Agenda item

To receive a presentation from the NHS on Fit for the Future 2. 

24.1          The Chair introduced the Associate Director Engagement and Experience and the Fit for the Future 2 Programme Director from NHS Gloucestershire.  The Associate Director Engagement and Experience advised that NHS Gloucestershire was currently engaging with the public as part of the consultation in respect of Fit for the Future 2 and all district councils in Gloucestershire had been offered the opportunity to start a dialogue in relation to the proposals.  Tewkesbury Borough Council had been quick to take up this offer and had invited them to today’s meeting to give a brief presentation and to answer any questions Members may have.

24.2          The following key points were raised during the presentation:

·     What is Fit for the Future 2? – A part of the One Gloucestershire vision focusing on the medium to long term future of some of its health services; building on early engagement and consultation (Fit for the Future 1), it aimed to open up the conversation in relation to the continued development of the Centres of Excellence approach at Cheltenham General and Gloucestershire Royal Hospitals, including inpatient care and support for people in their own home, GP surgery or in the community.

·     Gloucestershire Health and Wellbeing Priorities – Using the learning from Fit for the Future 1 and the response to the COVID-19 pandemic, the aim was to: provide the very best care for people at each stage of their illness or injury; explore opportunities to join-up care – improving communication and making care simpler and smoother across services and communities; reduce health inequalities – ensuring that health outcomes were improved for everyone, regardless of where they lived in the county and their social, environmental or economic circumstances.

·     Summary of Focus Areas and Proposed Ideas – The service areas being considered were very specific: Benign (non-cancerous) Gynaecology – Day-case - COVID-19 temporary change (majority of operations) made permanent at Cheltenham General Hospital; Diabetes and Endocrinology – Inpatients and Community – centralise inpatient service at Gloucestershire Royal Hospital; Frailty/Care of the Elderly – Inpatients and Community – improved assessment pathway at Gloucestershire Royal Hospital, better integration of services and admission avoidance options; Non-interventional Cardiology – Inpatients – centralise remaining Cardiology inpatient beds at Gloucestershire Royal Hospital, consultant referral service for Cheltenham General Hospital inpatients requiring Cardiology input; Respiratory – Inpatients – COVID-19 temporary change made permanent at Gloucestershire Royal Hospital alongside Respiratory High Care Unit, consultant referral service for Cheltenham General Hospital inpatients requiring Respiratory input; Stroke – Inpatients – COVID-19 temporary change made permanent at Cheltenham General Hospital, Hyper-Acute and Acute Stroke Units both at Cheltenham General Hospital.

·     Benign Gynaecology: Our ideas – Following changes due to COVID-19, continue to deliver the majority of Benign Gynaecology Day Case surgery at Cheltenham General Hospital; continued choice of outpatient appointments across hospital sites, in the community and virtually as appropriate; potential benefits – Centre of Excellence approach with a greater focus on planned care in Cheltenham General Hospital; improved environment once new unit opens at Cheltenham General Hospital in December 2022; increased capacity and fewer cancellations; potential drawbacks – some patients will have further to travel for day case surgery.

·     Diabetes and Endocrinology: Our ideas – Centralise inpatient Diabetes and Endocrinology Service at Gloucestershire Royal Hospital; continue to provide support to other hospital inpatients who happen to have diabetes at both Gloucestershire Royal Hospital and Cheltenham General Hospital; further develop community clinics and virtual ward; potential benefits – ensure safe, consistent and resilient staffing; create better training opportunities and joined-up working; fewer cancelled outpatient appointments and reduced hospital visits; potential drawbacks – increased travel times for some patients and their relatives/carers.

·     Frailty/Care of the Elderly: Our ideas – To develop an integrated frailty service offering rapid access to services, support and treatment for people in their own homes and good pathways for hospital discharge; GPs and other professionals would be able to refer patients directly to the Frailty Assessment Unit; options for additional frailty services at Cheltenham General Hospital site; potential benefits – support people to stay well and independent; prevent unnecessary hospital admissions and reduce Accident and Emergency and ambulance waits; reduced length of stay in hospital with a return home with ongoing support; potential drawbacks – negative impact if outcomes and experience of patients fails to improve.

·     Non-interventional Cardiology: Our ideas – Following changes agreed through Fit to the Future 1, centralise all Cardiology inpatient beds at Gloucestershire Royal Hospital; continued choice of outpatient appointments across hospital sites, in the community and virtually as appropriate; consultant referral service for inpatients at Cheltenham General Hospital in other specialty beds who may require review/input from Cardiology; potential benefits – reduced length of stay and likelihood of transfers between sites; improved staff cover, out of hours care and cross-speciality working; enhanced training opportunities and joined-up working; potential drawbacks – increased travel times for some patients and relatives/carers.

·     Respiratory: Our ideas – Following emergency temporary changes due to COVID-19, continue to provide specialist Respiratory inpatient beds at Gloucestershire Royal Hospital as well as the newly developed Respiratory High Care Unit; Respiratory team consultation service for inpatients at Cheltenham Royal Hospital, in other speciality beds, who may require their review/input; potential benefits – current service showed improved quality of care and patient outcomes, respiratory admissions to intensive care; more efficient use of staff and improved cross-speciality working, easier to co-ordinate care and provide staff training; whilst the risk of COVID remains, this model provided flexibility to establish a controlled Respiratory ward; potential drawbacks – increased travel times for some patients and relatives/carers; additional investment will be required to deliver the new high care services on a permanent basis.

·     Stroke: Our ideas – Both the Hyper Acute Inpatient Stroke Unit (HASU) and the Acute Inpatient Stroke Unit (ASU) remain permanently at Cheltenham General Hospital; these units were temporarily located to support the COVID-19 response; potential benefits – high quality inpatient environment supporting a seamless service and access to the right specialist staff at the right time; co-location of HASU and ASU provided improved staff cover and resilience; option of co-locating the HASU and ASU at Gloucestershire Royal Hospital would be very difficult due to limited availability of beds; potential drawbacks – increased travel times for some patients and their relatives/carers; patients with ‘stroke mimics’ taken to Cheltenham General Hospital may be required to transfer to Gloucestershire Royal Hospital; clinical protocols would need to be in place for any suspected stroke patient attending Gloucestershire Royal Hospital including safe transfer to Cheltenham General Hospital.

24.3          The Associate Director Engagement and Experience advised that consultation on the ideas had commenced in May with the engagement originally planned to close at the end of June; however, the survey within the engagement booklet had been extended until 31 July 2022 and conversations would continue over the summer.  Any feedback received would be collated into an output report which would be considered by the Fit for the Future 2 Programme Director and his policy team as well as senior decision-makers in the NHS.  Members would be kept up to date on progress.  Regular updates were provided to the Gloucestershire Health Overview and Scrutiny Committee in relation to all projects involving potential service changes and the output report in respect of the Fit for the Future 2 consultation would be provided at its meeting in October; she confirmed she would be happy to share the report with this Committee at that time.  She went on to advise that information bus events were held across the county and the bus was often located at Morrisons in Tewkesbury which provided an opportunity to share information and help people to complete the survey.  Representatives from NHS Gloucestershire also went out into the local community to talk to residents so she asked Members to make her aware of any events within their Wards which would benefit from their attendance.

24.4          A Member raised concern that Cheltenham General Hospital was not fit for continued adaptation due to the nature of the building and he was of the view that it was now necessary to consider a new purpose built hospital so he asked if that was something which was being proposed.  In response, the Fit for the Future 2 Programme Director explained that this was on the table and the options would be considered; however, that would be an investment in the region of £750m and a lot of new hospitals had not lived up to expectations so, whilst those comments were reasonable, it was not a simple solution.  COVID-19 cases were on the rise once again and, although it was unclear what the future would hold with regard to that, Gloucestershire was able to manage its performance better than other parts of the south-west through the way the two hospital sites were operated which meant that Cheltenham General Hospital could be deemed as a COVID negative site.  The Member questioned whether the division of services between the two hospital sites had fostered competition among staff and the Fit for the Future 2 Programme Director explained that it was a relatively new way of working and, in his experience, as new staff came in and worked for a service rather than a site, it was actually becoming less competitive.  He accepted that car parking was an issue but there were advantages of centralising services and building a single team broke down barriers - there were examples of teams working against each other and that culture needed to be addressed in the round.  The Associate Director Engagement and Experience indicated that she had seen major change in the last six years as certain characters and personalities retired or moved on and due to the introduction of the Centres of Excellence approach – the shuttle bus provided between the two hospital sites had also helped.

24.5          A Member asked what was being done to get patients with manageable conditions back into their homes after time in hospital.  The Fit for the Future 2 Programme Director advised that there were multifaceted reasons around the workforce for domiciliary care, for example, the impact of COVID on care homes and changes to risk assessment of patients; however, a very big problem within Gloucestershire which needed to be addressed was the flow through the whole system - 40% of people did not have a medical requirement to go into hospital - so measures needed to be put in place around admission avoidance and speed of discharge.  He suggested this was a potential topic which NHS Gloucestershire could discuss with the Committee going forward.  The Associate Director Engagement and Experience advised that a major piece of work had recently been commissioned in relation to this and communications had been sent out to Chief Executives across Gloucestershire.  The Fit for the Future 2 Programme Director stressed that a lot of work was being done day-to-day to try to get patients out of hospital – some had been found to be in for over 70 days, which was not good for them, and that number had been halved, nevertheless, it needed to be further improved.

24.6          A Member noted that one of the proposals within the consultation was to centralise Stroke care and she raised concern there was no 24 hour Accident and Emergency department at Cheltenham General Hospital which was the proposed permanent site.  In response, the Fit for the Future 2 Programme Director explained that it was standard practice for Stroke Units to be located on the emergency site; however, because of COVID, the ASU had been moved to the Woodmancote Ward at Cheltenham General Hospital which had been built as a Stroke-specific ward so there was more space for rehabilitation and performance metrics had improved during the temporary arrangement.  It had been intended to move back to Gloucestershire Royal Hospital once COVID allowed; however, there had always been an issue with space and, based on volume, it had been decided to establish why the units needed to be located at Gloucestershire Royal.  It was considered that all of the positive reasons for having the units there was also true of having them in Cheltenham and it also meant that the emergency department was bypassed so the hospital was aware when a Stroke patient would be coming.  Whilst traditionally Stroke units were located at the emergency site, arguably a better service could be provided at the Cheltenham site with the right team in place.  It was noted that this was a proposal as opposed to a confirmed plan and, if it did become a permanent arrangement, it would be necessary to work with GPs to ensure that anyone having a Stroke was aware they needed to go to Cheltenham General Hospital as opposed to Gloucestershire Royal Hospital.

24.7          A Member queried what was being done in respect of dementia and other illnesses associated with an ageing population.  He pointed out that people with dementia had specific requirements in terms of equipment, for example, orange clocks, and he understood through the Tewkesbury Hospital League of Friends that this had been difficult to obtain.  The Fit for the Future 2 Programme Director advised that dementia was not part of the Fit for the Future 2 Programme but Frailty/Care of the Elderly was included as the Frailty Assessment Unit was not performing as well as it should.  Consideration was being given to locating all frailty services on the Gloucestershire Royal Hospital site in the gallery wing where there was extra capacity and that included plans for a dedicated dementia-friendly area.  Once this had been addressed, it was intended to look at what could be done on the Cheltenham General site.  In response to the point about equipment, the Associate Director Engagement and Experience confirmed that this would be provided if needed.  The Member also sought assurance that it was no longer the case that children were required to be transferred by ambulance from Cheltenham General to Gloucestershire Royal Hospital where the paediatrics department was located.  The Fit for the Future 2 Programme Director confirmed there were no plans within the consultation to move the department from its current location and he undertook to find out if this was still happening and, if so, what action was being taken to address it.  The Associate Director Engagement and Experience indicated that it would be interesting to hear any particular examples as paediatrics had all been located at the Gloucestershire Royal site for some time.

24.8          A Member indicated that work was ongoing in Brockworth with the local GP surgery to establish community needs and it was clear that a lot of people did not feel able to attend their local surgery for a number of reasons, for instance, they were reluctant to go to the surgery following COVID, they were unsure of the arrangements in place for face-to-face contact and were not able to access services online etc.  As such, he asked what percentage of people attending hospital could have been dealt with by a GP.  He pointed out that his local GP surgery in Brockworth was 50% oversubscribed and he asked what was being done to address that.  The Associate Director Engagement and Experience advised there had been similar feedback from across the country, particularly post-COVID.  She talked to a lot of patient groups linked to GP practices and there had been numerous restrictions to accessing face-to-face appointments during COVID with many people moving online – some had liked that change whereas others had not but, regardless of that, it was here to stay to some extent.  Notwithstanding this, there would always be face-to-face appointments available to those who needed them.  In terms of issues with isolation, a lot of work was being done across the county around introducing social prescribing services which offered solutions such as health walks, social groups, crafting etc. as opposed to medication or operations and this aimed to address factors affecting health which were related to lifestyle or opportunities.  Brockworth had a fantastic patient participation group and she would be happy to talk about the potential options with the Member outside of the meeting.   There had been a lot in the media about not being able to get a GP appointment and this had been discussed at the Gloucestershire Health Overview and Scrutiny Committee meeting earlier that day where a paper had been presented giving an update on the current position.  It was noted there were 13% more appointments available than in 2019, albeit some of those would be online, so whilst there was increased demand there was also increased supply, although that was still not enough to meet that demand and every service was under pressure.  In terms of the percentage of people who attended hospital that could have been dealt with in a local setting, she did not know if that was a statistic which was available but she suggested that members of the public be directed to the NHS Gloucestershire social media accounts which gave advice on where to go in an emergency or when unsure where to go.  A Member raised concern that some patients were experiencing long waits which could be putting their health at risk and the Associate Director Engagement and Experience apologised if this was happening and indicated that, once the outcomes from the engagement were available, it would be beneficial to come back and share these with the Committee.  The Fit for the Future 2 Programme Director explained that a lot of lessons had been learnt during the pandemic, one of which was around virtual wards which was about managing people at home with a safety net, for example, people being able to take their own blood pressure etc. with someone looking out for them – this would not be right for every patient but was a possibility for some.  Another Member understood that in London it was possible to sign up for an ‘online only’ GP service and she questioned if there was any intention to introduce that in Gloucestershire.  The Associate Director Engagement and Experience advised that the service referenced by the Member was one where the patient did not have a relationship with a particular GP practice so healthcare advice could be accessed regardless of location.  Whilst this was not live in Gloucestershire, GP practices were looking at different options based on the learning about different ways of working during COVID, although she stressed that any such initiatives would be a choice.

24.9          In response to a query regarding staffing levels in Gloucestershire, the Associate Director Engagement and Experience advised that all areas were under pressure. A lot of the benefits associated with the Centre of Excellence approach were related to becoming more efficient and robust as well as improving staff wellbeing through improved training and supervision – an important outcome measure would be staff numbers and satisfaction levels.

24.10        The Chair thanked the representatives from NHS Gloucestershire for their informative presentation and looked forward to welcoming them back to report on the outcomes of the Fit for the Future 2 consultation later in the year.  It was

RESOLVED           That the Fit for the Future 2 presentation be NOTED.