Independent report

IRP advice to the Minister of State for Health on the Dorset Clinical Services Review (accessible version)

Published 13 January 2020

Applies to England

1. Letter to the Minister of State for Health

Chris Skidmore MP
Minister of State for Health
39 Victoria Street
London
SW1H 0EU

30 August 2019

Thank you for forwarding copies of the referral letters and supporting documentation from Councillor Bill Pipe and Councillor Peter Shorland, Chair and Vice-Chair respectively, Dorset Health Scrutiny Committee (HSC). NHS England and NHS Improvement (South West) completed the Independent Reconfiguration Panel (IRP) information template. A list of all the documents received is at Appendix One. The IRP has undertaken an assessment in accordance with our agreed protocol for handling contested proposals for the reconfiguration of NHS services.

In considering any proposal for a substantial development or variation to health services, the Local Authority (Public Health and Wellbeing Boards and Health Scrutiny) Regulations 2013 require NHS bodies and local authorities to fulfil certain requirements before a report to the Secretary of State may be made. The IRP provides the advice below on the basis that the Department of Health and Social Care is satisfied the referral meets the requirements of the regulations.

The Panel considers each referral on its merits and concludes that, with further action locally, the proposals should proceed.

2. Background

Dorset is a largely rural county on the south coast of England with a population of just over 770,000, projected to grow to over 800,000 by 2023. Main population centres include Bournemouth (195,000), Poole (151,000), Weymouth and Portland (66,000), Christchurch (50,000) and Purbeck (47,000). Elsewhere some 102,000 people live in the west of the county, 89,000 in the east and 71,000 in the north. Overall, the resident population enjoys relatively good health though with variations in life expectancy of five to six years between those in the most affluent and deprived areas. The age profile is older than the England average with around 17 per cent of the population over 70 and growing.

Acute health care is provided by Royal Bournemouth & Christchurch Hospital Foundation Trust, Poole Hospital NHS Foundation Trust (approximately eight miles apart) and Dorset County Hospital Foundation Trust in Dorchester. Dorset HealthCare University NHS Foundation Trust provides community, mental health and other services. Ambulance services are provided by South Western Ambulance Service NHS Foundation Trust (SWASFT). Many services are commissioned by NHS Dorset Clinical Commissioning Group (CCG) alongside NHS England who commission specialised services and primary care.

In March 2014, following a period of public engagement, NHS Dorset CCG decided to initiate a clinical services review (CSR). Its purpose was to consider how health and care services could be improved across Dorset by addressing difficulties with staffing, the needs of a growing elderly population with increasingly complex conditions, variations in quality of care and a worsening financial position. The CSR was formally launched in October 2014 and over the following months clinicians, the public, patients and others from partner organisations were involved in working groups to design clinical models, advise about engagement and consultation, and provide assurance around finance.

In January 2015, the CCG published information setting out the need to change. To facilitate objective differentiation between the available options, six evaluation criteria were identified:

• the quality of care and patient safety
• access to services (travel)
• cost and affordability
• the impact on staff (workforce)
• whether the changes would be delivered within the required timescale (deliverability)
• other factors such as research and education

A range of proposals were drawn up around the following themes:

• care closer to home – locality hubs with or without community hospital beds
• maternity and paediatric services – creating a pan-Dorset service (potentially linked to services in Somerset)
• acute care – networked service incorporating a major emergency hospital and a major planned hospital in the east of Dorset along with a single emergency and planned hospital in the west of the county
• mental health services – looking at the acute care pathway

During March 2015, the Wessex Clinical Senate was engaged to peer review emerging clinical design and a Patient and Public Engagement Group made recommendations on consultation principles. Stage one assurance was received from NHS England in April 2015.

Dorset HSC had first been made aware of the intention to launch the CSR through a briefing paper provided to a meeting on 10 September 2014. A further briefing paper was presented to the HSC in November 2014. On 22 May 2015, the HSC received a report updating members on progress with the CSR. The Committee was asked to nominate members for a joint health scrutiny committee (JHSC) to be convened with Bournemouth Borough Council, Borough of Poole and Hampshire County Council to scrutinise the CSR and respond to a formal consultation.

The JHSC first convened on 20 July 2015 when it was agreed that each constituent body would retain its own right of referral. The meeting was provided with context for the CSR and heard broad proposals. Also in July 2015, the Wessex Clinical Senate submitted its report making 16 recommendations that were subsequently incorporated into a pre-consultation business case.

A series of engagement meetings with the Dorset Association of Parish and Town Councils began in September 2015. The HSC received briefing updates on progress at meetings on 8 September and 16 November 2015.

The JHSC meeting on 2 December 2015 received a revised timetable for the CSR. Members noted concerns about workforce and transport.

In March and April 2016, the Wessex Clinical Senate carried out a review of further work carried out and made recommendations for areas of development. Nine locality based Integrated Community Services engagement events were held between March and April 2016. A review of the CSR by the Royal College of Paediatrics and Child Health in April 2016 made a number of recommendations.

In June 2016, the JHSC received an update on progress, a meeting with NHS England concluded that the CSR could be partially assured subject to National Investment Committee approval and Integrated Community Services Roadshows were held in 27 locations.

Informal meetings between NHS officials and the JHSC were held on 14 July and 10 August 2016 to provide an outline of pre-consultation engagement on proposals for integrated community services and proposals for public consultation.

The Dorset Sustainability and Transformation Plan was launched in October 2016 building on the work of the CSR and outlining how the NHS five-year forward plan would be delivered. The JHSC received a report on proposals to go forward to NHS England for Stage two assurance and public consultation. Stage two assurance was confirmed in November 2016 following completion of work required by the NHSE Investment Committee and the CSR pre-consultation business case was published.

The CSR public consultation, ‘Improving Dorset’s healthcare’, began on 1 December 2016 running until 28 February 2017. Two options, having emerged from the clinical working groups and subjected to the agreed evaluation criteria, were put forward in respect of acute hospital services. Option A saw Poole Hospital as the major emergency hospital with Royal Bournemouth Hospital as the major planned care hospital and Dorset County Hospital as a planned and emergency care hospital. Under Option B, Poole Hospital would be a planned care hospital with Royal Bournemouth Hospital as the major emergency care hospital and Dorset County Hospital as a planned and emergency care hospital. Two options were proposed for maternity and paediatric services. Option A would see two centres – at the major emergency hospital in the east of Dorset and an integrated service across Dorset County Hospital and Yeovil District hospital for residents in the west of the county. Option B would see a single specialist centre at the site for the major emergency hospital in the east of Dorset.

Proposals for integrated community services aimed to support more people in the community as an alternative to major hospitals, increase the range of outpatient and therapy services in the community, create joined-up teams of health and social care staff, move towards seven day services available for longer hours, improve the use of community hospitals as community hubs and support the mental health acute pathway review running alongside the CSR.

A workshop was held on 20 February 2017 for Dorset HSC members to consider questions in the formal consultation in preparation for a JHSC meeting on 23 February 2017. Concerns were raised about finance, workforce capacity, potential loss of beds in community hospitals and the use of beds in care homes. On acute services, concerns were expressed about ambulance response times and the validity of travel time analysis. On maternity and paediatrics, HSC members opposed the loss of services in west Dorset but supported the proposal for an integrated service with Yeovil and Dorset County Hospital.

A collective response from the JHSC was submitted on 3 March 2017. It urged the NHS to take account of the concerns raised as it developed the proposals and sought reassurance on two key issues:

• that full and detailed financial modelling will be undertaken with all key partner agencies, particularly the Local Authorities, to ensure that the cost of proposals has been adequately established and that they are affordable and achievable for all partners
• that maternity and paediatric services will be maintained to serve the west Dorset area, in recognition of the genuine concerns that some Members have regarding travel times, should consultant-led maternity and paediatric services be based in Bournemouth in future

Consultation responses were independently analysed by Opinion Research Services and quality assured by the Consultation Institute. A report of the findings was published in May 2017. Additional work to address the concerns raised was undertaken during May and August 2017 including work on emergency and non-emergency travel times, equality impact assessments and clinical risk assurance. In July 2017, SWASFT published a report ‘Modelling the potential impact on the emergency ambulance service’. It identified a small net increase in requirement for emergency ambulance resource and recommended further work to refine both the activity modelling and the review of clinical risk. Dorset County Council’s review of non-emergency transport concluded that CSR travel times were within acceptable parameters. NHS England provide confirmation of capital support - later confirmed at £147 million.

At an informal meeting of the HSC on 1 August 2017 CCG representatives presented findings from consultations into the two reviews (CSR and the mental health acute care pathway) ahead of a JHSC meeting on 3 August 2017. The JHSC wrote to the CCG on 29 August 2017 highlighting areas for consideration and it was agreed these would be taken into account at the CCG Governing Body meeting on 20 September 2017.

The CCG published its decision-making business case in September 2017 ahead of a CCG Governing Body decision-making meeting on 20 September 2017. In all, 23 recommendations were approved including those about acute hospital services (Option B), maternity and paediatrics (Option A) and commissioning integrated community services closer to home, delivered through integrated community teams and local community hubs to deliver better care.

A meeting of the HSC on 13 November 2017 received an update report on the CCG’s response to the JHSC’s recommendations. The HSC resolved to refer the proposals to the Secretary of State subject to the outcome of a meeting of the JHSC on 12 December 2017, convened in response to concerns raised by the HSC. At its meeting, the JHSC received presentations from representatives of the CCG and local NHS providers. The JHSC voted not to support the HSC decision to refer, proposing instead that detailed scrutiny of emergency ambulance services be undertaken. The HSC met on 20 December 2017 and heard evidence from CCG representatives outlining the rationale for the decisions made. The Committee resolved not to refer but to continue the scrutiny of ambulance services and emergency transport.

On 8 March 2018, following an update report to the HSC, the Committee decided to establish a task and finish group to review existing and new evidence and determine criteria for making a referral in future. The HSC Task and Finish Group met on 1 May 2018 and agreed to adjourn until the outcome of a judicial review brought by a local resident was known. The HSC met on 15 June 2018 and decided that the Task and Finish Group should recommence its work. The Task and Finish Group met on 4 July 2018 to scope its remit and invite speakers to a meeting on 22 August 2018. Subsequently, 19 questions were submitted to local NHS bodies for discussion at a meeting on 18 September 2018 in which the Group, having heard further evidence, resolved to recommend to the HSC not to make a referral to the Secretary of State but to continue scrutinising the CSR and ambulance performance through the JHSC. The Task and Finish Group’s recommendation was reported to the HSC at a meeting on 17 October 2018. The HSC voted by a majority of six to four to submit a referral on two specific ‘elements’:

• concern that the travel times by South West Ambulance Service NHS Foundation Trust have not been satisfactorily scrutinised and that the evidence needs further investigation to the current claim that these travel times will not cause loss of life
• concern that there is no local alternative to the loss of community hospitals given Dorset’s demographic with its ageing population and how that service will be delivered

The HSC wrote to the Secretary of State on 5 November 2018 to refer the matter.

A motion for the Borough of Poole Health and Social Care Overview and Scrutiny Committee to refer the matter was defeated in December 2018. The Committee instead wrote to the Secretary of State on 4 January 2019 to support the referral made by Dorset HSC.

On 1 April 2019, following local government re-organisation, the nine councils that previously existed in Dorset were abolished and two new unitary councils – Dorset Council and Bournemouth, Christchurch & Poole Council – were created. Both of the new councils contain areas that formed part of the previous Dorset County Council and both, therefore, retain an interest in this referral.

An application to the Court of Appeal to consider permission to appeal the previous judicial review was heard on 24 July 2019. The Court’s judgment was handed down on 7 August 2019. The appellant was refused permission to appeal on all grounds.

3. Basis for referral

The HSC’s letter of 5 November 2018 states:

The decision to make a referral was made on 17 October 2018 in respect of Section 23 of the Local Authority (Public Health, Health and Wellbeing Board and Health Scrutiny) Regulations 2013, Section (9) (c) – that Dorset considers ‘that the proposal would not be in the interest of the health service in its area’.

4. IRP view

With regard to the referral by the Dorset HSC, the Panel notes that:

• the CSR has been the subject of detailed health scrutiny by an appropriately formed joint health scrutiny committee that decided not to refer
• the CCG separately and extensively responded to Dorset HSC before (against the recommendation of its own Task and Finish Group) the HSC decided to refer - more than a year after the CCG’s decisions
• this referral provides further evidence in support of reviewing current scrutiny guidance
• the two ‘elements’ of the CSR that are the subject of this referral were both covered by the original judicial review, the judgment of which was upheld by the Court of Appeal
• emergency ambulance provision under the proposals has been subject to much analysis and debate about the benefits of taking patients to the appropriate location for care over the possibility of added travel time
• the current pattern for community services is not fit for purpose – the case for care closer to home and for integrated community-based services is widely supported by those providing the services but a cause of concern to the local population

5. Advice

The Panel considers each referral on its merits and concludes that, with further action locally, the proposals should proceed.

5.1 Scrutiny

The IRP has commented previously on the process for establishing and operating joint health scrutiny committees. In this case, a joint health scrutiny committee was established by Dorset, Bournemouth, Poole and Hampshire Councils as the health body to be consulted on matters relating to the planning, provision and operation of the health services in the area under the Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013. The JHSC is the appropriate and only scrutiny body with which the CCG must consult on any proposals developed in respect of the Clinical Services Review. It is also the only body that the NHS is required to provide information to in these circumstances. The NHS in this instance made additional efforts to engage with the constituent scrutiny committees separately but ultimately still found that its decisions were the subject of referral to the Secretary of State by one of those constituent committees, namely Dorset HSC.

Both the JHSC and Dorset HSC resolved not to refer the proposals in December 2017 whilst committing to undertake further joint scrutiny of ambulance services and transport arrangements related to the changes. In the Panel’s view, the HSC’s subsequent change in position and referral in October 2018 cannot be explained by the evidence presented. They, with their joint scrutiny partners, had failed to do the further scrutiny relating directly to one of the two specific issues raised. The NHS engaged fully with the HSC’s own Task and Finish Group, providing further and new information in response to the questions raised by other parties, leading to a recommendation not to refer. The first court judgment was also available, providing information and analysis of the issues leading to a clear judgment in favour of the NHS.

The HSC has always acknowledged the case for change and agreed that the referral would be on two specific grounds and not on the entirety of the 23 decisions agreed by the CCG on 20 September 2017. The Panel is concerned that after four years of scrutiny, the HSC was either unable or unwilling to articulate a clear view on the NHS’s proposals or indeed put forward alternatives. As a consequence, valuable time and effort has been diverted from implementing and improving services.

While some of the events recorded in the background above are undoubtedly unique to the Dorset CSR, this case provides further evidence for reviewing the purpose and processes for scrutiny of health services. When revising its existing guidance on health scrutiny the Department may wish to consider the need for a review of the performance of joint committees to ensure that they are operating as originally intended. Revisions to guidance might also make clearer that a referral depends upon scrutiny taking a view on proposals and making purposeful effort to resolve differences of view with the local NHS.

5.2 Proposals not in the interests of the health service

The Panel notes that the two ‘elements’ of the CSR which the HSC chose to highlight in its referral were covered in some detail by both the original judicial review and by the Court of Appeal and the context provided by these proceedings is certainly unique in the IRP’s experience of advising on health service change. However, referral to the Secretary of State and judicial review are entirely separate processes and the Panel has always been clear that it does not advise on matters that are for lawyers and the courts but rather considers each case on its merits, in line with our general terms of reference.

Emergency ambulance services provision and performance are integral to these proposals and the potential impact of increased travel time on outcomes for some cases has been the subject of much analysis, review and debate. From a respectably sized survey sample which showed most patients will experience shorter travel times or no change, concern has been focused on the possibility that for a very small proportion of cases (around 0.6 per cent) extended travel may present a risk. Having considered all the evidence presented to it carefully, including the retrospective clinical case review, the Panel was not persuaded by the assertion that worse outcomes would likely result from the longer emergency ambulance travel time.

Further, one of the central purposes of the proposals is to improve the quality of care once a patient has been delivered to hospital. The Panel recognises that the benefits of patients being taken to the appropriate place for the right care has yet to be fully appreciated by the public who, understandably, see the possibility of added journey time to the place of care as a potential risk factor. This is to underestimate the quality of care that can nowadays be provided by paramedic ambulance crews in stabilising and treating patients before transferring them directly to the best location for the next stage of their care and expert management.

Providing any health service, but especially those that concern urgent and emergency care, involves clinical risks that need to be monitored and managed. As the proposed changes to services are introduced incrementally over the next five years, open dialogue with interested parties about the issues to be addressed will contribute to building confidence.

The case for care closer to home and vision for integrated community-based services is well developed and has been widely supported. The current pattern of services is not fit for purpose in terms of staffing, facilities and geographical distribution. This is recognized by those who work in them and they have been instrumental in developing and designing the new model and related proposals.

The Panel agree that the ambition, model and approach are critical for the future and the CCG’s proposals offer a strong platform to both resolve current issues and meet future needs. However, latterly the message about what is intended and how it will be delivered seems to have been lost. Patients and the public reasonably want to know what their local services are and that their needs will continue to be met through these proposals. There is a clear narrative to be told about the outcome of consultation, incremental changes to services and new investment, including an overall increase in bed capacity. The IRP understands that translating high level proposals into detailed changes on the ground takes time and is subject to variation and iteration. Engaging the two recently formed local authorities as partners responsible for social care and the users of local services will be critical to making progress.

6. Conclusion

These proposals have been developed over a long period of time and command the confidence of local clinicians who have been leading their development. The approach is comprehensive and changes to services will be incremental and carefully considered with any new risks identified and mitigated. The Panel considers that the proposals are in the interest of local health services, will improve outcomes and that the five tests have been met.

All parties must engage constructively in the future development of health services. That there remain issues and matters of local concern is to be expected but there is an opportunity now to inject new vigour into progressing the proposals to the next phase of implementation.

That phase should involve greater co-production between interested parties than has hitherto been evident, not least in identifying the best ways of explaining to local people the rationale behind the changes and how they can influence the development of services. Those interested parties should include all arms of the NHS, local government for the area in its new guise as well as local Healthwatch and public and patient groups. In this regard, the Panel was struck, despite their evident interest, by the apparent lack of involvement to date of the Dorset Defend the NHS Residents Group in the development of proposals. Whatever the reasons behind this, it is to be hoped that a more constructive relationship can be built going forward.

Your predecessor, in his commissioning letter, asked the Panel to consider the potential relevance of the development of an ‘A&E Local model’ as referred to in the NHS Long Term Plan. NHS England and NHS Improvement advised the Panel that, within the urgent and emergency transformation programme, work is underway on what might be a viable model between the standard urgent treatment centre and a conventional district general hospital A&E. The work is looking to build on what is already being considered in front line services, bringing clinical expertise and design together to explore options. No doubt, the NHS locally will wish to keep abreast of developments in this sphere as new thinking emerges nationally.

Yours sincerely,
Lord Ribeiro CBE
Chairman, IRP

7. Appendix One - list of documents received

7.1 Dorset HSC

1. Referral letter to Secretary of State from councillors Bill Pipe and Peter Shorland, Chair and Vice-Chair, Dorset HSC, 5 November 2019

Attachments:

1. Referral document

2. Appendix 1 – Links to agenda papers and minutes for Dorset HSC, Joint HOSC and Task and Finish Group

3. Appendix 2 – Response of Joint HOSC to the consultation

4. Appendix 3 – Letter from Joint HOSC in response to outcomes of consultations on CSR and MH ACP

5. Appendix 4 – letter from CCG in response to letter from Joint HOSC, 29 August 2018

6. Appendix 5 – Evidence provided to Dorset HSC Task and Finish Group by invited representatives, 22 August 2018

7. Appendix 6 – CCG and Trusts responses to 19 questions submitted by T&FG

8. Appendix 7 – Letter to Chief Officer, NHS Dorset CCG re intention to refer, 23 October 2018

7.2 NHS

1. IRP template for providing assessment information with embedded documents

Attachments:

1. Dorset Clinical Services Senate Council Report

2. Pre-Consultation Business Case (PCBC)

3. PCBC appendix A

4. PCBC appendices B, C, D, I, N, O

5. PCBC appendix E

6. PCBC appendix F

7. PCBC appendix G

8. PCBC appendix H

9. PCBC appendix J

10. PCBC appendix K

11. PCBC appendix L

12. PCBC appendix M

13. PCBC appendix P

14. PCBC appendix Q

15. Clinical Services Review (CSR) Consultation Document

16. Consultation Institute Document re good practice

17. Consultation Institute Document re best practice

18. ORS Document on consultation findings

19. ORS report of findings

20. ORS summary report of findings

21. CSR Decision Making Business Case (DMBC)

22. CSR DMBC appendices

23. NHS England letter of stage one assurance

24. Dorset CSR Gateway report

25. NHS England letter approving progression to consultation

26. CCG Governing Body (GB) approval to proceed to consultation

27. GB decision to delay proceeding to consultation

28. GB approval of acute hospital site specific consultation options, 18 May 2016

29. GB approval of community site specific consultation options, 20 July 2016

30. GB approval of recommended CSR options, 20 September 2017

31. GB special minutes, 20 September 2017

32. Judicial Review judgment (full)

33. Judicial Review judgment (summary)

34. Debby Flemming witness statement

35. Patient Benefits PBC lite v4

36. South West Ambulance Service Foundation Trust (SWAST) report, September 2017

37. SWAST Clinical Risk Review Outcome, December 2018

38. SWAST Clinical Risk Review Data, December 2018

39. Stroke Transformation Plan FBC, 2019

40. Community Beds data, August 2019

7.3 Other evidence

1. Letter to Dorset HSC from Richard Drax, MP for South Dorset, 16 October 2018

2. Borough of Poole letter to Secretary of State for Health and Social Care, 4 January 2019

3. Borough of Poole appendix A - Future of Poole Hospital presentation

4. Borough of Poole appendix B – Public questions and responses by local NHS partners

5. Borough of Poole appendix C – summary of supplementary questions and responses

6. Borough of Poole POSC minutes of special meeting, 17 December 2017

7. Hinsull v Dorset CCG judgment

8. Hunsull v Dorset CCG summary

9. Hinsull permission to appeal

10. Capsticks appeal outcome letter to CCG, 24 July 2019

11. Hinsull order

12. Hunsull judgment for Hand Down

13. Defend Dorset NHS Residents Group (DDNHS) submission to IRP, 5 August 2019

14. Covering emails to submission to IRP from DDNHS, 15 November 2018

15. Referral letter, 5 November 2018

16. DDNHS Index and appendices to submission

17. DDNHS Our Case

18. DDNHS CCG cumbers at potential harm

19. DDNHS likely fatalities from SWAST report

20. DDNHS Poole A&E Freedom of Information request

21. DDNHS Poole Maternity Freedom of Information request

22. DDNHS Royal Bournemouth hospital Freedom of Information request

23. DDNHS Environment Agency re Link Road

24. DDNHS CCG presentation to Poole Council, 29 November 2017

25. DDNHS Langton Freedom of Information request pt1

26. DDNHS Langton Freedom of Information request pt2

27. DDNHS A&E consultant of patient safety

28. DDNHS community hospital beds

29. DDNHS Why the CCG plan will fail

30. DDNHS letter to Secretary of State, 27 November 2018

31. DDNHS Poole A&E Freedom of Information request pt1

32. DDNHS CCG numbers at potential harm

33. DDNHS letter, 11 January 2019

34. DDNHS additional information, 24 August 2019

35. Documents provided by Gerald Rigler (GMR)

36. GMR A338 hospital access

37. GMR request to MP

38. Philip Jordan (PJ) email to Secretary of State, 8 January 2019

39. PJ communication to help CCG decisions, 20 September 2017

40. PJ questions for CCG Board meeting, 20 September 2017

41. PJ Referral letter from Dorset HSC to Secretary of State, 5 November 2018

42. PJ referral to Secretary of state from Dorset HSC, November 2018

43. PJ appendices 1 to 5 referral to Secretary of State from Dorset HSC, November 2018

44. PJ appendix 6 referral to Secretary of State from Dorset HSC, November 2018

45. PJ appendix 7 referral to Secretary of State from Dorset HSC, November 2018

46. PJ Conclusion to be read with 30 August 2017 communication, 12 September 2017

47. PJ Governing Body public questions, 21 January 2015

48. PJ Document 4 specification, 18 May 2015

49. PJ draft notes re meeting, 17 August 2017

50. PJ Page 7 of 8 Need to Change

51. PJ Please postpone CSR decisions, 20 September 2017

52. PJ DHC travel survey