Agenda item
Question Time.
A number of questions
have been submitted by the public and the questions and answers will be published
on the day of the meeting.
Minutes:
The Chief Executive reported that 13 questions had been received under Standing Order 34.
1.
Question by Godfrey Jennings
In
light of the Covid pandemic and limited awareness among the general
public of the Better Hospitals for the Future consultation and that no
community provision assurances have been given do you not think an extension of
the consultation period should be considered?
Reply by the Chairman:
“When looking at
the current circumstances the world finds itself in, then in
order to fulfil our duty and to continue to exercise our functions we
have adapted our processes to achieve that objective. The use of technology to
hold meetings, share information and promote the consultation has enabled a
wider reach across communities. This
activity has been combined with off-line activities to reach communities not
digitally enabled. We are able to measure the majority
of our activities confidently. This
demonstrates that the vast majority of adults across
Leicester, Leicestershire and Rutland will have had the opportunity to be aware
of the proposals, often through multiple channels, and participate in the
consultation process if they wish.
We are confident
that our activities to date and the approach we have taken has allowed us to
meet both our statutory and common law duties.
Therefore we see no reason to extend the
consultation period, which will close on 21 December 2020.”
2.
Question by Glynn
Cartwright,
Melton Mowbray
I, along with many others, am deeply
concerned that the UHL Acute and Maternity Reconfiguration consultation process
itself contravenes the Gunning Principle of those being consulted having sufficient information to respond appropriately to what is
being asked of them.
Given that the proposals signify a particular loss of services to the communities of Melton
Mowbray and Rutland specifically and generally
to North East Leicestershire, East
Leicestershire and South Nottinghamshire areas:
a) What steps have been taken to ensure
information has been adequately provided in these population groups, about
which exact services are going to be lost, especially with those who are not
able to access online meeting facilities or use the internet frequently?
The NHS bodies involved in this
decision-making process have been quite clear what acute services they intend
to move, why and the impact of the change, which means the Gunning Principle
referred to has been met.
NHS England and Improvement run a thorough
assurance process on all service reconfiguration programmes which are
undertaking public consultation and, throughout this process,
the CCGs have been advised by Gerard Hanratty of Browne Jacobson, who is a
solicitor specialising in public law and service reconfiguration advice for the
NHS. This ensures the CCGs have been advised on their compliance with both
their statutory duties and common law obligations, including those set out in
the Gunning Principles.
When looking at the
current circumstances the world finds itself in, then in
order to fulfil their duty and to continue to exercise their functions
the CCGs had to adapt their processes to achieve that objective.
The pandemic has shown how technology can be
used to involve and engage the public on a range of issues. The CCGs have
adapted and adopted new ways of working including the use of technology which
has enabled them to reach more communities. This is in addition to off-line
communications and engagement activities in order to
reach people not digitally enabled.
To reach people the CCGs have used a variety
of both online and offline tools and techniques. These are set out elsewhere in
the papers for this meeting of the Leicestershire, Leicester and Rutland Joint
Health Scrutiny Committee and the Committee will further scrutinise the issue
during the meeting.
b) Can you confirm the areas that have received
a leaflet to their home addresses regarding the proposals, and explain why
there has not been a leaflet provided to ALL households in LLR as promised,
even at this late stage in the consultation process?
Reply by the Chairman:
The CCGs have undertaken solus door drops of
an information leaflet to 440,000 residential properties across Leicester,
Leicestershire and Rutland. In addition, rural communities in Rutland were sent
a leaflet via Royal Mail as solus was not an option.
Whilst many people have said that they have
received this leaflet, the CCGs are also aware that some believe they have not.
Solus delivery is not an exact science and is dependent on many key factors.
This includes the attitude of recipients to unsolicited deliveries, with some
people simply disposing of leaflets immediately upon receipt. Other issues
include the volume of marketing material being received by households, which
can reduce the impact and recall of specific items, as well as the exposure of
different people within the household to the material following delivery.
The CCGs have raised concerns from residents
with their delivery partners who have provided GPS tracking information for
their agents. This is in addition to
feedback from telephone calls to a sample of homes within each of the postcode
areas to validate delivery, which is undertaken by an organisation called DLM.
However, it is important to recognise that
the door-drop is only one small part of the overall awareness activities CCGs
have undertaken, details of which can be found elsewhere in the papers for this
meeting and the Committee will seek further reassurances during the meeting
regarding this issue.
c) Can you outline the reasons the Clinical
Commissioning Group have gone ahead with a consultation of this magnitude,
during the restrictions of a global pandemic, when engaging with the issues at
hand is more challenging for those whom it impacts, and many are more focussed
on the problems caused by Covid 19?
Reply by the Chairman:
I have put this question to the Clinical
Commissioning Groups and they have provided the following answer:
“The CCGs recognise that the world has
changed, for everyone, not just the NHS. One of the only certainties being
that we will be living with increased uncertainty for a long
time.
That being the case it is tempting for
organisations to shelve plans, put off decisions and hunker down, in the hope
that the future becomes more certain or that someone comes along to tell them
what to do.
The CCGs think that is the wrong approach
especially now when we consider all that we have learnt in planning for, and
dealing with, the impact of the first wave.
So, at the heart of the clinical strategy
(which drives the £450m reconfiguration plan) is the desire to focus emergency
and specialist care at the Royal and the Glenfield hospitals and separate
non-emergency care from emergency care so that when the hospitals are very busy
those patients waiting for routine operations are not delayed or cancelled
because of having to prioritise an influx of emergency patients.
More recently, the CCGs have asked ‘Does
this still make sense when we look at what the pandemic has taught us?’ The
CCGs believe the short answer is yes, and these are the reasons:
Intensive Care:
One of the biggest challenges faced
preparing for the first COVID peak was to create enough adult Intensive Care
Unit (ICU) capacity. In steady state UHL have 50 ICU beds, the initial pandemic
modelling suggested that UHL would require closer to 300 beds. Which was a
daunting ask of clinical teams. Nonetheless within a fortnight UHL had a plan
to increase its capacity in line with the peak, largely as a
result of converting every available space with the right oxygen supply
into makeshift ICUs and by suspending children’s heart surgery so that we could
convert children’s ICU, into adult ICU.
Thankfully, largely as a
result of the success of lockdown halting the spread of the virus, the
peak was not as pronounced as first expected and UHL had at the highest peak,
64 patients in intensive care.
In the reconfiguration plans it is said that
UHL will create two ‘Super ICUs’ at the Royal and the Glenfield doubling
capacity to over 100 ICU beds. Had these been in
place at the time of the pandemic UHL’s response would have been very
different; they would have had enough ICU capacity with plenty to spare.
Children’s Heart
Surgery:
As mentioned above, UHL knew that COVID
would require them to care for very many more adult patients on ICU. Mercifully
children were less affected by the virus. With limited ICU capacity UHL
therefore took the difficult decision to halt children’s heart surgery in
Leicester, transfer those children awaiting their operation to Birmingham
Children’s Hospital and convert the Paediatric Intensive Care Unit at the
Glenfield into an adult ICU. On balance we took the decision based on what
would save the most lives, knowing that our children would still have their
surgery albeit not in Leicester and as a consequence
we could care for more of the terribly sick adults whose only hope was sedation
and ventilation.
However, in our reconfiguration plans we are
going to create a standalone Children’s Hospital at the Royal; the first phase
completes in spring 2021. Had the Children’s Hospital been built we would have
been able to continue with heart surgery during COVID knowing that the children
were safe in a standalone hospital with a totally separate ICU.
Cancer and
Elective operations:
Locally and nationally patients who had been
previously listed for operations and procedures were cancelled in very large
numbers as hospitals made preparations for the
pandemic. This affected all services and all types of patients even some with
cancer. The only surgery we were able to continue was for those emergency cases
that without an operation within 24-72 hours would have been likely to die. In
terms of cancer cases where patients are often immuno-compromised there was the
added concern about bringing them into a hospital with positive COVID patients
and the impact that this could have if, in their already poorly state they
picked up the virus.
In our reconfiguration plans we are going to
build a standalone treatment centre at the Glenfield Hospital; this will be a brand new hospital next to the existing hospital. It fulfils
our desire to separate emergency and elective procedures. Meaning that when we
are busy with high numbers of emergencies, our elective patients still receive
care. Had this been in place by the time of the pandemic we would have been
able to maintain significant amount of our non-emergency work and create a
‘COVID clean’ site.
Impact on staff:
Even before the pandemic we regularly
struggled to effectively staff our services. The fact that we have three separate
hospitals with the duplication and triplication of services that entails means
that we often have to spread our staff too thinly in
order to cover clinical rotas. During the first peak of COVID we had 20%
sickness across all staff groups meaning that 1 in 5 staff were either sick or self isolating. It is a testimony to all our staff that
despite this we kept going but it is unsustainable in the long term.
Once reconfigured, we will no longer have to
run triplicate rotas for staff on three hospital sites. For example
with two super ICUs rather than the current 3 smaller ones we would have been
able to consolidate our staffing making it easier to cover absences when they
occurred and perhaps even give staff the time to ‘decompress’ after repeat days
of long and harrowing shifts.
Overall, it is clear to us that had the
timing been different our hospitals would have been better able to cope with
COVID 19 in their reconfigured state and our patients would have received a
better, safer service.”
d) Can you explain why the removal of the
postnatal facility along with the trial of the LGH birth centre is not
specifically mentioned in the consultation documents, using misleading language
of "relocation", instead of closure, which prevents people from understanding
fully the impact of the proposals being consulted on?
Reply by the Chairman:
I
have sought a response from the Clinical Commissioning Group/UHL and they have
stated the following
“Our proposal and the consultation documents do include the relocation of the midwifery-led unit at St Mary’s Hospital to Leicester General Hospital, where it will be accessible to many more women. While we are proposing to move the midwifery-led unit, we would maintain community maternity services in Melton Mowbray. We would ensure that there is support for home births and care before and after the baby is born in the local community. If someone has a complicated pregnancy, antenatal care would be provided in an outpatient service located at Leicester Royal Infirmary or in remote/virtual clinics.
If the consultation shows support for a standalone midwifery-led unit run entirely by midwives, it would need to be located in a place that would be chosen by enough women as a preferred place of birth and ensures fair access for all women regardless of where they live in Leicester, Leicestershire and Rutland. It would also need to be sufficiently close to more medical and specialist services should the need arise.
This is important since it will provide more reassurance to women who may need to be transferred to an acute setting during or after birth. Transfer rates in labour and immediately after birth, according to the Birth Place Study, is currently 45% for first time mums and 10% for 2nd, 3rd or 4th babies.
The consultation document describes the proposed unit as running as a pilot for 12 months to test public appetite for this service with an indicative target of 500 births per year. To be clear, this is not a hard target that must be achieved in year one. Instead we are looking for evidence that a clear trajectory for 500 births in subsequent years is likely to be achieved.
If the consultation shows support for the Midwifery Led Unit at Leicester General Hospital and the proposal is implemented and the centre is open, a review body would be established comprising of midwifes, parents and other stakeholders who will co-produce the service with UHL.”
Supplementary
Question
Glynn Cartwright submitted that the transfer rate
for first time mothers was actually 36.3% not 45% as
stated by the Clinical Commissioning Groups and that for 2nd and 3rd time
mothers the transfer rate was under 10%. He questioned whether the Clinical
Commissioning Groups were serious about allowing St Mary’s Birth Centre to
succeed or whether they were trying to end the use of birth centres such as St
Mary’s altogether. The Chairman asked the Clinical
Commissioning Groups and UHL to cover these issues as part of their
presentation on agenda item 7: UHL Acute and Maternity Reconfiguration
Consultation: “Building Better Hospitals” and advised Glynn Cartwright that he would
receive a written answer to his supplementary question after the meeting.
e) Bearing in mind the future of St Mary's Birth
Centre has been discussed for over 20 years (ref Ian Scudamore) and more
particularly in the last 8-10 years, when did the Leicestershire, Leicester and
Rutland Health Overview and Scrutiny Committee first scrutinise the proposals?
Reply by the Chairman:
At its meetings on 14 December 2016 and 4
September 2018 the Leicestershire, Leicester and Rutland Health Overview and
Scrutiny Committee touched upon issues relating to St Mary’s Birth Centre and
the UHL Acute and Maternity Reconfiguration plans as part of scrutiny of the
Sustainability and Transformation Plan/Partnership (STP). The Committee then
began looking in more detail at the reconfiguration plans including the
proposal to close St Mary’s Birth Centre at its meeting on 24 January 2020, and
then held a further meeting on 15 October 2020 where explanations were sought
regarding the proposals in relation to St Mary’s Birth Centre.
f) At that time did the Leicestershire,
Leicester and Rutland Health Overview and Scrutiny Committee consult
with any members of the public, in particular in the
affected areas, for their views of the proposals?
If not why not and
do you normally make decisions for the public on proposals of this magnitude
without asking for their views?
Reply by the Chairman:
The consultation on the UHL Acute and
Maternity Reconfiguration plans, including the plans for St Mary’s Birth Centre,
is being run by the Clinical Commissioning Groups. The Leicestershire,
Leicester and Rutland Health Overview and Scrutiny Committee is a consultee
therefore it is not required to carry out consultation with the public on this particular issue. The Committee has not made any decisions
regarding the UHL Acute and Maternity Reconfiguration plans. The Committee’s
role is to scrutinise the way the consultation process is carried out and feed
its own views into the consultation. However, the public are welcome to submit
comments and questions to the Committee regarding UHL’s reconfiguration plans
and the Committee will raise those comments and questions with the CCGs/UHL on
the public’s behalf.
g) What was the outcome of the scrutiny of the
proposals undertaken by the Leicestershire, Leicester and Rutland Health
Overview and Scrutiny Committee?
Reply by the Chairman:
The Committee has submitted comments both
positive and negative to the CCGs and UHL regarding the Acute and Maternity
Reconfiguration proposals and raised some areas of concern. The details of the
issues raised are recorded in the minutes of Committee meetings which can be
found on the Leicestershire County Council website: http://politics.leics.gov.uk/ieListMeetings.aspx?CommitteeId=1182
However, this scrutiny process is still
ongoing and there has been no final outcome.
h) Is the Leicestershire, Leicester and Rutland
Health Overview and Scrutiny Committee acquainted with the paper written
recently by Dr Ruane of DMU which suggests the suggestion of closing the SMBC
in favour of a new birth centre at LGH is not sustainable?
The Committee is aware of the paper written
by Dr Ruane and it has been included in the agenda pack for this meeting.
3.
Question by Louise Wilkinson
I stayed at St
Mary's from the 28th September to 1st October, during this time the staff at St
Mary's literally helped me to keep my baby alive through breastfeeding. I
required hourly face to face support from the staff in St Mary's and would not
have been able to feed my baby had I not been receiving post-natal support on
the ward. How can you claim that mothers will be able to access the same level
of post-natal support through community care and watching online videos after
the closure of St Mary's? In the same situation would I be able to call a
mid-wife to my house every hour during the night to help me feed?
I have put this question to the Clinical
Commissioning Groups and they have provided the following response:
“There is the full expectation that short
term postnatal stays for uncomplicated pregnancies and births will be provided
in both the proposed standalone midwifery led unit and in the birth centre running alongside the proposed new Maternity
Hospital at Leicester Royal Infirmary. Taking this into account, and from
looking at the details of patients using the facility, it is clear that in the
overwhelming majority of cases it is more appropriate for those new mums to be
recovering at home, away from the risks, including from infection, of being in
a communal inpatient areas. From there they will be
able to access support including from family and experience the essential
mother and family bonding in familiar surroundings. Access to care can either be delivered in
that home setting or through community-based drop-in type services.
Of course, we recognise that some mums
require additional inpatient postnatal care for clinical reasons, either
maternal or neonatal and, where this is the case, it is important that they are
cared for in an appropriate medical environment. Under our proposals this would
be provided from the new maternity hospital at Leicester Royal Infirmary.
Sadly we
do not believe that it would be possible to provide this kind of service from a
community location. Most significantly this is because of the requirement for
around-the-clock 24/7 medical cover.”
4.
Question by Louise Wilkinson.
I
live on Craven Street, please can you explain to me
why I have not received a leaflet to my home explaining the planned changes and
consultation process?
Reply by the Chairman:
Whilst many people have said that they have
received this leaflet, I am also aware that some believe they have not. Solus
delivery is not an exact science and is dependent on many key factors. This
includes the attitude of recipients to unsolicited deliveries, with some people
simply disposing of leaflets immediately upon receipt. Other issues include the
volume of marketing material being received by households, which can reduce the
impact and recall of specific items, as well as the exposure of different
people within the household to the material following delivery.
The CCGs have raised concerns from residents
with their delivery partners who have provided GPS tracking information for
their agents. This is in addition to
feedback from telephone calls to a sample of homes within each of the postcode
areas to validate delivery, which is undertaken by an organisation called DLM.
Industry standards dictate that feedback
from these telephone calls would expect to establish a level of positive recall
of between 40% - 60% to substantiate that deliveries have been completed to the
standards expected. We are still receiving the community reports from this
exercise, but at the moment the recall is within this
range for communities across Leicester, Leicestershire and Rutland.
However, the door-drop is only one small
part of the overall awareness activities the CCGs have undertaken. These are set out elsewhere in the papers for
this meeting of the Joint Health Scrutiny Committee and the Committee will seek
further reassurances regarding this issue during the meeting.
5.
Question by Louise Wilkinson
At 22 weeks
pregnant I had to travel by car to Leicester General Hospital as I was
suspected of going into early labour- the journey took me over an hour. Please
can you explain to me, if it’s not acceptable for women in the city to travel
to Melton Mowbray, why is it acceptable for women in Melton Mowbray to travel
to the city, where there is increased traffic, surely this will add to the
congestion?
Reviews of maternity services have
identified that the standalone birthing centre at St Mary’s Hospital in Melton
Mowbray is not accessible for the majority of women in
Leicester, Leicestershire and Rutland. It is also under-used with just one
birth taking place approximately every three days, despite attempts to increase
this number. This means the unit is unsustainable, both clinically and
financially.
The CCGs/UHL believe underutilisation of the
unit may, at least in part, be due to concerns over the length of journey from
Melton Mowbray to Leicester should mum or baby experience complications during
the birth, as well as its relative inaccessibility to the majority.
The proposal would
see the relocation of the midwifery-led unit at St Mary’s Hospital to Leicester
General Hospital, subject to the outcome of the consultation.
While it is proposed to move the midwifery-led unit, community maternity
services in Melton Mowbray would be maintained. It would be ensured that there
is support for home births and care before and after the baby is born in the
local community. If someone has a complicated pregnancy, antenatal care would
be provided in an outpatient service located at Leicester Royal Infirmary or in
remote/virtual clinics.
Access at Leicester Royal Infirmary site
where it is proposed to develop the new Maternity Hospital would actually be easier in future. This is because it is proposed
to provide approximately 100,000-day case procedures and 600,000 follow up
appointments done each year in a different way e.g., carried out closer to home
in the community which is what patients say they want. More appointments will
also be done remotely, over the phone and via the internet. Others will move to
the new Treatment Centre at Glenfield Hospital
UHL are also creating extra parking spaces
on site at both Glenfield and the Royal Infirmary so access and parking would
be easier.
6.
Question by Liz Warren
Has the Clinical
Commissioning Group seen or asked for any evidence to
support UHL’s assertion that St Mary’s Birth Centre is not cost-effective?
If there is evidence can the Joint Committee request the CCG/UHL to publish
it?
How can UHL justify
the 500 births a year requirement for the midwifery unit at the General to be
considered viable?
Reply by the Chairman:
I have put these
questions to the Clinical Commissioning Groups and they have provided the
following response:
“The Clinical
Commissioning Groups have worked closely with UHL to develop these plans and
supports the Pre-consultation Business Case, which was approved by the Clinical
Commissioning Group Governing Body. The plans have also been independently
reviewed by NHS England, as well as clinicians locally and regionally to test
their appropriateness.
When considering
the financial viability and sustainability, looking at births alone is not
reflective of the wider value. The model of providing 24 hour
cover for 130 births as opposed to 500 is more expensive per birth. In a bigger unit midwives have more opportunity to maintain
skills, and students will receive a more meaningful learning experience. There
is a gap in Midwifery Led Birthing Unit’s nationally between capacity (the
number of births that can take place) and actual use, all of which are
underutilised. If we can care for 500+ women then
costs per birth with the staffing models to support this will prove cost
effective and sustainable.
The consultation
document describes the proposed unit as running as a pilot for 12 months to
test public appetite for this service with an indicative target of 500 births
per year. To be clear, this is not a hard target that must be achieved in year
one. Instead they are looking for evidence that a clear trajectory for 500
births in subsequent years is likely to be achieved.
If the consultation
shows support for the Midwifery Led Unit at Leicester General Hospital and the
proposal is implemented and the centre is open, a review body would be established
comprising of midwifes, parents and other stakeholders who will co-produce the
service with UHL.”
The Committee will
further scrutinise this issue during the meeting.
Supplementary Question
Liz Warren asked if
she could see the facts and figures which supported the assertion that St
Mary’s Birth Centre was not cost-effective? The Chairman
asked the Clinical Commissioning Groups and UHL to cover this issue as part of
their presentation on agenda item 7: UHL Acute and Maternity Reconfiguration
Consultation: “Building Better Hospitals” and also stated that Liz Warren would receive a written answer after the
meeting.
7.
Question by Kathy Reynolds
Neuro Rehabilitation services were for many years provided in Wakerley Lodge in the grounds of LGH. It
was a 1980's purpose built centre with plenty of space
both indoor and outdoor for therapy, wider corridors and moving space for
wheelchairs, purpose designed bedrooms, bath/shower areas with hoists, a “gym”,
and a central communal area for social and occupational activities. By 2016 it
had been allowed to fall into such a poor state of repair that the patients
were moved out on a “temporary basis” into Ward 2 at Leicester General
Hospital, they are still there. This is a conventional ward, cramped for space
and having none of the special facilities of Wakerley Lodge. Over the last few
years, therapists have performed heroics with their disabled patients in these
conditions. Is the Joint HOSC satisfied that the services formerly provided to
severely disabled people at Wakerley Lodge Neuro Rehab Centre have been
adequately considered in the reconfiguration plans for UHL? There is little
evidence in the PCBC document to suggest it has. Does it not suggest the needs
of these disabled people are of little import to those leading the
reconfiguration?
Reply by the Chairman
I have sought
reassurances from the Clinical Commissioning Groups and they have provided the
following answer:
“The
Reconfiguration team has worked with the Neurological Rehab and Brain Injury
services concurrently and both were in agreement that
to remain on an acute site that has access to ICU support was of paramount
importance. The growing dependency between the two units within recent years
also led to the request that the services be co-located as interdependencies
between the two patient cohorts has benefits for the patient groups.
At the time of
writing the Pre-Consultation Business Case the space identified at the
Leicester Royal Infirmary site would allow for both services to provide
facilities which would allow for the appropriate delivery of care that is
necessary for the patients. However the clinical team
during the consultation have been exploring whether the Glenfield might be a
better option, because of the opportunity to access more open space to support
rehabilitation. The clinical services along with patient representation will be
involved in the design development.
The plans are being
thoroughly reviewed as part of the process to ensure the users of the service
get facilities that meet their needs. The final decision, taking on board the
learning from the consultation, will be presented as part of the decision making business case for consideration by the CCG
at their governing body.”
It is important
that the assurances are followed up, so scrutiny will continue to review this
service in our ongoing work programme.
Supplementary Question
Kathy Reynolds asked when would
firm plans be in place for permanently relocating the Neuro
Rehabilitation services following the closure of Wakerley lodge. The Chairman asked the Clinical Commissioning Groups and
UHL to cover this issue as part of their presentation on agenda item 7: UHL
Acute and Maternity Reconfiguration Consultation: “Building Better Hospitals”,
stated that Liz Warren would receive a written answer after the meeting and
re-iterated his commitment to have Neuro Rehabilitation Services as a specific
agenda item at a future Committee meeting.
8.
Question
by Bob Waterton
(a) The
methodology underpinning the Total Net Present Cost calculations appears to be
missing from the appendices to the PCBC. Please could you provide the
methodology which has informed the 'bottom line' (ie
the Total Net Present Cost) in Table 6.12 on page 163 of the PCBC. Specifically I wish to know precisely which costs and benefits
have been included, what values have been assigned to each of these costs and
benefits and how you have arrived at those values. In addition, I would like a
clear statement on the period over which each of the costs and benefits have
been assessed.
The
Trust has used the Comprehensive Investment Appraisal Model as mandated by the
Department of Health and Social Care. This identifies a methodology which is
described in and consistent with the HM Treasury Green Book appraisal and
evaluation in Central Government.
In
line with the Treasury Green Book, costs have been discounted by 3.5% for the
first 30 years and 3% thereafter to reflect the time value of money. Therefore the Net
Present Cost of an additional item of expenditure is less than the total cost
if it expended over a number of years beyond the present year.
Please
see the Treasury Green Book for more detail on the modelling methodology – link
below.
Costs and Benefits
The
financial modelling in all options uses the UHL 2019/20 recurrent Forecast
Outturn as the “baseline” which was submitted to the CCG in September 2019
representing activity, workforce and finance assumptions for the 2019/20
financial year.
For
each of the three options, this baseline was then adjusted for the financial
impact of each option. These adjustments are described in Table 6.9 on page 161
of the PCBC with further detail provided below:
1.
The
clinical and overhead savings identified in the first six items in table 6.9
incorporate savings identified as a direct result of Reconfiguration and
changes in models of care.
a.
Option
3: savings are described in detail, including the underlying assumptions, in
the table in pages 4-6 of Appendix AB.
b.
Options
1 and 2: same themes as Option 3 with different values calculated due to still
maintaining services across three acute sites and inherent inefficiencies.
Detailed as per excel spreadsheet provided,
a copy of which is filed with these minutes.
2.
Estates
and Facilities savings represent the savings from vacating the Leicester
General.
a.
Option
3: outlined in the table in page three of Appendix AB.
b.
Option
2: same value as Option 3 whereby the financial impact between maintaining 2.25
and 2 sites was considered minimal.
c.
Option
1: Pro-rated to represent 50% of savings could only be achieved.
3.
Estates
and Facilities costs represent additional costs to maintain the new build and
larger area at the LRI and Glenfield. These costs are similar in nature to cost
savings from vacating the Leicester General and are detailed in the excel
spreadsheet.
In
addition to the specific costs and benefits described above, the options within
the PCBC includes Societal and non-cash releasing benefits as reflected in
table 6.10
The
Net Present Value of Savings and Benefits as summarised in Table 6.12 in the
PCBC are detailed below:
|
Area |
Option 1 £m |
Option 2 £m |
Option 3 £m |
|
Efficiencies |
441 |
543 |
729 |
|
Estates Efficiencies |
102 |
203 |
203 |
|
Non Cash
Releasing Benefits |
|
|
|
|
Improvements in Staff motivation as a result of better facilities and care pathway also
proxy for quality of care |
41 |
83 |
123 |
|
Societal Benefits |
|
|
|
|
Carbon Emissions |
2 |
2 |
2 |
|
Impact of ALOS reduction on
economy |
21 |
21 |
21 |
|
Multiplier impact on economy |
350 |
440 |
456 |
Appraisal period
The
appraisal period for each option was over a period of 67 years reflecting
construction time and a 60 year period post
construction. Costs for each option have
been identified in relation to Construction and Lifecycle costs for buildings
and equipment.
Supplementary Question
Bob Waterton referred to table 6.10 of the Pre-Consultation
Business Case which set out the proposed benefits as a result
of improvements in staff motivation which the Business Case stated would
remain the same for each year. He questioned whether the benefits should in
fact be expected to decline over time and questioned over what period these
benefits were expected to be accrued. The Chairman asked
the Clinical Commissioning Groups and UHL to cover this issue as part of their
presentation on agenda item 7: UHL Acute and Maternity Reconfiguration
Consultation: “Building Better Hospitals” and stated that Bob Waterton would receive a written answer after the
meeting.
(b) Please
could you tell me if, when valuing the costs and benefits of the project, the
following have been included in your costs:
·
the cost of not having enough beds;
·
the cost of additional travel time; details
included in PCBC;
·
the cost of the additional care which will be required
of family members and friends from models of care which entail more care given
in the patient's own home;
Medical care
the cost of losing staff through the
reorganisation;
·
the cost of maintenance for the life of the
project;
·
the cost of additional congestion on the roads
arising from the proposed concentration of services at the LRI;
·
the cost of out of hours care for deteriorating
patients at the General Hospital following interim moves;
• the
cost of not having enough beds;
Reply
from the Chairman
The Pre-Consultation Business
Case (PCBC) includes detailed bed modelling to take into
account activity, growth in demand and the reconfiguration of services.
All options have been evaluated on the same number of beds with the assumption,
in line with bed modelling, that the Trust will have provide sufficient
beds through Reconfiguration.
The cost of additional
travel time
There is cost breakdown of
additional travel time shown in the travel impact assessment in the PCBC
Appendix X
The cost of the additional
care which will be required of family members and friends from models of care
which entail more care given in the patient's own home
The PCBC does not assume that
there are any changes to models of care that require additional care of family
members and friends.
The cost of losing
staff through the reorganisation
In line with Trust policy, the
Trust will look for all redeployment opportunities for staff which are impacted
by the reconfiguration and changes in models of care. A transitional cost of £2 million per annum
has been assumed for 5 years which will be used for any reorganisation costs.
The cost of maintenance
for the life of the project
Lifecycle costs have been
allowed for in the option appraisal of £623 million (£188 million discounted).
The cost of additional
congestion on the roads arising from the proposed concentration of services at
the LRI
The reconfiguration results in
service moves from the Leicester General and across the two sites at LRI and
Glenfield Hospital. The net impact of the reconfigured estate results in less
patient activity at LRI and is therefore likely to result in less congestion.
The cost of out of
hours care for deteriorating patients at the General Hospital following interim
moves.
This was factored into the interim
ICU business case previously.
Supplementary
Question
Bob Waterton stated that the implication of a
policy of low bed numbers at the Leicester Royal Infirmary over the next
decade, together with the loss of community hospitals, meant that more of a
burden would be placed on the community. He submitted that the answer given by
the Chairman did not take account of the costs of community care and questioned
whether the cost of community care should be incorporated into the calculations?
The Chairman asked the Clinical Commissioning Groups and
UHL to cover this issue as part of their presentation on agenda item 7: UHL
Acute and Maternity Reconfiguration Consultation: “Building Better Hospitals”
and stated that Bob Waterton would receive a written answer after the
meeting.
(c) The
Total Net Present Cost (TNPC) results in Table 6.12 of the Pre-Consultation
Business Case show relatively small differences between the options (for
example, it is £448,000 between Options 1 and 3). Please could you tell me,
therefore, what the variances are around the TNPC for each of the options shown
in Table 6.12 since significant variance is likely to eliminate the small
differences between the option totals. Could you also, please, explain the
level of confidence you have in the estimates for the Multiplier effects on the
economy and for 'Improvement in Staff Motivation' since both
of these are given the biggest number for Option 3 but both are very
difficult to measure; different assessments may, again, eliminate the small
differences between the TNPC option results.
Reply
by the Chairman
The difference is
£448 million not £448,000 which is a significant difference between the
options. The significant part of this difference is the cash releasing benefits
of £389 million. This difference is caused by the need to maintain a
significant element of multi-site working in Option 2, as more services would
remain on the Leicester General Hospital site.
These are broken down in table 6.9.
The multiplier
effects relate to the level of capital investment and how that then has a
consequential impact on the local economy.
The higher the investment, the bigger the effect. The calculation has been based on evidence
provided from other schemes and reviewed by NHSE/I and
a prudent view has been taken on this.
Further detailed work will take place in producing the OBC.
The staff
motivation is a qualitative view quantified in relation to sickness absence and
vacancies. Following the new
Emergency Department at the LRI, there was a material improvement in staff
turnover from approximately 15% to 6% (the Trust average is 8%) which provides
confidence in the benefits within the PCBC.
It is important to
note that the Total Net Present Cost is one consideration in the options
appraisal. Other factors are taken into consideration in determining the
preferred option including Value For Money and
strategic fit. In terms of strategic fit, clinical sustainability underpins the
PCBC to ensure safe patient care which is challenging whilst operating on three
acute sites. Whilst the Treasury advises that all benefits and costs are
quantified which is difficult and some elements do remain qualitative.
Supplementary Question
Bob Waterton questioned whether further detailed work on the
multiplier effects could establish that the multiplier effects would
significantly reduce over time due to leakages from the local economic system?
The Chairman asked the Clinical
Commissioning Groups and UHL to cover this issue as part of their presentation
on agenda item 7: UHL Acute and Maternity Reconfiguration Consultation:
“Building Better Hospitals” and also stated that Bob Waterton would receive a written answer after the meeting.
9.
Question
by Lorraine Shilcock
The
WHO have been predicting the increase in pandemics for a few years now. Due to
many reasons worldwide Covid will not be the only
pandemic in the next 40 years. There is a lack of pandemic preparedness in the
Pre-Consultation Business Case. There are no plans for redesign of new
developments in design and capacity to future proof these new buildings to cope
with pandemics. Will this increase costs and by how much?
Reply
by the Chairman
Whilst not
explicitly spelt out, the current proposal will respond well to a future pandemic.
For example, the plans include:
–
a
doubling of Intensive Care Unit capacity. During the peak of the Covid-19
pandemic UHL had to use some theatres, and move
children’s heart intensive care to Birmingham for a period of time. UHL needed in excess of 70 Intensive Care beds at the peak; the scheme
will provide over 100 Intensive Care beds.
–
In
addition, the development of the new treatment centre allows UHL to split a lot
of planned care from the emergency care. This means that at times of peak emergency
pressure UHL can maintain their planned activity.
New buildings also have a more generous
footprint. This will make it easier to separate flows of people and goods
around the new buildings.
Supplementary
Question
Lorraine Shilcock
stated that being pandemic ready was not just about providing more intensive
care/elective care capacity but also related to the design of buildings. She
asked whether the proposed design of the hospital buildings would be modified
to achieve pandemic readiness and requested details of what other aspects of
the £450 million proposals would help the system to become pandemic ready. The
Chairman asked the Clinical Commissioning Groups and UHL to cover this issue as
part of their presentation on agenda item 7: UHL Acute and Maternity
Reconfiguration Consultation: “Building Better Hospitals” and
also stated that Lorraine Shilcock would receive a written answer to her
supplementary question after the meeting.
10. Question by Jean Burbridge
Can you estimate the percentage of the 440,000 households in Leicester,
Leicestershire and Rutland to which a Solus leaflet drop was arranged actually received the leaflet (Building Better Hospitals)?
Please clarify the size of the leaflet - was it the A4 6 page “Summary Document? What percentage of the total delivery was checked by GPS? Who was the 'Independent Third Party who telephoned random households to “backcheck” delivery and how many households gave answers?
The CCGs have undertaken a solus door drops
of an A5 information leaflet to 440,000 residential properties across
Leicester, Leicestershire and Rutland.
In addition, rural communities in Rutland were set a leaflet via Royal
Mail as solus was not an option.
Whilst many people have said that they have
received this leaflet, we are also aware that some believe they have not. Solus delivery is not an exact science and is dependent
on many key factors.
This includes the attitude of recipients to
unsolicited deliveries, with some people simply disposing of leaflets immediately
upon receipt. Other issues include the volume of marketing material being
received by households, which can reduce the impact and recall of specific
items, as well as the exposure of different people within the household to the
material following delivery.
The CCGs have raised concerns from residents
with their delivery partners who have provided GPS tracking information for
their agents. This is in addition to
feedback from telephone calls to a sample of homes within each of the postcode
areas to validate delivery, which is undertaken by an organisation called DLM.
Industry standards dictate that feedback
from these telephone calls would expect to establish a level of positive recall
of between 40% - 60% to substantiate that deliveries have been completed to the
standards expected. We are still receiving the community reports from this
exercise, but at the moment the recall is within this
range for communities across Leicester, Leicestershire and Rutland.
However, the door-drop is only one small
part of the overall awareness activities the CCGs have undertaken. These are set out elsewhere in the papers for
this meeting of the Joint Health Scrutiny Committee and the Committee will seek
further reassurances during the meeting.
Supplementary Question
Jean Burbridge questioned what was meant in
the reply by “Solus delivery is not an exact science” and submitted that surely
the leaflets were either delivered or not. She also asked how much the CCGs
paid for the solus delivery and what compensation was sought for the leaflets
not being delivered to all areas the first time? The
Chairman asked the Clinical Commissioning Groups and UHL to cover this issue as
part of their presentation on agenda item 7: UHL Acute and Maternity
Reconfiguration Consultation: “Building Better Hospitals” and also stated that Jean Burbridge would receive a
written answer to her supplementary questions after the meeting.
11. Question by Sarah Seaton
Please could you tell me what
your calculations are in terms of:
(a)
reduction in footfall and car movements on or around the site of the LRI once
the departments moving off the site have moved (eg
elective care);
(b) the
increase in footfall and car movements on and around the site of the LRI as departments
are moved to the site (eg the larger maternity
provision);
and
(c) the
net position.
The footfall to each site has been
calculated using actual activity data with the baseline of 718,289 from the
year period 2019/20. The figures are overall footfall and do not distinguish
the mode of transport used. The following data is provided as part of the
sustainable travel solutions in the Travel Action Plan.
a.
Reduction in footfall to the Leicester Royal Infirmary in year 2025/26 once
departments have moved off the site is forecast as 384,084
b.
Increase in footfall to the LRI in year 2025/26 once departments have moved on
to the site is forecast as is 23,109 taking the numbers up to 407,193
c.
The net difference in footfall is 23,109
Supplementary
Question
Sarah Seaton asked for further
detail on what was covered by the 23,109 increase in footfall referred to in
part c of the answer and asked for further clarification on the net
increase/reduction in footfall/traffic overall? The
Chairman asked the Clinical Commissioning Groups and UHL to cover this issue as
part of their presentation on agenda item 7: UHL Acute and Maternity
Reconfiguration Consultation: “Building Better Hospitals” and also stated that Sarah Seaton would receive a
written answer to her supplementary questions after the meeting.
12. Question
by Ann Cowan
(a) What
proportion of the £24m to be cut from Prescribing and Continuing Healthcare
will be applied to cut Continuing Healthcare (CHC) from patients who by definition are eligible? Page 94 of Appendix C states
"A saving of 2% per annum for CCGs focussed on Prescribing and Continuing
Healthcare costs equating to £24m"
I have some personal experience of CHC funding and know only too well
that without it, personal finances rapidly run out, leaving local authorities
with large care bills.
(b) Can you provide a breakdown of the £48m cuts
proposed by "Transformation savings relating to Community Services
Redesign, Planned Care and Urgent Care Transformation of £48m”? Additionally please provide a breakdown of the "£26m of
savings which are still to be identified which will be delivered through
transformation in the latter years of the plan (from 2021/22 onwards)"
just 4 months away. (Page 94 of the LLR 2019 plan)
Reply by the Chairman
The Clinical
Commissioning Group state as follows:
“The world has
changed over the last 9 months. We are now working in a different
environment and therefore we need to revisit our plans from 2019, to ensure
that they are still appropriate given the learning of the NHS during the
pandemic. This will include reviewing services and finances. A new
Operational Plan will be developed in 2021.
A central tenet of our overall clinical strategy for
health and care services is and always has been about delivering as much care
as we can as close to where patients live as is practically possible.
We have already started discussions in some local
areas as the first step to developing plans for what local health and care
services should look in communities across Leicester, Leicestershire and
Rutland. These plans would include discussions relating to GP provision
and the usage of local infrastructure, such as the community hospital, to
deliver a greater range of services locally.
We are committed to continuing these conversations
over the coming months. Our focus will be on working with each local
community to identify services that can and should be delivered locally through
the development of new local services, potentially in partnership with other
local public sector bodies, should that be deemed to be preferable or more
viable. When we have developed the plans as an outcome of these
conversations, we will be able to quantify the care that will be provided in
the community and the cost of delivering this care.”
13. Question by Giuliana Foster
Can you quantify the extra
amount of care which will be undertaken in the community by 2025 as a result of changing hospital use and new models of care
and how much it will cost to deliver this care in community settings'?
Reply
by the Chairman
Please see my response to
question 12 above.
Supplementary Question
Giuliana Foster
pointed out that the Pre-Consultation Business Case repeatedly stated that
hospital plans were premised on new models of care and extra work in community
settings and questioned whether this extra care had been quantified and costed.
The Chairman asked the Clinical Commissioning Groups and UHL to cover this
issue as part of their presentation on agenda item 7: UHL Acute and Maternity
Reconfiguration Consultation: “Building Better Hospitals” and also stated that
Giuliana Foster would receive a written answer to her supplementary question
after the meeting.
Supporting documents:
-
Questions from the public JHOSC 141220, item 23.
PDF 476 KB -
Question 8 supporting information, item 23.
PDF 141 KB
-
Supplementary Questions JHOSC 14 December, item 23.
PDF 313 KB
-
Supplementary Questions Appendix 1, item 23.
PDF 138 KB