Members will receive a presentation update on the UHL Acute and Maternity Reconfiguration Consultation Results.
Background papers, (Consultation findings and Decision-Making Business Case for the UHL Reconfiguration) have already been published and can be found at the following link:
The Chair explained that a presentation would be received and taken in four subject areas with questions from the public to be taken under the relevant subject area followed by any questions from committee members.
Sara Prema, Leicester City CCG, presented the first subject area and outlined the consultation process and how that was undertaken, this included details of the range of media used such as social media: Instagram, snapchat, twitter as well as live events and the information gathered. Details were also given of the “reach” of the consultation using digital, print and broadcast methods and the work undertaken to engage people of all demographics across Leicester, Leicestershire and Rutland (LLR).
The Chair interposed questions from members of the public and invited officers to provide responses:
The Chair on behalf of Jean Burbridge asked: Following the Building Better Hospitals for the Future consultation, who are the patient representatives who were involved in reviewing the public feedback? In what ways are they representative?
Richard Morris, Leicester City CCG responded that the feedback received through the consultation was independently analysed and evaluated by Midlands and Lancashire Commissioning Support Unit, who produced the Consultation Report of Findings. The Report of Findings was then reviewed by the Public and Patient Involvement Assurance Group for Leicester, Leicestershire, and Rutland. It was not their role to approve the proposals that were being consulted upon. ACTION: Officers agreed to provide a full written answer in due course.
Sally Ruane on behalf of Sarah Patel asked: How does the profile of respondents in terms of a) ethnicity and b) deprivation match that of the population as a whole, taking Leicester, Leicestershire and Rutland each in turn?
Richard Morris replied that all details regarding profile were set out in detail in the report of findings which showed the people who participated in the consultation were statistically representative of the LLR population and endorsed through the Equality Impact Assessment.
Sally Ruane clarified that the question was about how the profile of respondents matched or did not match the profile of the area in terms of the broader population of Leicester, Leicestershire, and Rutland.
Richard Morris explained how the level of responses were reflective of LLR and the findings showed that of the responses received 46% were from Leicestershire, 26% were from Leicester city, and 6% were from Rutland, 28% of responders provided no post code or asked not to be profiled. There were various category breakdowns as an example there was a breakdown by age, this showed typically higher levels of engagement with people over 45 years old but there was another piece of work carried out with voluntary groups to engage with younger people between 25-34 years, this category represented 11.8% of the population, in terms of responses 16.4% of Leicester city replies were within this age category showing a fair representation of that age group. In relation to male/female by and large this was 50/50 across LLR, in terms of consultation responses it was found more women participated with 72% of responses being from women. Regarding ethnicity for example 78.4% of the population of LLR was white and 81.1% of respondents identified as white so again reflective of the population, the same was also found with other demographic profiles. ACTION: Officers agreed to provide that data in a written response with the benchmarks.
Sally Ruane asked: What changes have been made to the Building Better Hospitals for the Future proposals following public, not clinical feedback?
Richard Morris replied that it was important to note they were trying to achieve a statutory duty and to have a broad demographic view and to meet equality requirements a view was taken with certain voluntary organisations. The CCG looked at several areas across the country who used similar models successfully and decided to use the same model.
Sally Ruane set out her next questions about the use of an "impartiality clause" used by the CCGs during the consultation process which would have had the effect of stifling the expression of points of view at odds with those of the CCGs. Via a Service level agreement with an impartiality clause, the CCGs commissioned and remunerated organisations to undertake engagement with people as “supporters” of the consultation exercise. However, the impartiality clause obstructed the ability of these organisations to inform their members (or those they engaged with) of any concerns they had about the proposals and it obstructed the ability of these organisations to draw on independent sources or their own body of knowledge in responding to members’/followers’ questions. The Impartiality clause stated, “Organisations are not expected to express views or opinions on the consultation when engaging with their communities …and all queries and questions should be signposted to official literature or NHS leads”.
It appears, therefore, that these organisations far from being impartial, could be said to be the voice of the CCGs, able only to point people to the official
literature so providing them with a single, very particular narrative.
1. I would like to know if this practice is legal.
2. I would like to know if this is seen as good practice and what dangers
were considered in deciding to proceed with these agreements.
3. Are the CCGs able to tell us what steps they took to ensure that
organisations under contract informed their members/followers in any
engagement they (the organisations) had with their members/followers
that they were working under a service level agreement which contained
an ‘impartiality clause’.
4. How many of the 5,675 responses to the consultation were as a result of
Richard Morris indicated the purpose of the clause was to protect the voluntary and community organisations that were agreeing to promote the consultation to their communities. The clause ensured that they could freely state the organisations views on the proposals and gave them impartiality to be neutral. ACTION: Officers agreed to provide a full written response that would cite the impartiality clause in full.
Sally Ruane in supplementary response suggested the impartiality clause prevented those organisations from expressing any concerns they may have and expressed concern that this practice was unlawful.
Richard Morris assured that none of those participating was barred from making their own or an organisational response to the consultation and of the total responses received to the consultation approx. 600 came through this route.
Jennifer Fenelon on behalf of Rutland Health & Social Care Policy Consortium (RHSCPC) asked: We are told approximately £260,000 was spent on consultation by LLR CCGs. The people of Rutland submitted many comments and proposals to mitigate the impact of moving acute services from East to West and consequent increased complexity of journeys and increased travel times making access to services more difficult. The summary of decisions
published on 26th June offers no clarity on how services will be delivered closer to home to mitigate these problems. Can the CCG explain why there are none?
Sara Prema responded that the CCG were working to improve place led services and developing that in several ways, with the Health & Wellbeing Board, through Rutland partners and other stakeholders. Many community services were already delivered and that was being built upon and would be refined.
Jennifer Fenelon in supplementary commented that the CCG had an obligation to look at communities and groups. The Rutland Health & Social Care Policy Consortium had submitted a large document that included 26 points made and that had not been responded to.
Sara Prema replied that some of those points had been picked up as pledges within the business case. ACTION: Officers to provide response to the 26 points suggested.
The Chair invited comments from members and the ensuing discussion included the following points:
· Regarding any potential conflict of interest with the impartiality clause it was clarified that all activity undertaken was designed to meet the equality duty. CCG were keen not to rely on just one tool and to give people the chance to take part in the consultation. The total cost of the consultation was £260,000 and a significant portion of that was spent on the analysis and findings of Midlands and Lancashire Commissioning Support Unit. Typically, £2-3k was given to 18 organisations. ACTION: Officers agreed to provide breakdown of cost to each organisation.
· None of the voluntary organisations engaged in the consultation were coerced in any way to take part, there was no preferential treatment and those organisations were just as challenging in public meetings as they should be.
· In terms of how far they had exercised their duty to assess the impact on various communities and identify negative impacts it was explained that Equality Impact Assessments (EIA) were undertaken and are included within the business case, these were held up as an example of very good equality impact assessments. A post EIA on the consultation was also undertaken which is included in the appendices of the business case.
· Concerns were expressed that despite taking part in consultation events answers to questions raised there had still not been provided and there was delay in providing responses. ACTION: Officers to provide response to the questions raised by Councillor King at recent public meetings.
· In relation to concerns that the consultation was undertaken during the pandemic it was found that more people were taking part than would normally engage, the reasons for that were tested that out and many said it was because they had more time on their hands. As to whether their responses outside of a pandemic would have been any different, it was always a challenge and can’t answer definitively if those responses would have been different but there was monitoring and content with responses and qualitative responses being received.
· Overall responses from Rutland compared to the population of the City and County seemed low and concern was raised that this was such a small response. In answer it was stated that overall population of Rutland was 4% of the City/County yet 6% of responses were from people that declared themselves to be from Rutland, so it was felt to be fairly representative. In terms of overall response rates, it was uncertain what a definition of a good response rate is as every consultation is different. However, nationally 1-2% was good but more emotive subjects achieved higher response rates. The Chair expressed interest in seeing figures of overall responses. ACTION: Officers to provide various breakdowns of overall responses outside this meeting.
· In relation to general digital exclusion, from the outset the CCG were aware of the risk of digital exclusion and determined not just to consult online, a lot of work was done through radio and publicity materials and in other languages too. Materials were handed out in villages/local areas and shops. All virtual meetings were set up to have access to dial in by phone if someone was unable to link in and there was also put in place a dedicated phone line to help people complete the consultation survey that way.
· There were in region of 90,000 visiting the website and there were a lot of views as to why there were only maximum 5-6k responses. It was felt that this has been a dialogue going on over a decade, a lot of people looked at the proposals on the website and where they were generally in agreement with proposals, they didn’t feel need to complete the survey. It was suggested that there was a tendency to find those that do respond have a particular view on proposals.
Sara Prema then moved to the second subject area and outlined the process for considering feedback from the consultation and the consultation outcomes noting that 58% of respondents agreed with the proposals.
· During the consultation people wanted to understand the impact of Covid on plans and whether services would be future proofed by releasing some of the Leicester General Hospital site.
· A Travel Action Plan had been developed to support the reconfiguration in conjunction with the Local Authority’s this would include improvements to the bus and hopper routes, increasing park and ride facilities, increasing parking at LRI and Glenfield and improving sustainable travel options.
· The rationale behind the speciality changes in location proposals and the DMBC decision.
· A review was undertaken by clinicians into the impact of Covid which found that if the changes had been in place before the pandemic, they would have managed the pandemic better.
· An analysis of developable land post reconfiguration showed there would be 25 acres of developable space so there would be scope for further development should this be needed in future although it was difficult to say what may happen in terms of medical advancements in 10-15 years’ time.
· In relation to the new treatment centre, 60% of respondents agreed with the proposal. The clinical case set out in the pre-consultation business case and the review of proposals post Covid set out the advantages of separating elective and emergency care.
· The outcomes in relation to the proposals including use of new technologies; new haemodialysis treatment units; hydrotherapy pools and a children’s hospital that would include a consolidated children’s intensive care unit, co-located with maternity service.
· Leicester was one of a few areas without a dedicated children’s hospital although it provided one of the biggest services for children across the East Midlands.
· The LRI was chosen as the site for a dedicated children’s hospital as it had the children’s emergency department and from 2021 it would be the home of children’s congenital heart services (CHD). Part of the requirement for continued delivery of CHD services was the formation of a children’s hospital.
Public questions on this subject area were then taken as follows:
Sally Ruane on behalf of Godfrey Jennings asked: If adequate additional Public Dividend Capital (PDC) is not forthcoming, which elements of the scheme are you likely to alter? (p25 of the DMBC “Whilst the original funding of £450m PDC has been identified, in the event that further PDC funding is not made available to fund the additional national policy changes such as the requirement for New Zero Carbon and Digital, then the scope of the scheme will be reviewed again
in order to fit the budget available.”)
The Chair on behalf of Lorraine Shilcock asked: 1. What is the meaning of the following statement on p25 of the Decision- Making Business Case? “However, work is ongoing with the New Hospital Programme to agree the scope of inclusion in the programme, and the potential sources of capital.”
2. Which proposals/services do you plan to cut if the necessary finances
are not forthcoming?
Mark Wightman, UHL Leicester, replied in respect of patients accessing services that of 100% of people 30% would have a slightly longer journey time because of the reconfiguration.
Nicky Topham, UHL Leicester responded to the questions as a whole and outlined the survey findings, noting that when the process started the CCG/UHL were clear that £450m would deliver the scope of services in the business case but what had changed was that any policy changes such as around carbon emissions or digital requirements would have to be factored too.
The Chair questioned the difference between scope and services, and queried, if ambitious environmental efficiency targets were set then what would give in terms of scope or services?
Nicky Topham clarified that the £450m would provide for the move of the clinical services across the three sites and enable delivery of a high quality building. It was the net zero carbon in terms of the scope of the building being discussed, not about clinical services included in the programme.
Mark Wightman explained that the reconfiguration was covered by the £450m but there had to be consideration if the expectation of the modern building requirement changed, this was part of a series of steps in the process. The overall scheme was a solution with a series of interconnected components.
The Chair commented that concerns were not allayed by the response and expressed concern that there was not sufficient reassurance.
Mark Wightman acknowledged these were valid questions and that concerns could not be fully allayed other than to say there was still a way to go in the process to reach a full business case and full business case approval. The project was however based on a thorough understanding of clinical strategy and parts of that could not be dismantled.
Andy Williams, CCG Leicester, Leicestershire and Rutland, confirmed the reconfiguration proposals had been agreed as a package in their entirety but in approval terms each scheme would have to be planned and implemented individually.
Jennifer Fenelon on behalf of RHSCPC put that: The CCGs have refused to say how alternative services will be funded where patients are unable to access the new facilities (They estimated this to be about 30% of patients in the PCBC). The consequences of this will result in more patients accessing services outside Leicester, Leicestershire and Rutland. As the CCGs will have to meet these costs can they supply the cash flow estimates for this work which will relocate
elsewhere as a result of Reconfiguration? ACTION: Officers to provide figures in writing outside the meeting to this question.
During the ensuing discussion the following points were noted:
Concerns were raised about the UHL Financial arrangements, deficit budget and whether that would impact on service delivery. It was advised that the £450m was capital funding which was a separate allocation of funding although the revenue consequences of that had to be managed locally. The rationale was that efficiencies come from managing the estate more effectively and so reducing estate was another way of achieving that. Regarding the deficit position LRI was currently spending more than allocated. Recovering the deficit required achieving certain levels of efficiency. The second issue to address was the imbalance as a system, to readdress that and optimise by moving secondary care business into primary services. It was expected over time growth will gradually close the gap. Assurance was given that there was no decreasing budget and there was no loan of money, the UHL were authorised to pull down a certain amount of budget each year. The financial recovery plan was to close the gap between the agreed budget total the treasury would like the hospital to live within.
The Chair drew discussion back to the agenda and advised that a separate discussion on the UHL financial arrangements and deficit would be arranged outside this meeting.
Andy Williams agreed to provide a level of detail in terms of the emerging strategy and patterns of activity and how that would develop over next few years in relation to primary care for a future discussion.
Discussion progressed onto the Travel Action Plan, concerns about accessibility to service/hospitals from rural communities and included queries about carbon emissions and environmental impacts.
Councillor Harvey on behalf of Dr Janet Underwood, Healthwatch put: The UHL reconfiguration plans were discussed and agreed at the CCG governing body meeting on 8th June 2021. However, the Chair of the CCG governing body noted the increased inequalities in accessing health care for those living in rural communities; especially in the east of the city.
The UHL Travel Plan creates improved and environmentally sustainable travel around and within the city but no mention of improved travel facilities or better accommodation of the needs of those who live in rural areas.
Healthwatch Rutland asks what plans, other than a trial park and ride for just 80 cars at Leicester General Hospital, UHL, working with partners in the Integrated Care System, they have to mitigate these inequalities?
Responding to points made about taking into account any potential increase in carbon emissions caused by more people travelling from rural areas it was recognised that the LRI was in a central position and the plan was to take up to 35% of activity off the LRI site to Glenfield so that would improve the impact of pollution around LRI. Officers agreed to share details of the BREEAM sustainability assessment.
Despite the Travel Action Plan, it was suggested that some would face difficult journeys, congested roads and junctions, and lengthy bus journeys so people would not be discouraged from using their cars if they have one. Public transport was not always a viable option particularly in more rural areas and it was noted that the Travel Action Plan did not go beyond the city borders although considerable engagement had taken place with groups to inform the travel plan, this included with patients, partners, local authorities, bus and train operators and did included Healthwatch too.
Responding to concerns about the number of car parking spaces in the proposals it was clarified that this was not a total of 300 spaces but 300 additional spaces to the Glenfield and LRI sites.
The CCG acknowledged that travel was a difficult issue to address as it went to wider infrastructure issues outside of UHL/CCG control. The CCG had tried to set proposals that disadvantaged as few people as possible. It was asserted that the reconfiguration proposals overall, either make no or little difference, or would be better for the vast majority of people across LLR. Everyone would get qualitative benefits and the CCG were trying to mitigate the downside of centralising services and continuing to develop other services such as the community hospital. The wider issue relating to rural infrastructure was a bigger question than the UHL/CCG could address but with the reconfiguration proposals for the hospitals the UHL/CCG were trying to get the best result they could.
In relation to the speciality changes around ophthalmology and any effect of moving their location it was confirmed that lower acuity eye problems were dealt with at Rutland and other ophthalmology issues at LRI and that would not change.
Regarding paediatric outpatients’ services, most children’s outpatient services would continue at LRI although there would be some services exported into the community.
The dedicated children’s hospital would be developed through the refurbishment of the Kensington Building, this was considered an elegant solution given that the CCG were not able to say, “money is no object”. In August 2021 the first stage to move children’s services from Glenfield to Kensington would begin and progress on that transition could be shared with members.
The Chair moved the meeting on to the next subject area and Sara Prema presented details of the proposal to create a primary care urgent treatment centre at Leicester General Hospital site and the consultation outcomes around that.
The Chair referred to questions received from the public and on behalf of Giuliana Foster asked: What are the estimated costs of the primary care urgent treatment centre and other community services planned for the site of the Leicester General Hospital and where will these funds come from?
Jennifer Fenelon on behalf of RHSCPC put that: Any attempt to clarify with the CCGs how much capital and revenue has been allocated to community services has not been answered on the grounds that only UHL acute capital is being considered. We were, therefore pleased the June CCGs Extraordinary Board Meeting approved “creating a primary care urgent treatment centre at Leicester General Hospital site and scope further detail on proposals for
developing services at the centre based upon feedback and further engagement with the public.” Can the CCG explain why proposals did
not also included community services for residents across LLR which
are needed as a consequence of reconfiguration?
Responding to both questions’ it was advised that the consultation dealt with the proposals outlined in the Pre Consultation Business Case, which included the future of the Leicester General Hospital campus.
The ongoing work to improve community services for residents across Leicester, Leicestershire, and Rutland to provide more care closer to home was part of separate and ongoing work around a number of key programmes. This included the Better Care Fund (a programme that supports local systems to successfully deliver the integration of health and social care in a way that supports person-centred care, sustainability and better outcomes for people and carers), Ageing Well (an NHS programme to support people to Age Well) and Place-Led Plans. Improvement work would be funded through a mixture of funds available to the NHS e.g. baseline commissioning budgets and through the Ageing Well programme.
The Chair commented that there had been some concern about the publicity used for the General Hospital site proposals, in particular the image portraying what the centre may look like.
Sara Prema answered that there was public support for the primary care urgent treatment centre and the CCG were keen to do it as it would relieve pressure on services elsewhere and was in line with National policy. There were no circumstances envisaged in which the primary care urgent treatment centre would not be delivered as it was part of the overall package although the CCG cannot say it would look exactly as the artist impression used but there was a firm intention to have a primary care facility at that site.
With regard to land at the General being sold off because there was land available at Glenfield for expansion in future, and the suggestion that the General Hospital could be used post pandemic to address backlogs and waiting times, members were reminded that during the 1st phase of the pandemic Nightingale hospitals were set up but not put into use as they couldn’t be staffed. This situation was similar, although currently the General Hospital could be used, longer term there would be the issue of spreading staff too thinly across the sites and the reconfiguration was about getting the most out of the facilities in the future and the staff resources too. In terms of backlogs, UHL/CCG were hopeful those would not take too long to address, whereas this reconfiguration programme was not due to complete until 2027.
The CCG said they were committed to continuing an ongoing dialogue with communities on the further scope of primary care and what the end process would look like. The next step was to take that conversation out of the consultation process and move to informal discussions with communities.
In relation to the hydrotherapy proposal to move to community facilities it was explained that when scoping this proposal, the CCG did a piece of work to look at existing facilities and created a list of those. The list would need to be reviewed to ensure facilities would remain available into the future and each facility would be assessed to strict criteria including looking at issues of safeguarding and accessibility to determine which could be used. In due course that list of hydrotherapy services could be shared with members.
It was noted that there was a general perception and fear within some communities that services could be lost, and the CCG sought to assure that they were doing their best to do what was needed for all patients.
There was further discussion regarding developable land, its commercial value and whether there was a link between the Community Infrastructure Levy (CIL) and Section 106 funding to this for the primary care unit. It was noted that the Hospital Close site had been acquired by the City Council and the reference within the presentation to £16m was for the main General site. The CCG advised that in relation to any large housing development the CCG would put in an application for developer contributions if there was any impact on primary care, no differently to if there were large developments in other parts of the county.
Discussion then moved on to the final subject area and Sara Prema presented the proposals and outcomes in relation to the new maternity hospital, breastfeeding services and the standalone midwifery led unit.
It was noted that the decision regarding maternity services sat within the ongoing strategic improvement work across maternity care. It had also been established that the standalone midwifery led unit could not be assessed in one year and that would take longer with a commitment to assess over 3 years.
The Chair referred to questions submitted by members of the public and read Giuliana Foster’s question: “You set out the estimated capital costs of the various parts of the proposals on pages 23 and 113 of the DMBC but these do not include the estimated capital costs for the freestanding midwife led unit on the site of Leicester General Hospital. What are the estimated costs for
both the trial and the ongoing existence of the unit and where will these
funds come from?
Sara Prema replied that the capital figure of £450m for the reconfiguration project included the cost of the standalone midwifery led unit which would cost in estimate circa £1m.
Sally Ruane on behalf of Brenda Worrall asked: Why has a target of births of 500 been set when this is larger than all other Free Standing Midwife led units (FMUs) in the country. Is the FMU being set up to fail?
Ian Scudamore, Director of Women’s & Children’s Services UHL, responded that the target was based on the point of viability and explained how it was recognised by organisations providing obstetric and maternity services that for a standalone unit to be sustainable long term and financially viable there needed to be around 500 births a year and it was therefore appropriate to have a target of 500.
The Chair enquired whether there was a need to have 500 births to deliver a quality clinical service? Ian Scudamore replied that the standalone unit would be a midwife led service and would not provide any different clinical service from a home birth service or an alongside birth service. In practical terms there would be the same services across all four settings and in those terms more resource. Financial viability however was achieved at 500 births.
Sally Ruane in a supplementary comment expressed concern that there was the perception that there was no real commitment to the standalone unit.
Ian Scudamore confirmed there was an absolute guarantee that UHL and the local health care community were committed to providing maternity health care options across LLR and to provide the four NICE options for maternity care but there needed to be the numbers to make it sustainable and so it needed to be located in a place where more people could use it.
Floretta Cox, Community Midwifery Matron UHL, commented that Leicester was the first to create the home alone service however the birth rate at St Mary’s was not as high as they would like it to be and that was because of its location. There was a dedicated home birth team already in place and they supported St Mary’s at night. It was expected that the St Marys staff would be used at the new standalone unit and the unit could also be used for pre-natal services too which was something that women wanted.
Andy Williams commented that the CCG motivation was to ensure a positive future for this birthing option across LLR, trying to locate it and support it to ensure its future as part of the maternity services landscape but there was a need to balance the resource that’s committed and provide a genuine option for women.
The ensuing discussion with members included the following points:
· In relation to community services and breastfeeding levels in the community and the funding around that, Sure Start centres were dependent upon local authority funding, current services provided included liaison in homes, peer support and the CGG were looking to employ more community support workers.
· The standalone midwife led unit would be co-located with LRI, this would provide bigger and better facilities including a pool in every delivery room which more women preferred as an option for analgesia. Community midwives would stay in the community, so for example Melton midwives would continue to be based in local communities and at GP surgeries. The plan was that staff at St Mary’s would be relocated to the new unit although those staff would all be given options.
· Returning to the issue of viability it was confirmed there was a commitment to develop a framework to assess the financial viability of the standalone midwife led unit and that would be done with those who had a vested interest in maternity services and meeting maternity care needs.
· In terms of current and projected birth rates across LLR and the percentage needed at the unit it was advised that often women choose a maternity service based on experience or word of mouth. There were currently 10,000 women delivering in UHL, 2000 chose to deliver outside LLR and of those 2,500 were at co-located birth centres. A target of 500 therefore equated to about 5% of the current level of births needed to migrate to the unit.
· It was noted that the co-located design work could begin at any time, but the changes would not be enacted immediately. The process of talking to groups would be started and a piece of work undertaken to see what the co-located design may look like and the time frames, this could then be brought to a future meeting. The difference at the General will be that it is totally midwife led but if there was an emergency they would be transferred to the LRI and that journey would be a lot shorter and thereby quicker than from St Mary’s so more women may choose it.
The Chair thanked officers for their responses and commitments given during the meeting and asked to be kept informed of progress.
1. That CCG/UHL officers provide full written responses/information to the actions set out in the body of the minutes of the meeting, as soon as possible.
2. That CCG officers provide a level of detail in terms of the emerging strategy and patterns of activity and how that would develop over the next few years in relation to primary care for a future discussion.
3. That a progress report on the first stage to move children’s services from Glenfield to Kensington and transition be provided for the next meeting.
4. That a list of hydrotherapy services be shared with members in due course.