The Chair invited representatives from the CCG / NHS to present their evidence and explained that the purpose of this meeting was to review the consultation arrangements for the Urgent Care Review.

Nesta Hawker, Director of Commissioning and Transformation - Wirral Health and Care Commissioning introduced her report that outlined the current position of the urgent care transformation work providing an update with regards to consultation and engagement feedback and next steps. She informed that a future report on the decision-making process will come back to the Joint Health Overview and Scrutiny Committee once the decision has been made by the CCG Governing Body on 9 July 2019.

Director of Commissioning and Transformation informed that the NHS Long Term Plan outlined the aim to ensure patients received the care they needed fast and to relieve pressure on Accident and Emergency Departments (A&E). Her report informed that it was recognised nationally that there was unnecessary pressure on A&E and other parts of the urgent and emergency care system, and that Wirral was not immune to these issues. Analysis of data showed that half of the patients that attended A&E could have been treated in a more appropriate setting to deliver the same outcome, e.g. community health venues, pharmacies. This additional pressure meant that those patients who were very poorly and in need of emergency interventions, may not be seen as timely as they could be. She added that the consultation on proposals for Wirral was not a ‘tick box exercise’ for national proposals and must be sustainable clinically.

Director of Commissioning and Transformation explained the methods of public engagement / pre decision consultation had taken place between 20 September and December 2018 had included surveys, website communications, postcards, statutory meetings, public meetings, and focus groups for those with protected characteristics. She added that post consultation, at request of the Wirral Overview and Scrutiny Committee had resulted in an independent company undertaking analysis of the feedback on 2 specific matters i.e. 24hrs or 15hrs Urgent Care and walk-in access originally being limited to Children and dressings treatments.

Dr Paula Cowan – Chair, Wirral Health and Care Commissioning informed the Joint Health Committee that there had been a quite a lot of feedback, highlighting a depth of interest within local community and raising issues regarding the utilisation of services, the need for walk-in centres. She further informed that the consultation exercise had demonstrated transparency, resulting in the initial survey of 1965 respondents having been followed up by comments from in the region of 45 thousand residents.

Dr Cowan apprised the Joint Health Committee that there had also been a lot of positive feedback relating to the co-location and access to diagnostics at Arrowe Park (Wirral University Teaching Hospital (WUTH) A&E, and the benefits of standardised healthcare as detailed in the report. She added that the consultation also highlighted resident’s displeasure regarding the closure of walk-in centres, and the difficulties of WUTH as choice of location due to public transport issues. Childrens’ services met with positive response, but there had been significant number of comments on how a (sick) mother presenting with a sick child would be treated.

Jacqui Evans Assistant Director, Unplanned Care and Community Care Market Commissioning referred Members to statistical information regarding referral activity data that summarised information on 3645 visits, whereby 26% had been referred to GPs, 9% to A&E, with 21% of referrals relating to dressing wound care and similarly 21% relating to the age group 0-19 years of age. 

Paula Cowan – Chair, Wirral Health and Care Commissioning advised the Joint Health Committee that independent assessment of the consultation process had been undertaken by an invited Clinical Senate (for Manchester, Lancashire and Cumbria) who acted as a critical friend – a summary report was also included in the Committee agenda papers. Dr Cowan informed that a number of key considerations/messages had been highlighted, and the views of local populations were clear in their wish to retain, local walk-in centres. She summarised her report stating that it had been a responsive consultation and that the CCG had heard the views of residents and the involvement of the Clinical Senate had been helpful in shaping things going forward.

Dr Cowan informed that the next steps in the process would be that the CCGs recommendations will be discussed at the CCG Board / Joint Strategic Commissioning Board on 9 July 2019, and the decision would be reported back to the Wirral Adult Care and Health Overview and Scrutiny Committee and the Joint Health Overview and Scrutiny Committee later that month.

Councillor Yvonne Nolan, Chair of the Joint Health Overview and Scrutiny Committee opened the meeting to questions from Members.

Councillors identified a number of concerns, questioning the timing of (late) involvement of the Clinical Senate, and why this did not happen early in process as per normal practice. Members were advised that the Senate involvement can happen at different stages, and in this particular case consultation dates were moved i.e start date.

The Assistant Director, Unplanned Care and Community Care Market Commissioning advised Members that she had not been aware of any issues arising from this and had been a diary issue to allow for Member’s availability, avoiding purdah.

A Member commented that the consultation had ultimately

teased out what people want, and that the CCG should not have been afraid of using public feedback, however the question remained as to the reason why the changes had been proposed.

Dr Cowan explained that it had been crucial to engage with the Wirral population (i.e. 300 thousand patients), and the CCG would strive to do better and keep conversation open and reflect on lessons learned. The issue was always utilising a defined budget wisely – based on clinical need - providing the service required, but not to a cost.

A Member questioned access to urgent appointments but expressed concerns about where such appointments were to be located and whether sufficient capacity had been factored into the available GP appointments, and what would happen out of hours.

Director of Commissioning and Transformation informed that the two existing contracts with GP federations had incorporated cover and were to work together to cover hours. In some cases arising from the national request some alternate provision might not be provided by GPs, but could be pharmacy, nurse, etc. She added that as commissioners the CCG were confident of meeting any demand for additional appointments.

Members questioned the visiting officers on a range of additional subjects that included:

• Sufficiency of staffing
• New builds, and how the CCG planned to cope with growth in housing.
• The number of GPS reaching retirement age.
• The role of physicians assistants.

Further detailed questioning took place, with responses from the CCG Officers on the subjects:

• Additional hours (capacity).
• Patient demand / movement across the local authority boundaries.
• Making sure people know where services are.
• Dressings etc – role of community teams.
• Reducing the need to travel.
• Work to ensure funding follows patient.
• GP / out of hours appointments could be anywhere – people have assumed it would be local.
• Concern over continuity of care e.g. dementia (must see same people)
• If seeing different GP – telling story once not always possible.
• Interaction with, and information provided by, NHS 111 system.
• Opportunity to drive behavioural change – although many services covered - when unwell a patients first thought is ‘wanting to see a doctor’
• Different responses from primary care networks.
• Digitalisation of patient records
• Gold standard – palliative care – see same person – including cancer, dementia, etc

The Chair thanked the witnesses for their attendance and responses to questioning, and allowed them to leave the meeting, to allow Members to discuss their formal response.

Following the departure of the CCG Officers, Members reviewed the responses, and although acknowledging its role in focusing on the consultation exercise summarily expressed views on the next stage of the Joint Scrutiny exercise and requirement for a further meeting to discuss the decision of the CCG Board to be taken on 9 July 2019.

Vicki Shaw, Solicitor informed the Joint Health Committee that, under the Act, the Committee had the power to decide whether consultation had been adequate, and should consider the proposals ‘in the interests of the area’, with the ultimate sanction (if not satisfied) that the matter be referred to the Secretary of State.

A Member commented that she had no issues with the consultation on clinical issues, but had concerns about the access / travel arrangements i.e public transport. She believed that, alone, these might not be sufficient reason to refer to the Secretary of State, but access arrangements had not been adequately considered.

Another Member expressed concern that GPs might not be best positioned to deal with Acute Care matters.

It was suggested that the Joint Health Committee reconvene in 6 months to look at progress, after it had reviewed the final decision of the CCG Board on the 9 July 2019.

In summary, the Joint Health Scrutiny Committee therefore reiterated its initial concerns, namely:

1.  Significant concern regarding the process, whereby a decision to site an Urgent Care Treatment Centre on the WUTH site was delivered as a fait accompli, with only 2 options, namely opening hours being presented to the public / residents / service users.

2.  Delays and added costs arising as a result of the NHS / CGG management of the initial consultation process and the agreed need for a broader – more open consultation. 

Concerns also remained:

3.  Over the level of meaningful discussion with public transport providers regarding accessibility to the revised provision for disadvantaged residents of Wirral, and Cheshire West and Chester who utilise public transport as their primary access to health care. These concerns extend to access to health care services for residents in rural locations where limited public transport services are available.  

4.  The Joint Scrutiny Committee similarly expresses its concern over the level of meaningful discussion with local Authorities and planning professionals regarding the impact of new and proposed housing developments in locations across Wirral, and bordering areas of Cheshire West and Chester, and the impact on the proposed / revised Walk-In Centre facilities.

5.  The Joint Scrutiny Committee also sought reassurance that the GP federations and GP surgeries who were not part of the federation have sufficient capacity and commitment to the new ways of working.

6.  The Joint Scrutiny Committee was concerned that the proposed changes to service provision in Moreton and New Ferry will lead to an in-balance of care, resulting in an inequality of access to services for residents in those localities.

The Joint Scrutiny Committee acknowledged that any change to the delivery of healthcare was unsettling for residents, and was hopeful that there would be an ongoing commitment to the CCGs positive statements regarding future communication that included reference to the access to and delivery of services, use of technology to reach isolated residents, promotion and assistance with self-care, digitalisation of patient records and ‘telling the patient story only once’, i.e. a demonstration of the CCG had taken into account the outcome of the consultation.

The Chair thanked Members for their contributions, and it was:

Resolved that the Wirral & Cheshire West and Chester Joint Health Scrutiny Committee:

1) notes the outcome of the consultation undertaken by Wirral CCG on the options for the development of an urgent care centre and in doing so re- iterates its concern that the consultation:

a) was too limited in scope and failed to offer an appropriate choice of options, focusing instead on the details of a decision that had already been made; and

b) did not examine in sufficient depth the transport and access implications of the options which were consistently raised as one of the primary concerns of the public, especially those who have to rely on public transport;

2) urges the Wirral CCG Governance Board to ensure that the model of service which they are minded to approve:

a) demonstrates clearly how it has been shaped by the many comments and contributions made as part of the consultation process, especially the 45,000 signatures accruing on petitions which support the continuation of the existing all age walk in centres;

b) shows clearly how a centralised UTC service is better than the current system at fulfilling the principle which the CCG itself has emphasised in that services must be local and accessible;

c) provides evidence to ensure that the new model of service is based firmly on inclusivity and has the health and wellbeing of the most vulnerable and disadvantaged communities at its heart, particularly where people may be isolated due to age, frailty or geography;

d) will not be seen as a stepping stone to further centralisation once the Urgent Treatment Centre has been established;

e) has a very clear plan which will show in detail how the extended GP hours which are a key part of the proposals will be provided, including replacement for retiring GPs, meeting additional demand through, for example an ageing population and additional extensive housing developments and the provision of GP out of hours services;

3) is disappointed that at this late stage there has still been no formal opportunity to discuss the physical proposals and accordingly requests that the CCG takes no decision to implement the proposals  until the Committee has received and considered the full  transformation business case , such consideration to  have due regard to the points made in 2) above;

4) the Wirral CCG be requested to attend a further meeting of this joint Committee as soon as practicable after the Governing Board meeting on 9 July, such meeting to receive clear information about:

a) the exact nature of the decision the Board has made;

b)  what the decision means in practice including the opening and closure of any facilities and the timescale for putting the service changes into effect; and

c) the plans for communicating any service changes to the public and how the new system will avoid the current level of confusion identified as a key reason for the change.