Agenda item

Michael Ridgwell (Programme Director, Kent & Medway STP), Simon Perks (Accountable Officer, NHS Ashford & NHS Canterbury and Coastal CCGs), Hazel Smith (Accountable Officer, NHS South Kent Coast and Thanet CCGs), Liz Shutler (Director of Strategic Development & Capital Planning & Deputy Chief Executive, EKHUFT) and Lesley White (Divisional Director, East Kent Hospitals University NHS Foundation Trust), were in attendance for this item.

(1)       The Chair welcomed the guests to the Committee. The Chair noted that the Committee had received an additional report regarding reconfiguration of services in East Kent and the focus of the discussion would be on the new information rather than the general STP update which had been printed as part of the agenda. Ms Smith confirmed that the additional report had been published as part of the papers for the East Kent Joint CCG Committee.

(2)       Ms Smith began by updating the Committee about the development of local care in East Kent which would not be subject to public consultation; GPs were working together to develop primary and community care to support their local populations of 30,000 – 60,000. She noted that a frailty pathway developed at a Kent & Medway level was being implemented locally with the same model across East Kent. In addition to this, she reported that five specialties, including rheumatology, cardiology, diabetes, and the tiers of care to support those specialities at a primary and secondary care level had been identified. She reported that in Thanet three primary care homes had been developed in Margate, Ramsgate and Quex & Broadstairs to bring  together GP practices in those areas; the aim was for the homes to provide services relevant to their populations and strengthen primary care. In Margate the CCG was working with the District Council to relocate relevant services, such as the Margate Task Force, to be part of the home. In South Kent Coast all GP practices had come together to form the Channel Health Alliance which had been contracted to provide three primary care hubs in Dover, Deal, Folkestone; an additional hub to support Hythe and Romney Marsh was being developed. Mr Perks noted, in addition to GPs working together and taking responsibility for their populations as part of the development of local care, there were tangible benefits; the provision of a multidisciplinary team at the Estuary View vanguard had reduced urgent care admissions by 7%.

(3)       Mr Ridgwell stated the importance of a local care model across Kent & Medway to meet the rising demand. He noted that the issues raised in the previous item, EKHUFT Operational Issues, had highlighted the case for change to acute services in East Kent.

(4)       Ms Shutler began by outlining the engagement with the Committee over the last 18 months including the presentation of the East Kent and Kent & Medway Cases for Change. She reported that urgent and emergency care and orthopaedic services had been identified as priority areas as it was not feasible for the Trust to continue to provide a large number of services across three hospital sites due to the sustainability of the rota, recruitment and the training of junior doctors. She noted the importance of local care in supporting the Trust; at any one time the Trust had 250-300 patients who did not require hospital care and could be discharged if alternative provision was available.

(5)       Ms Shutler stated that the potential options for urgent and emergency care and acute medicine had been developed using the Keogh Review and a commissioned review of clinical adjacencies by the South East Coast Clinical Senate. She noted that the options did not include a major trauma unit because of the large catchment population of two-three million people  required to support very specialist services such as neurosurgery and cardiothoracic surgery; patients would continue to travel to access the major trauma centre at King’s College Hospital in London.

(6)       Ms Shutler explained that hurdle criteria had been applied to a long list of options which included:

§  each of the existing hospital sites operating as:  a major emergency centre with specialist services; or an emergency centre or medical emergency centre; or an urgent care centre or integrated care hospital.

§  a new hospital on a “Greenfield” (i.e. on a new site);

§  consolidation of existing hospitals onto one site; and

§  consolidation of the existing hospitals on to two sites, by closing an existing hospital.

(7)       For the clinical sustainability criteria, Ms Shutler explained the catchment populations required to deliver specialist services were reviewed. The Trust currently provided specialist vascular, renal, trauma and cardiac services to a population over one million which had indicated that the Trust could support one major emergency centre with specialist services. The population in East Kent was 695,000 which indicated that the Trust could also support an emergency centre to assess and initiate treatment for the majority of emergency services. The Keogh guidance stated that emergency departments with over 40,000 attendances were required to be co-located alongside acute medicine and intensive care. There were over 110,000 attendances in East Kent which suggested that East Kent could support two emergency centres including a major emergency centre with specialist services but no more than two emergency centres due to workforce. None of the options were removed at this stage.

(8)       For implementable criteria, Ms Shutler reported the Trust had looked at the cost and timescale to build a new hospital or remove services from one site. The estimated cost of a new build was over £700 million and recent examples of new build hospitals of a similar size in Derby and Glasgow took 9 - 11 years to build. She stated that a Greenfield or single site options on a current acute site were removed as options due to the cost and not being implementable by 2021.

(9)       For the accessibility criteria, Ms Shutler noted that a travel time of one hour or less by car had been set. Analysis found that the entire East Kent population was within one hour's car drive of emergency, urgent care and acute medical services and all options remained.

(10)     For the strategic fit criteria, Ms Shutler highlighted that two measures were taken into account. The first was the national and regional designations which included the designation of a percutaneous coronary intervention (PCI) service and trauma unit at the William Harvey Hospital. The second was public consultations undertaken in the early 2000s which had resulted in the removal of the Accident & Emergency department at the Kent & Canterbury Hospital. She explained that taking these two measures into account the William Harvey Hospital had been identified as the major emergency centre with specialist services; with the Queen Elizabeth The Queen Mother (QEQM) Hospital becoming the second emergency centre and the Kent & Canterbury Hospital becoming an integrated care hospital or urgent care centre.

(11)     For the financially sustainable criteria, Ms Shutler stated that the final option to be tested was whether the QEQM Hospital should be an emergency centre or medical emergency centre. She reported that due to the significant capital costs of making the QEQM Hospital a medical emergency centre, it was concluded that the site would need to be an emergency centre. This resulted in option one as outlined in the additional report with William Harvey Hospital as the major emergency centre with specialist services, QEQM Hospital as second emergency centre and the Kent & Canterbury Hospital becoming an urgent care centre.

(12)     Ms Shutler explained that the Trust had received a proposal from a commercial third party, to build the shell of a new hospital on or adjacent to, the current Kent & Canterbury Hospital site. It was proposed that the new hospital would be a single major emergency centre with specialist services in Canterbury and be supported by two peripheral hospitals at the William Harvey and QEQM sites. She noted that whilst the proposal sat outside of the process to date, legal advice stated that it would be unreasonable not to consider the proposal from the developer and it was therefore being considered as an additional option, option two.

(13)     With regards to the elective orthopaedic services in East Kent, Ms Shutler reported that the long list of eight options included:

§  no inpatient orthopaedics unit on any of the Trust’s three acute hospital sites in east Kent but a centralised Kent and Medway unit in west Kent;

§  a single east Kent inpatient orthopaedic unit on one of the three hospital sites;

§  all combinations of two orthopaedics units on two of the acute hospital sites;

§  an inpatient orthopaedics unit on all three hospital sites.

(14)     For the clinical sustainability criteria, Ms Shutler highlighted evidence from the South East Clinical Senate that had suggested that elective units undertaking more than 3,000 joint procedures a year would enable the delivery of higher standards of care and improvements for patients and would improve the efficiency of the service. As the Trust undertook more than 3000 joint procedures a year, it demonstrated that East Kent could support its own elective surgery and therefore the only options going forward would be delivered from one, two or three sites.

(15)     For the implementable and accessibility criteria, Ms Shutler stated that only 43 elective inpatient orthopaedic beds would be required in East Kent, it had been concluded that the service could be delivered from any one, two or three of the current EKHUFT sites which were all within the hour travel time.

(16)     For the strategic fit and financially sustainable criteria, Ms Shutler noted that previous consultations had reduced the number of sites for inpatient orthopaedic services from three to two in 2004/5 due to workforce pressures; the three site options had therefore been discounted.

(17)     Ms Shutler stated that the hurdle criteria had produced a medium list of six options:

§  Only Kent and Canterbury Hospital (K&C)

§  Only QEQM Hospital (QEQM)

§  Only William Harvey Hospital (WHH)

§  Both K&C and WHH

§  Both K&C and QEQM

§  Both WHH and QEQM

(18)     Ms Shutler noted that the medium list options for both urgent, emergency and acute medical care and  planned inpatient orthopaedic care in east Kent would now be discussed in more detail by the East Kent Joint CCG Committee who would assess which options should go forward to public consultation next year.

(19)     The Chair requested that the final options be brought to the Committee prior to the start of the public consultation; Ms Smith confirmed this. Ms Shutler invited the Committee to attend public events which will be held as the options were evaluated further. The Chair enquired about patient flow between East Kent and its neighbouring areas.  Mr Ridgwell explained that whilst the initial findings indicated that patient flows between the different areas was limited, which  would be further tested as part of the detailed evaluation of the options and the NHS England assurance process, he noted that these proposals sat within the wider Kent and Medway strategic framework.  

(20)     The Chair invited Paul Carter, Leader of Kent County Council, to speak. Mr Carter expressed concerns about the lack of investment in local care and the focus of reconfiguring acute services in East Kent only. He highlighted that population growth in East Kent may require one major emergency centre and two emergency centres to support this and the need for a new hospital in Canterbury. He suggested that the current proposals were sufficiently concerning to warrant a potential referral to the Secretary of State for Health.

(21)     Mr Ridgwell acknowledged that the financial position was difficult but as part of the STP’s investment case, spending was being re-profiled to invest in local care. He stated that the challenges faced by the acute sector in East Kent were more pronounced than the rest of Kent and Medway and required urgent action. Ms Shutler commented that analysis of patient flow had shown that when services were changed in East Kent, patients did not flow to West Kent. She noted that discussions were taking place in West Kent about urgent care services but due to the operational issues in East Kent, urgent change was required and they were unable to wait for the rest of Kent & Medway. She stated the creation of a single emergency centre with specialist services would require 900 - 1000 beds and become the 17th largest A&E in the country; similar new build hospitals in Birmingham & Derby had cost £700 - 900 million. She noted that the proposal from the developer was significant as there would be less capital costs but there was a risk to the timescale. 

(22)     Members commented about travel times particularly those from deprived areas who may not have access to a car or from rural areas. Ms Shutler explained that the entire East Kent population was within one hour's car drive of the Trust’s three sites including Faversham and Swale.  This finding had been verified by Basemap, a piece of software which used data from journey at peak and non-peak times via satellite navigations systems. Ms Shutler committed to share the travel data with the Committee. She noted that an Equality Impact Assessment had been commissioned which would look at social demographic factors such as car ownership; Mr Ridgwell committed to sharing the Equality Impact Assessment with the Committee. Ms Shutler stated that if a 30 minute travel time had been applied as a hurdle criteria, it would have indicated that  services should be provided on all three sites which was not sustainable. She reported that travel times had previously been discussed at the Committee and public events. She noted as part of the changes to outpatient services, the Trust had paid Stagecoach £400,000 to provide additional bus routes which now paid for themselves.

(23)     In response to a specific question about the difference between the current model and option one, Ms Shutler acknowledged that whilst the transfer of acute medicine and junior doctors from the Kent & Canterbury Hospital was an emergency and temporary move due to workforce pressures, until a decision was made following public consultation, emergency services were technically provided from three sites. She noted that the Trust currently provided a range of specialist services across three sites including PCI and trauma at the William Harvey Hospital, renal and vascular at the Kent & Canterbury Hospital and gynaecology at the QEQM Hospital; in option one, these specialist services would be moved to a single major emergency centre. In terms of elective orthopaedic services, she reported that the number of patients had increased by 75% over four years, and pressures from emergency and medicals services had resulted in an increasing number of elective procedures being cancelled. The proposal for orthopaedic services was for it to be delivered from one or two site depending on the urgent care option chosen.

(24)     Members enquired about workforce. Mr Ridgwell stated whilst additional money would be welcome, it would not resolve the workforce shortages; the delivery of services was required to change. He stressed the importance of having optimally configured and modern services alongside multidisciplinary teams to attract and retain staff. Ms Smith reported a Kent & Medway framework was being developed to support staff’s training and development. She gave the example of a national programme which recruited pharmacists into primary care; pharmacists in Shepway and Dover were working with GPs to support care homes and their staff with medicine management. She noted that a single bank for staffing was being developed across Kent & Medway.

(25)     Members asked about the medical school, joined up working and the STP.Ms Smith confirmed that the medical school was not predicated on a new build site in Canterbury. The focus of the bid for a medical school was to support primary care development as set out in the national criteria. She highlighted that whilst the medical school would be in Canterbury, it would support hospitals across Kent and Medway. Mr Perks acknowledged that the NHS needed to better demonstrate how these proposals were joined up with the STP. He stated that the STP had joined up elements of planning including local care and it was important that the NHS was able to show the Committee successful work being undertaken.  Mr Ridgwell noted that there was a significant focus on improving integrated working and efficiency and productivity as part of the STP.

(26)     The Chairman invited Steve Inett, Chief Executive, Healthwatch Kent to comment. Mr Inett noted that the impact of social care, particularly in relation to patient flow, as part of hospital reconfigurations. He stated the importance of senior KCC leaders participating in upcoming engagement events.

(27)     The Chair concluded the discussion. She stated that the proposed changes were predicated on local care and it was important that the Committee had a clear understanding of the local care model. She stated that Members had challenged some of the assumptions regarding the proposed options and requested that the guests reflect on these. She noted that it had been difficult to consider the additional information and invited the NHS to present to the Committee again in January.

(28)     RECOMMENDED that the report on the Kent and Medway Sustainability and Transformation Partnership be noted and a full update on the proposed reconfiguration of services in East Kent be presented to the Committee in January.

Cllr Lyons, in accordance with his Other Significant Interest as a Governor of East Kent Hospitals University NHS Foundation Trust, withdrew from the meeting after the presentation and took no part in the discussion or decision.