Agenda item
TRANSFORMING SERVICES TOGETHER - Report to the Inner North East London Joint Health and Overview Scrutiny Committee
Minutes:
The Committee was reminded that at its meeting on 25th July 2016, Members had requested that the Chair and Vice-Chair meet with senior officers from the relevant Clinical Commissioning Groups (CCGs) to discuss bringing more detailed reports regarding the Transforming Services Together (TST) programme to committee.
It was noted that the Chair and Vice-Chair met with CCG Chief Officers on 29th September 2016 and it was agreed that INEL would host two meetings in November for more detailed scrutiny of the TST across specific areas of concern identified by members.
The report and its accompanying summary included items covering:
1. The financial implications of TST and progress on delivery; and
2. Modelling for the future of the primary care workforce.
Whilst the following meeting scheduled to take place on 17th November it was noted would explore TST further, receiving a report covering plans for self-care, elective care, and movement of services and patient journeys. In addition, the Committee received a submission from Dr Jackie Applebee, Chair Tower Hamlets Local Medical Committee which is set out in Appendix A of these minutes.
The Committee considered the report and Dr Applebee’s submission and this was followed by questions and comments from Members who stated:
1. Cllr Munn – Whilst I note that acute care hubs are to bring together clinical areas focused on initial assessment and rapid treatment without the need for hospital admission. However, how will these hubs deliver the anticipated savings;
2. Cllr Masters – It would be helpful to know what conditions are considered appropriate for the Ambulatory Care Pathway (ACP).
3. Cllr Masters – There is considerable focus on integrated care but consideration must also be given to the reduction in funding across all partner agencies.
4. Cllr Masters and Cllr Mustaquim – Has the cost of living for key worker’s also been factored into the consideration regarding the development of this new structure.
5. Cllr Mead – Whilst noting that it is not considered feasible to provide outpatients services unchanged in the current financial climate of a real reduction in revenue against a backdrop of increasing demand. How is it envisaged that the service will work through the local clinics e.g. what will be the cost and how will the individual needs of patients be addressed?
6. Cllr Potter – Will hospitals outside of the Barts Health NHS Trust be able to access the new structure;
7. Cllr Mead – What assurances have we that there will not be any misdiagnoses?
8. Cllr Harrison – Can we be assured that clinician’s will have access to the resources to meet the needs of those communities that they seek to serve?
9. Cllr Masters – Where will the finances come from to deliver expansion at Whipps Cross Site?
10.Cllr Masters – If we had known in 2011 what we now know about the population increase would we have closed King George’s emergency department?
11.Cllr Harrison – What is the difference between the Physician Associate and General Practice Nurse?
12.Cllr Masters – At what stage would a Physician Associate become involved in a patients care?
13.Cllr Harrison – Is there not a concern that patients will be reluctant to speak with a Physician Associate instead of a General Practitioner?
14.Cllr Harrison – Will there be equitable access under the new structure for all the communities?
15.Cllr Harrison – Under the new structure how will residential care be provided?
16.Cllr Masters – What is the intended career pathway for the Physician Associate?
17.Cllr Masters – What assurances have we that the Physician Associates will be properly skilled and what will be the process to monitor their work?
In response to the above, NHS Representatives stated the following that:
a. the proposed savings will not lead to a reduction in the overall resource expended on healthcare and that the total expenditure will rise in every year;
b. the savings are intended to be the difference between the costs of the growing demand provided in the traditional way and providing the same services in a new more efficient way.
c. the efficiency savings do not represent a net reduction in the investment in any service; they are intended to be a measure of the potential saving that can be achieved;
d. the introduction of Acute Care Hubs are intended to bring together clinical areas focused on initial assessment, rapid treatment and recovery so more people can be seen and treated without the need for attending a hospital admission. Instead they will have a Clinical Pathway identified for them which it was hoped would reduce admissions by 3%. The scheme would look to increase the number of those suitable to ambulatory care or medical care provided on an outpatient basis, including diagnosis, observation and consultation e.g. asthma; influenza, pneumonia; chronic pain, pain management; urinary tract infections and other vaccine-preventable diseases. In addition, the scheme could support patients through Social and Community Services as part of the Three Borough’s Rapid Response Service that has been designed in consultation with partner agencies and provides rapid health and social care assessment for service users and carers who are in or approaching a crisis and reduce unnecessary admissions;
e. consideration will need to be given to the impact the budgetary reductions has had upon the provision of integrated social care by all agencies;
f. the cost of the provision of "affordable" housing needs to be factored into helping “key” workers finding somewhere locally to live;
g. it is important to look at the demands being placed upon the system by both increasing needs and rising costs. Therefore, careful consideration needs to be given to the addressing of the demand in the system and the balancing of access and the quality of the outcomes achieved e.g. the services offered at the Orthopaedics Department at Newham General Hospital who have developed an expertise and are able to achieve the best outcomes (Including enhanced recovery), which is balanced by having the surgical teams for emergency cover;
h. the Outpatient Service can be delivered within the setting of General Practitioners Surgeries which can provide the advice in a different way yet deliver savings in time and improve the out patients experience;
i. the NHS e-Referral Service which combines electronic booking with a choice of place, date and time for first hospital or clinic appointments will have the potential for huge savings (£50m). Patients can choose their initial hospital or clinic appointment; book it in the GP surgery at the point of referral, or later at home on the phone or online. The Committee was advised that this should provide a 20% reduction in actual hospital referrals; address patients’ needs and improve the level of preventative care;
j. discussions are ongoing on the development of the scheme in East London and beyond for those served by Barts Health e.g. a dialogue has begun with Homerton University Hospital; King George Hospital and the North Middlesex University Hospital;
k. Service aims to identify what is needed for the patients and that tests are undertaken on what is actually required so as to reduce unneeded testing which should deliver significant savings by stopping inappropriate testing;
l. by linking the relevant care systems there is the potential for delivering increased efficiencies e.g. linking councils; hospices and the NHS 111 non-emergency medical helpline thereby enabling them to store and share relevant information. This will provide agencies with real-time information on patients by using the same records across nursing and social care teams;
m. with regard to the disposal of the unused land at the Whipps Cross Site in Leytonstone by Barts Health, the Trust have developed a vision of what patients should expect from their care in the 21st century and are developing a strategy to make this happen with a better utilisation of the Trusts Estate and to ensure that services are delivered where they are needed e.g. Patients' health, wellbeing and social care needs will be met in one place; as the population is growing and the needs of patients is changing. The Trust needs a hospital that works well into the future and will provide an affordable environment;
n. as part of the devolution process the receipts for the sale of the unused land will be retained for use by the Boroughs and not be transferred to the Treasury;
o. the downgrading of those services provided as King Georges Hospital had been necessary to ensure the provision of these services more effectively in a more centralised fashion;
p. the development of Physician Associates as part of multi-disciplinary teams in local practices will support General Practitioners in the diagnosis and management of patients;
q. whereas Nursing Staff in these teams are primarily specialists the Associates will be trained to perform a number of day-to-day tasks including examinations; diagnosing illnesses; analysing test results and the developing of management plans all under the direct supervision of a doctor;
r. the introduction of these Associates will help to address the increasing workload crisis brought about through and increasing population and a reduction in the numbers of General Practitioners;
s. the establishment of the Associates as part of a cohesive team based in the local surgeries will provide opportunities for local people to have local jobs and work would be undertaken to ensure that local people were made aware that these careers pathways were available to them should they have the required skill sets. In addition, that they would be able to develop and enrich their skills through their work;
t. the quality of care provided by the Associates would be subject to the regular monitoring by their General Practitioners who they worked alongside. Whilst patients when asked had indicated that they would not be reluctant to speak to an Associate about medical issues;
u. with regards to the future provision of residential care this would be based on patients’ needs and wants being at the centre of high quality, safe residential care services, through the development of a skilled high quality workforce, in a flexible environment more fitting to people’s needs, via sustainable resourcing and commissioning;
v. they would be providing the Committee with of illustrative model to show them how the Physician Associates Model would be delivered locally.
The meeting ended at 8.30 p.m.
Chair, Councillor Clare Harrisson
Inner North East London Joint Health Overview & Scrutiny Committee
Appendix A
Dr Jackie Applebee, Chair Tower Hamlets Local Medical Committee.
I. "Where is the evidence that wholesale transformation is needed? While none of us would disagree that collaborative care across health, including primary, secondary, community, mental health etc. and social services is a very good thing for patients, it is the markets in the NHS both internal and external and the chronic underfunding which make this very difficult. The changes they are proposing are on the backdrop of unprecedented cuts. Where is the evidence that moving care out of hospitals into the community will be cheaper? Where are the nursing homes to look after the elderly? Where is the social care to support people who would rather stay at home? Where is the evidence that people want "virtual" consultations and on line access to booking etc., a survey that came out last week showed the opposite in that only 4 of patients have used on line booking! I am concerned that these "transformations" are financially and not clinically driven.
II. How will the proposed transformation be implemented when there is a huge workforce crisis across the NHS? For example the TST document mentions that the number of General Practitioners’ (GP) will decrease from 600-400 and this in the face of a quickly rising population. How will it be possible to move care from hospitals into the community in this situation? More worryingly, there is ambiguity as to whether this decrease in numbers is a projection due to the numbers retiring and the poor recruitment of Junior Doctors to General Practice, or an aspiration to save more money.
III. I am a GP; I see the effects of the systematic underfunding of the NHS every day. The STP states that NE London must make £834 million of "savings" and I know that the Government have cut 25 from local authority budgets since 2010. I contend that none of this "transformation" is possible with the current level of funding. I think that we should be honest and admit to this, not collude with the myth that gold can be spun out of straw?
IV. I urge the councils to join with us and campaign to restore health and social care funding to a level which is realistic to provide the services which our population deserves and which those of us who work in the sectors want to provide.
V. There is plenty of evidence to support the wisdom of investing in health and social services, if you are not familiar with the work of Sir Michael Marmot it is well worth reading his very well written book "The Health Gap" which shows without a doubt that the cuts that are being proposed are bad for all of us."
Supporting documents:
- item 6 cover sheet TST, item 4. PDF 65 KB
- Item 6_ INEL JHOSC TST Report, item 4. PDF 741 KB
- Item_6_INEL JHOSC TST Presentation final, item 4. PDF 545 KB