Independent report

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

Published 3 October 2019

Applies to England

Letter to the Secretary of State for Health and Social Care

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

31 May 2019

Dear Secretary of State,

Thank you for forwarding copies of the referral letters and supporting documentation from Councillor Shaun Davies, Leader, and Richard Partington, Managing Director, Telford & Wrekin Council. NHS England (Shropshire and Staffordshire) provided assessment information. A list of all the documents received is at Appendix One. The Independent Reconfiguration Panel (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 your agreement it will consider further the evidence, as indicated below, before providing final advice.

Background

‘Future Fit: Shaping Health Care Together’ is led by NHS Shropshire Clinical Commissioning Group and NHS Telford and Wrekin Clinical Commissioning Group (the CCGs). The populations served by the CCGs are broadly the same as those who live in the local authorities of Shropshire and Telford and Wrekin respectively. To the west, the population of Powys in mid Wales also make significant use of the services under consideration.

Shropshire has a population of around 320,000 and is a sparsely populated rural area apart from Shrewsbury with a population of around 72,000 and a few market towns such as Ludlow in the south. It has a larger number of older people compared to many other locations across the country. People living in Shropshire are relatively affluent compared with the national average, however there are areas of deprivation, including in rural areas where access to transport and higher costs for everyday essentials are a challenge for people.

Telford and Wrekin’s population is around 170,000, the majority of whom live in Telford itself, and is projected to grow at a faster rate than the population of England. The proportion of the population aged under 20 is above the national average but this proportion is decreasing as more than half the projected population increase is in the over 65 age group. The population has higher than national rates of poor health with lower life expectancy and higher rates of people reporting long term limiting health problems or disability. Within the Borough, 15 areas are ranked in the 10 per cent most deprived nationally.

Powys has a population of just over 130,000 and the lowest population density of all the principal areas of Wales. Much of Powys is upland or mountainous making north-south transport difficult and there are high levels of rural poverty.

Apart from primary care, most NHS services for the area are provided by one of five organisations. Mental health and community services are provided by Midlands Partnership NHS Foundation Trust and Shropshire Community Health NHS Trust respectively. Ambulance services are provided by West Midlands Ambulance Service (WMAS) with the Welsh Ambulance Service (WAS) covering Powys. The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust in Oswestry provides a range of bone, joint and tissue services, not only locally but also as specialised service for the region and beyond.

Acute hospital services are provided by Shrewsbury and Telford Hospital NHS Trust (SaTH) from two sites, the Royal Shrewsbury Hospital (RSH) and the Princess Royal Hospital Telford (PRH) which are 16 miles apart. Both hospitals currently provide a wide range of services including A&E, outpatients, diagnostics, inpatient medical care and critical care. The RSH is currently the designated Trauma Unit. Following service reconfigurations in 2013/14, inpatient adult surgery (excluding breast) is provided at RSH, with women and children’s services (consultant-led obstetrics, neonatology, inpatient and day case paediatrics and inpatient women’s services), head and neck and acute stroke care being provided at PRH. It is the future configuration of these acute hospital services that is the main subject of this referral and the IRP’s advice.

Developing an acute services strategy has been the subject of work by the local NHS since at least 2008. Future Fit was set up in 2013 in response to the Government’s ‘Call to Action’ which asked NHS staff, patients, the public and politicians to come together and agree what changes are needed to make local NHS services fit for the future. In November 2013, the CCGs ran a consultation exercise with the public and clinicians. The response was to design a new pattern of services that would offer excellence in meeting the distinctive and particular needs of the rural and urban populations of the local health economy. A Clinical Reference Group (CRG) was established, comprising senior clinicians from across healthcare, social care and patient representatives. Together, they developed and agreed an initial case for change and a set of ‘whole system’ design principles.

In March 2014, the Telford & Wrekin Council and Shropshire Council Joint Health Overview and Scrutiny Committee (JHOSC) received a report on the progress of the Future Fit programme including the development of the clinical model and future work around options appraisal, benefits realisation, consultation and the business case. The JHOSC resolved that ‘the Case for Change and Principles for Joint Working be endorsed’ and to receive further reports.

The CRG was extended to over 300 members, including stakeholder and patient representatives. The clinical model that emerged for acute hospital services comprised one emergency centre, one planned care centre, two urban urgent care centres and local outpatient and diagnostic services.

In June 2014, the JHOSC received an update report on the Future Fit programme. It was noted that ‘no decision had yet been made on the location of the new acute facility but could either be at the PRH in Telford, the RSH in Shrewsbury or on a site between the two’. The JHOSC commended the work undertaken to date and requested further information before endorsement of the proposed models would be considered.

A stakeholder panel was established in 2014 where initially a total of 40 options were considered, each of which contained a single site emergency care centre and various combinations of locations and co-locations of the other elements within the clinical model. The stakeholder panel developed the criteria for options appraisal and used them to produce a shortlist of five options. These were taken forward for further work along with a ‘do minimum’ and two variant options that would see consultant-led obstetric services located with the planned care centre rather than the emergency centre.

In January 2015, the Stage 1, Phase 1, Report from West Midlands Clinical Senate provided informal advice and expert critical challenge as part of NHSE’s assurance process. The report noted an unsustainable health model which warranted a need for fundamental change and improvement to achieve both clinical and financial sustainability. Whilst commending the ambition of the Future Fit programme and the engagement of clinicians and patients to date, it advised the need for more detailed work and testing of key assumptions around the clinical model, including urgent care centres and travel, activity and bed numbers, workforce and working practices. It also noted the need to engage the public and local government in the development of the proposals.

In February 2015, the JHOSC received an update report on the Future Fit programme that included details about how the shortlist of eight options had been reached, proposals for urgent care centres and next steps.

Three of the eight options in the short list involved the use of a ‘greenfield site’. Following an independent study commissioned to examine the feasibility and capital cost of all the shortlisted options, in August 2015 the Programme Board excluded the greenfield options on financial and affordability grounds.

In September and November 2015, and March and July 2016, the JHOSC received further update reports on progress with the Future Fit programme. These reflected the changing NHS context of Sustainability and Transformation Plans being introduced and the need to address the local financial deficit. Early discussions about plans for consultation were overtaken by circumstances and the timetable revised.

In September 2016, the formal non-financial appraisal of the four remaining shortlisted options was undertaken by a multi-stakeholder panel of 50 members, including patient representatives, Healthwatch, Community Health Council (CHC) Powys, clinicians, managers, local authority representatives, ambulance services, commissioners and all NHS providers. It concluded that Option C1 (Emergency Centre at RSH, Planned Centre at PRH) ranked first over Option B (Emergency Centre at PRH, Planned Centre at RSH) second. A technical financial appraisal was performed and conversely Option B ranked first over Option C1 by a small margin. Combining the two elements, the overall economic analysis demonstrated that Option C1 offered the best value for money over the long term.

In one of the four remaining options (C2) the Women and Children’s inpatient unit remained at the Princess Royal Hospital (PRH) with the Emergency Centre at the Royal Shrewsbury Hospital (RSH). Concerns around the implementation and delivery of this option were formally raised by local clinicians. External, independent, clinical advice on the potential of retaining the women and children’s consultant-led unit at PRH was sought and concluded that, having considered internal opinion and external reviews, this option was not clinically deliverable.

In December 2016, the Future Fit Joint Committee of the CCGs received the recommendations of the Programme Board but was unable to agree on a preferred option. It commissioned two further pieces of work to inform its deliberations: an additional Women and Children’s Impact Assessment and an Independent Review of the Option Appraisal Process. The latter concluded that there had been no material evidence presented that would change the original recommendations to the Joint Committee.

In August 2017, the Joint Committee reconvened and unanimously supported the recommendation from the Programme Board. This reaffirmed that Option C1 was to be taken into the consultation process as the preferred option. The Committee also acknowledged that Option B was both clinically and financially deliverable and therefore both would form part of the public consultation.

In September 2017, The JHOSC received an update including draft consultation documents and the pre-consultation business case. These were considered further at the JHOSC meetings on 2 November and 5 December 2017.

In October and November 2017, NHS England undertook a stage two assurance checkpoint in line with the guidance. A Panel was convened by the Regional Operations and Delivery Director, on behalf of the Regional Director, comprising a clinician, finance expert, members with experience of reconfiguration and representatives from NHS Improvement. The Panel considered the pre-consultation business case (PCBC) approved by the CCGs’ Governing Bodies alongside the reports from the West Midlands Clinical Senate and other evidence provided. The Panel sought to ensure that the four tests for service change set by the Secretary of State and the test set by NHS England regarding reductions in hospital beds were met. The PCBC was subjected to the various best practice checks set out in the guidance, including around clinical and financial sustainability, affordability, engagement undertaken and planned and governance. The Panel concluded that the evidence provided was sufficient and gave its support for the programme to proceed to consultation, subject to the source of the required capital finance being identified.

In January 2018, a Consultation Stakeholder Reference Group was established including representatives from the CCGs, Powys Health Board, Shropshire and Telford & Wrekin local authorities, SaTH, Healthwatch, public and patient representatives and the voluntary sector. Its remit was to oversee all communication and engagement activities. In co-production with this group, the Programme worked with the Consultation Institute (TCI) to design the consultation materials and inform the development of the consultation plan to ensure best practice standards.

In February 2018, NHS Improvement’s National Resources Committee gave its support for the capital finance to be made available to the programme and this was announced by the then Secretary of State for Health and Social Care in March 2018. On this basis, NHS England’s Regional Director wrote to the CCGs’ Accountable Officers, the joint Senior Responsible Officers for Future Fit, to confirm assurance and support to launch the formal public consultation.

On 10 May 2018, the JHOSC received final versions of consultation documents and plans, a report of the NHS England assurance process and the proposed timeline and process for decision making after consultation. The NHS confirmed that the JHOSC would receive the final report on the consultation for their consideration.

Consultation with the public commenced on 30 May 2018 and was planned to run for fourteen weeks to 4 September 2018. A wide range of activities were undertaken including drop-in public exhibition and panel events, pop-up displays, patient participation groups and GP patient forum meetings, council meetings, business community engagement, meetings with seldom heard groups, targeted Facebook advertising, Twitter chats with clinicians and a dedicated consultation website.

Prior to the formal consultation, further public and stakeholder engagement had sought views on the clinical model and its impact across Shropshire, Telford and mid Wales. Some members of the public, the JHOSC and Telford & Wrekin Council raised the potential of ‘the Northumbria model’ and if it should be considered as an option. The model comprises a new build ‘Specialist Emergency Care Hospital’ within a network of non-emergency care hospitals. A feasibility study was commissioned to look at the application of the model into the local health economy. In July 2018, the study’s conclusions included that the capital costs of this option would be significantly higher than the allocated capital funding of £312 million and it would address neither the significant current backlog maintenance at RSH and PRH nor the workforce sustainability challenges experienced by the Trust.

A midpoint review considered feedback from stakeholders, including the JHOSC at its meeting on 30 July 2018, and it was agreed to hold three additional public meetings and to extend the consultation by a week to 11 September 2018.

Independent consultation specialists, Participate Limited, collated and analysed feedback from the consultation and produced a Consultation Findings report. In addition, they facilitated two meetings at which the consultation findings were presented, scrutinised and discussed. The NHS concluded that the consultation findings presented no new viable alternative models and no new themes or key issues

In December 2018, the JHOSC and Powys CHC meetings received presentations on the consultation findings and mitigations. After a further meeting on 17 December 2018, the JHOSC formally responded on 3 January 2019 recording that because of disagreement between its members it was unable to make any joint recommendations relating to the consultation’s adequacy or regarding the committee’s overall response. It also noted:

the provisions of the Local Authority (Public Health, Health & Wellbeing Boards and Health Scrutiny) Regulations 2013 and accompanying guidance and reserves its right to comment further when formally consulted on the final proposals in accordance with regulation 23 et seq of those regulations.

The Powys CHC formally responded on 8 January 2019, noting its satisfaction with the consultation and confirming its support for the preferred option.

Consequent to the JHOSC formal response making no recommendations, on the 11 January 2019 the CCGs wrote to the JHOSC asking whether it intended referring to the Secretary of State and if so when. On 23 January 2019, the joint chair of the JHOSC, Councillor Andy Burford, wrote to the CCGs on behalf of the Telford & Wrekin members of the JHOSC expressing the view that consultation with the JHOSC would fall short of the requirements of the relevant regulations unless it was consulted about the conclusions and recommendations of the CCG’s Decision-Making Business Case before a final decision was made. The CCGs responded the same day disagreeing with this view but confirming that any comments received before 29 January 2019 would be taken into consideration.

Having received the necessary assurance and permission from NHS England, on 29 January 2019 the CCG Joint Committee unanimously confirmed that Option 1 was the preferred option. Five areas of mitigation were set out to be progressed: these related to the Travel and Transport Mitigation Plan; the 14 recommendations in the Equalities Impact Mitigation Report; progression of the out of hospital care strategies by the two CCGs; clear descriptions of services for the public, particularly the provision at Urgent Care Centres and reconfirming affordability at Outline Business Case stage.

On 18 February 2019, the Telford & Wrekin Full Council unanimously decided to refer to the Secretary of State the decision of the Joint Committee of Telford and Wrekin and Shropshire Clinical Commissioning Groups, to proceed with recommendations contained in the Decision-Making Business Case to reconfigure acute hospital services across Telford & Wrekin and Shropshire.

Basis for referral

The supporting documentation supplied with the Telford & Wrekin Council’s letter of 20 March 2019 states that:

This referral is made in accordance with Regulation 23(9) of the 2013 Regulations on the grounds that this Authority at a meeting of the Full Council on 18 February 2019 unanimously agreed that it:

1. Is not satisfied with the adequacy of the content of the consultation with the Joint Health Overview and Scrutiny Committee (JHOSC).
2. Is not satisfied that sufficient time has been allowed for consultation with the JHOSC.
3. Considers that the proposals would not be in the interests of the health service of the area and hence in the interests of the people of Telford & Wrekin (and will have a negative effect on the sustainability of health services in the area).
4. Considers the proposals are not consistent with the overwhelming views and wishes expressed by the people of Telford & Wrekin in the public consultation.”

IRP view

With regard to the referral by the Telford & Wrekin Council, the Panel notes that:

Consultation issues

• a joint health scrutiny committee was formed and so the CCGs were not required to provide information to Telford & Wrekin Council – only to the JHOSC
• only Telford & Wrekin contend that the JHOSC should have been consulted further before the CCGs made their final decisions based on the DMBC.
• there has been a clear effort throughout on the part of the JHOSC and NHS to work together in overseeing and scrutinising the development of these controversial changes
• the period prior to consultation, when the PCBC, draft consultation document and associated materials were discussed with the JHOSC on several occasions, was a missed opportunity for both parties
• the JHOSC failed to agree any recommendations to the NHS
• the NHS’s approach to engagement and consultation is open to criticism

Whether the proposals are in the interests of local health services

• the JHOSC endorsed the case for change
• the current safety and sustainability of some acute hospital services is a cause for concern
• the model of a single site emergency centre proposal along with a separate site for planned care has some clear benefits for patient care
• the model also has some disadvantages to be considered which have been highlighted through consultation
• questions remain about how the proposal fits within the wider health and care system and how the changes will be delivered successfully

Advice

The Panel considers each referral on its merits and concludes that with your agreement it will consider further the evidence, as indicated below, before providing final advice.

Consultation issues

The Panel has been asked to advise whether consultation with Telford & Wrekin Council was procedurally correct. In submitting its referral, Telford & Wrekin Council has cited Regulation 23(9) of Local Authority (Public Health, Health and Well Being Boards) Regulations 2013 but has not specified any of that regulation’s sub-sections. In relation to consultation issues, Regulation 23(9)(a) covers consultation with the relevant scrutinising body. Regulation 30(1-6) describes the circumstances in which a joint scrutiny committee should be appointed.

A JHOSC was established between Telford & Wrekin and Shropshire Councils as the health scrutiny 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 Well Being Boards) Regulations 2013. The JHOSC is the appropriate and only English scrutiny body with which the CCGs must consult on any proposals developed in respect of the Future Fit Programme. It is also the only body that the NHS is required to provide information to in these circumstances. Based on the IRP’s understanding of the Regulations, and bearing in mind that matters of law are for the courts, the Panel considers that the consultation with Telford & Wrekin Council was procedurally correct. However, we offer the following further comments on the consultation with the JHOSC.

Power of referral was retained by the individual councils and has been exercised by Telford & Wrekin Council. In its referral, the Council contends that the consultation with the JHOSC was inadequate in terms of both content and time allowed. The Panel noted that this contention was not endorsed by the JHOSC or the other party to the JHOSC, Shropshire Council. In contrast, the Welsh counterpart to the JHOSC, Powys CHC, formally recorded its satisfaction with the content and time allowed for consultation.

The Panel commends the effort and commitment of both the NHS and JHOSC to work together on proposals of such significant potential impact for their communities and over such a length of time. Close to five years elapsed between the JHOSC endorsing the Future Fit Case for Change in 2014 and the NHS making the decisions that are the subject of this referral. In that time many meetings took place, typically supported by detailed papers and, as the minutes record, sensible and appropriate questions were asked with many responses provided. However, it is the Panel’s view that the length of the process, combined with the potential of the Future Fit programme eventually to divide the parties involved, explains many of the issues raised in this referral.

It was predictable and inevitable that the options appraisal and identification of a preferred option would trigger renewed scrutiny and questions about both process and consequences. Although regular dialogue with the JHOSC continued throughout, the lags in process and time between the options appraisal in September 2016, the production of the pre- consultation business case towards the end of 2017 and the start of consultation in May 2018 undoubtedly explain some of the apparent gaps in information and consequent misunderstanding. These were exacerbated by changes in personnel, the NHS’s processes for assurance and perhaps most frustratingly, the uncertainty about capital financing and its effect on the affordability and deliverability of the consultation proposals.

Notwithstanding the frustrations and delays described above, the Panel agrees that, given the evident risks for both parties, the period covering the production of the pre-consultation business case and associated preparation for public consultation was a missed opportunity. For the NHS, the JHOSC had consistently raised significant issues such as ambulance provision and travel time that reasonably needed to be addressed. For the JHOSC, the divisive nature of the proposals and consultation placed a premium on its own process for undertaking scrutiny effectively and producing its recommendations. Although significant time and effort from all parties went into reviewing, debating and amending the content of key documents before public consultation started, clarity and agreement between the NHS and JHOSC about issues raised, and the process and timetable to be followed by each party, jointly and severally, through to decision-making was absent at the start of the public consultation.

The Panel agrees that with more forethought and collaboration from both parties, the disputes that crystallised in the period after public consultation would have been less likely. However, given the evident disagreement between members of the JHOSC and its inability to make recommendations to the NHS, the Panel’s view is that further time and information for the JHOSC to undertake more scrutiny in the run-up to decision-making would not have provided a remedy and addressed the concerns that are evident locally.

Although not cited by Telford & Wrekin Council as a reason for its referral, the Panel has received submissions from local campaigners expressing discontent with the formal public consultation that took place. The Panel does not underestimate the challenge for the NHS in engaging its stakeholders on a controversial agenda in the face of changing circumstances that are sometimes out of local control, and over a prolonged period. However, there is concern that the NHS’s approach with its stakeholders and the public has too often been to share what it has done and when challenged to react by asserting its rationale backed with more information.

In this case the framing of the consultation rather served to reinforce the approach taken. The scope of the consultation was constrained to acute services, the acute model and two options for its implementation. This had a predictable effect seen in the responses. It reinforced a view that the NHS was setting an agenda rather than seeking views that would influence its decisions; it left relevant questions about the wider context of NHS services unanswered and unexplained; and the clear majority of responses divided along geographical lines.

The best consultation can never make up for lack of engagement from the outset. This view is common to much of the statutory and good practice guidance that exists to assist the NHS and partners in involving and engaging with the public in developing local health services. It should be practised by any organisation that wishes to avoid a referral at the end of a multi-year process. The Panel understands that work is in hand within NHS England to bring together all the extant guidance into one document which will undoubtedly be helpful.

That said, in this instance the views of sections of the public and the position of the NHS seem to be so markedly far apart that it is difficult to imagine how even the very best involvement/engagement/consultation process would have avoided a referral from one of the two local authorities. For this reason, the Panel sees no benefit in further raking over the past. The focus from now on should be on how to move forward in the best interests of local health services.

Whether the proposals are in the interests of local health services

The case for change that provides the context for these proposals was first articulated in 2013 and endorsed by the JHOSC in 2014. It identified opportunities to provide better quality, more appropriate health care and the need to adapt existing services to meet future challenges such as changing population needs, clinical advances and making the best use of available financial and human resources. It also noted the longstanding concern about the sustainability of running two A&E services in terms of safety and quality.

Over the subsequent five years of Future Fit, the case for change has been the subject of external review, scrutiny and endorsement. The Panel agrees with the view that doing nothing is neither sustainable nor in the interests of local health services. This view is reinforced by the evidence that sustaining two A&E services has become more precarious, not least because the recruitment and retention of key medical staff is more difficult now than ever. As a result, the gap between the quality of existing A&E services and what is reasonably expected is greater than ever and today there is the real threat of temporary closure of one service on grounds of safety.

The single site emergency centre proposal was one element of the clinical model developed in response to the case of change. Along with a planned care centre, it has been at the heart of all options considered for acute hospital services since 2014

The clinical case for concentrating all the relevant services for those with emergency needs in one location, and separating these from planned care, is based on the available evidence, the associated professional consensus and relevant standards. In summary, more availability of senior staff across a range of specialist expertise is better for the sickest patients and separating planned care from emergency care reduces cancellations and delays.

The Panel notes that, through all the external assurance, scrutiny, and consultation, the basic proposition that a single emergency centre and separate planned care centre would have benefits for the care of patients has not been contradicted. However, putting this model at the centre of proposals for changing local health services brings many practical challenges, risks and issues – first articulated in the West Midlands Clinical Senate Report in 2014.

Following consultation, the NHS’s decision to locate the emergency centre at RSH has been disputed by Telford and Wrekin who argue it should be at PRH. They have also highlighted gaps in the proposals and expressed a lack of confidence in the NHS’s capability to deliver the necessary changes. The Panel agree that given the passage of time, the position reached, and the fragility of some services, the priority is to provide advice that will enable progress rather than a revisiting of what has been done so far.

Consequently, before providing final advice about the NHS’s proposals, the Panel wishes to test the evidence put to us, 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.

We are conscious of the pressures on local services and the need to move forward as soon as possible. We plan to visit the two acute hospitals and test the evidence of key parties before reporting finally no later than the end of July.

Yours sincerely
Lord Ribeiro CBE
Chairman, IRP

Appendix One - list of documents received

Telford and Wrekin Council

Referral letter to Secretary of State from Councillor Shaun Davies, Leader, and Richard Partington, Managing Director, Telford & Wrekin Council, 20 March 2019

Attachments:

1. Referral document with embedded documents and appendices:
2. Appendix 1 – notification to CCGs re decision to refer
3. Appendix 2 – Future fit chronology
4. Appendix 3 – Summary of information requested by JHOSC
5. Appendix 4 – Future Fit Programme Director report to Telford CCG, October2018
6. Appendix 5 – JHOSC Joint Chair letter, 21 January 2019
7. Appendix 6 – CCG response to JHOSC joint Chair, 23 January 2019
8. Appendix 7 – Telford & Wrekin Council Future Fit consultation response
9. JHOSC draft minutes, 17 December 2018
10. JHOSC draft minutes, 11 January 2019

NHS

IRP template for providing assessment information with embedded documents

Attachments:

1. Appendix 1 Summary of impact on journey time analysis
2. CCGs letter to Councillor S Davies and Mr R Partington, Telford & Wrekin Council, 25 February 2019

Other evidence

1. Station Drive Surgery Patients’ Group submission to IRP, 28 March 2019
2. Powys CHC report on Future Fit consultation, 8 January 2019
3. Powys CHC response to Future Fit consultation, 9 January 2019
4. Shrewsbury & Atcham Constituency Labour Party submission to IRP, 17 April 2019
5. Shropshire, Telford & Wrekin Defend our NHS submission to IRP, 2 May 2019
6. South Shropshire Green Party submission to IRP, 26 April 2019
7. West Midlands Ambulance Service paper for Shropshire health and adult social care scrutiny committee, 20 May 2019