Simon Freeman – Accountable Officer Shropshire CCG and Ros Francké, Director of Finance Shropshire Community Health Trust will be present at the meeting. 

The Committee have requested the following information:

i)     An explanation of Shropshire CCG’s financial situation and explanation of how it is intended to meet the necessary savings

ii)    An explanation of the CCG’s Recommissioning and Disinvestment Policy

iii)   A clear explanation of how services proposed for disinvestment/recommissioning have been identified

iv)   An explanation of how communication and engagement with your stakeholders, including the Council, Voluntary Sector and public will be carried out

The Committee will ask questions on the above areas and will also explore the impacts of the

recommissioning/disinvestment in the services identified. 

Documents attached, marked 6: 

CCG Governing Body Paper 10 August 2016 – Decommissioning and Disinvestment Interim

Policy

CCG Governing Body Paper 10 August 2016 – Disinvestment and Decommissioning Decision

Paper

CCG Governing Body Paper 14 September 2016 - Decommissioning and Disinvestment Update Paper

The Chairman welcomed Simon Freeman, Accountable Officer Shropshire CCG, Ros Francke, Director of Finance Shropshire Community Health Trust and Debbie Kadum, Chief Operating Officer Shrewsbury and Telford Hospital Trust to the meeting. 

Dr Freeman explained that he had been in post as Interim Accountable Officer for Shropshire CCG for two weeks.  His remit was to understand and stabilise the financial position and provide a recovery plan to NHS England that would address a year end deficit now projected to be £26 million.  He confirmed that the full £26m would not have to be achieved in a single year and it had been agreed that it would be possible to have a 2017/19 year end deficit of £20m.  It was also confirmed that the deficit would be funded by an increased allocation from NHS England, and not from reserves or borrowing so interest would not be payable. 

He said the number one priority for the CCG was appropriate, safe healthcare for patients.  However, difficult decisions would need to be taken about what the CCG would do or not do in the future.  He confirmed his commitment to proper and appropriate engagement with all stakeholders and the public in decision making and accepted that the way the interim Decommissioning and Disinvestment policy had been previously handled was unfortunate.    

Members asked for clarification around what Dr Freeman referred to as ‘proper and appropriate’.  He explained that he meant in an open and transparent way so that the basis of any decision was clear.  Members said they were reassured to an extent by this but consultations in the past had been difficult to understand and had not identified the knock on effects, for example on other stakeholders such as the Council or voluntary sector.  Assurance was needed that the public would be able to understand what was going on, the terms ‘disinvestment and decommissioning’ were not easily understood. 

In response to questions, it was confirmed that NHS England required all CCGs to have a clear policy on recommissioning and disinvestment of services.  Shropshire CCG’s policy was expected to be finalised in a number of weeks and was likely to be presented to the CCG’s December board meeting.  Dr Freeman confirmed that there were no decommissioning or disinvestment proposals currently in existence, the list previously identified was on hold and it would be remiss not to consider the unintended consequences of any decisions proposed in future. Individual decisions would be brought to consultation as necessary.   Members emphasised that the implications of any decisions needed to be clearly recognised and absolutely transparent. 

The Chairman asked about the status of Lifestyle Physiotherapy which he understood had come to the end of its contract and not been renewed.  Dr Freeman said he would check the position and report back on this. 

The CCG would not change the thresholds to treatment but would have to deploy its resources in the best possible way.   As an example he cited investment in an effective falls strategy as having the potential to save hundreds of thousands of pounds. Rapid action was needed or problems would worsen.   The Director of Public Health referred to audit work carried out on 240 cases of people who had experienced serious falls in the last year.  If it had been possible to prevent 10% of these falls it would have saved £400,000 for the NHS and £1m for Adult Social Care.  This clearly demonstrated the need for all organisations to work together to prevent serious falls. 

The Chairman asked about frequency and severity of falls at Shrewsbury and Telford Hospital Trust.  The Chief Operating Officer explained falls prevention measures in place and agreed to forward up to date information on fall frequency and severity to the Chairman. 

A Member referred to a scheme in another part of the country whereby an Ambulance Crew and an occupational therapist were dispatched to a patient who had fallen.  If the patient was not admitted, measures could then be taken to help avoid repetition of a fall.  Dr Freeman said Shropshire CCG would be making enquiries into the success of this scheme. 

Members also asked about a recent government announcement that GP payments would be based on actual patient numbers rather than those registered.  Dr Freeman confirmed that this would not impact on the CCG’s funding allocation.

A Member asked whether payments for routine checks for patients age 40 – 75 were coming to an end.  The Director of Public Health confirmed that it was a statutory requirement of the Department of Health for Councils to commission the health check schemes.  They continued in Shropshire and there were no plans for them to end this year or next.    However the 2018 – 2019 Public Health Grant would be funded from business rates and the plans for after then were not clear.

A Member referred to the potential ripple effect on the Acute Sector of disinvestment in pharmacy and primary care services.  She urged for definitions of all terms to be absolutely clear, for example,  Urgent Care Centres, Emergency Centre, Minor Injury Units.  Confusion around these terms was very unhelpful.  The Committee reiterated the need for this to be very clear in the forthcoming Future Fit consultation.  Another Member asked for clarity around the definition of ‘rural’, particularly in the light of a pilot ‘rural’ urgent care centre being located in the town of Bridgnorth. 

Dr Freeman agreed that there was confusion around these terms.  Shropshire’s rurality index was very high.  Members offered to provide Dr Freeman with a tour of the South Shropshire area.  The Committee also pointed out that the template for disinvestment decisions had not provided a holistic picture, for example, it had not referred to geography and access or cross border issues.  The Committee needed to know that these issues would be taken into account.  Dr Freeman said that he would make sure that these issues would be incorporated in the policy going to the December Board meeting.  Board meetings were held in public and Committee members would be welcome to attend.  He also said he was happy to bring the policy back to the Scrutiny Committee.

The Chair invited Councillor Dave Tremellon to speak.  Councillor Tremellon referred to the significant challenge of helping people understand that sustaining two A&E departments was not feasible, not because of financial issues but due to staffing levels and recruitment issues.  He felt that this had not been explained clearly enough.  The Chief Operating Officer, SATH, said that the Royal College recommendation was for 10 consultants per site, and that SATH only had six over both sites.  She referred to discussions with another Hospital Trust regarding the possibility of joint working and sharing consultants for a period of time.  The Director of Public Health reported that the Leaders of both Shropshire and Telford and Wrekin Councils had written to NHS England in support of this request. 

The Chairman invited Mr C Deaves to ask his supplementary question.  Mr C Deaves’ questions covered the level of difficulty to establish a joint falls process; asked that Shropshire has the best policies and procedures in place; asked about a rolling deficit; suggested using ‘cuts’ and ‘change’ as terms more understandable for members of the public; asked about non-clinical decommissioning and disinvestment  

In response, Dr Freeman said he appreciated having the best possible policy and procedures in place was important, particularly in facing the difficulties experienced in Shropshire.  The policy would be made more robust than the interim version and provide proper guidance, all decisions would be evidence based and assurance would be built in.  He also confirmed that there was a rolling deficit and NHS England would issue control totals and that in relation to non-clinical decommissioning staffing was strictly regulated to £22 per head of the population.    

The Chairman agreed to receive questions from Members of the Public.

In following up the question from Mrs George, a Member of the public asked if the Committee intended to do its level best to maintain worthwhile accessible maternity services and to maintain Minor Injury Units in community hospitals.  Members explained that the role of the Committee included carrying out overview and scrutiny of policies, whether changes were carried out in a fair and equitable manner and to ensure services were safe and providing for communities.  It could make recommendations but not form policy. The Chairman quoted from a letter he had received from the Community Health Trust regarding Midwifery Led Unit and Minor Injuries Unit at Ludlow

Another Member of the public from Oswestry expressed concern that Oswestry did not have a community hospital and there was no representation on the Scrutiny Committee from Oswestry. He also asked about the Committee’s views on protest groups formed in relation to health matters.  The Chairman explained that the Committee did not yet know the proposals for services across the county. The Director of Finance, Shropshire Community Health Trust, reported that she attended Oswestry Health Forum which was working to establish the needs of Oswestry.  Although this was not a public meeting, there would be open engagement with the people of Oswestry.  She agreed to put the member of public in touch with her colleague arranging this work.    With regard to the comments about protest groups, the Committee confirmed that it welcomed the views of anyone especially with expert or local knowledge.

Another member of the public expressed concern at:   an apparent lack of coherence with regard to policy making particularly between the Sustainable Transformation Plan, Future Fit and Strategic Outline Plan; the frequent change of CCG accountable officer; poor ambulance performance; and lack of sharing of patient records between the Ambulance Service, Acute and Primary Care;  She said there were significant concerns and misunderstanding in the community, and appeared to be a lack of thorough evidence informing plans to date and lack of identification of financial implications for others including the third sector. She asked for transparency and that deprivation, rurality and transport be taken into account.  She went on to ask how many geriatric specialist consultants there were.

In response, Dr Freeman said that he could only agree that the picture was very confusing, it would be necessary to remove this confusion and establish longevity.  Sharing of records was restricted by information governance demands and as a rule consultants could not access GP records although a discharge summary would be sent to the GP.  The Chief Operating Officer, SATH, confirmed that there were not enough geriatric consultants, and reported that a new fraility model was being developed.      

A representative of Shropshire Healthwatch said that communication should be a primary issue for the CCG.  Communication with Healthwatch and Patient Groups appeared to have dropped off, it was necessary to have speedy and effective communication at the time of any developments to prevent skewed messages being spread. A successful way to communicate with Councillors and the public needed to be found although she could not identify the solution herself.  

The Chief Operating Officer, SATH referred to the significant volume of communication undertaken, including consultants clearly stating the case in the Shropshire Star, people were still obviously not hearing enough. 

A Committee Member said quality communication delivered in the right way was required.  She referred to a recent pop up stand in Shrewsbury which had been very difficult to find and had not appeared proactive in getting information out.   

A Member of the public referred to her experiences whilst working as a nurse, and drew attention to a nursing recruitment and retention problem in addition to consultant recruitment issues.  She stated that the Royal College of Emergency Medicine had said that 10 consultants was an optimum level but that service could be delivered by 7.  The Chief Operating Officer reminded the Committee that SATH had only six consultants spread over two sites and there was a firm belief that one Emergency Department would attract more consultants.

The Committee thanked Simon Freeman, Ros Francke, and Debbie Kadum for attending the meeting and answering questions. 

The Chairman reported that he had been contacted by the Care Group Director – Shropshire Women and Children’s Centre regarding improvements being made in the children assessment unit at Royal Shrewsbury Hospital.  These were to be presented to a Healthwatch meeting and members of the Scrutiny Committee would be invited to attend.