Independent report

Advice to the Minister of State for Health on Mid and South Essex acute services

Published 30 July 2019

Applies to England

1. Letter to the Minister of State for Health

Stephen Hammond MP
Minister of State for Health
39 Victoria Street
London
SW1H 0EU

17 July 2019

Dear Minister,

Thank you for forwarding copies of the referral letters and supporting documentation from Councillor Cheryl Nevin, Chair, Southend-on-Sea Borough Council People Scrutiny Committee (PSC) and from Councillor Victoria Holloway, Chair Thurrock Council Health & Wellbeing Overview and Scrutiny Committee (HOSC). NHS England (East of England) provided assessment information. A list of all the documents received is at Appendix one. The IRP provides this advice 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 Chairman, Lord Ribeiro, a former consultant surgeon at Basildon University Hospital, declared a conflict of interest and consequently took no part in the consideration and production of this advice. The sub-group leading this work was chaired by Suzanne Shale, IRP member.

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

2. Background

The population of mid and south Essex is around 1.2 million of which around 180,000 live in Southend-on-Sea on the south east coast of the county and around 170,000 in Thurrock on the north bank of the River Thames. Throughout the area - the population of which is projected to grow by some 136,000 by 2031 - there is considerable demographic diversity in affluence and deprivation.

Acute health care is provided by Basildon and Thurrock University NHS Foundation Trust (Basildon Hospital and Orsett Hospital), Southend University Hospital Services NHS Foundation Trust (Southend Hospital) and Mid-Essex Hospital Services NHS Trust (Broomfield Hospital). Services are commissioned by Mid & South Essex Clinical Care Group (CCG) Joint Committee and NHS Specialised Commissioning. Community and mental health care is provided by Essex Partnership University NHS Foundation Trust, North East London NHS Foundation Trust, and Provide.

In June 2015, health and care organisations in mid and south Essex were selected to enter the NHS Success Regime, a national programme to improve health and social care in locations where there were deep-rooted systemic pressures. With the establishment of Sustainability and Transformation Partnerships (STP) in 2016, it was decided to embed the work of the Success Regime into the Mid and South Essex STP with the same footprint and governance processes.

Consideration of possible changes to health services in Thurrock dates back to 2015 leading, in Spring 2016, to the commencement of a local engagement process run jointly by Thurrock Council and Thurrock CCG For Thurrock in which residents were asked about their priorities for integrated medical centres (IMC) and services that should be provided locally. In March 2016, a Healthwatch Thurrock report on For Thurrock in Thurrock received over 9,000 responses with respondents reporting a strong desire to have care delivered closer to home. Also, in March 2016, an ‘acute leaders group’ was formed comprising more than 50 local clinicians to develop options for change.

East of England Clinical Senate reports, covering progress in developing the Success Regime, were published in June and October 2016. The Thurrock HOSC received an update on the success regime/STP on 10 November 2016.

An options appraisal workshop, Mid and South Essex Success Regime – A programme to sustain services and improve care, was held on 22 February 2017. On 17 May 2017, a ‘Memorandum of Understanding’ (MOU) for Thurrock was co-signed by relevant partners including Thurrock CCG, Thurrock Council and Basildon Hospital. The MOU stated that:

Provision of services at Orsett Hospital would not cease prior to the construction and opening of the integrated medical centres

and

a comprehensive review of health and care services provided at Orsett would be undertaken to inform the appropriate clinical services which may be mitigated to each IMC or other appropriate location, taking account of the specific care needs of the population of each of the four localities in Thurrock.

In August 2017, NHS representatives provided a presentation to the Thurrock HOSC of the action plan for the Thurrock IMCs.

On 20 September 2017, NHS representatives presented a paper to the Southend Health & Wellbeing Board about the STP and detailing progress with a pre-consultation business case, describing the options appraisal process and a change to the clinical service model proposed that would maintain three fully functioning A&E departments at Basildon, Broomfield and Southend. The NHS England National Clinical Director for Stroke emailed NHS officials on 30 September 2017 to offer views on the proposed model for stroke services under the STP. The model differed from the national model of a single hyper-acute stroke unit (HASU) in that people suspected of having a stroke would access care via their nearest A&E department. All three A&E departments would be able to diagnose and initiate treatment if required. The patient would then be transferred to the specialist stroke unit at Basildon Hospital for the first 72 hours post-stroke to receive intensive support and care from a dedicated team before being transferred back home, to their local hospital for ongoing acute care or to a community facility. A third East of England Clinical Senate report, published in September 2017, questioned whether there was evidence to support the plan to initiate stroke treatment (thrombolysis) on three sites.

The East of England Clinical Senate’s fourth report of October 2017 considered further evidence about the proposed model for stroke services and made recommendations, including about additional modelling work required. A meeting of the Southend PSC on 18 October 2017 noted progress on the STP and expressed some reservations about financial modelling and clinical evidence. The need to establish a joint health overview and scrutiny committee with Essex and Thurrock Councils, to be led by Southend-on-Sea Council, was agreed.

The Chancellor of the Exchequer’s budget statement of 22 November 2017 announced a capital investment of £118 million for the Mid and South Essex STP acute reconfiguration. A pre-consultation business case was published on 23 November 2017. A CCG Joint Committee meeting on 29 November 2017 gave approval to proceed with a public consultation. Your Care in the Best Place was launched on 30 November 2017, initially to run to 9 March 2018 and subsequently extended to 23 March 2018. A supplementary document, ‘The future of locally based health and care services currently provided at Orsett Hospital’, was also produced together with additional materials concerning finance, the clinical transport service, stroke and workforce.

The proposals consulted on outlined a series of changes to acute hospital services aimed at improving access to and the quality of care provided to patients. The proposals focussed on maintaining current centres of excellence across three hospitals:

• burns and plastic surgery at Broomfield Hospital
• ear, nose and throat (ENT) surgery and oral-maxillofacial surgery at Broomfield Hospital
• specialist cancer care at Southend Hospital
• specialist cardiothoracic care at Basildon Hospital

GP and community services would be developed to support the changes to acute services. Care for patients showing symptoms of a stroke would continue to be via the nearest A&E and transfer to Basildon Hospital (that is, the model as described above). Services currently provided at Orsett Hospital would be transferred to a range of locations within Thurrock, Basildon and Brentwood delivering care closer to home and allowing stronger integration between primary, community and social care. Orsett Hospital would not be closed before services had been re-provided elsewhere.

Members of the STP team met the chairs of the Southend, Thurrock and Essex Health & Wellbeing Boards on 16 January 2018 to discuss the consultation. A presentation was provided to the first informal meeting of the Mid and South Essex STP Joint HOSC on 22 January 2018 and again at its first public meeting on 20 February 2018. Clinicians leading the programme attended a Joint HOSC informal meeting on 8 March 2018 and a further presentation on the STP was provided at the Joint HOSC public meeting on 13 March 2018.

The Joint HOSC formally responded to the public consultation on 22 March 2018. It supported the STP in further progressing its proposals whilst expressing concerns about a number of issues and reserving the right to continue its scrutiny of certain aspects of the proposals. The Joint HOSC was content that “significant consultation work has been undertaken” and expressed the view that “the engagement work undertaken has been adequate and in some respects very encouraging”. It noted that the MOU had been agreed between partners regarding the closure of Orsett Hospital as well as seeking further data on stroke patient numbers. The public consultation closed on 23 March 2018. Pre-election purdah, prior to local government elections on 3 May 2018, began on 27 March 2018.

A fifth East of England Clinical Senate report was produced in May 2018. On 22 May 2018 an independent analysis of the public consultation was published. Produced by specialist consultation analysts, The Campaign Company, the analysis reported that 16 large scale public meetings had been attended by 700 people, 40 deliberative workshops had been held for people most likely to be directly affected, three meetings had been held specifically about the future of Orsett Hospital and that 750 people had taken part in a telephone survey. It was estimated that 3,500 people had taken part in the consultation. Key findings included:

• broad agreement with the overall approach to provide care in the best place in the home, in community settings and in hospital
• concern about access issues, the feasibility of delivering the plan given the resource challenges faced by the NHS and the difficulty of recruiting GPs, community nurses and specialist hospital staff
• concern amongst patients and residents from Thurrock about the potential impact on the community of the Orsett Hospital proposals and from patients and residents from Southend about possible downgrading of services at Southend Hospital

STP representatives provided a presentation to the Joint HOSC on 6 June 2018 outlining the process so far and high-level findings. At an informal Joint HOSC meeting on 19 June 2018, STP representatives provided draft recommendations to be made in the decision-making business case (DMBC) and a presentation on the clinical transport model. Approval to progress the DMBC was provided by NHS England on 28 June 2018.

The CCG Joint Committee met on 6 July 2018 to consider the DMBC and made 19 decisions. On Decision 12, the CCG Joint Committee approved:

Access to care for patients showing symptoms of a stroke would continue to be via the local A&E department, where patients would be assessed, stabilised and, if indicated, treated with thrombolysis.

After the patient was stabilised, and after discussion between the patient/family and clinicians, the patient would be transferred to Basildon Hospital for a short (approximately 72 hour) period of intensive nursing and therapy support.

The CCG Joint Committee also noted that:

Following a stroke and an inpatient stay at Basildon Hospital for a short period of intensive treatment, patients would be transferred home, if their condition had improved sufficiently, or back to their local hospital or community facility for on-going care and treatment. All follow-up outpatient appointments, tests and scans would continue to be offered at all three hospital sites.

Should a patient be confirmed as suffering from a bleed on the brain, they would continue to be transferred to a specialised designated centre, as now. This would either be Queen’s Hospital, Romford, or Cambridge University NHS Foundation Trust in Cambridge.

The Joint Committee also strongly supported the ambition to develop a Mechanical Thrombectomy service in mid and south Essex, noting that such a service may be commissioned by NHS England.

On Decision 15, the CCG Joint Committee approved:

The relocation of services currently provided at Orsett Hospital to a range of locations within Thurrock, Basildon and Brentwood, enabling the closure of Orsett Hospital.

The CCG Joint Committee also noted that:

There would be a period of co-production with the local community through the establishment of a “People’s Panel” supported by Healthwatch organisations in Thurrock and Essex to determine the best site(s) to relocate these services to.

Alongside the period of co-production, further detailed assessments would be undertaken on equality and health inequality impacts, and the quality impact of proposed service relocations.

Once the period of co-production was completed, and with the detailed work on impact assessment, the CCG Joint Committee would be asked to make a decision on which sites would provide the relocated services, and

In accordance with the agreement between Thurrock CCG, Thurrock Council and the three mid and south Essex hospitals, the Orsett Hospital site would not be closed until the new services were in place at the agreed new locations.

On 19 July 2018, a meeting of the Southend Council unanimously carried a motion reiterating concerns expressed during the consultation and about the public consultation process itself, including that no other options for the location of the specialist unit had been consulted upon. Amongst its concerns, the Council stated that it could not support the STP without better rationale and evidence for moving stroke services to Basildon Hospital. The motion requested that the Southend PSC give due consideration to a referral to the Secretary of State.

The Joint HOSC met on 30 August 2018 to consider the CCG Joint Committee’s decisions. A letter of 25 September 2018 from the Joint HOSC Chair to the CCG Joint Committee Chair confirmed that the Joint HOSC would not be making any further recommendations or comments regarding the decisions made.

The Southend PSC resolved on 9 October 2018 to refer the STP to the Secretary of State.

STP representatives presented a paper to a meeting of the Thurrock HOSC on 5 December 2018. Thurrock Council resolved on 21 December 2018 to refer the decision concerning Orsett Hospital to the Secretary of State.

3. Basis for referral

The Southend-on-Sea Borough Council People Scrutiny Committee’s letter of 15 January 2019 states that:

Southend-on-Sea Borough Council can refer decisions to the Secretary of State under certain prescribed criteria outlined in legislation. Based on these criteria the grounds for this referral are outlined in para 9(a) and 9(c) (regulation 23) as follows:

i. Scrutiny is not satisfied with the adequacy of the consultation with Southend-on-Sea Borough Council regarding the Mid and South Essex STP – ‘Your Care in the Best Place’; and

ii. Scrutiny considers that the CCG Joint Committee decision regarding stroke services (decision #12) is not in the best interests of the health service in the area.

The Thurrock Council Health & Wellbeing Overview and Scrutiny Committee letter of 8 January 2019 states that:

Thurrock HOSC wishes to submit a referral on 2 of the 4 grounds for referral as set out in the Local Authority Health and Scrutiny Regulations: June 2014 and Regulation 23 (Local Authority Public Health, Health and Wellbeing Boards and Health Scrutiny Regulations 2013). The referral is being submitted on the basis of HOSC not being satisfied with the adequacy of the consultation and that the proposal to relocate services currently provided by Orsett Hospital are not in the interest of health services in Thurrock.

4. IRP view

With regard to the referrals by the Southend-on-Sea Borough Council PSC and Thurrock HOSC, the Panel notes that:

• as a joint health scrutiny committee was formed, the CCGs were not required to provide information to Southend Borough Council or to Thurrock HOSC – only to the Joint HOSC
• the constituent committees of the Joint HOSC retained their own right of referral – two of those constituent committees resolved to refer on grounds of not being satisfied with the consultation
• Southend PSC contends that the CCG Joint Committee decision regarding stroke services (CCG Joint Committee Decision 12) is not in the best interests of the health service in the area
• the Panel has been asked to comment on the sequencing of changes in relation to the closure of Orsett Hospital – Thurrock HOSC contends that the proposal to relocate services currently provided by Orsett Hospital (Decision 15) is not in the interest of health service locally
• concerns remain locally about specific, practical aspects of the proposals – further work is required to provide necessary reassurance

5. Advice

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

5.1 Consultation issues

A Joint HOSC was established between Southend-on-Sea, Thurrock and Essex 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 Wellbeing Boards and Health Scrutiny) Regulations 2013. The Joint HOSC is the appropriate and only scrutiny body with which the CCGs must consult on any proposals developed in respect of the Your Care in the Best Place STP programme. It is also the only body that the NHS is required to provide information to in these circumstances. Nevertheless, the NHS in this instance made additional efforts to engage with the constituent scrutiny committees separately.

The IRP notes that in responding to the consultation the Joint HOSC, of which Southend PSC and Thurrock HOSC formed two thirds of the membership, acknowledged that significant consultation work had been undertaken and that the engagement work undertaken had been adequate and in some respects very encouraging. The Panel finds it difficult to reconcile these statements with the criticisms subsequently made by the scrutiny committees, both of which retained their rights of referral. The Panel understands that DHSC is currently considering revisions to its existing guidance on health scrutiny and may wish to ponder this apparent paradox.

Both referring bodies have declared that they were not satisfied that public consultation on the proposals was adequate. This is addressed by the Panel under Regulation 23(9)(c) as not being in the interests of the health service in the area. As the Independent Chair of the CCG Joint Committee stated in replying to the referring bodies, it was disappointing that greater numbers did not formally respond to the consultation though social media marketing showed a higher ‘reach’ in excess of 350,000 people. The Panel understands some of the criticisms levelled about a lack of clarity on detailed planning, for example, on exactly where the services currently provided from Orsett Hospital will be located in the future. There is inevitably something of a ‘chicken and egg’ situation in that the detailed work relies on a decision first being made. The IRP has yet to advise on a consultation that, with hindsight, could not have been improved upon. Overall, the Panel considers that the consultation with the Joint HOSC and the public consultation were satisfactory.

5.2 Whether the proposals contested are in the interests of local health services

In considering whether proposals are in the interests of local health services, of the 19 decisions made by the CCG Joint Committee on 6 July 2018 in relation to the STP, the Panel has considered only those raised in the two referrals – namely, Decisions 12 and 15. The Panel was concerned to hear that other proposals that are supported and have benefits for patients are being stalled.

Southend PSC contends that the CCG Joint Committee decision regarding stroke services (Decision 12) is not in the best interests of the health service in the area. It is acknowledged that the model proposed differs from the national model of a single HASU in that people suspected of having a stroke would access care via their nearest A&E department – at Basildon, Broomfield or Southend. Patients requiring intensive support would be transferred to the specialist unit at Basildon for 72 hours before transferring back to an appropriate place for further care. The PSC contends that Southend Hospital would be a more appropriate location for the specialist care provision. The model proposed has been the subject of much consideration by, amongst others, the East of England Clinical Senate, the NHS England National Director for Stroke, University College London (UCL) Partners, the Stroke Association as well as the PSC and local health and wellbeing board. When implemented, the model will be subject to ongoing assessment by a specially appointed evaluation team from University College London’s Department of Applied Health Research. That evaluation will no doubt consider the long-term sustainability of the model. The Panel does not presume to have any greater expertise than those bodies already closely involved. We simply note that, had the national model been adopted - and while evidence of a formal options appraisal for site selection is perhaps a little light - clinical interdependencies and geography suggest that Basildon Hospital would have been the more likely site for a single HASU serving the whole population. Under that model, Southend residents suspected of having a stroke would have been taken to Basildon from the outset rather than transferring after stabilisation for a short period of intensive nursing and therapy support. The proposed model is a variant from what might normally have been expected, affording Southend residents access to stroke care via their own A&E and its ongoing evaluation will no doubt be of interest to other locations.

Thurrock HOSC contends that the proposal to relocate services currently provided by Orsett Hospital (Decision 15) is not in the interest of health services in Thurrock. The Council has been party to the development of these proposals, including the introduction of integrated medical centres and closure of Orsett Hospital, since 2015. The Memorandum of Understanding co-signed by the CCG, Council and Basildon Hospital in 2017 explicitly stated that services at Orsett Hospital would not cease prior to the construction and opening of the IMCs. The CCG Joint Committee decision of 6 July 2018 quoted the agreement and reiterated that services at Orsett Hospital would not be closed until new services were in place in agreed new locations. The Panel expects this undertaking to be honoured. Services to be provided in the new facilities across Thurrock, Basildon and Brentwood are expected to include outpatient clinics, diagnostics and some day-case treatments. The Panel appreciates that more clarity may be required locally on the precise ‘how/where/when’ details of the programme – not least on how the workforce will transfer from the old setting to the new - but that is not a sufficient reason not to proceed. With intelligent dispersing of the new services, that minimises possible travel/transfer disruption for patients who may need to access more than one service, the IMCs should be an improvement on current service provision. They will need to be developed, and the outstanding details agreed, with the collaboration of relevant partners including the proposed People’s Panel and local Healthwatch and subject to ongoing consideration by the relevant scrutiny bodies.

In summary, the Panel consider that both Decision 12 and Decision 15 are in the interests of health services locally. If issues around safe transfers and workforce, that were raised in the consultation, are still the cause of concern locally then the opportunity exists to deal with these concerns and provide necessary assurance as the NHS works with its stakeholders towards the implementation phase.

Yours sincerely,
Suzanne Shale
IRP Member and Chair for this sub-group

6. Appendix one - list of documents received

6.1 Southend-on-Sea Borough Council PSC

Referral letter to Secretary of State from Councillor Cheryl Nevin, Chair, Southend-on-Sea Borough Council People Scrutiny Committee, 15 January 2019, with attachments:

1. PSC Chair letter to Chair of CCG Joint Committee, 14 November 2018
2. Draft referral to Secretary of State, 23 November 2018
3. CCG Joint Committee letter to PSC Chair, 21 November 2018
4. Report to Southend-on-Sea Council Cabinet re STP, March 2018
5. Paper providing dates of relevant meetings
6. Report of Southend-on-Sea Council chief executive to PSC, 10 October 2017

6.2 Thurrock HOSC

Referral letter to Secretary of state from Councillor Victoria Holloway, Chair, Thurrock HOSC, 8 January 2019 and further letter, January 2019, with attachments:

1. DHSC letter to HOSC, 10 January 2019
2. CCG Joint Committee minutes of meeting, 10 January 2019
3. Health and Wellbeing Board minutes of meeting, 30 January 2018
4. Health and Wellbeing Board minutes of meeting, 21 September 2018
5. Joint HOSC minutes of meeting, 6 June 2018
6. Joint HOSC minutes of meeting, 30 August 2018
7. HOSC minutes of meeting, 18 January 2018
8. HOSC minutes of meeting, 12 March 2018
9. HOSC minutes of meeting, 8 November 2018
10. HOSC minutes of meeting, 5 December 2018
11. CCG Joint Committee letter to HOSC Chair, 3 June 2019

6.3 NHS

IRP template for providing assessment information with attachments:

1. Clinical Senate report, June 2016
2. Clinical Senate report, October 2016
3. Clinical Senate report, September 2017
4. Comments on stroke proposals, NHS England Director for Stroke, September-November 2017
5. UCL partners review of hyper-acute stroke care
6. Clinical Senate report, October 2017
7. Clinical Senate report, May 2018
8. Clinical senate report, January 2019
9. Options appraisal process and outcome
10. Pre-consultation business case, November 2017
11. Your Care in the Best place consultation document, 30 November 2017
12. Orsett Hospital specific consultation document, 30 November 2017
13. Independent analysis of consultation responses, The Campaign Company, May 2018
14. Decision-making business case
15. CCG Joint Committee minutes of meeting, 6 July 2018
16. CCG Joint Committee letter to PSC Chair, 21 November 2018
17. CCG Joint Committee letter to HOSC Chair, 3 January 2019
18. Joint HOSC response to consultation, 22 March 2018
19. CCG Joint Committee letter to Joint HOSC, 19 April 2018
20. Mid and South Essex stroke evaluation, 6 July 2018