Agenda item

Liz Shutler (Director of Strategic Development and Capital Planning, East Kent Hospitals NHS University Foundation Trust), Marion Clayton (Divisional Director, Clinical Support Services, East Kent Hospitals NHS University Foundation Trust), Rachel Jones (Divisional Director, Surgical Services, East Kent Hospitals NHS University Foundation Trust), and Felicity Cox (Kent and Medway Area Director, NHS England) were in attendance for this item.

(a)       The Chairman welcomed the Committee’s guests who then explained that they would be delivering a presentation covering three areas (see Appendix). Although representatives from East Kent Hospitals NHS University Foundation Trust (EKHUFT) had attended HOSC meetings in the past to discuss their clinical strategy, the first part of the presentation would provide some background as there were a number of Members new to the Committee. The other parts of the presentation would focus on two areas, the outpatients’ strategy and options for breast surgery.

(b)       By way of background it was explained that EKHUFT was a good Trust but that it still aimed to improve and deliver sustainable, efficient, services. The Trust was looking to boost outcomes as well as improve facilities and ensure they were fit for purpose. There were four workstreams: emergency care; planned care including general surgery and breast surgery; outpatients care; and trauma. Real progress had been made in outpatients’ care and breast surgery.

(c)        Beginning with the outpatients’ strategy, it was explained that the clinical strategy aimed to make sure patients saw the right person at the right time in the right place. Currently services were delivered across more than 20 sites. Much of the estate the services were delivered from was substandard and only a limited range of services were available. The plan was for outpatient services to be consolidated across 6 sites. These would be ‘One Stop’ services where the results of diagnostic tests would be available on the same day and patients would have a treatment plan agreed before they left. Where the appointment was for a surgical assessment, a day for surgery would be agreed before the patient left. This would reduce the need for follow up and return appointments. These services would be open longer hours than the normal 9-5 now and would open from 8am to 8pm, 7 days a week. Members questioned the detail of how this would work and whether it would involve spending a whole day at one site. It was explained that the expectation was for patients to have to attend for 2-3 hours at most. Many diagnostic tests could produce results quickly or even immediately. This would not be the case in every instance, so there would be occasions when patients would need to return.

(d)       It was further explained that a full booking service was introduced in January. This meant an appointment time was negotiated with the patient and this result in a drop of those who did not attend their appointments (DNAs) of 10% to 6.9%. The average waiting time had reduced from 8 to 6 weeks as waiting times reduce when access is improved. It was hoped that the same system would be introduced for follow-up appointments. Urgent referrals were seen in 2 weeks.

(e)       The Trust aim was for the majority of patients to be within a 20 minute care journey of any site and for there to be a 15% increase in people accessing services locally. This would mean 75,000 patients travelling shorter distances. 5 sites for outpatients’ services were clear, and in response to a direct question about one of them it was confirmed that services would be expanded at the Royal Victoria Hospital in Folkestone. There was more discussion about the site in North Kent, but the representatives of EKHUFT believed that the Estuary View Medical Centre in Whitstable was the preferred choice. Only 8.7% of patients accessed services locally, and it was believed this could be increased to 21.4%. This would mean an increase in the number of people visiting Estuary View from 6,500 to 19,000. Concern was expressed about the capacity at Estuary View. It was explained that the current GP reception area would not also be the reception for the services under discussion. There was a large area of the first floor which was being vacated and which would be utilised. The increase in demands on car parking would be offset by the extended opening hours. Estuary View also had diagnostic machines, including an MRI, and these would be available as part of the rental agreement. This meant Estuary View was also the best option following financial analysis.

(f)         The Committee were informed that work was being carried out with Stagecoach on ways to improve access by public transport.

(g)       A direct question was asked about services on Sheppey. A Member explained that it was common to be referred to Medway Hospital from Sheppey even when a particular service was available locally and the request was made to improve communications within the NHS. In response it was explained that the importance of services remaining local to Sheppey was recognised and the Trust was in discussions with the local Clinical Commissioning Group (CCG) on this. It was suggested as well that Sheppey could perhaps be the site of a 7^th service at some point in the future.

(h)        There was also specific discussion about the future of Deal Hospital. It was explained that although Deal Hospital was not one of the sites of Outpatient Services, it had a definite future and this had been confirmed recently at a meeting by the local CCG. Some ¾ of patients local to Deal chose to go elsewhere and most outpatient appointments at Deal were follow-ups, with local commissioners aiming to reduce the number of follow-up appointments. It was further explained that no services would move to Buckland Hospital in Dover until the new site had been built. Services such as diagnostics, phlebotomy and community dermatology would remain at Deal. The NHS would work with local patients and GPs on the best services for the area. In addition, telehealth would be available to allow access to consultants based on other sites.

(i)         Telehealth, telecare and other related technologies more broadly formed a big part of the outpatients’ strategy. Pilots in cardiology and stroke care were beginning. In response to a specific question, it was acknowledged that Kent County Council had done a lot of good work in these areas but that the terms telehealth and telecare covered a wide range of different services. The pilots were being carried out to build confidence in the system and technologies.

(j)         In addition, the importance of educating patients was recognised and using pharmacists to explain medicines was expecting to produce benefits for patients as well.

(k)        EKHUFT representatives explained that they were interested in the Committee’s views on whether they needed to go to carry out a full public consultation on the outpatients’ strategy. They also explained that they had already delivered 130 presentations on the issue. Some Members felt that if there was a clear case for change, it was important for the NHS to progress with the plans but that it was very important to make certain the public were given clear information about the changes and why they were happening. One Member felt that this was a topic where the public would be likely to want to express a view, particularly in North Kent. The view was also expressed that if there was not a real choice, then ensuring clear information was available would be the appropriate route.

(l)         When the discussion moved onto breast surgery, it was explained by way of background that in October and November of 2012, the Royal College of Surgeons (RCS) had been invited in over concerns regarding the delivery and training of general surgery. Two reports had been received from the RCS and as a result an immediate investment of £600,000 made. This funded two additional new breast surgeons, two at Queen Elizabeth the Queen Mother in Margate (QEQM) and the William Harvey Hospital in Ashford (WHH). Reports from the Deanery had also been considered. Clinical leadership was also looked at and the level of this leadership was increased on each site. The RCS reports were available on the Trust’s website (http://www.ekhuft.nhs.uk/patients-and-visitors/about-us/documents-and-publications/statements-and-declarations/royal-college-of-surgeons/.)

(m)      EKHUFT representatives further explained that recently vascular surgery had been separated out from general surgery and become a separate specialism. There was a move nationally for breast surgery to make the same move away from general surgery to being a separate specialism. Another issue to take into account was the separation of emergency and elective on call rotas. They were already separate at WHH, but mixed at QEQM. This meant a different solution was required for each site as historically different practices had evolved. The separation of breast surgery as a specialism and separation of emergency and elective pathway management was what the Trust was aiming towards.

(n)        The upshot was that there was a need to look closely at the service delivery of medium and high risk breast surgery. The Committee were informed that the choice between the different options was a real one and there was a proper discussion to be had. On being asked for their opinions about whether to go to public consultation, several Members commented that if the options were viable and there was a real choice, this would be appropriate. Representatives from EKHUFT explained that they would also be consulting with local Health and Wellbeing Boards across East Kent as well as the local CCGs.

(o)       EKHUFT representatives outlined the different possible options and Members asked questions about the details.

(p)       Option 1 was to do nothing meaning no patients would need to move for their surgery. This would be sustainable as it would be a continuation of the current situation, with breast surgeons taken off the emergency general surgery rota. However, there were concerns about delivering the necessary standards in elective care. The view was expressed that if there was a public consultation, the benefits of any change would need to be strongly emphasised to overcome the public’s resistance to change.

(q)       Option 2 would involve centralising all day and major surgery, meaning 763 patients would need to move for their surgery.

(r)        Option 3 would centralise major surgery, have stereotactic wire localisation at the Kent and Canterbury Hospital but continue day surgery on all 3 sites. This would require 355 patients moving for surgery.

(s)        Option 4 would provide all surgical services on all 3 sites and resource stereotactic wire localisation at WHH and QEQM. No patients would need to move for their surgery.

(t)         It was further explained that specialist breast surgery was currently carried out at East Grinstead and that it was unlikely that it would be possible to centralise this specialist surgery in East Kent for at least 5-7 years.

(u)        Option 2 was favoured by the RCS but local clinicians rated Option 3 highest. In addition, they put forward an additional option where a single Breast unit for East Kent would co-locate out-patient clinics, diagnostics, screening and surgical services. This was more of a long-term vision, it was explained.

(v)        No specific site was named for any centralisation. All of the options would keep one-stop outpatient services at all 3 hospitals. Breast screening in the community would also remain unaffected. Screening would continue as currently, although it was conceded that more needed to be done to reach certain groups in society and increase uptake in screening. It was emphasised that only those on the surgical pathway would be affected. In response to a specific question, the Committee were informed that all breast referrals were seen within 2 weeks, and this was the national standard and applied whether it was suspected cancer or not.

(w)       Members asked questions about numbers of patients and future demand. The Committee’s guests did not have the exact figures relating to breast cancer prevalence in East Kent to hand but informed the Committee that there were around 900 breast cancer surgical interventions each year. The numbers of breast surgical interventions increased with the expansion of breast cancer screening. There was an increase in the numbers needing treatment when the age for screening was lowered 18 months ago. The Trust representatives were confident they had a good understanding of prevalence and future demand.

(x)        On a different topic, EKHUFT representatives were asked a question about neurosurgery. It was explained that neurosurgery required a huge support infrastructure and so it was still the best option to have services centralised at King’s College Hospital. However, the Committee were informed that Level 2 community rehabilitation was available at the Kent and Canterbury Hospital.

(y)        The Chairman proposed the following recommendation, seconded by Mrs A Allen:

§         “The Committee thanks its guests for their attendance and contributions today, agrees that the proposed changes to outpatient services and breast surgery services do represent a substantial variation of service and look forward to receiving further updates in the future; and also requests that East Kent Hospitals NHS University Foundation Trust take on board the Committee’s comments regarding public consultation before the Trust takes any final decision on wider consultation.”

(z)        AGREED that the Committee thanks its guests for their attendance and contributions today, agrees that the proposed changes to outpatient services and breast surgery services do represent a substantial variation of service and look forward to receiving further updates in the future; and also requests that East Kent Hospitals NHS University Foundation Trust take on board the Committee’s comments regarding public consultation before the Trust takes any final decision on wider consultation