Independent report

Final IRP advice to the Secretary of State on Shrewsbury and Telford acute services (accessible version)

Published 3 October 2019

Applies to England

The Right Honourable Matt Hancock MP
Secretary of State for Health and Social Care
39 Victoria Street
London
SW1H 0EU

31 July 2019

Dear Secretary of State,

Further to my letter of 31 May 2019, in which the Independent Reconfiguration Panel (IRP) provided interim advice on the above, I write now to offer the Panel’s final advice.

In summary, subject to the recommendations made below, the Panel’s view is that the proposal to establish a single emergency centre at Royal Shrewsbury Hospital with a full range of complementary services at Princess Royal Hospital, Telford, is in the interests of health services in Shropshire, Telford and Wrekin and should proceed without further delay.

Background

Our remit

The Secretary of State first wrote to the IRP to commission advice on 22 March 2019.

The Panel was asked to advise:

1. whether consultation with Telford and Wrekin & Council was procedurally correct and/or functionally adequate: and if not, then what could be done to improve this
2. whether the proposals are in the interest of local health services
3. whether the proposals meet the five reconfiguration tests
4. what could have been done differently by local organisations to avoid a referral at the end of a multi-year process of developing a case for change

The Secretary of State’s full commissioning letter is included at Appendix One.

The Panel’s letter of 31 May 2019, included at Appendix Two, provided advice on sections one and four above and included a chronological record of the main events leading up to this commission for advice. It concluded that the Panel wished to test the evidence put to it, focussing on two related areas. First, whether, as some have suggested, there is any credible alternative to the widely accepted single emergency centre and planned centre model. Second, were the single emergency centre and separate planned care centre model to proceed, how in practice the whole health system will function to meet the wider needs of the population, including the mitigation of the negative effects of centralising some services.

Our process

A sub-group of the full IRP carried out this commission. It consisted of the Panel Chairman, Lord Ribeiro, and four Panel Members, Diane Davies, Simon Morritt, Linn Phipps, and Helen Thomson. Sub-group Members visited the two acute hospital sites and took oral evidence from invited parties. Members were accompanied on visits and evidence sessions by the IRP Secretariat. Details of the people seen during these sessions are included at Appendix Three. To provide context and aid preparation, a short briefing about lines of enquiry was shared in advance with participants and is included at Appendix Four.

Local Members of Parliament were contacted to seek their views. Meetings were held with Owen Paterson, MP for North Shropshire, and Lucy Allan, MP for Telford, Philip Dunne, MP for Ludlow, Daniel Kawczynski, MP for Shrewsbury and Atcham and Mark Pritchard, MP for Wrekin County, on 23 July 2019.

A list of written evidence received after 31 May 2019 is included at Appendix Five. The Panel considers that the documentation received, together with the information obtained in meetings, provides a fair representation of the views from all perspectives.

Throughout our consideration of these proposals, our aim has been to consider the needs of patients, public and staff, taking into account the issues of safety, sustainability and accessibility as set out in our general terms of reference. In this particular case, we have also reflected the partnership arrangement in place between health organisations across the border of England and Wales to consider the needs of the Powys population who depend on the services in question.

The Panel wishes to record its thanks to all those who contributed to this process. The advice contained in this letter represents the unanimous views of the Chairman and all Members of the IRP.

Our advice

The clinical case for change and moving forward

The opportunity to visit the services and test the evidence with those involved locally served to reinforce the written evidence about the case for change. The Panel was struck on its site visits by the poor state of the main ward block and outpatient facilities at Royal Shrewsbury Hospital (RSH).

Even if the ever-present problems of recruiting clinical staff to achieve safe rotas were resolved, the current model of emergency services provided through the two hospitals, RSH and Princess Royal Hospital, Telford (PRH), compromises safety and quality. The Panel heard frequently from the clinicians responsible for delivering these services that this is a daily concern and drives their advocacy for a new model of hospital care which will provide what the population currently do not get – access to consistently safe, high quality emergency care and treatment 24 hours a day, seven days a week.

The case for change was first articulated some ten years ago and the status quo declared not an option. In the period since, interim changes have been required to mitigate clinical risks in services. These include the centralisation of emergency surgery at RSH and, in the face of deteriorating facilities at that hospital, the relocation of women and children’s services from RSH to PRH. The Panel agree that the current situation is not acceptable and cannot continue.

In all its discussions, the Panel has explored views about how best the local health system can move forward with its partners. There are genuinely held differences of view and unresolved issues that need to be tackled openly and collaboratively by the local NHS, its local authority partners and others. The long history of Future Fit clearly casts a shadow over people’s perceptions and for some it has undermined confidence and trust. Changes in leadership of organisations brings uncertainty but also opportunity. The Panel heard from both local authorities a strong commitment to partnership with the local NHS and positive feedback about the changes being made to strengthen the Sustainable and Transformation Partnership (STP) and its approach to working with them.

Recommendation One
The STP is making welcome changes and must be fully supported to enable the NHS and its partners to collaborate effectively.

Acute services in context

The Panel agrees with the view expressed by some of those we met that the original whole system approach, described vividly at the outset of Future Fit, has not been sustained and converted into whole health system transformation. Although work is being done on out of hospital services, there is a legitimate concern that without a coherent and comprehensive approach, a balanced and sustainable health system will not be achieved.

That there is a critical interdependency between primary and community care on the one hand and acute hospital care on the other is not disputed by anyone. Nor is there any dispute about the need to integrate out of hospital services with the ‘front door and back door’ of acute hospitals to optimise admissions and discharges.

Tackling the issues described above is a non-negotiable priority in every health system, irrespective of the model of hospital care that is in place. The Panel found no reason to support the view expressed by some that the decision to implement the new model of hospital care will necessarily stop the development of the complementary services that are needed to achieve a sustainable health system. Rather, for Shropshire, Telford and Wrekin the immediate opportunity is to build on existing work, including community hospitals and maternity services, to transform out of hospital services in a way that will shape and enhance the implementation of the new model of hospital care.

Capital finance of £312 million has been earmarked to enable the implementation of the new model for hospital care. As with any major NHS capital scheme, Future Fit is following standard processes of planning and approval. The Panel support the decision to bring these processes within the STP’s remit as a matter of collective responsibility, providing the vehicle to identify and manage the associated risks and ensure it proceeds firmly within the context of what must be achieved for the whole health system.

Recommendation Two
The STP has already brought the Future Fit hospital programme under its auspices as one element of the work to deliver the NHS Long Term Plan. The STP should ensure that out of hospital services are given the priority and leadership required to achieve whole health system transformation within available financial resources.

The new model for hospital care

The IRP heard from many of the stakeholders involved that they have come to understand and accept the case for change knowing that it would lead them into uncomfortable discussions with local people and staff about how and where to consolidate some hospital services. They share a view that the NHS’s decision to proceed is not without risks and uncertainties. However, they also recognize that after many struggles, there is an opportunity to create better hospital services which must be grasped.

Telford & Wrekin Council and Shropshire, Telford and Wrekin Defend our NHS both expressed the view that the local NHS’s decision to implement the new model of hospital care is wrong and should be put aside. The Panel’s view is that this is not a credible alternative to the preferred option. It would be a choice to accept the safety and quality shortcomings of the current hospital services, ignore the views of clinicians and deny the population the opportunity of access to consistently safe, high quality emergency care and treatment 24 hours a day, seven days a week.

Recommendation Three
The new model of hospital care should be implemented without delay.

Location of the emergency care centre

The Panel noted in in its advice of 31 May 2019, that options for the emergency centre, including a new build between Shrewsbury and Telford and variations of the ‘Northumbria Model’, were considered and ruled out before RSH was identified as preferred to PRH. The options appraisal demonstrated the trade-offs involved between the two locations and the differential impacts for different sections of population. The Panel, having reviewed the options appraisal and arguments put forward by Telford & Wrekin Council in their referral, agree that on balance RSH is the better location for the emergency centre.

A key factor in this choice is the need to address the challenge of sustaining the increasingly specialised nature of hospital care for the catchment population served, including mid-Wales, in the face of existing alternatives to the north and east in Stoke and the West Midlands conurbation. For trauma care, locating the emergency centre at RSH establishes a critical mass of hospital infrastructure and expertise that is required for the operation of a wider trauma network. Beyond trauma services, it will also provide the means to underpin the more local provision of other specialist services such as cancer services.

Recommendation Four
The emergency care centre is better located at RSH.

Services at PRH

Under the preferred option, PRH will be the centre for planned care (surgery and post-acute rehabilitation), the location for an urgent treatment centre and continue to provide the current range of outpatient, diagnostic and related services.

The Panel has previously commented about the confusion caused by the inconsistent use of names and models across the NHS and it is hoped that the current national policy to implement a standard urgent treatment model will improve matters. Although national policy must be implemented at RSH and PRH in the interim, the Panel shares concerns expressed that a more appropriate and ambitious model must be developed and implemented to complement properly the single emergency centre at RSH.

Accepting the constraint that acute admissions will not be available at PRH, the Panel agrees that the aim should be to provide as much clinically appropriate urgent care and treatment as possible at the hospital. In this context, the future model must consider the range of diagnostics available to be used, ambulatory emergency care and frailty assessment. This will both serve local needs better and when replicated at RSH will ensure the single emergency centre is used only when necessary and not by default.

Recommendation Five
The urgent care model should enable as much clinically appropriate care to be delivered at PRH as possible. Options for diagnostics, ambulatory emergency care and frailty assessment must be considered.

Independent expertise and challenge

The Panel has been impressed by the clinical engagement in developing services locally over a long period. The next phase brings fresh challenges including the co-production of new service models and integrating service delivery across clinical and organisational boundaries. The Panel has seen elsewhere the value of bringing independent clinical and other expertise to bear on this type of work and believes Shropshire, Telford and Wrekin needs this to complement its strengths.

Recommendation Six
The STP should ensure that independent expertise is brought in to facilitate development of the new models of service.

Workforce

In the recent history of local NHS services, difficulties recruiting and retaining clinical staff in vital services have featured large and undermined efforts to provide high quality services. Whilst these difficulties continue, the workforce agenda is now shifting to broader consideration of how services will be delivered in the future and what types of staff with what skills will be needed. The Panel has seen some specific examples of the workforce development required. However, we note that to achieve the transformation of services envisaged requires a more fundamental approach than filling existing vacancies and incremental changes in workforce roles and numbers.

Recommendation Seven
The STP should ensure the transformation of service delivery and its impact on staff roles and skills is fully reflected in its workforce programme and plans.

Conclusion

The Panel notes that NHS England has assured the process throughout against the five tests. In common with any proposals of this nature, there are ongoing risks that need to be managed. The NHS is aware of these risks and they will be managed by the STP in conjunction with NHS England and Improvement.

Since the new model of hospital care was first articulated in 2014, the simple message that it will provide something that the population currently do not get – access to consistently safe, high quality emergency care and treatment 24 hours a day, seven days a week – has not changed but has got somewhat lost.

The opportunity to bring the benefits of sustainable, high quality emergency care to this population, and with it a critical mass of clinical expertise that will underpin and sustain other services in the area, must not be squandered.

These changes cannot stand alone. They are one necessary and beneficial element in the wider transformation of health services led by the STP to achieve the aims of the NHS Long Term Plan for the local population.

Yours sincerely
Lord Ribeiro CBE
IRP Chairman

Appendix one - letter from the Secretary of State

The Lord Bernard Ribeiro
Chair, Independent Reconfiguration Panel
6th Floor, 157-197 Buckingham Palace Road
London
SW1W 9SP

22 March 2019

Dear Lord Ribeiro,

Referral to the Secretary of State under Regulation 23(9) of the Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013 of changes to healthcare services in Telford and the Wrekin through the ‘Future Fit’ programme.

I am writing to request the initial advice of the Independent Reconfiguration Panel (IRP) in relation to the above referral by Telford and the Wrekin Council.

In particular, I would like the panel to look into the following aspects of this case:

• whether consultation with Telford and the Wrekin Council was procedurally correct and/or functionally adequate; and, if not, then what could be done to improve this
• whether the proposals are in the interests of local health services
• whether the proposals meet the five reconfiguration tests
• what could have been done differently by local organisations to avoid a referral at the end of a multi-year process of developing the case for change

I should be most grateful if the advice could, in line with the agreed protocol between the Department of Health and Social Care and the IRP, be provided by no later than the end of May, if at all possible. However, if it becomes apparent that this deadline is not achievable (or can be exceeded), do please let me - and copy recipients - know what a more realistic timetable would be.

I enclose copies of my letters to Telford and Wrekin Council and the relevant CCGs informing them of my decision.

I look forward to hearing from you.

Matt Hancock

Appendix two - initial advice

Read the IRP’s initial advice to the Secretary of State, 31 May 2019

Appendix three - site visits, meetings and conversations held

Site visit to Princess Royal Hospital, Telford and Royal Shrewsbury Hospital, 2 July 2019

Independent Reconfiguration Panel:

• Lord Ribeiro CBE
• Simon Morritt
• Linn Phipps
• Richard Jeavons
• Martin Houghton

Evidence testing session, 3 July 2019

Independent Reconfiguration Panel:

• Lord Ribeiro CBE
• Simon Morritt
• Linn Phipps
• Helen Thomson
• Richard Jeavons
• Martin Houghton

The local NHS:

• David Stout, Accountable Officer, NHS Shropshire CCG
• David Evans, Chief Officer, NHS Telford and Wrekin CCG
• Julian Povey, Chair, NHS Shropshire CCG
• Jo Leahy, Chair, Telford and Wrekin CCG
• Jess Sokolov, Medical Director, NHS Shropshire CCG
• Bev Tabernacle, Interim Deputy Chief Executive, Shrewsbury and Telford Hospital NHS Trust
• Paula Clark, Interim Chief Executive, Shrewsbury and Telford Hospital NHS Trust
• Ben Reid, Chair, Shrewsbury and Telford Hospital NHS Trust
• Barbara Beal, Interim Director of Nursing, Shrewsbury and Telford Hospital NHS Trust
• Arne Rose, Medical Director, Shrewsbury and Telford Hospital NHS Trust
• Mark Cheetham, Consultant Colorectal Surgeon and Scheduled Care Group Medical Director, Shrewsbury and Telford Hospital NHS Trust
• Andrew Tapp, W&C Care Group Director, Shrewsbury and Telford Hospital NHS Trust
• Kevin Eardley, Consultant Renal Physician and Unscheduled Care Group Medical Director, Shrewsbury and Telford Hospital NHS Trust
• Ed Rysdale, Consultant in Emergency Medicine, Shrewsbury and Telford Hospital NHS Trust
• Julia Clark, Director of Corporate Governance, Shrewsbury and Telford Hospital NHS Trust
• Victoria Rankin, Workforce Director, Shrewsbury and Telford Hospital NHS Trust
• James Drury, Interim Director of Finance, Shrewsbury and Telford Hospital NHS Trust
• Jill Price, Deputy Director of Finance, Shrewsbury and Telford Hospital NHS Trust
• Dave Thomas, Interim Associate Director of Estates, Shrewsbury and Telford Hospital NHS Trust
• Hayley Thomas, Director of Planning and Performance, Powys Teaching Health Board
• Adrian Osborne, Assistant Director (Engagement and Communication), Powys Teaching Health Board
• Mark Docherty, Director of Clinical Commissioning and Strategic Development/Executive Nurse, West Midlands Ambulance Service University NHS Foundation Trust
• Janet Budd, Interim Programme Director for Sustainable Services, Shrewsbury and Telford Hospital NHS Trust
• Louise Jones, Clinical Programme Lead for Sustainable Services, Shrewsbury and Telford Hospital NHS Trust
• Debbie Vogler, Associate Director, NHS Shropshire and Telford and Wrekin CCGs
• Martin Harris, Sustainability and Transformation Director, Shropshire Telford and Wrekin Sustainability and Transformation Partnership
• Jill Robinson, Finance Director, Shropshire Telford and Wrekin Sustainability and Transformation Partnership
• Claire Skidmore, Chief Finance Officer and Deputy Accountable Officer, NHS Shropshire CCG
• Mark Tunstall, Head of Assurance, NHS England and NHS Improvement, Shropshire
• Di Gamble, Head of Delivery, NHS England and NHS Improvement, North Midlands

Evidence testing sessions, 9 July 2019

Independent Reconfiguration Panel:

• Simon Morritt
• Linn Phipps
• Richard Jeavons

Session 1: Powys Community Health Council (CHC):

• Frances Hunt, Chair
• Katie Blackburn, Chief Officer

Session 2: Shropshire, Telford and Wrekin, Defend Our NHS:

• Gill George
• Peter Gillard

Evidence testing session, 10 July 2019

Independent Reconfiguration Panel:

• Simon Morritt
• Linn Phipps
• Richard Jeavons

Shropshire County Council:

• Councillor Peter Nutting, Leader and Portfolio Holder for Strategy
• Councillor Steve Charmley, Deputy Leader, Portfolio Holder for Assets, Economic Growth & Regeneration
• Councillor Dean Carroll, Portfolio Holder Adult Social Services & Climate Change
• Councillor Karen Calder
• Andy Begley, Executive Director Adult Social Services, Housing & Public Health
• Rachel Robinson, Director of Public Health

Evidence testing session, 16 July 2019

Independent Reconfiguration Panel:

• Lord Ribeiro CBE
• Diane Davies
• Simon Morritt
• Helen Thomson
• Richard Jeavons

NHS clinical model and capital programme:

• David Evans, Chief Officer, NHS Telford and Wrekin CCG
• Mark Cheetham, Consultant Colorectal Surgeon and Scheduled Care Group Medical Director, Shrewsbury and Telford Hospital NHS Trust
• Andrew Tapp, Women’s and Children’s Care Group Director, Shrewsbury and Telford Hospital NHS Trust
• Louise Jones, Clinical Programme Lead for Sustainable Services, Shrewsbury and Telford Hospital NHS Trust
• James Drury, Interim Director of Finance, Shrewsbury and Telford Hospital NHS Trust
• Jill Price, Deputy Director of Finance, Shrewsbury and Telford Hospital NHS Trust
• Dave Thomas, Interim Associate Director of Estates, Shrewsbury and Telford Hospital NHS Trust
• Ben Brookes, Partner, Rider Hunt Construction Consultants LLP
• Debbie Vogler, Associate Director, NHS Shropshire and Telford and Wrekin CCGs

Evidence testing sessions, 17 July 2019

Independent Reconfiguration Panel:

• Lord Ribeiro CBE
• Diane Davies
• Richard Jeavons

Session 1: Local NHS leadership:

• David Stout, Accountable Officer, NHS Shropshire CCG
• David Evans, Chief Officer, NHS Telford and Wrekin CCG
• Julian Povey, Chair, NHS Shropshire CCG
• Jo Leahy, Chair, Telford and Wrekin CCG
• Paula Clark, Interim Chief Executive, Shrewsbury and Telford Hospital NHS Trust
• Ben Reid, Chair, Shrewsbury and Telford Hospital NHS Trust
• Andrew Tapp, Women’s and Children’s Care Group Director, Shrewsbury and Telford Hospital NHS Trust
• Jan Ditheridge, Chief Executive Shropshire Community Health NHS Trust
• Hayley Thomas, Director of Planning and Performance, Powys Teaching Health Board
• Pippa Wall, Head of Strategic Planning, West Midlands Ambulance Service University NHS Foundation Trust
• Robert Till, Senior Operations Manager, West Midlands Ambulance Service University NHS Foundation Trust
• Louise Jones, Clinical Programme Lead for Sustainable Services, Shrewsbury and Telford Hospital NHS Trust
• James Drury, Interim Director of Finance, Shrewsbury and Telford Hospital NHS Trust
• Debbie Vogler, Associate Director, NHS Shropshire and Telford and Wrekin CCGs
• Sir Neil McKay, Independent Chair, Shropshire Telford and Wrekin Sustainability and Transformation Partnership
• Jill Robinson, Finance Director, Shropshire Telford and Wrekin Sustainability and Transformation Partnership
• Mark Tunstall, Head of Assurance, NHS England and NHS Improvement Shropshire
• Jon Cooke, Chief Finance Officer, NHS Telford and Wrekin CCG

Session 2: Telford & Wrekin Council:

• Councillor Shaun Davies, Leader
• Councillor Andy Burford, Cabinet member for Health & Social Care
• Clive Jones, Director of Children’s and Adult Services
• Liz Noakes, Assistant Director of Health & Well-being
• Helen Onions, Consultant in Public Health
• Jonathan Rowe, Chief Operating Officer (interim)

Meeting with Members of Parliament, 23 July 2019

Independent Reconfiguration Panel:

• Lord Ribeiro CBE
• Richard Jeavons

Members of Parliament:

• Owen Paterson, MP for North Shropshire
• Lucy Allan, MP for Telford
• Philip Dunne, MP for Ludlow
• Daniel Kawczynski, MP for Shrewsbury and Atcham
• Mark Pritchard, MP for Wrekin County

Appendix four - Future Fit – background briefing for meetings

Acute hospital services on this patch were pronounced unsustainable by the National Clinical Advisory Team (NCAT) ten years ago. NCAT’s successor the Clinical Senate made the same judgement five years ago. Some acute services such as women and children’s have been changed in the meantime. The core acute services around A&E, however, remain a significant concern.

We have often heard the phrase ‘no change is not an option’. Proposals have been brought forward and been disputed. The task for the Panel is to explore the issues and help find the way forward that will meet the future needs of the population served.

Having read the history and evidence in the many documents provided, the Panel concluded that it wished to test further the evidence, focussing on two related areas.

First, whether, as some have suggested, there is any credible alternative to the widely accepted single emergency centre and planned centre model.

Second, were the single emergency centre and separate planned care centre model to proceed, how in practice the whole health system will function to meet the wider needs of the population, including the mitigation of the negative effects of centralising some services.

To stimulate discussion here are some lines of enquiry:

What variations to the model proposed in the DMBC should be considered further?

• why not retain two A&E services?
• what about Ambulatory Emergency Care on two sites?
• what about a frailty unit and/or medical admissions on the second site?
• why are RSH admissions being transferred to PRH mid episode?
• is the urgent care offer now fixed and clear to everyone?

How does the proposed model fit with services outside RSH and PRH?

• what will be available for urgent care needs outside RSH and PRH?
• what will be available for planned care needs away from RSH and PRH
• what is proposed around care closer to home and keeping the frail away from RSH?
• what if any are the critical dependencies between out of hospital services and the new model?

How the model works in practice for patients, what is changing and what is the impact on them?

• the worried parent and their sick baby
• the person referred by their GP for a common cancer
• the frail older person with multiple conditions living at home
• the working adult with inflammatory arthritis

What needs to happen in what order to progress the service changes?

• what new workforce is needed, how and when will it be recruited?
• what has to happen in what order to implement the DMBC decisions
• how do the Outline Business Case, CCG commissioning priorities and system revenue position fit together?

Appendix five - documents made available to the IRP

Documents are in addition to those recorded in advice of 31 May 2019 (Appendix two)

Telford & Wrekin Council:

• letter to IRP Chairman from Councillor A Eade, Leader Conservative Group, Telford & Wrekin Council, 16 July 2019

NHS:

• NHS letter to CCGs accountable officers, 22 January 2019
• update paper for Future Fit programme, 22 January 2019
• NHS presentation to IRP, 16 July 2019
• zip file containing documents re Future Fit Option C1

Other:

• letter to IRP Chief Executive from Shropshire Defend our NHS, 14 July 2019
• urgent care centres, proposal for evaluation panel, 20 January 2015
• letter to Mr D Evans, Accountable Officer Telford & Wrekin CCG, from Mr D Sandbach, 15 July 2019
• press release, South Shropshire Green Party and Telford & Wrekin Green Party, 23 July 2019
• letter to IRP Chairman from Lucy Allan, MP for Telford, 24 July 2019