Independent report

Independent Reconfiguration Panel Report: Shrewsbury and Telford Hospitals Transformation Programme

Published 21 December 2023

Applies to England

Letter to Lord Markham from Professor Sir Norman Williams, Chair of the Independent Reconfiguration Panel

Lord Markham CBE
Parliamentary Under Secretary of State
Department of Health and Social Care

4 December 2023

Dear Minister,

I am writing following your request of 23 October 2023 to provide the formal advice of the Independent Reconfiguration Panel in response to the concerns raised by Telford & Wrekin Council which were set out in a letter sent to the Secretary of State for Health and Social Care dated 20 March 2023.

We have reviewed the formal advice given by the Panel in 2019 to the Secretary of State and the series of events that have occurred since then along with the latest version of the outline business case. Further evidence was also requested by the Panel from the NHS Trust, Telford & Wrekin Council and the other parties involved in the local integrated care system, including Powys Teaching Health Board in mid Wales whose residents will also be impacted by the proposal.

The Panel has considered this evidence very carefully and made a series of recommendations to you in the attached report to respond to Telford & Wrekin Council’s concerns about the future of NHS services at both the Royal Shrewsbury Hospital and the Princess Royal Hospital in Telford. These include recommendations about the needs of residents in mid Wales to access NHS services in England; the impact of the capital funding constraint; the enhanced urgent care service (‘A&E Local’ model); emergency ambulance capacity and transfers between the hospital sites; and changes to population demographics. The Panel has also made further recommendations about the Local Care Transformation Programme and travel and transport issues which were highlighted to us during the course of our evidence review.

Overall the Panel concludes that, subject to the recommendations outlined in our report, the Hospitals Transformation Programme (as described in the NHS Trust’s outline business case) is the best way forward to improve acute hospital services for the whole population served in Shropshire, Telford and Wrekin, and mid Wales. I can also confirm that the critical advice about the clinical model and location of services given by the Panel to the Secretary of State in 2019 remains the view of the Panel today.

I would like to put on record my gratitude to the Panel members, colleagues from the NHS Trust, the NHS Shropshire, Telford and Wrekin Integrated Care Board and Telford & Wrekin Council, along with the other parties involved, for their support in undertaking this review.

It is clear that NHS services in the local area are under great strain and therefore the Panel hopes to see the Hospitals Transformation Programme proceed with your support to improve the sustainability of the two hospitals and the quality of care for all.

Kind regards,

Professor Sir Norman Williams

Chair of the Independent Reconfiguration Panel

History of the proposal

Background

The Shrewsbury and Telford Hospitals Transformation Programme, previously known as the ‘Future Fit’ programme, is a reconfiguration proposal which aims to make the Royal Shrewsbury Hospital a specialist emergency care site and the Princess Royal Hospital in Telford a dedicated planned care site. The programme is led by The Shrewsbury and Telford Hospital NHS Trust.

The proposal would result in the relocation of the emergency department and consultant-led women’s and children’s services from Telford to Shrewsbury. Both sites would provide urgent treatment centres, diagnostics, outpatient clinics, midwife-led maternity services, frail and elderly services, and day case chemotherapy.

The decision to approve the proposal was made after a public consultation by a unanimous vote of the Joint Committee of the NHS Shropshire Clinical Commissioning Group and the NHS Telford & Wrekin Clinical Commissioning Group in January 2019 (the two organisations are now known as the NHS Shropshire, Telford & Wrekin Integrated Care Board).

Telford & Wrekin Council’s referral (2019)

On 20 March 2019, the Leader of Telford & Wrekin Council, Councillor Shaun Davies, objected to the decision made by the clinical commissioning groups via a formal referral to the Secretary of State for Health and Social Care. The grounds for objection were that the decision had not been properly consulted upon and was not in the interests of the health services in Telford and Wrekin.

The Independent Reconfiguration Panel (IRP) was commissioned to assess the case by the Secretary of State and the Panel submitted its initial advice to ministers on 31 May 2019, followed by final advice on 31 July 2019.

The IRP concluded that:

the proposal to establish a single emergency centre at the 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.

The Secretary of State’s decision (2019)

On 2 October 2019, the Secretary of State (the Rt Hon Matt Hancock MP) issued a decision letter to Telford & Wrekin Council which stated that he had accepted the IRP’s advice and had asked NHS England to suggest how urgent care at the Princess Royal Hospital in Telford could be delivered through an ‘A&E Local’ model.

In the subsequent years following the decision, Telford & Wrekin Council approved several full council motions to continue their public opposition to the proposals. They have written multiple letters of complaint to the government since 2019 seeking a further review and to request an intervention from ministers to overturn the Secretary of State’s decision, including a petition signed by over 22,000 people presented to No.10 Downing Street in January 2023.

Capital funding approvals

The proposal requires capital investment at both hospitals to refurbish existing facilities and create new buildings. The Department of Health and Social Care therefore approved £312 million of capital funding from HM Treasury to support the reconfiguration.

On 26 August 2022 the first stage of the government’s capital approvals process, the strategic outline case, was formally approved by the Joint Investment Committee (JIC) of the Department of Health and Social Care and NHS England.

The IRP understands that the outline business case, the next stage of the capital approvals process, has been considered by the JIC and is currently with ministers in the Department of Health and Social Care for review.

The Minister of State for Health and Secondary Care confirmed in Parliament on 17 October 2023 that enabling works had recently been approved for the hospital transformation programme and are expected to commence this financial year.

Funding has also been provided for the development of the full business case, the final stage of the government’s approvals process, which is expected to be submitted in the coming months.

The purpose of this report

A full council motion to formally ask the government to reconsider the plans for the Princess Royal Hospital and the decision made by the Secretary of State in 2019 was approved by Telford & Wrekin Council on 2 March 2023.

Councillor Shaun Davies, as Leader of the Council, then wrote to the Secretary of State on 20 March 2023 with a formal request to reconsider the proposals and for the case to be referred to the Independent Reconfiguration Panel for advice.

Lord Markham, Parliamentary Under Secretary of State and the minister responsible for NHS capital in the Department of Health and Social Care, wrote to Sir Norman Williams, the Chair of the Independent Reconfiguration Panel, on 23 October 2023 to look into the concerns raised by Telford & Wrekin Council’s letter and reflect on whether circumstances had changed sufficiently to warrant a change to the final 2019 IRP advice.

A subgroup of Panel members was convened to consider the case and further evidence was requested from the main parties involved: The Shrewsbury and Telford Hospital NHS Trust, the NHS Shropshire, Telford and Wrekin Integrated Care Board, NHS England, Powys Teaching Health Board and Telford & Wrekin Council.

The Leader of Shropshire Council, the co-chairs of the Joint Health Overview and Scrutiny Committee for Shropshire, Telford and Wrekin, the Royal College of Emergency Medicine and local MPs were also invited to submit comments. A list of all evidence received by the Panel is enclosed in Appendix 4.

After a review of the evidence received, the Panel considered whether to visit the local area and concluded that this was not necessary but that it would be helpful to hear directly from the NHS and the local authority to test the evidence further on the key lines of enquiry identified. Separate meetings took place via video conference on 22 November 2023 with both The Shrewsbury and Telford Hospital NHS Trust and the NHS Shropshire, Telford and Wrekin Integrated Care Board, and on 23 November 2023 with Telford & Wrekin Council.

Panel member Professor Simon Brake declared an interest having previously worked as the independent chair of the NHS Shropshire, Telford and Wrekin ‘Future Fit’ Joint Committee and therefore recused himself from all matters related to this report and has taken no part in the formulation of the Panel’s advice.

The local integrated care system

The Shropshire, Telford and Wrekin Integrated Care System (ICS) is a partnership of organisations whose aim is to plan and deliver joined up health and care services for the local area. The ICS includes two unitary authorities - Shropshire Council and Telford & Wrekin Council – who share a joint health overview and scrutiny committee.

The NHS Shropshire, Telford and Wrekin Integrated Care Board (ICB) is the commissioning body within the ICS which is responsible for buying NHS services for around 500,000 people in the area, including some for residents in mid-Wales due to its location on the Welsh-English border. The ICB was formed after changes to legislation in the Health and Care Act (2022) which transferred the duties and responsibilities from the former clinical commissioning group to the ICB.

The Hospitals Transformation Programme fits within a broader programme of work across the whole ICS, including the Local Care Transformation Programme, which aims to deliver more integrated care closer to home and in the community.

Shropshire has a largely rural population of around 320,000 people, 25% of which are aged 65 years and over. It is the second-least densely populated local authority area in the West Midlands and ranks around average among local authority areas in England for health, with female healthy life expectancy better than the UK average.

Telford and Wrekin has a population of around 186,000 people and experienced higher population growth (11.3%) between the last two censuses held in 2011 and 2021 than the West Midlands overall (6.2%). It ranks higher than the England average for additions to the housing stock, including new builds, and is in the bottom 10% of local authority areas in England for health, with male healthy life expectancy worse than the UK average.

The Shrewsbury and Telford Hospital NHS Trust is the main provider of district general hospital services for the ICS and mid Wales. The majority of its services are provided at the Royal Shrewsbury Hospital in Shrewsbury and the Princess Royal Hospital in Telford, which together have around 700 beds. Both hospitals have their own emergency departments open 24 hours a day, seven days a week, with urgent treatment centres alongside them open from 9am to 9pm every day.

In 2012 Shrewsbury became the Trust’s main centre for acute surgery and Telford became the main centre for women’s and children’s services in 2014, with a consultant-led obstetric unit, an alongside midwifery-led birth unit, and a local neonatal unit for high dependency care.

Provision of NHS healthcare in Shropshire, Telford and Wrekin for the residents of mid Wales

Overview

The county of Powys in mid Wales is a large rural county of 133,000 people who are sparsely populated across 2,000 square miles of land, approximately a quarter of the total land in Wales. Because of its rural nature, the county does not have the required critical mass of people to sustain its own district general hospital, therefore the Powys Teaching Health Board, the body responsible for NHS services, pays for Powys residents to receive specialist care in hospitals outside the county in both England and Wales, including hospitals located within the Shropshire, Telford and Wrekin Integrated Care System (ICS).

In their letter to the Secretary of State dated 20 March 2023, Telford & Wrekin Council claims that there are plans for significant expansion in the provision of healthcare in Powys and therefore it is now wrong to include the needs of those residents when making decisions about healthcare in the ICS. They suggest that to do so would be to detriment of patients who reside within the ICS, such as those from lower socio-economic groups in the Telford area.

The Council relies on evidence from Powys Teaching Health Board’s Integrated Medium Term Plan 2022 - 2025, arguing that this plan aims to repatriate as many services as possible from outside Powys back to hospitals within its county so that the residents of mid Wales will no longer need to travel to Shropshire for healthcare.

Discussion and advice

The Panel has considered a statement that was agreed by NHS England and NHS Wales in 2018 on cross-border healthcare for patients along the England and Wales border. This sets out the principle that local health boards in Wales have a statutory responsibility to take reasonable steps to provide healthcare that meets the needs of their local populations by either directly providing healthcare or by commissioning healthcare from other service providers, including those in England, and that NHS emergency care will be available for all patients without regard to the border.

The statement confirms that cross-border issues are to be taken into consideration in the development of any relevant future service reconfiguration and that proposals for changes to NHS services should have regard to the impact on healthcare delivery along the border with public engagement for all groups affected.

The Powys Teaching Health Board wrote to the NHS Trust on 20 June 2023 to give their support for the Trust’s outline business case and its executive directors noted that the service model was fully aligned with the proposals consulted on with the public in 2018. The letter of support confirmed that Powys Teaching Health Board is exploring the development of complementary services that may mitigate the impact of additional travel for their residents due to planned care being centralised in Telford, through plans for a replacement community hospital in Newtown via the North Powys Wellbeing Programme. The respective programme teams for Powys and Shrewsbury and Telford continue to meet to ensure co-ordination and alignment of their plans.

After consideration of Powys’ Integrated Medium Term Plan for 2022-2025 and the more recent version for 2023-2026, along with further evidence submitted by the NHS Trust, the Panel understands that the services planned to be repatriated from England to Wales for care closer to home are few, being constrained to what is appropriate to provide in a community hospital setting. These include low complexity day cases, diagnostics and outpatient services, with only a small impact on the number of people using services provided by The Shrewsbury and Telford Hospital NHS Trust. Powys patients will continue to need access to emergency and planned care in Shropshire, Telford and Wrekin, and the NHS Trust’s data modelling has considered all activity, including from Powys, to determine future demand for their services which is included in the outline business case.

The Interim Chief Executive of the Powys Teaching Health Board wrote to the IRP on 8 November 2023 stating that they continue to support the Hospitals Transformation Programme and that The Shrewsbury and Telford Hospital NHS Trust is the single largest provider of acute hospital services for their residents by volume. In their words the rural communities, particularly in north Powys, “remain critically dependent on the Trust for time critical access to life saving services”.

The Panel concludes that the approach and evidence set out in the NHS Trust’s strategic outline case and outline business case to consider the needs of the population of mid-Wales remains correct and in line with national guidance on cross-border healthcare.

Recommendation 1

The healthcare needs of the residents of mid Wales must continue to be considered as part of the Shrewsbury and Telford Hospitals Transformation Programme.

NHS capital funding allocation

Overview

£312 million of public dividend capital was allocated to the NHS by the Department of Health and Social Care and HM Treasury and announced by the Secretary of State in 2018. The NHS Trust is required to ensure that its capital plans are affordable within this maximum limit and produce a series of business cases with evidence on the service requirements and the ability to complete the project within budget and on time for approval by government. These include a strategic outline case, an outline business case, and a final full business case.

The Department of Health and Social Care and NHS England wrote jointly to the NHS Trust on 19 November 2020, noting that the latest capital estimate for delivering the proposal was £533 million but confirmed the allocation remained at £312 million. The letter directed the NHS Trust “to ensure the project is affordable” and that it was expected that efficiencies could be brought into the programme to reduce the cost of delivery by working with the central programme team. It is understood by the Panel that the increase in costs was primarily due to inflation.

On 17 June 2021, Telford & Wrekin Council’s Health and Wellbeing Board raised concerns about the transparency of the project, as well as its escalating costs, to the Interim Accountable Officer of the NHS Shropshire, Telford and Wrekin Clinical Commissioning Group (CCG). The CCG recognised that there were questions around affordability of the plans and agreed that if there needed to be a significant deviation from the original proposal, the NHS would be required to re-consult.

Concerns about the capital funding constraint were further raised in Parliament by local MPs on 22 March 2022 and 31 March 2022, which the Minister of State for Health responded to by confirming that £312 million remained the capital allocation for the proposal and they encouraged the NHS Trust to propose a solution to meet that budget.

Telford & Wrekin Council claims in their letter to the Secretary of State dated 20 March 2023 that because the capital funding is in real terms due to inflation “very much less” than was originally agreed, the inevitable consequence is that some of the services planned in the original proposal will now be cut to fit the capital limit of £312 million. They argue that because of this funding shortfall, the mitigations included in the decision-making business case agreed in 2019 will no longer be effective at reducing the negative impacts of the proposal.

The Council argues that the NHS has not been clear to them or with the public about changes made to the proposal since the public consultation in 2018. They ask that the NHS publishes information to explain what will be done differently because of the reduction in capital funding. In their words, the proposal has been “newly amended”.

At a meeting of Telford & Wrekin’s Cabinet on 21 September 2023, the Leader of the Council stated that:

over the last few weeks, it had been announced that cancer care, including all planned care, would not be available at the Princess Royal, as well as no planned paediatric care.

In a statement to the IRP on 10 November 2023, Telford & Wrekin Council clarified this further by referring to information they had seen from the NHS Trust, including the planning application for building works submitted to Shropshire Council in 2023, which they claim only recently made clear that all planned care for children and cancer services will not be located at the Princess Royal Hospital site in Telford.

At a meeting with the Panel on 23 November 2023, Telford & Wrekin Council further highlighted their concerns that the NHS Trust has not been open or transparent with them. They stated that the capital plans are not deliverable within the budget and fear that because of this there is a risk that the proposal will only be partially implemented before being shelved to the detriment of their local residents.

Discussion and advice

The Panel considers that the baseline for the service changes that were originally agreed in 2019 is set out in the decision-making business case which followed the public consultation from 2018, the IRP’s advice to the Secretary of State submitted on 31 May 2019 and 31 July 2019, and the Secretary of State’s decision letter of 2 October 2019. These documents have been reviewed by the Panel and compared against the strategic outline case dated 23 July 2022 and the outline business case dated 5 July 2023 produced by the NHS Trust.

The strategic outline case sets out that the NHS Trust’s preferred way forward is the so-called ‘do minimum’ option to deliver the core requirements of the decision-making business case within the £312 million capital allocation, namely the establishment of an emergency care centre at the Royal Shrewsbury Hospital, a planned care centre at the Princess Royal Hospital, and outpatients, diagnostics and urgent treatment centres at both sites. Alongside a separate approved allocation of around £24 million from the Targeted Investment Fund for elective day case services at the Princess Royal Hospital, this option would enable the core elements of the service reconfiguration as described in the public consultation from 2018 to be delivered, but would not address the key estates risks linked to the physical environment of the hospital, such as the need for new wards and the refurbishment of surgical theatres, or deliver the benefits of further integration of health services across the local system.

The NHS Trust explains that by implementing the do minimum option, they will be in a strong position to address estates issues and health integration needs in the future should further capital become available. The Panel also notes that separate funding for renal dialysis facilities has been allocated on top of the £312 million to complement the Hospitals Transformation Programme and the wider strategic goals for the local system.

The strategic outline case confirms that the NHS Trust’s estate is expected to require investment of around £96 million over the next five years, including £48 million of backlog maintenance, £28 million of which is described as being of a “high and significant risk” and the NHS Trust contends that this cannot be addressed through the current level of allocated capital. A survey commissioned in 2021 demonstrated that 68% of the Royal Shrewsbury Hospital’s building stock is rated as “poor” or “unacceptable”, some of which consists of inpatient wards, critical care, theatres, imaging and outpatients. The Princess Royal Hospital’s building stock is described as slightly better but still with 28% of its estate rated as “poor”. The Panel is therefore concerned that the condition of the NHS Trust’s ageing estate is negatively impacting the quality of patient care, particularly with regards to privacy, dignity and wellbeing, and the working environment for staff.

The outline business case seen by the Panel contains an economic appraisal of the options to deliver the service changes agreed in 2019 and which the public were consulted on in 2018. The document sets out clearly that the scope of the service changes that the NHS Trust is seeking to implement matches that which was agreed in 2019. The benefits of the capital investment are made explicit, together with an analysis of the benefits available from further investment to the hospital estate over and above the £312 million as alternative options. A summary of this information has been provided by the NHS Trust in Appendix 2.

On the assertion from Telford & Wrekin Council that it was only recently announced that all planned care for cancer and children is being removed from the Princess Royal Hospital, the Panel put this to the NHS Trust in a meeting on 22 November 2023. The Trust disputed this claim and explained that it has always been the case that planned inpatient care for children and some planned cancer care, for example complex surgery, would be at the Royal Shrewsbury Hospital under the proposal. There will be some planned cancer surgery at the Princess Royal Hospital for non-complex cases and outpatient clinics will continue at both hospital sites. The Trust confirmed that nothing from a clinical services point of view has changed between the proposal agreed in 2019 and the current outline business case today.

In a statement to the IRP on 30 November 2023, the NHS Trust expanded further that there will be an increase in planned adult cancer care at the Princess Royal Hospital with the new provision of day case cancer medical therapy which includes chemotherapy. This is in addition to the increase in planned operations in the new elective care hub which will include patients undergoing diagnostic procedures and surgical treatments for cancer. Children will be seen as part of the 24/7 enhanced urgent care services (A&E Local model) and planned children’s outpatients will continue at the Princess Royal Hospital.

The Panel understands that perhaps due to NHS communications referring to the Princess Royal Hospital as a “dedicated planned care site” that the original proposals may have been interpreted by some, including Telford & Wrekin Council, as meaning that all planned care in its entirety will be located in Telford. Looking back at the development of the proposal and the decision-making business case from 2019, it is clear to the Panel that this was not what was proposed originally. This is specifically because the presence of critical care at the Royal Shrewsbury Hospital meant that complex cancer surgery would need to take place there along with the presence of inpatient paediatrics which meant that the admission of children for surgery could only take place in Shrewsbury.

Although the impact of the funding constraint has been set out transparently in the capital business cases which are in the public domain, these documents are produced with a specific purpose to satisfy the government’s capital approvals process and are marked as “not intended for a public audience”. It is therefore understandable that Telford & Wrekin Council may feel that the public has not been well informed about the issue.

The IRP concludes that the proposal today for the service reconfiguration is consistent with the proposal agreed by the Secretary of State in 2019. The Panel has found no evidence that the capital funding constraint has reduced the range or volume of services that are planned at each site, however the Panel is concerned about the impact on the hospital estate and the physical environment for staff and patients due to the residual backlog of maintenance required.

Recommendation 2

The risks related to the residual estates issues and maintenance backlog must be monitored and their mitigations kept under review by the NHS Trust.

Recommendation 3

The hospital estate should be a a priority for further capital funding. The NHS Trust should continue to consider the options available to access capital investment to ensure the estate is fit for purpose and to reduce the risks to both the clinical service delivery and the negative impact on staff and patient experience.

The ‘A&E Local’ model at the Princess Royal Hospital in Telford

Overview

The decision-making business case in 2019 described that the A&E department at the Princess Royal Hospital in Telford would be reconfigured into an urgent care centre which would be open 24/7 for patients who have an injury or illness that is urgent and cannot be treated by their GP practice.

The IRP supported this urgent care model in its advice to the Secretary of State on 31 July 2019 and further recommended that as much clinically appropriate care as possible should be delivered at the Princess Royal Hospital, including options for diagnostics, ambulatory emergency care and frailty assessment.

On 2 October 2019, the Secretary of State accepted the IRP’s recommendation with an additional direction for NHS England to advise how the urgent care model at the Princess Royal Hospital could be delivered through “an A&E Local”.

Professor Stephen Powis, National Medical Director, and Dame Pauline Philip, National Director of Emergency and Elective Care for NHS England, provided advice to the Secretary of State on 5 November 2019. They stated that the A&E Local would be an enhanced service, distinct from an urgent treatment centre, with an emergency medicine consultant present during core hours, a consultant-led same day or ambulatory emergency care service for certain conditions such as low risk chest pain or pneumonia, and a frailty assessment service together with other urgent treatment services.

On 6 January 2020, the IRP understands that the Secretary of State directed NHS England to work with the two clinical commissioning groups and the NHS Trust to implement the A&E Local model at the Princess Royal Hospital, however this work was subsequently paused due to the Covid-19 pandemic.

The chief executives of the NHS Trust and the Integrated Care Board wrote to NHS England on 13 June 2022 with an update on their proposed approach to the implementation of the A&E Local model. This letter set out concerns from their clinicians about the use of the A&E name, particularly if the Trust would be required to advertise the service as an A&E during core hours, as this may encourage patients with potential life threatening illnesses or injuries to attend the Princess Royal Hospital in the expectation that they would be able to access the same facilities as a Type 1 consultant-led major emergency department which would increase the risk of patient harm.

Telford & Wrekin Council’s letter of 20 March 2023 to the Secretary of State claims that the plans for the A&E Local at the Princess Royal Hospital in Telford are still “totally opaque” and that the NHS has failed to explain what the clinical service will provide, particularly in relation to opening hours, staffing and the facilities available. They ask the IRP to consider whether the A&E Local model is the same as what was consulted on in 2018 and whether the service will be safe, sustainable and accessible. They also assert that Telford will be the largest town in England without a fully functioning A&E department.

They go on to suggest that the two emergency departments at Shrewsbury and Telford are currently safe and sustainable because they have both remained open over the years since the decision on the proposal was made in 2019. Telford & Wrekin Council points to examples of changes made to A&E services at the Weston General Hospital in Somerset and Grantham and District Hospital in Lincolnshire, which they claim as a result have “suffered serious failings in care”.

Telford & Wrekin Council wrote to the Prime Minister on 29 September 2023 and stated that not all local clinicians are supportive of the proposal and that in 2016, the NHS Trust’s board papers showed that there was a clear majority in favour of the emergency centre being at the Princess Royal Hospital.

In a statement made to the IRP on 10 November 2023, the Council contends that the model is “untested” and that clinicians have raised concerns about the risk of residents being confused about what the service provides. They also highlight advice they have received from health colleagues that any A&E signs along local roads would need to be removed to avoid any misunderstanding about which clinical services will be available in Telford.

At a meeting with the Panel on 23 November 2023, Telford & Wrekin Council further submitted that senior clinicians locally have expressed concerns to them privately about the proposal and have told them that there would need to be an emergency ambulance permanently stationed outside the Princess Royal Hospital to take people to the Royal Shrewsbury Hospital because they do not feel assured by the A&E Local model. The Council further outlined their unresolved questions about how the service would be safely staffed overnight and stated that they had been asked by the NHS for help to explain to residents in Telford and Wrekin that they will not be able to attend the Princess Royal Hospital in an emergency because it will not be staffed to provide that type of care. Because the A&E Local model was not described in the consultation document in 2018, the Council is asking for a further public consultation to take place so that the public can be made aware of what it is they will be getting as a service in Telford.

Discussion and advice

On the type of services to be provided under the A&E Local model, the Panel notes that the NHS Trust published an open letter on 27 February 2023 with an update on the proposal. This letter described the model as “24/7 enhanced urgent care services” accessed by NHS 111, by a GP, or by self-presenting, with direct access to a multi-disciplinary team of health, care and community professionals for diagnosis and treatment in the same place, on the same day. The letter confirmed that some emergency ambulance patients will also be transported directly to Telford for their treatment where appropriate, with those patients being identified during the triage performed by the ambulance control centre.

The NHS Trust submitted to the Panel on 8 November 2023 that the A&E Local model will include services over and above a standard urgent treatment centre and will be open 24/7, with medical same day emergency care (SDEC) available 12 hours a day for the assessment and treatment of all common medical conditions. NHS England defines SDEC as care for emergency patients who can be rapidly assessed, diagnosed and treated without being admitted to a ward, and if clinically safe to do so, will go home the same day their care is provided.

The NHS Trust’s statement goes on to confirm that the A&E Local service will provide a multi-disciplinary frailty assessment centre, the ability to stabilise any seriously ill patients who ‘walk in’ to the Princess Royal Hospital, and immediate access to extended imaging services such as CT or ultrasound with blood and urine testing. They confirm that the service will be staffed by general practitioners, qualified advanced clinical practitioners, and emergency care practitioners supported by registered nurses and health care assistants with competencies to care for children. Emergency medicine consultants will be present five days a week between 9am to 5pm to provide training, supervision and effective clinical governance. Other staff in emergency medicine will rotate from the emergency department at the Royal Shrewsbury Hospital to the Princess Royal Hospital to further support training and patient care.

The NHS Trust confirmed to the Panel in a meeting on 22 November 2023 that they are confident that the staffing model planned for the A&E Local model will be safe. A description of the proposed service and its staffing provided by the NHS Trust to the Panel is set out in Appendix 3.

On the sustainability of the two current emergency departments in Shrewsbury and Telford, the NHS Trust submitted to the Panel on 8 November 2023 that in the 12 months between October 2022 and September 2023, there were 13 critical incidents, 10 of which were because of severe capacity issues. Due to extreme pressure at the NHS Trust, the ambulance service has needed to regularly deploy ‘intelligent conveyancing’ meaning that once a maximum number of ambulances at the emergency department had been reached, ambulances had to be diverted to other hospital trusts outside the area. The Trust claims that the new emergency department at the Royal Shrewsbury Hospital, supported by urgent treatment centres at both sites, will help ensure that there is capacity for both emergency and urgent care needs and reduce the prevalence of these critical incidents.

The NHS Trust says that their workforce situation is not sustainable due to the duplication of emergency services across both sites and the risk of unsafe staffing. Clinical workforce data submitted by the Trust for their urgent and emergency care services at both hospital sites over the last 12 months shows that they are short of 10 consultants and 66 nurses against their full time equivalent funded establishment. Some emergency department and anaesthesia vacancies have been unfilled for over five years and informal feedback from trainees has shown that they would be reluctant to return to the Trust as senior clinicians with the current clinical model. They say that delays in implementing the new model have had an adverse impact on the recruitment and retention of staff as well as staff morale, and there is a risk that a significant proportion of their substantive consultants would leave their workforce if the proposal did not go ahead.

The Panel was further concerned to read the findings of the latest Care Quality Commission inspection report dated 18 November 2021, which rated the NHS Trust overall as “inadequate” and highlighted that the design, maintenance and use of facilities in the emergency department at the Royal Shrewsbury Hospital did not keep people safe.

Regarding the concept of an A&E Local, the Panel understands that this was first proposed within the NHS Long Term Plan in 2019 by NHS England as an option for hospitals implementing ‘hot’ (emergency care) and ‘cold’ (planned care) sites where it would not be possible for a cold site to fully shift its services to provide planned care only. At the time, a draft framework for A&E Local was suggested by NHS England to enable a standard service in locations which were unable to provide a full Type 1 consultant-led emergency department but still had a need for emergency medicine services within restricted hours.

NHS England’s submission to the IRP on 7 November 2023 confirmed that following the Secretary of State’s decision in 2019, work to develop the A&E Local model was then deprioritised during the Covid-19 pandemic and the model has not been developed any further at a national level.

Following advice received from NHS England, the Panel understands that there is scope for the standard urgent treatment centre model to be locally adapted to provide an enhanced service if clinically safe and appropriate, however the Panel notes that NHS England’s guidance on the principles and standards for urgent treatment centres, first published in 2017 and formally refreshed in 2023, does not include the term A&E Local. The guidance states that the NHS needs to clearly communicate to the public about what the service is for using consistent urgent treatment centre terminology to ensure that it is understandable and accessible to all. It goes on to say that the name ‘urgent treatment centre’ must be adopted on both road signage and on site signage, on relevant websites, and in all other communications for internal and external stakeholders about the service.

The IRP approached the Royal College of Emergency Medicine (RCEM) for comment and they provided a statement on 13 November 2023. This confirmed that after corresponding with local clinicians, they are supportive of the aim to reconfigure the emergency department in Telford into an urgent treatment centre. They stated that they do not support the term A&E Local for the urgent treatment centre in Telford because it is not a recognised term and could create confusion among the public. They explained that a patient with a serious and time critical condition, such as a stroke, heart attack or sepsis, could present to an A&E Local expecting the same level of care as a Type 1 emergency department, causing a risk to patients who attend a facility with much reduced capability. In RCEM’s view, the urgent treatment centre brand is well understood and they therefore recommend that the facility at the Princess Royal Hospital is called an urgent treatment centre.

With regard to these factors, which the Panel has considered very carefully, it is the Panel’s view that the A&E Local concept has been the source of some confusion and debate. The term was introduced before there had been a standard definition agreed for the NHS, and as Telford & Wrekin Council has pointed out, after the public consultation in 2018 and IRP advice in 2019. Four years later, while the A&E Local model has been pursued for Telford, the use of the A&E Local name does not appear across England or in NHS England’s national guidance on urgent treatment centres. The Panel therefore empathises with Telford & Wrekin Council’s point of view that the name and what it means for the people who will use the services at the Princess Royal Hospital in the future has not been fully explained.

In the IRP’s view, the service proposed for Telford is a 24/7 urgent treatment centre enhanced by wraparound services on the Princess Royal Hospital site. The Panel is reassured by the level of care contained in the proposal for paediatrics, frailty, same day emergency care and diagnostics. It is anticipated that this will support primary and community care services in the locality and contribute to better emergency and planned services for the whole population served. However, it is important that the public are aware of the limitations of the service and understand that it will not provide emergency care to the same level as a Type 1 consultant-led major emergency department.

On the issue raised by Telford & Wrekin Council on transparency, the strategic outline case stated that since 2019 there has been significant stakeholder engagement with NHS staff, the public and system partners. The NHS Trust’s stakeholder plan demonstrates an awareness that they need to communicate and engage effectively with the local community, particularly about what the clinical pathways mean for patients, to ensure that the public is aware of the changes being made and how they may be affected, with the benefits clearly communicated.

In a statement to the IRP of 8 November 2023 the NHS Trust contends that they have hosted a series of public webinars online and created targeted focus groups to share the latest information on the proposal and to answer questions from the public. The NHS Trust has a community membership of over 3,500 local stakeholders through which a monthly update is provided on the Hospitals Transformation Programme, and the Trust plans to involve the public further to inform the full business case, the final stage of the capital approvals process.

The Panel is satisfied that the services proposed under the A&E Local model are in line with what was consulted on in 2018, the decision-making business case from 2019, the IRP’s recommendations from 2019, and NHS England’s latest guidance on the principles and standards for urgent treatment centres.

The model is consistent with the aspiration to offer more than a standard urgent treatment centre at the Princess Royal Hospital, and builds on existing clinical practice and established models of care, therefore the Panel does not support the suggestion that further consultation with the public is required. However, the NHS Trust has a continuous duty to involve the public in the development of its services. The Panel therefore advises that it is important that the public and other stakeholders are engaged in shaping the design of services and made aware of the different types of urgent and emergency care within the local system, including the different scenarios that may cause people to seek treatment.

Turning again to the meaning of the term A&E Local, the NHS Trust explained to the Panel on 22 November 2023 that what they are describing for the urgent care service is an “A&E Local model” aligned with national guidance and enhanced by the provision of same day emergency care. The Trust however accepted that questions such as the signage and what to put over the door when the service opens will need to be addressed and resolved.

The Panel shares the view of the Royal College of Emergency Medicine that the use of the term A&E for anything other than a Type 1 emergency department presents a risk to patient understanding and safety. It is therefore vital to be clear with the local population about what they need to do and when in order to access the appropriate urgent or emergency care services within the local integrated care system.

Recommendation 4

The NHS Trust and the NHS Shropshire, Telford and Wrekin Integrated Care Board need to continue their communication and engagement programme to keep the public, stakeholders and clinicians within the integrated care system informed and updated about how the enhanced urgent treatment centre at the Princess Royal Hospital in Telford will operate. This includes its clinical leadership and supervision, staffing, opening hours and how it works with other services within the Trust and wider system.

Recommendation 5

Before implementation of the enhanced urgent treatment centre, a public information campaign and appropriate signage will need to be in place to ensure that people know where to go to receive the right care at the right time and in the right place.

Ambulance response times and transfers between the hospital sites

Overview

The NHS Trust’s decision-making business case from 2019 accepted that the reconfiguration proposal would mean that some people would have to travel further than they do now for emergency care and outlined that there had been consistent concerns raised around ambulance response times, including the increase in average journey times for ambulances transporting patients to the new emergency centre at the Royal Shrewsbury Hospital. Mitigation plans were developed at the time to ensure that there would be sufficient emergency ambulance and non-emergency patient transport services and policies for the safe transfer of patients between the two hospital sites, which are approximately 17 miles apart via the A5 dual carriageway.

The Chief Executive of the West Midlands Ambulance Service advised in 2019 that while there may be longer journey times to the new emergency department at the Royal Shrewsbury Hospital, the proposal would improve the flow of patients in hospital which would in turn improve the turnaround times for ambulance crews and increase ambulance availability. They also stated that they were assured that the local clinical commissioning groups would commission the right level of service provision to maintain patient safety and standards of care.

The NHS Trust committed in 2019 to developing a new service specification and standard operating procedure for the safe transfer of patients to support the reconfiguration proposal with the aim that the ambulance service would make a clinical decision on the most appropriate hospital site to take the patient to for treatment, whether that be the emergency care site in Shrewsbury or the urgent treatment centre in Telford.

Telford & Wrekin Council submits in their letter to the Secretary of State on 20 March 2023 that the proposal to locate the emergency department at the Royal Shrewsbury Hospital relies on the ability of ambulances to convey patients there within a safe timeframe. They suggest that the NHS has shown no regard to the changes to mean ambulance response times which have increased over the last few years, meaning that those with the greatest need will now take “dramatically longer” to reach the Royal Shrewsbury Hospital.

In a statement to the IRP on 10 November 2023, Telford & Wrekin Council set out their concerns that seriously ill patients in Telford will be waiting a long time for ambulances to transfer them to the proposed emergency department at the Royal Shrewsbury Hospital, citing performance data from January 2023 which recorded over 200 patients waiting at least an hour to be transferred upon arrival at the Trust’s hospital sites and that ambulance response times were the longest on record. They claim that clinicians have raised concerns about the risk of residents being confused about what the urgent care service in Telford will provide, therefore requiring ambulances to be on standby at the Princess Royal Hospital site to transfer patients who require emergency care to Shrewsbury, potentially delaying the appropriate care.

Discussion and advice

The Panel has seen data on the average ambulance response times for the Shropshire, Telford and Wrekin Integrated Care System and notes that they have deteriorated significantly between the years of 2020 and 2023 and are not meeting national performance standards. The Leader of Shropshire Council has further highlighted concerns about ambulances to the Panel, citing a report from the local Healthwatch organisation on people’s experiences of ambulances in Shropshire, Telford and Wrekin. This report was published on 2 February 2023 and found that 66% of respondents were concerned about the length of time they had to wait for an ambulance.

The NHS Trust submitted to the Panel on 8 November 2023 that one of the biggest reasons for this decline in performance is due to ambulance handover delays outside their emergency departments. They advise that they are confident that the reconfiguration proposal will address this because the separation of planned and emergency care will improve patient flow through the new emergency department at the Royal Shrewsbury Hospital which will also be supported by an increased number of beds. They suggest that this will reduce waiting times for patients and improve ambulance handover times which in turn is expected to have a positive impact on ambulance response times.

On the issue of transfers between hospital sites, it is important to note that the NHS Trust currently does not have all of its clinical services available at both hospital sites and therefore already has emergency transfer policies in place that have been agreed with the ambulance service to safely transport patients between the two hospitals in Shrewsbury and Telford, or to other major acute centres such as Stoke-on-Trent or Birmingham for specialist care, including for surgery, paediatrics, stroke or trauma care.

The NHS Trust confirmed to the Panel that their current ambulance conveyance protocols will be updated to reflect the new model of care in the Hospitals Transformation Programme and that both the West Midlands Ambulance Service and the Welsh Ambulance Services have been consulted with throughout the development of the strategic outline case and the outline business case. They explained that skilled clinical teams at the Princess Royal Hospital will have the ability to assess, stabilise, treat and transfer seriously ill ‘walk in’ patients and in the event that a patient became critically unwell, they would be quickly and safely transferred directly via ambulance to the emergency department or an appropriate specialty assessment area at the Royal Shrewsbury Hospital. In rare cases they would be transferred out of the county to an appropriate tertiary centre, such as for complex trauma or a heart attack, as is already current practice.

The NHS Shropshire, Telford and Wrekin Integrated Care Board confirmed to the Panel in a meeting on 22 November 2023 that they are working collaboratively with the NHS Black Country Integrated Care Board, who are the lead commissioner for ambulance services for the West Midlands region, to ensure that the West Midlands Ambulance Service has the capacity to ensure that the right vehicles will be in the right place for patients to be safely conveyed to both hospital sites.

The Panel agrees with Telford & Wrekin Council that the urgent and emergency care model in Shrewsbury and Telford relies on the stabilisation of seriously ill patients and their timely transfer via emergency ambulance from the Princess Royal Hospital to the Royal Shrewsbury Hospital. It is therefore vital that there are appropriate numbers of ambulances available and transfer protocols in place to deliver safe and effective patient care.

The Panel further identified a general risk that if demand for emergency care is not managed with a whole system approach then in times of ‘escalation’ due to major operational pressures, surgery may be cancelled to free up beds, acute patients presenting to the Telford site may be prevented from being transferred to Shrewsbury or acute patients in Shrewsbury may be admitted to the Telford site inappropriately due to a lack of bed capacity. At a meeting with the Panel on 22 November 2023, the NHS Trust confirmed that the Princess Royal Hospital will be a site for planned care and planned admissions only and that the best and safest model is to have all the acute (unplanned) admissions on one site in Shrewsbury.

Recommendation 6

Ambulance conveyance protocols for the Princess Royal Hospital and the Royal Shrewsbury Hospital must continue to be be developed and updated by the NHS to ensure the safe and timely transfer of patients.

Recommendation 7

To support the Hospitals Transformation Programme, the revenue funding consequences for emergency ambulances must be reviewed regularly to ensure that the appropriate capacity is available when needed for transfers. Whether this would involve an ambulance being permanently on standby at the Princess Royal Hospital is for the NHS Trust to consider locally in agreement with the West Midlands Ambulance Service.

Recommendation 8

The NHS Shropshire, Telford and Wrekin Integrated Care Board and the NHS Trust must together together review their escalation procedures to ensure that in times of limited bed capacity at the Royal Shrewsbury Hospital, acute patients are not inappropriately held at or admitted to the Princess Royal Hospital site temporarily because of the significant risk to patient safety and the impact on the delivery of planned care in Telford.

Changes to population demographics in Shropshire, Telford and Wrekin

Overview

An equality impact assessment (EIA) was conducted in 2018 by the NHS which reviewed the demographic profiles across the different local authority areas. Telford and Wrekin was found to have the highest levels of deprivation, higher percentages of people aged 0-19 and 30-44 years and a higher percentage of ethnic minorities and women of child-bearing age. In comparison, a higher percentage of older people aged 50 plus were found in Shropshire and Powys.

Population projections contained in the decision-making business case from 2019 estimated that by 2036, people aged 70 and over would account for 25% of the population of Shropshire and 29% in mid Wales vs 18% in Telford and Wrekin, which was cited as a factor influencing the decision to locate the emergency care centre at the Royal Shrewsbury Hospital.

The EIA acknowledged that the proportion of people over 65 was increasing in Telford and Wrekin, and the overall population in the borough was projected to grow at a faster rate than the England population, to over 196,000 people by 2031.

In their letter to the Secretary of State dated 20 March 2023, Telford & Wrekin Council argues that the proposals are now based on out-of-date evidence, including the EIA from 2018, which they say relies on demographic data from 2015 and does not reflect current circumstances.

Since the proposal was developed, the Council submits that the Telford population has grown at a faster rate than in Shropshire and most other places in England, with a greater proportion of children, women of child-bearing age, those over the age of 65, and those in lower socio-economic groups in Telford compared to Shropshire. They claim that the NHS did not make any allowance for this rate of change in the proposal and this will increase inequalities because of the many more people who will need to access an A&E department and women’s and children’s services in Telford.

The Council also submits that healthy life expectancy is lower in Telford than in Shropshire, worse than the average for England, and that Telford is more economically deprived than Shropshire. They suggest that the proposal will make it more difficult for people in their area to access the healthcare they need and asks the IRP to review the proposal in light of up to date demographic information. They also claim that the NHS proposal runs counter to the government’s ‘Levelling Up’ commitment to narrow the gap in healthy life expectancy between areas.

Discussion and advice

The Panel has reviewed the submission from Telford & Wrekin Council which contains an analysis of data from the 2021 Census and the 2019 Index of Multiple Deprivation, and acknowledges that there have been considerable changes to the population of the local area since 2011, with particularly high population growth in Telford and Wrekin (11.4%) when compared to Shropshire (5.7%). It is recognised that there has been a large increase in people aged 65 years and over (up by 35.7%) in Telford and Wrekin, that the number of women of child bearing age (18-44 years) is projected to increase at twice that of Shropshire by 2032, and that overall, Telford and Wrekin is more deprived with a lower healthy life expectancy than Shropshire.

Telford & Wrekin Council submitted further population data to the Panel from the Office for National Statistics on 4 December 2023. This data demonstrates that Telford and Wrekin had in-year population growth of 3,014 or 1.6% per annum, double that of Shropshire at 0.8% for the same period. They state that this is faster growth than the West Midlands average rate of 1.1% (with Telford and Wrekin being the fastest growing in that period), and also faster growth than the England average of 1.0%, and that the last time the population grew by more than 3,000 per year was in 1998. They go on to say that this data reinforces the sustained and long-term dramatic population growth being experienced by Telford and Wrekin and the population trends they have highlighted with regards to children and women of child-bearing age, as well as the elderly.

The Panel notes that the strategic outline case from 2022 did not include an updated equality impact assessment, however it did contain a statement from the NHS Trust that they would review and refine this at the outline business case and full business case stages to ensure that the proposal was not detrimental to any protected group. The strategic outline case contains population projections showing that Telford and Wrekin’s over 65 population is expected to grow at a rate higher than the national profile, from around 18% in 2018 to 23% by 2043. It is significant to note that the report also demonstrates that the over 65 population in Shropshire is expected to grow from around 25% in 2018 to 33% by 2043.

On 6 February 2023, the Chair of the NHS Shropshire, Telford and Wrekin Integrated Care Board (ICB) wrote to the Leader of Telford & Wrekin Council following a meeting between representatives from the Council and NHS colleagues to discuss the Hospitals Transformation Programme. This letter acknowledged the concerns raised about the residents of Telford and Wrekin and stated that the changes in health system population demographics had been fully considered by the programme and that the NHS was confident that their needs, along with the needs of the wider population, are addressed in the integrated care partnership interim strategy for Shropshire, Telford and Wrekin.

The ICB stated that they wanted the improvements in care through the Hospitals Transformation Programme to act as a catalyst for major changes in health and care services across Shropshire, Telford and Wrekin, through a process of integrating care out of hospital and in, or as near to, people’s homes as possible, and that they want to work with Telford & Wrekin Council as a critical partner as they continue to develop their integrated model of health and care.

The NHS Trust submitted to the Panel on 8 November 2023 that both Shropshire and Telford and Wrekin have seen significant growth in their populations, particularly in the number of people aged over 65 years. They state that these changes in local population demographics were reviewed towards the end of 2022 with their local authority partners, including Telford & Wrekin Council, as part of their engagement to develop a new integrated care strategy for the local system, which the Hospitals Transformation Programme is a major part of. The NHS Trust goes on to say that the data has been fed into the ICB’s joint health and wellbeing strategies, their two place-based strategies and ultimately the overall Joint Forward Plan, agreed by the ICB and their partner NHS trusts, which sets out how the health and care system will work together to deliver their priorities jointly over the next five years to improve outcomes and reduce health inequalities.

The IRP has reviewed the population projections from the decision-making business case back in 2019 and noted that the options appraisal demonstrated that centralising emergency services in Shrewsbury would involve certain trade-offs because it would impact residents in Shropshire, and Telford and Wrekin, differently. The Panel concluded at the time that locating the emergency department at the Royal Shrewsbury Hospital would establish a critical mass of hospital infrastructure and clinical expertise to support a wider trauma network for the entire integrated care system and mid Wales.

The Panel has considered the latest version of the outline business case which confirms that the NHS Trust’s demand and capacity requirements were refreshed in January 2023 to take account of the latest population projections from the Office for National Statistics. The document recognises that inequalities are particularly high in Telford and that opening the planned care hub will improve accessibility for residents and support improvement in population health outcomes. In particular, early mortality from preventable cancer is prevalent in Telford and will aim to be addressed through the improved clinical model enabled by the Hospitals Transformation Programme.

Contained in the appendices to the outline business case is information to confirm that clinical teams have developed 12 refreshed equality and health inequality impact assessments (EHIAs) aligned with individual clinical services such as urgent and emergency care, maternity and paediatrics. These EHIAs include vulnerable groups and protected characteristics in line with the Equality Act 2010 and the Public Sector Equality Duty, and it is expected that the EHIAs will be further refined at the full business case stage to ensure any potential negative impacts can be mitigated.

The draft combined EHIA seen by the Panel states that patients who require emergency care living in the east of Shropshire will have further to travel and that people living in deprived areas may need to access acute services more often because of poorer health, but will benefit from having all 24/7 surgical, medical, intensive care, and specialty experts in one place at the new emergency centre in Shrewsbury. Age-appropriate environments for children and a greater number of single rooms will be available in the new build at the Royal Shrewsbury Hospital. The document recommends that information is shared about eligibility for patient transport and the recovery of expenses, with any individual requirements to be discussed with patients to accommodate their needs.

It is acknowledged by the Panel that there have been some changes to demographics and socio-economic indicators in the local population over the last few years as Telford & Wrekin Council have highlighted. However, given population projections are estimates and the need to consider the populations of Shropshire, Telford and Wrekin, and mid Wales, the Panel is satisfied that any difference between those used for the decision-making business case and the latest available data would not significantly affect the balance of factors and evidence for either the clinical case for change or the decision about the location of the emergency department in Shrewsbury.

The Panel considers that the population changes are relevant to the ongoing work of the NHS and its system partners in addressing health and healthcare inequalities and agrees with Telford & Wrekin Council that socio-economic deprivation is important to consider as a key driver of inequalities, including its impact on healthy life expectancy. Healthcare inequalities in relation to access to healthcare, the patient experience and health outcomes are also important factors that should be measured by the NHS but in the Panel’s experience can often be overlooked when developing equality impact assessments.

Recommendation 9

The NHS Trust’s equality and health inequality impact assessments should continue to be refreshed to reflect the most up to date population data and take account of any changes in demographics, levels of deprivation and healthy life expectancy, as well as access to healthcare, the patient experience and health outcomes.

Recommendation 10

The Hospital Transformation Programme’s work on mitigating inequalities must continue as part of a system-wide approach working in partnership with all health and care organisations within the Shropshire, Telford and Wrekin Integrated Care System to deliver joined-up and person-centred care for the whole population.

The future of NHS services in Shropshire, Telford and Wrekin

The Local Care Transformation Programme

A common theme during the public consultation for the Hospitals Transformation Programme was the desire for more investment in community services, including making better use of the existing community hospitals in the Shropshire, Telford and Wrekin Integrated Care System (ICS) for people to receive care closer to home, particularly for those in rural communities. The decision-making business case in 2019 therefore included a mitigation to make progress on out-of-hospital care strategies and their interdependencies for delivering the new model of care.

The Local Care Transformation Programme for the ICS, which is referred to in the strategic outline case, aims to complement the Hospitals Transformation Programme by caring for patients in more appropriate settings outside of an acute hospital setting where possible. The ICS suggests that providing more joined-up, integrated and proactive care in the community will lead to a much lower increase in acute bed requirements over the medium to long term. A range of initiatives are planned, including virtual wards (meaning the use of technology to receive acute care and monitoring at home), reducing the length of stay in hospital and preventive measures to avoid hospital admissions in the first place.

The Panel recognises that the Hospitals Transformation Programme relies on an effective integrated care pathway for acute and community services. Building on the work already in progress on mitigating inequalities by the ICS, and in response the concerns highlighted by Telford & Wrekin Council about the population growth and deprivation within their area, the Panel suggests that the Local Care Transformation Programme presents an important opportunity to focus on prevention and better integration, particularly by linking up services with the urgent treatment centre in Telford and by improving access to primary and community care to prevent the need for people to attend hospital.

Recommendation 11

As part of the Shropshire, Telford and Wrekin Integrated Care System’s wider inequalities strategy, the impact of the Local Care Transformation Programme in mitigating the effects of the Hospitals Transformation Programme needs to be regularly refreshed and reviewed.

Travel and transport

The public consultation on the proposal in 2018 found that travel to the two hospital sites was raised as one of the most common concerns and a mitigation plan for travel and transport was therefore agreed in 2019 as part of the decision-making business case.

Telford & Wrekin Council wrote to the Secretary of State on 3 July 2023 to follow up on their original complaint from 20 March 2023 and stated that Telford and Wrekin has a disproportionately higher number of residents without access to a private motor vehicle than in Shropshire, meaning that their residents face significant challenges in potentially needing to travel more than 20 miles to Shrewsbury to access hospital care and treatment. They give an example of someone living in their borough having to take six buses and travel for three hours to get to the Royal Shrewsbury Hospital which they say is “not realistic or fair”.

The Panel has seen the NHS Trust’s travel plan dated 15 September 2023 that was submitted to Shropshire Council as part of the planning application for building works at the Royal Shrewsbury Hospital. This includes a plan for a new bus service between the two hospital sites in Shrewsbury and Telford which would be available for staff, patients and visitors and would be free of charge for all. The Panel finds this to be an encouraging development and notes that full details are subject to further discussions to determine specific requirements.

At a meeting with the NHS Trust and the NHS Shropshire, Telford and Wrekin Integrated Care Board on 22 November 2023, the Panel further challenged the NHS about these issues. The Trust confirmed that they have reviewed all of their travel and transport mitigations and they have identified existing travel networks and the community transport providers already available. They are continuing to engage with local people and stakeholders via focus groups to develop an action plan to support implementation of the new reconfigured model of care which is planned to open in 2026-27. The Trust pointed out that there will also be digital links across the two hospital sites for patients to access virtual consultations and avoid the need for travel in some circumstances.

Recommendation 12

To address the travel and transport impact of the Hospitals Transformation Programme the NHS Trust should continue to develop and update its action plan, with support from its established focus groups, to improve access to both hospital sites in Shrewsbury and Telford.

Overall conclusion

The IRP has reviewed the issues raised by Telford & Wrekin Council, the further evidence submitted by the various parties involved, and the series of events that have occurred since the Secretary of State’s decision in 2019.

Telford & Wrekin Council raised with the IRP during a meeting on 23 November 2023 a potential option to build a new single site hospital in Shropshire between the two existing hospitals. A feasibility study in 2018 concluded that the capital costs of this option would be significantly higher than the £312 million allocated. In the current financial climate, and given the impact on timescales for completion and delivery of the new clinical model, the Panel would not advise further consideration of this as a credible option.

After reviewing the clinical case for change again, the Panel considers that there are clear benefits from having a centralised emergency care site with a separate planned care site for the future safety, sustainability and accessibility of the NHS Trust. The Panel is satisfied that the Royal Shrewsbury Hospital remains the best location for the emergency care centre because it will establish a critical mass of hospital infrastructure and expertise for the operation of a wider trauma network to support the whole population of Shropshire, Telford and Wrekin, and mid Wales.

Taking account of all the evidence, and subject to the recommendations made in this report, the Panel concludes that the current proposal for clinical services, as described in the outline business case, is consistent with what was agreed in 2019. The critical advice about the clinical model and the location of services given by the Panel to the Secretary of State in 2019 remains the view of the Panel at this time.

Final recommendation

Subject to the recommendations in this report, the Hospitals Transformation Programme is the best way forward to improve acute hospital services for the Shropshire, Telford and Wrekin Integrated Care System.

Recommendations

1. The healthcare needs of the residents of mid Wales must continue to be considered as part of the Shrewsbury and Telford Hospitals Transformation Programme.

2. The risks related to the residual estates issues and maintenance backlog must be monitored and their mitigations kept under review by the NHS Trust.

3. The hospital estate should be a priority for further capital funding. The NHS Trust should continue to consider the options available to access capital investment to ensure the estate is fit for purpose and to reduce the risks to both the clinical service delivery and the negative impact on staff and patient experience.

4. The NHS Trust and the NHS Shropshire, Telford and Wrekin Integrated Care Board need to continue their communication and engagement programme to keep the public, stakeholders and clinicians within the integrated care system informed and updated about how the enhanced urgent treatment centre at the Princess Royal Hospital in Telford will operate. This includes its clinical leadership and supervision, staffing, opening hours and how it works with other services within the Trust and wider system.

5. Before implementation of the enhanced urgent treatment centre, a public information campaign and appropriate signage will need to be in place to ensure that people know where to go to receive the right care at the right time and in the right place.

6. Ambulance conveyance protocols for the Princess Royal Hospital and the Royal Shrewsbury Hospital must continue to be developed and updated by the NHS to ensure the safe and timely transfer of patients.

7. To support the Hospitals Transformation Programme, the revenue funding consequences for emergency ambulances must be reviewed regularly to ensure that the appropriate capacity is available when needed for transfers. Whether this would involve an ambulance being permanently on standby at the Princess Royal Hospital is for the NHS Trust to consider locally in agreement with the West Midlands Ambulance Service.

8. The NHS Shropshire, Telford and Wrekin Integrated Care Board and the NHS Trust must together review their escalation procedures to ensure that in times of limited bed capacity at the Royal Shrewsbury Hospital, acute patients are not inappropriately held at or admitted to the Princess Royal Hospital site temporarily because of the significant risk to patient safety and the impact on the delivery of planned care in Telford.

9. The NHS Trust’s equality and health inequality impact assessments should continue to be refreshed to reflect the most up to date population data and take account of any changes in demographics, levels of deprivation and healthy life expectancy, as well as access to healthcare, the patient experience and health outcomes.

10. The Hospital Transformation Programme’s work on mitigating inequalities must continue as part of a system-wide approach working in partnership with all health and care organisations within the Shropshire, Telford and Wrekin Integrated Care System to deliver joined-up and person-centred care for the whole population.

11. As part of the Shropshire, Telford and Wrekin Integrated Care System’s wider inequalities strategy, the impact of the Local Care Transformation Programme in mitigating the effects of the Hospitals Transformation Programme needs to be regularly refreshed and reviewed.

12. To address the travel and transport impact of the Hospitals Transformation Programme the NHS Trust should continue to develop and update its action plan, with support from its established focus groups, to improve access to both hospital sites in Shrewsbury and Telford.

13. Subject to the recommendations in this report, the Hospitals Transformation Programme is the best way forward to improve acute hospital services for the Shropshire, Telford and Wrekin Integrated Care System.