Agenda item

To receive a report from UHL on their intention within the STP to consolidate acute care onto two acute hospital sites, subject to formal public consultation.

Members received a report from UHL on their intention within the STP to consolidate acute care onto two acute hospital sites, subject to formal public consultation.

John Adler, Chief Executive, University Hospitals of Leicester NHS Trust (UHL) attended the meeting to introduce the report and respond to Members questions and comments.

It was noted that:-

a)            The proposal to reduce the number of acute sites from three to two sites was dependent upon the proposals in the wider STP because the reconfiguration of the acute service provision could only happen if other reconfigurations in the STP were in place.

b)            The direction of travel for the acute services provision was first announced in the summer of 2014 and there was some frustration that it had taken so long to progress the plans which had previously been discussed with the Commission and the County Council’s Health Scrutiny Committee.  Nothing had materially changed in recent months within the overall plan to concentrate acute services at the Royal Infirmary and the Glenfield Hospital sites.

c)            The projected numbers of acute bed numbers in the STP, whilst only being one part of equation, was nevertheless an important component; especially in the eyes of the public.  The reduction of the number of acute beds in the STP from 1,940 to 1,647 was still ‘work in progress’.  The Trust was learning from the good practices of the vanguard Trusts around the country.  It was envisaged that the next update would include a revised figure for acute beds.  This reflected a modification of the scale of change that was feasible.

d)            The proposals would also be dependent upon capital funding within the national capital programme available in the NHS.  Part of the capital provision would come from the NHS and other parts from PF2 initiatives.  PF2 had retained the better elements of the previous PFI and eliminated those elements that did not work in the interests of the NHS.  The NHS felt this was a pragmatic approach to provide a combination of funding of £114m of public funding by the NHS and the remainder through PF2 funding streams.  UHL’s request for its capital funding programme was known to be towards the top of the regional programme within the Midlands and East; which was one of the four national areas along with the north, the south and London.  The outcomes of the national funding awards were expected to be announced in the next few months.  Any public consultation on proposals within the STP would be delayed until it was known that capital funding was available to deliver the proposals.  If the UHL were successful in receiving a capital allocation from the NHS prioritisation process, it would then begin the process of going through the pre-consultation preparation process.

Members commented that:-

a)            It was difficult to comment effectively on proposals that were dependent upon other elements of change and was reliant upon capital allocations that may or may not be available.

b)            The proposals for the acute provision are also heavily dependent upon community and GP services and many elements of these do not work effectively at the moment.  The STP proposes to put more reliance on community and primary care provision.  If the new focus on care work and prevention worked it may not be necessary to provide the current number of acute beds.  It would be better to allow investment in community and primary care in the next three years in order to get existing services working better before considering whether to burden it with extra work and responsibilities. Until these elements were working well, it was felt it was premature to consider the implications of proposals such as this.

c)    There were also variances in GPs services, as not all GP were prepared to accept Shared Care Agreements, whereby care can be transferred from a consultant to a GP to provide some elements of the patient’s care. If these were not working already, it would again seem premature to direct more care towards the community care and primary care sector.

In response to comments made by Members and in response to further questions, the following responses were received:-

a)            Calculating the projected number of acute bed provision was not a precise science but the vanguard programme and the observations of overseas experiences were adding valuable input to the process.  It was felt that it was better to be adaptive on the basis of what works locally and elsewhere.  It was accepted that there were elements that do not work well at present and which could be made better with appropriate investment in services.  It was difficult, with the limited resources now available, to provide for double running; which did provide a tension within the system to build up alternative services elsewhere while still trying to provide the existing services.  However constrained this process may be, the direction of travel was considered to be correct since the current situation was not sustainable in the long term.

b)            There was a general acceptance throughout the whole health sector that not all parts of it were working well and the STP provided an opportunity to change this.  For example, by creating the integrated health teams.  The SCA was considered to be a good arrangement where it worked; but it was accepted that this was not universal across the system.

c)            UHL would not reduce the number of acute beds until viable beds were available and effective in the community setting.  UHL had the highest number of acute beds open in recent years arising from increased demands. The numbers were now levelling out from emergency care and it was felt that this was the result, in part, of the initiatives introduced such as the assessment unit at the emergency department, which had prevented admissions whilst providing high quality care. 

d)            The transformation monies had now reduced and this placed constraints on double running while trying to develop new services to reduce acute beds.  However the cost of supporting new services will eventually reduce acute costs.

e)            UHL were introducing a number of initiatives to use existing financial resources more efficiently.  One such initiative was the ‘Red to Green’ implemented on the 14 medical wards.  In-Patient processes were being monitored to reduce the number of ‘red’ days where a patient was in hospital and nothing happening to the patient in clinical terms, which was unproductive time and could be considerable.  The ‘green’ days represented a key clinical process happening with the patient; such as seeing a consultant, having a scan, physiotherapy or being discharged and waiting for medications to go home.  Medical teams were being encouraged to become more focused to reduce the ‘red’ days so that patients stayed in hospital for less time which made the use of beds more efficient.

f)     There was emerging evidence elsewhere in the country and abroad that different models of care could work better and produce better outcomes for patients.  For example, keeping frail and elderly people in hospital longer than was needed was not good for their long term health as it increased their dependency on support once they left hospital to go home; which, in itself, used community, primary care and social care resources.  The aim was to reduce delays in system and to make sure there was adequate support available when patients are discharged.  It was difficult to translate how much this intervention would reduce the number of acute beds required in the future, but providing a better fall prevention service had been proven to reduce elderly persons’ admissions elsewhere in the country.

g)            GPs shared the frustration of only being able to spend 8-10 minutes per patient when sometimes a patient needed 20-25 minutes for more complex health care.  GPs currently spent too long with patients who didn’t need their level of expertise and input for their health conditions. Work was progressing with GPs to identify groups of high risk patients and how services could be wrapped around them to allow GPs to deliver preventative medicines to 20% of their patients.  The Kings Fund and Nuffield Foundation had produced evidence that these initiatives had worked.  GPs were being offered support from specialist colleagues to expand their expertise and also export their knowledge into the community.  The vanguard initiative was also a good process for testing different models of care without introducing them on a large scale until they had been proven to work.

h)           The STP plans were developed on the best available evidence and the proposals were adjusted in view of changing evidence.

i)             30,000 bed places had been taken out of the NHS system in recent years; which would have seemed impossible 20 years ago.  Advancements in medical procedures such as key-hole surgery, mothers having caesarean sections being discharged after a short stay instead of the traditional 10 day hospital stay and GPs carrying out minor surgical procedures had all contributed to reducing the need for hospital beds.

j)              There are insufficient capital funds nationally to fund all the capital projects in the 44 STP areas in the country, without the additional use of the capital funds through the PF2 initiative.  PF2 was designed to have the benefits of the previous PFI initiative in providing access to other funding sources through banks and financial institutions.  The less attractive elements of PFI, such as the high costs of finances and refinancing options have been taken out of the process.  PF2 funding was separated from the construction process as constructors quoted for building costs and then the financiers bid for opportunity to provide funding, with the Government taking a stake in the funding circle.  A new hospital build for Sandwell was a pioneer for PF2 and the finance costs were much less than had been projected.  PF2 was considered a better delivery vehicle for capital projects and it was designed to avoid Trusts becoming overstretched, as they did under PFI, and ending up in long term financial difficulty.

k)            The STP workforce plans were in the public domain and the system would spend more on people in different places and in different roles than at present.  Eventually there would be less spent in the acute sector and more in the community, primary care and social care sectors.

AGREED:-

1)         That the report be received and the officers be thanked for their responses. 

2)         That Commission cannot offer its views on the proposals until it has heard the views of public, patient groups and other interested community organisations at the meeting on 29 March 2017.

3)         That the Commission consider that transitional funds should be made available to improve, enhance and expand existing community services so they are operating at the levels required to cope with the current demands before considering further re-configurations of acute hospital services.

3)         That the Commission receive a briefing paper on the PF2 initiative and implications for funding capital project by this method, once UHL have been informed of whether their capital bids to NHS England have been successful.

5)         That copies of the workforce and financial plans be submitted to the Commission.