To receive a presentation from NHS Gloucestershire on the outcomes arising from the Fit for the Future 2 engagement. 

69.1          Attention was drawn to the Fit for the Future 2 Outcomes presentation, circulated separately.  The Chair introduced the Associate Director Engagement and Experience and the Fit for the Future 2 Programme Director from NHS Gloucestershire and the Fit for the Future 2 Programme Director indicated that the purpose of today’s presentation was to inform Members of the outcomes of the engagement activity in relation to Fit for the Future 2. 

69.2          Members were advised that the key objective was around using the Cheltenham and Gloucester hospital sites as effectively and efficiently as possible by separating planned and emergency care to maximise the opportunity for planned operations without the risk of cancellation due to emergency activity.  Five services were being considered as part of the consultation: at Gloucestershire Royal Hospital this was Diabetes and Endocrinology (in-patient), Respiratory (in-patient and high care) and Non-Interventional Cardiology (in-patient); at Cheltenham General Hospital this was Benign Gynaecology (day case) and stroke (in-patient).  The Associate Director Engagement and Experience explained that comprehensive engagement had taken place with the residents of Gloucestershire with over 50 engagement events, group meetings and online sessions. Over 3,000 engagement booklets had been distributed and made available in places such as libraries and GP surgeries.  There had also been live streaming on Facebook Live – this had been used successfully during the pandemic to connect with new audiences and attract a different demographic and was something which would continue to be used going forward.  Over 1,800 face to face conversations had taken place with members of the public and staff through focus groups or when out and about on the NHS Information Bus which had been located in Spring Gardens Car Park and Morrison’s in Tewkesbury.  More than 200 surveys had been completed which showed people’s dedication due to their comprehensive nature – people had been asked to answer the questions which were relevant to them as it was recognised that not everyone would have an interest in all five services.  There had also been a lot of communication with partners and presentations had been given to the Primary Care Networks (PCNs), Integrated Locality Partnerships (ILPs) and Clinical Programme Groups (CPGs) as well as the Gloucestershire Health Overview and Scrutiny Committee (HOSC).

69.3          In terms of what had been learnt from the engagement, the Fit for the Future 2 Programme Director explained that staff responses had been separated from the public although he stressed they were not treated differently in their views.  There was overall support of more than 90% for four out of five services with the results for Stoke slightly lower at 84% which was primarily due to concerns about vascular surgery and a misunderstanding about how the service would be configured.  As well as this qualitative feedback, it was equally important to know what people had to say and several themes had been identified in the feedback from public and patients around supporting the centre of excellence approach; travel and transport; car parking; ward environment – Stroke patients would benefit from a better environment in Cheltenham General Hospital as it was built for rehabilitation with larger rooms etc.; innovation ; and clinical considerations.  Similar themes had been identified from staff feedback in terms of benefits of the centre of excellence approach; clinical considerations; travel and transport; car parking for patients; health inequalities; interdependencies with other clinical services – focus on the person as a whole; and improved integration with primary and community services.  It was noted that frailty had also been included as part of the engagement to seek views of the population regarding that pathway and the Fit for the Future 2 Programme Director explained that no changes were being proposed to where the service was based but there may be opportunities to enhance service integration.  The feedback had highlighted a real desire to achieve as much as possible outside of hospital in recognition that it was not always the best place for people to be.

69.4          With regard to the next steps, Members were advised that the report was being reviewed by partners including the Integrated Care System Board Executive, Gloucestershire Hospitals NHS Foundation Trust, National Health Service Executive and Gloucestershire Health Overview and Scrutiny Committee and was being taken into consideration along with the Clinical Senate Review report to test whether the proposals were clinically appropriate.  Subject to the partners being satisfied, it was intended to move to implementation with a decision-making business case in March 2023.  It was noted that four out of five services had already re-located (Diabetes and Endocrinology, Respiratory, Stoke and Benign Gynaecology) on a temporary basis but it was necessary to formalise the arrangement in order to make this permanent.

69.5          A Member asked whether the care system would be supporting the changes and raised concern as to whether there were enough staff to be able to implement the changes.  In response, the Fit for the Future 2 Programme Director clarified that it was about the relocation of services and it was not expected that additional activity would be generated as a result.  Staffing across the health and social care sector was a challenge and the benefits of centralisation and moving services from two sites to one included more resilient rotas and better management of current resources.  Although there was no requirement for additional staff, it was hoped that retention and recruitment would improve.  The Member was aware that six patients at Stroud Hospital who were ready to go home last week had been forced to stay as there were no carers available to support them.  The Fit for the Future 2 Programme Director recognised that this was a problem and, whilst these proposals were not part of the solution, they were impacted by it.  Another Member went on to challenge the idea that the changes were somehow optimising health services within the county.  Cheltenham General Hospital had been operating as a Minor Injury Unit and, in his view, running a single 24/7 Accident and Emergency site out of Gloucestershire Royal Hospital for the population of the county was ridiculous.  He raised concern that the relocation of teams would mean that, even during the daytime, there would be no specialists available to deal with emergency cases coming to Cheltenham General Hospital.  He questioned whether relocation of four out of five services was ever a temporary measure as the fact the Fit for the Future 2 consultation reinforced this seemed a “fait accompli” and he queried whether the consultation had properly followed the gunning principles.  With regard to delayed discharge, the Member went on to reference the Care Quality Commission’s State of Care report and concerns regarding morale, recruitment and retention.  The Fit for the Future 2 Programme Director indicated that he was not in a position to comment on the Care Quality Commission report but this had been discussed at Gloucestershire HOSC in November.  He reiterated that it was the in-patient element only so there were still respiratory, diabetes and cardiac patients on the Cheltenham site.  There would be more investment in things such as transport between the sites, out of hours etc. to ensure the Cheltenham site had the support it needed.  The NHS Gloucestershire Hospitals Foundation Trust had been on record in terms of its support for the Accident and Emergency Department at Cheltenham and it had reverted to its pre-pandemic state in July 2021 opening between the hours of 8am and 8pm.  With regard to issues around recruitment and retention, the stress for staff was significant – he worked for the NHS but did not feel the same pressure experienced by colleagues, friends and family on the frontline.  It was important to do whatever possible to support their jobs and delayed discharge was of no benefit to anyone.  In terms of the gunning principles, the Associate Director Engagement and Experience advised these were not rules, but very good guidelines by which to carry out any public consultation about probable service changes which required consideration to be given to including people at the start of the ideas process and ensuring people had enough time etc.  All public sector organisations were required to have regard to the principles and she confirmed that feedback from the engagement had been consciously considered which was the reason for such an extensive output report.  It was possible to be challenged on the gunning principles but she confirmed there had been no challenge in relation to this particular piece of work.  The Fit for the Future 2 Programme Director indicated that, if Members were concerned about the process, they could write to the NHS to express those concerns and how things could be done differently.  He provided assurance that, if there was a need to reconsider plans around public improvement then they would do so and it was noted that the business case would not be brought forward until the time for consultation had passed.

69.6          A Member questioned if the proposal to build a completely new hospital had been raised during the consultation as he felt a more radical solution of that nature was needed to address the issues – he had recently seen on the news that the NHS had been built to cope with 55 million people but there were now over 70 million so the reality was it could no longer cope.  Morale was at an all-time low and he felt that trying to adapt buildings which were not adaptable was not the answer.  The Fit for the Future 2 Programme Director noted this had been touched on at the previous Overview and Scrutiny Committee meeting in July and he recognised that a single hospital had been suggested around five years ago but had not been properly addressed; however, he believed that had now changed and was something which was now being considered more closely.  Notwithstanding this, his personal opinion was that, even if the right site could be found, it was a £600m project so funding would be a significant issue.  The Associate Director Engagement and Experience advised that, in the 20 years she had been doing her job, she did not think there was a single consultation where the idea of a new hospital had not been raised.  The Member was quite right in that some of the infrastructure was old but fantastic remedial work was being carried out at both sites and the reality was that a new hospital was not something which could be afforded currently.  She pointed out that the problems would not go away even if a new hospital was agreed as there would be considerable debate about where it was located and its proximity to Cheltenham and Gloucester.  The Fit for the Future 2 Programme Director reminded Members that, during the pandemic it had been beneficial to have two hospital sites – a green site and a red site – as this had meant it had been possible to maintain some level of elective treatment which was not an option for single sites; whilst he recognised this was not a reason not to do something, it was a factor worthy of consideration.  The Member raised concern that, in reality, both sites had been red – it was not possible to control who went into hospital and, if they had COVID, infection rates inevitably increased.  Staff, including surgeons, were currently being pushed between the two different sites and it was getting to the point that staff were being lost because they could no longer cope; his opinion was that this could not continue and he questioned how a service could be built to be ‘fit for the future’ if the solution was to plaster over old wounds.  Another Member agreed that the health service was not built for the current population; the population within Gloucestershire was growing at a considerable rate and he asked how much space was available for departments to grow.  If there was a shortage of space, he felt it was important to bring this into the political arena so pressure could be exerted to raise more interest in the county.  The Fit for the Future 2 Programme Director agreed that work would be needed in order to address population growth and there was a gap between where things were and where they should be; however, there were a number of things which could be done to maximise space with small differences adding up, for example, using procedure trolleys or chairs to maximise throughput and moving services to the new day care unit at Cheltenham General Hospital to free up the equivalent of more than 43 beds space at Gloucestershire Royal Hospital which could now be used as assessment rooms.  The Member indicated that he was impressed with the online service that was starting to roll out and expressed the view that online consultation had to be an option for a lot of people which would help to free up resources.

69.7          A Member sought clarification as to the implementation process and the services which were not yet in place and asked what the business case was designed to achieve.  The Fit for the Future 2 Programme Director advised that the Stroke unit at Gloucestershire Royal Hospital had been moved to Cheltenham General Hospital during the early part of the pandemic, around June 2021, and the Diabetes and Endocrinology (in-patient only) had moved in September 2021.  Respiratory could only be run from one location so the in-patient service had been centralised at Gloucestershire Royal in June/July 2021.  Benign Gynaecology had moved off the Gloucestershire Royal site during the pandemic with elective cases taking place in Cheltenham.  As had been referenced earlier in the meeting, there was a process to follow in accordance with the gunning principles; whilst it was possible to make temporary changes, it was necessary to draw up a business case to make these permanent and services would have to move back to their original sites if changes were not appropriate.  The only service which had not already moved was non-interventional Cardiology.  Subject to approval, the four services in situ would become permanent in April 2023 with Cardiology moving around August/September 2023.  The Member asked if any material changes would be made as a result of the consultation and the Fit for the Future 2 Programme Director advised that the consultation did ask for different ways of doing things but no alternative suggestions had been put forward in this instance.  Phase 1 of the consultation had proposed more significant change around planned general surgery but Phase 2 was more bounded in terms of the services so there were very few alternatives, for instance, the Hyper Acute Stroke Unit needed to be located on the same site as the Stroke Unit – from June 2020 to February 2022 the Hyper Acute Stroke Unit had been at Gloucestershire Royal and the Acute Stroke Unit had been at Cheltenham General which had not worked as staff had been required to move back and forth between the two sites.  The commissioners who ran the Stroke Unit had said themselves that, had the pandemic not happened, they would not have wanted the Unit to be located in Cheltenham; however, better outcomes were being achieved having done that with statistical data improving from D to B which could not have been forecast.  A Member noted the early improvements in relation to Strokes and asked if there were any other indications of improvement.  In response, the Fit for the Future 2 Programme Director advised that there were reduced cancellation rates for Benign Gynaecology day cases and the length of stay for Diabetes and Endocrinology patients had reduced by just under a day.   There was so much going on in healthcare that, to be able to say categorically that an outcome had been caused by one single factor would be unfair – it would be necessary to look at change over a much longer period to be clear what had actually caused it.  The Member asked whether any efficiencies had been identified in terms of staffing and was informed that the programme was not about saving money but there would be some financial savings as a result, for instance, having services over two sites required two sets of stock which could be combined if services were operating from a single location.  The NHS needed as many staff as it could get so no savings would be made from reducing staffing numbers; rather, it was about using existing resources in a more effective way.

69.8          The Chair thanks the representatives from NHS Gloucestershire for their informative presentation and it was

RESOLVED           That the outcomes arising from the Fit for the Future 2 engagement be NOTED.