Report from Kathy Doran, Chief Executive, NHS Cheshire, Warrington and Wirral (Primary Care Trust Cluster).

This item was considered in conjunction with the two previous items (see minutes 27 and 28 ante).

Kathy Doran, Chief Executive, NHS Cheshire, Warrington and Wirral (Primary Care Trust Cluster) submitted a report which updated the Committee on the Vascular Services Review.

The NHS Cheshire, Warrington and Wirral Primary Care Trust Cluster Board had considered a paper at its meeting on 2 November at which it had –

·  Accepted the recommendations of the Review Project Board;

·  Noted the Impact Assessment report conclusions and accepted the recommendation for a review of interventional radiology;

·  Endorsed the recommendation of relevant Clinical Commissioning Group Chairs that the South Mersey arterial centre should be based at the Countess of Chester Hospital NHS Foundation Trust, networked with Wirral, Warrington and Whiston;

·  Approved the consultation proposal with results to be reported at March Cluster Boards;

·  Agreed the proposed arrangements for implementation planning.

The Committee having heard presentations from Gary Doherty, Mr Chandrasekar, and Kathy Doran then debated the issue at some length and responses to questions from the Committee included the following:

Kathy Doran commented:

• From a process of pre-engagement over a 15 month period with the public and clinicians, there would now be a formal 12 week consultation period from December with the results being brought back to Hospital Board meetings in March.
• She would be happy to take advice from the Committee on whatever local meetings for Wirral should be arranged. Consultation would be taken forward through the PCT Cluster’s own website and via the press and, if feasible, the Council’s own website could also be used.
• If the timeframe was right she would also be happy to use the Council’s Area Forum meetings as a means of engaging with the public.
• Population density was not a concept taken into account in service planning but travel times and ease of access by public transport was.
• Deprivation was also an issue as well as age, and there were clearly areas of deprivation in all 3 areas, of Chester, Warrington and Wirral.
• Patients could be consulted in specific departments, but there was also a need to take a broader view as consideration needed to be given to potential patients.
• Co-location of services had been taken into account and advice had been sought from the Renal Tsar, both Arrowe Park and the Countess of Chester had intensive care facilities and the limb clinic was at Clatterbridge which was geographically between the two.
• The management of Arrowe Park Hospital had not sought to submit a separate bid and the commissioners’ view was that Trusts should come together consensually.

Mr Chandrasekar commented:

• There were currently more patients from Wirral than from Chester being treated for vascular services.
• It was not a question of submitting a competing bid but rather of determining which hospital was best placed to serve patients.
• There were currently very satisfactory on-call arrangements with the Countess of Chester, although there had been no formal contact with vascular surgeons at the Countess of Chester until after the announcement.

Gary Doherty commented:

• The process which had been outlined to Arrowe Park Hospital was to submit a network bid and that agreement on this had to be reached otherwise a Warrington / St Helens bid would have been the only submission.
• He acknowledged that there were lessons to be learnt about communication but there was already a good track record of working with the Countess of Chester.

Peter Herring, Chief Executive of the Countess of Chester Hospital Foundation Trust, also addressed the Committee and assured them that the Countess of Chester could provide safe patient pathways and once a decision was made the recruitment process for the necessary staff would commence.

After the debate the Chair then read out the following statement:

“This is the third time this Committee has looked at the proposal to establish an Arterial Centre south of the Mersey.

At the first of these meetings (22 March 2011, minute 72), the Vascular Review Consultation Document was presented by the Director of Health Systems Management, NHS Wirral, Cathy Gritzner and the OSC was informed that complex and emergency vascular surgery services would be carried out at a specialist centre, once an appropriate hospital had been identified following a consultation process.

At the June OSC meeting, (minute 5), Dr Tom Dent outlined the progress of the consultation to date, referring to both a Review Panel and a Review Board. Dr Dent explained that although there was opposition to the proposal from Clinicians at Arrowe Park Hospital, the Review Panel had recommended the Joint Application from WUTH/Countess of Chester to base the Arterial Centre at Countess of Chester Hospital be accepted.

Len Richards, then Chief Executive at WUTH explained approximately 150 – 180 Wirral patients annually would need to be taken to Countess of Chester for their surgery. These would be the patients needing complex or emergency surgery.

Dr Dent drew the Committee’s attention to the UK rates for mortality from Aortic Aneurysms – the worst in Western Europe.

At today’s meeting, we have had further representations from the acting Chief Executive, WUTH, the Chief Executive of NHS Cheshire, Warrington & Wirral and Clinicians at WUTH. The Countess of Chester remains the recommended site for an Arterial Centre. The Vascular Surgeons at WUTH remain opposed to this proposal.

The proposal to site the Arterial Centre at Countess of Chester Hospital appears to be based upon 2 factors:

·  Centrality of location, south of the Mersey in relation to the population it serves

·  The size of the population covered in the geographical area. This is relevant as it relates to the minimum 800,000 requirement by the NHS Abdominal Aortic Aneurysm Screening Programme. It is not clear if ‘clumping’ into urban areas, of affected population groups, was taken into account when this figure was proposed.

The data in the tables of the Joint Arterial Centre Application Assurance Report, (WUTH/Countess of Chester), seem to indicate that more patients from WUTH, (both emergency and elective surgery), will be making the journey to Countess of Chester than from the mid-Mersey area, (Warrington/St Helens).

For example, this report highlights that 17 patients annually, needing emergency Abdominal Aortic Aneurysm surgery, would need to travel from WUTH to Countess of Chester in comparison with 6 patients in the same category annually travelling from Warrington. On all the data in the table on P156 of this Agenda, Wirral appears to show higher rates of vascular related disease than Warrington. While it does state in this same report that, “due to low level data we were unable to make sound judgements,” it would appear from the information available to the Committee, Wirral has a greater need for specialist vascular provision than Warrington.

Given the clear result of public and professional consultations quoted in the reports before a recommendation was made, that patient safety was the most important factor in deciding where to site the Vascular Centre, (64.7% of respondents ranked this first), it is difficult to understand the logic of making 3 times as many emergency patients travel to Countess of Chester. It is further difficult to understand how, if the universally agreed aim is to reduce the death rate from Aortic Aneurysm, obliging 3 times as many emergency patients to travel further, will achieve a positive outcome.

The apparent fudged solution brought to this OSC seems to be that Arrowe Park Hospital will continue to take admissions and perform emergency surgery during the day, which surely undermines the whole purpose of the proposal to have a single centre of excellence? This may be the reason why the Vascular Review Board did NOT make a recommendation to the Cluster Board, between the mid-Mersey application and the WUTH/Countess of Chester application.

In the documents relating to the Cluster Board meeting, there is a recommendation that there are NO financial/staffing implications of the joint WUTH/Countess of Chester proposal. It is difficult to reconcile this with the information in the Joint Application Assurance report which clearly indicates the need for an extra Anaesthetic Consultant and the need to employ extra staff grade doctors. It is also stated in this report that currently, Countess of Chester does not have accreditation for intensive care training.

This OSC also notes that the Vascular Society ‘best practise’ advice is ideally, Vascular Centres and Renal Centres should be co-located on the same site. Arrowe Park Hospital is currently the Renal Centre and the Uro-Oncology Centre, in common with the Royal Liverpool. It indicates geographical proximity is less important than level of need and level of service provision, further undermining the case to have an Arterial Centre at Countess of Chester. The committee believes the suggestion that an Arterial Centre at WUTH would necessarily require the consideration of a 3-centre solution, unsupported by population numbers, to be a false argument. The only factor to consider is where is the population, as a whole, best served in Merseyside and Cheshire? The Committee believes this is the approach which has been taken in Manchester.

In the Consultation Document (P28) comments on the 4 Criteria are invited. This Overview and Scrutiny Committee believes Arrowe Park Hospital:

·  best meets criteria 1 and 2 for clinical provision and co-location of services for other medical conditions;

·  best meets criteria 3 for the maximum number of potential patients

·  best meets criteria 4 on potential costs to the NHS.

The Committee notes the high degree of cooperation between Trust Boards and Clinicians apparent in the mid-Mersey Impact Assessment, (p111-128). It draws particular attention to P116, “The Hospital clinicians felt that the Impact Assessment was the first time they had had a real opportunity to describe the service they offered and to be properly engaged in the process.” Irrespective of the final decision, by convening an Independent Panel, these Trusts appear to have been able to maintain positive working relationships with their Clinicians. It is a matter for regret, that even up to 17th October, (not 20th October as stated in the Cluster Board document), Clinicians from WUTH were being prevented from stating their case to the Chairs of the relevant Clinical Commissioning Groups. The Committee does not know if the CCG Chairs were aware WUTH Vascular Surgeons had not been allowed to attend. It also does not know if these CCG Chairs were aware that the Secretary of the Vascular Society was not representing the Society at that meeting, when they made their unanimous decision.

This Committee has serious reservations about the quality of information provided in the various documents and reports brought to the Committee and provided to others and the implications this has for decisions taken. It notes there is to be a further consultation period before implementation of any changes to services, due to begin in December. The Committee has been asked to consider establishing a Joint OSC with West Cheshire to oversee the process, which will be voted on next week by the West Cheshire OSC.”

It was then moved by the Chair and duly seconded that –

“In the light of the fact that:

.

1.  Data suggests that more people from WUTH (both emergency and elective surgery) will be making the journey to the Countess of Chester than from the Mid Mersey area (Warrington/St Helens) and that Wirral appears to show higher rates of vascular related disease than Warrington.

2.  Advice suggests that geographic proximity is less important than level of need and level of service provision.

3.  Best practice advice is ideally that Vascular Centres and Renal Centres should be co-located on the same site and that Arrowe Park is currently the Renal Centre and the Uro-Oncology Centre, in common with the Royal Liverpool.

4.  According to the criteria in the Consultation Document it seems clear that Arrowe Park Hospital: best meets criteria 1 and 2 for clinical provision and co-location of services for other medical conditions; best meets criteria 3 for the maximum number of potential patients; best meets criteria 4 on potential costs to the NHS.

5.  The Vascular surgeons at WUTH remain opposed to the proposal to site an Arterial Centre at the Countess of Chester.

6.  Clinicians from WUTH appear to have been prevented from stating their case to the Chairs of the relevant Clinical Commissioning Groups.

This committee expresses serious reservations about the proposal to site the Arterial Centre at the Countess of Chester.

It further expresses reservations about the unsatisfactory proposed compromise solution to allow Arrowe Park Hospital to continue to take admissions and perform emergency surgery during the day, which seems to undermine the whole logic of having a single Centre of Excellence.

This Committee also expresses its concern over the quality of the information provided in the various documents and reports to this committee and to others and the impact this may have had on any decisions taken.

Committee notes that there is to be a further consultation period before implementation of any changes to services, which is due to begin in December.

Committee also notes that they have been asked to consider setting up a joint OSC with West Cheshire to oversee the process and this will be voted on next week by the West Cheshire OSC.

Committee therefore agrees to refer this matter to Cabinet to examine the issues further and consider what recommendations should be made.”

It was then moved by Councillor Povall, duly seconded and accepted by the Chair as a friendly amendment, that –

At the end of the third paragraph from the bottom add-

“Committee strongly feels that consultation must take place on the Wirral as the Committee feels that the current proposals will have a dramatic impact on the outcomes for Wirral patients and residents and therefore the implementation date should be delayed until the New Year.”

Delete the last paragraph and replace with:

“Committee therefore wishes to receive a further report detailing the Wirral consultation to enable this Committee to further scrutinise the proposals and pass on its views to Cabinet.”

The motion, as amended, moved by the Chair and seconded by Councillor Clarke, was put and –

Resolved (unanimously) –

In the light of the fact that:

.

1.  Data suggests that more people from WUTH (both emergency and elective surgery) will be making the journey to the Countess of Chester than from the Mid Mersey area (Warrington/St Helens) and that Wirral appears to show higher rates of vascular related disease than Warrington.

2.  Advice suggests that geographic proximity is less important than level of need and level of service provision.

3.  Best practice advice is ideally that Vascular Centres and Renal Centres should be co-located on the same site and that Arrowe Park is currently the Renal Centre and the Uro-Oncology Centre, in common with the Royal Liverpool.

4.  According to the criteria in the Consultation Document it seems clear that Arrowe Park Hospital: best meets criteria 1 and 2 for clinical provision and co-location of services for other medical conditions; best meets criteria 3 for the maximum number of potential patients; best meets criteria 4 on potential costs to the NHS.

5.  The Vascular surgeons at WUTH remain opposed to the proposal to site an Arterial Centre at the Countess of Chester.

6.  Clinicians from WUTH appear to have been prevented from stating their case to the Chairs of the relevant Clinical Commissioning Groups.

This committee expresses serious reservations about the proposal to site the Arterial Centre at the Countess of Chester.

It further expresses reservations about the unsatisfactory proposed compromise solution to allow Arrowe Park Hospital to continue to take admissions and perform emergency surgery during the day, which seems to undermine the whole logic of having a single Centre of Excellence.

This Committee also expresses its concern over the quality of the information provided in the various documents and reports to this committee and to others and the impact this may have had on any decisions taken.

Committee notes that there is to be a further consultation period before implementation of any changes to services, which is due to begin in December. Committee strongly feels that consultation must take place on the Wirral as the Committee feels that the current proposals will have a dramatic impact on the outcomes for Wirral patients and residents and therefore the implementation date should be delayed until the New Year.

Committee also notes that they have been asked to consider setting up a joint OSC with West Cheshire to oversee the process and this will be voted on next week by the West Cheshire OSC.

Committee therefore wishes to receive a further report detailing the Wirral consultation to enable this Committee to further scrutinise the proposals and pass on its views to Cabinet.

The Chair then referred to the suggestion of a Joint Overview and Scrutiny Committee with Cheshire West and Chester Council to consider the matter further and proposed that she and the Cheshire West and Chester Council Chair could meet informally together with the party spokespersons to discuss this and come back to the Committee for their views.