At the request of the Cheshire West and Chester (CWAC) People Overview and Scrutiny Committee - a Joint Scrutiny Meeting has been convened to consider the impact of the Wirral Clinical Commissioning Group proposals for Urgent Care Services. CWAC have determined the proposed changes to urgent care to be a substantial development / substantial variation to the health service.

Report Papers and Minutes of the meeting of the Wirral Adult Health and Care (meeting jointly with Members of the Children and Families Overview and Scrutiny Committee) (Minute 28, 12 November) attached.   (Pages 11 – 164)

Urgent Care Transformation Update additional background briefing papers, circulated to all Wirral Councillors 6 November 2018, also attached.  

(Pages 165 – 242).

Chair’s Opening Remarks.

The Chair welcomed Members, Officers and members of the public to the meeting. With the agreement of the Committee the Chair then invited visiting Councillor Phil Gilchrist and Councillor Chris Carubia to the table. She informed the meeting that as Ward Councillors for Eastham Ward (the boundary of Wirral and Cheshire West and Chester) they had a detailed understanding of access to healthcare in that location and could provide the Committee with information on issues that may affect residents as a result of the proposal for the redesign of urgent care. It was noted that the visiting Councillors would not be entitled to a vote during the meetings proceedings.

Key Witnesses.

• Mr Simon Banks – Chief Officer, Wirral Clinical Commissioning Group (CCG)
• Dr Paula Cowan, G.P. Eastham Group Practice and Clinical Lead for Urgent Care for Wirral CCG
• Ms Jacqui Evans – Assistant Director Planned Services, Wirral CCG
• Mr Graham Hodkinson – Director for (Adult) Care and Health (Wirral)
• Ms Laura Marsh – Director of Commissioning, NHS West Cheshire CCG
• Dr Sue Wells - Chair,  Wirral CCG

Opening Presentation.

Doctor Paula Cowan and Ms Jacqui Evans provided the Committee with an overview of the proposals to alter the method by which patients would access urgent care treatment. Members noted that the proposals had been open to public consultation from 20 September 2018 to 12 December 2018. Following which, feedback received during the consultation period and other evidence would be reviewed by the NHS Wirral CCG Governing Body before a final decision on a future model of care was taken

Doctor Cowan and Ms Evans’ report informed that Wirral was not unique in the issues of people not always being able to get an urgent appointment at their own GP practice and how confusion about alternative services resulted in many people choosing to go to Wirral’s only Accident and Emergency (A&E) Department at Arrowe Park Hospital.

Members were apprised that NHS England had mandated a number of new service developments which included an improved NHS 111 service and the introduction of Urgent Treatment Centre’s across the country. The national developments aimed to make urgent care services work better for patients and to ensure that Accident and Emergency (A&E) Departments dealt with the most poorly and vulnerable people. Members were informed that it was Wirral CCG’s intention to locate the Urgent Treatment Centre (UTC) for Wirral at Arrowe Park Hospital by developing the existing Walk in Centre.  This location was believed to provide the best clinical model for patients as the UTC would be located adjacent to the Accident and Emergency Department and would provide a single ‘front door’ to access urgent care on the Arrowe Park site - to ensure A&E staff could concentrate their clinical skills on emergency care. 

Doctor Cowan and Ms Evans’ report informed that the UTC would offer bookable appointments and a walk-in facility and, as part of this consultation, the CCG was asking for people’s views on how many hours the UTC should be open.

Ms Evans explained that the CCG also wanted to simplify local urgent care services to make it easy for people to make the right choice when they need care and treatment.  This primarily involved improving local access to GP appointments to ensure that everyone who needed an urgent appointment could get one within 24 hours, usually on the same day. The CCG also proposed a new local urgent care service for children and better access to bookable appointments for wound care/dressings, the services would be delivered in four locations across Wirral (aligned to the current Wirral parliamentary constituencies). The proposal would mean that the current walk-in facilities across Wirral would be replaced by the provision of new local services and more urgent GP appointments.

Committee debate.

The Chair invited Members to present their questions and concerns, and for visiting Members to provide additional insight on matters of public transport and the impact of recent (temporary) changes to the operating hours of the Eastham Walk-In Centre.

Representatives of the Wirral CCG informed that the key message in respect of the consultation was that the services were being redesigned with clinicians to improve patient safety and advice, provide the treatment needed when it was needed and give the people of Wirral the best value for money by offering simpler options closer to home. The Joint Committee was informed that Arrowe Park Hospital’s A&E was not closing and was not part of the consultation. Members were informed that the current system was confusing, there was a need to ease pressure on A&E, and it was important to have more health and care services delivered closer to where people live.

Mr Simon Banks Chief Officer, Wirral CCG informed the Joint Committee that under the Gunning Principles, when proposals were still at a formative stage, public bodies needed to have an open mind during a consultation and not already made the decision, but must have some ideas about the proposals, and that sufficient reason must exist for proposals to permit ‘intelligent consideration' i.e. people involved in the consultation need to have enough information to make an intelligent choice and input in the process. 

Doctor Sue Wells Chair, Wirral CCG also informed that the consultation documentation could not (and was not allowed to) present any options that could not be delivered.

Doctor Paula McGowan re-iterated that the NHS and the CCG were always mindful of funding services and that bearing in mind demographics and geography, current delivery of services across the Wirral was not equitable. All CCG representatives were in agreement that the current service provision was not good enough and doing nothing was not an option.

The Chair provided the Joint Committee with examples of the impact on residents where lack of local provision compounded by a lack of public transport resulted in some, of those least able to afford it, having to use taxis to access medical treatments.

A Member pointed out that even though A&E was under extreme pressure, people would still go there because they knew they would ultimately receive treatment (after a wait). She expressed concerns that the proposed UTC would also become an overloaded mini A&E. Mr Banks responded, explaining that UTC would become the ‘front door’ and act as a triage to other service areas. Doctor Wells added that service changes would need significant timely communications.

A Member expressed the view that it was unlikely that individual’s attitude to using A&E would change and was the result of lack of access to GP appointments. He added that if additional funding was to be provided for additional appointments, as proposed, why could the current Walk-In Centres be retained rather than establish a new UTC? Ms Evans responded highlighting that this would not address the issue of patients attending A&E when they could be helped in pharmacies or by GPs and would ultimately result in an overprovision of services.

Members then questioned whether the proposed model for Wirral would impact on the West Cheshire GP services and what level of consultation had been undertaken with West Cheshire residents and service providers. Ms Evans informed that West Cheshire CCG operated a different model of service provision, but had been consulted and a number of consultation presentations had taken place. Both Wirral CCG and West Cheshire CCG worked closely together on a number of collaborative projects, and it was clear that residents from both areas accessed Walk-In services across the boundary e.g. attending Walk-In Centres or A&E if taken unwell at work for example, or as a result of their proximity to services

Discussion continued on a range of key issues that included:

• Digital access to appointments.
• Would the proposed additional GP appointments be sufficient.
• Urgent / non urgent appointments.
• Appointment hours / access.
• Staff training and retention for existing and proposed services.
• Access to Public Transport, areas with none, and service timings for those that do.
• Health inequalities between geographical areas.
• Impact on Ambulance Services – A&E waits and inappropriate use
• How UTC triage would work.
• Admissions and Discharge – Bed Blocking.
• Proposed UTC opening times.

Outstanding concerns.

During the course of the discussion Members highlighted a number of key areas of concern, seeking clarity on the following. The Joint Scrutiny Committee believed that:

Consultation was flawed by not being open about all the options – e.g. an earlier option to have a 12 hour UTC at Arrowe Park and retain the other Walk-In Centres. This should have been one of the options. I addition, the financial case hasn’t been clearly set out. 

The impression was that the CCG had already made its mind up - it was not consultation about whether to have a single UTC but merely about its opening hours. 

The changes must meet the needs of the population – Members were not convinced that they did. There were many people in the community who were anxious at the changes and the CCG must take their views into account (30,000 petition opposing changes). 

The proposal did not take into account the needs of deprived communities which the evidence confirmed were major users of A&E. These areas were some distance from Arrowe Park and the availability and cost of transport was a real issue.  This alone could increase the use of ambulance services and put consequent pressure on A&E

The evidence presented in the background reports was inconclusive and in places contradictory. National and research figures/reports have been used on occasions which don’t really back up the Wirral case for pressure on A&E.

If a key part of the plan was to use GPs to reduce the pressure on Arrowe Park  why can’t we keep the existing centres and extend the GP hours? What assurances can we have that there will be sufficient capacity to extend the GP hours and what will those hours be? 

CW&C and Wirral have different approaches e.g. CW&C an early adopter of the hub and spoke model. What will be the impact on Cheshire’s GPs? Concern that Wirral CCG hasn’t discusses the impact on Cheshire with West Cheshire CCG. 

When will the CCG consider the feedback and be ready to come back with how it plans to respond to the comments made? 

Request for a draft timetable/programme which includes sufficient plans for mobilisation and transformation. 

What happens when an adult with an urgent illness presents at a Children’s Walk-In Centre?  Would they be told to go to their GP?

Communication was key in trying to alter the mind-set of people to use GPs instead of Walk-In Centres. 

Members weren’t convinced that the proposals will much reduce the numbers of older people using A&E. Wirral has a high population of older people and inevitably many will be too frail or ill  to use Walk-In Centres or the UTC. The Equality Impact Assessments do not consider the impact of the closure of the existing services and only cover the two UTC options.

Chair’s Summary Statement and Joint Committee Resolution

This Joint Health Scrutiny Committee has been established by Wirral Borough Council and Cheshire West and Chester Council to consider and scrutinise the proposals put forward for statutory consultation by the NHS Wirral Clinical Commissioning Group in relation to Urgent Care Services. It is the view of both local authorities and the Joint Health Scrutiny Committee that the proposals amount to a substantial development or variation to the health service in their local area. The Joint Health Scrutiny Committee notes that the consultation period is due to end on 12 December 2018.

The Joint Health Scrutiny Committee has considered the following documentation provided by the CCG:

The Urgent Care Consultation report presented to the Wirral Adult Care & Health Overview & Scrutiny Committee on 12 November 2018 together with appendices:

Appendix1 - NHS Wirral CCG Urgent Care Consultation Document

Appendix 2 – NHS Wirral CCG Case for Change

Appendix 3 – Consultation Presentation

Appendix 4 – Activity Suite

The Joint Health Scrutiny Committee has also listened to oral submissions made to the Committee by the following people:

Jacqui Evans - Assistant Director, Unplanned Care and Community Care Market Commissioning

Dr Paula Cowan – Medical Director NHS Wirral Clinical Commissioning Group

Simon Banks – Chief Officer Wirral CCG

Dr Sue Wells – Chair of Wirral CCG Board

The Joint Health Scrutiny Committee has scrutinised the proposals put forward, and the consultation exercise undertaken, by the Wirral CCG in relation to Urgent Care Services and invites the CCG to reflect carefully upon the responses it receives from all stakeholders, and in particular, to formally take into account the views and comments of the Joint Health Scrutiny Committee set out below when making a final decision.

It is the view of the Joint Health Scrutiny Committee that it will be necessary to hold a further meeting of the Joint Committee in February 2019 (date to be confirmed) to consider:

a.  The Wirral CCG’s final proposals and any measures the CCG proposes to take to address concerns raised during the consultation and reasons for the same.

b.  Whether the Joint Health Scrutiny Committee is satisfied the consultation has been adequate.

c.  Whether the Joint Health Scrutiny Committee considers the final proposal of the Wirral CCG would be in the interests of the health service in its area

d.  Whether or not a referral should be made to the Secretary of State.

Resolved - That

(1)  A further meeting of the Joint Committee be held to consider pre-decision the outcome of the consultation, how that has been addressed by the CCG and any new or final proposals arising from the consultation. (probably mid-February 2019);

(2)  The committee seeks re-assurance that the proposals will meet the health and wellbeing needs of the people in Wirral and Cheshire  and in particular do not disadvantage  the area’s most deprived communities or residents who need treatment which cannot be provided by pharmacist or NHS 111;

(3)  The committee requests that discussions take place urgently  between the Wirral and West Cheshire CCGs on the model of service that best meets the needs of Wirral and Cheshire  residents and that the outcome of those discussions are reported to the Joint Committee at its next meeting; 

(4)  The committee requests further evidence that all options have been fully explored, including those which preserve an adult walk in facility and the reasons why those options have not been offered for consultation; and

(5)  The committee requests further information on the location and operation of the proposed wellbeing centres.