would save lives.
· The concern was whether a hospital designated as General would be a proper functioning local hospital. How could the public be assured this would be the case, particular in Stockport where Stepping Hill served a population of 300,000 plus?
· It was important to reduce the variability in GP primary care services and outcomes as part of the broader change agenda.
· There were a number of key issues that should also be emphasised, particularly the focus on prevention, community based services, fewer beds.
· It wasn’t clear from the consultation why four or five specialist hospitals were proposed and not six, etc. Why was the focus not on improving those services that were failing as a more effective means of reducing variation? It wasn’t clear that the proposals were not concerned with cost cutting.
· Patients would probably prefer to have treatment in specialist facilities where there was more expertise and experience even if this meant more travel, rather than simply to go to the most local hospital.
A number of councillors expressed broad support for the thrust of the proposals.
The Chair invited the speakers to make a final response to the points raised during the discussions.
Ann Barnes stated that the only way to secure a good hospital for Stockport was for Stepping Hill to be designated as a specialist hospital, as this would ensure the expertise remained there, building on hood services currently provided by the Hospital. She further stated that it was regrettable that the HT proposals were pitching two good hospitals against each other (Stepping Hill and Wythenshaw).
Dr Ranjit Gill emphasised the complexity of reforming primary, secondary and tertiary care systems and to get this across in a public consultation exercise. He stated that there was evidence available on the NHS website of where the system was good, but also that it good be much better to make it fit for the 21st century.
The consultation was proposing to narrow down the options that, based on the evidence, clinicians believed would work, and to ask the public and stakeholders if CCGs should do something, and if so, what.
Terry Dafter emphasised the change in focus of the system to prevention through identifying those most at risk.
The Chair then summarised the discussions as follows:-
That the Scrutiny Committee was broadly acknowledged and understood the reasons for the round of consultation on centralising certain specialist services, and:-
· had concerns about the consequences for other services, including ancillary services, that were not within the scope of the current Healthier Together proposals;
· had concerns about staffing and recruitment;
· believed that travel and access were important considerations in decisions about future service configuration; and
· supported Stepping Hill being designated a specialist hospital, in particular because of the catchment/ coverage of the hospital outside of Greater Manchester.
RESOLVED – (1) That Ann Barnes, Dr James Catania, Terry Dafter, Dr Ranjit Gill and Gaynor Mullins be thanked for their attendance and participation.
(2) That the Executive Councillor (Health & Wellbeing) be recommended to consider the discussion and comments of the Scrutiny Committee when responding to the Healthier Together consultation.