Health & Social Care Committee

HSC(4)-26-12 paper 2

Health board reconfiguration plans – Betsi Cadwaladr University Health Board

Healthcare in North Wales is Changing

1. Context

The Health and Social Care Committee has invited the University Health Board to attend a session on Thursday 11^th October 2012 to allow the Health Board to present information on proposed reconfiguration plans, and to allow Members of the committee the opportunity to ask questions about the development of the proposals.

In particular the committee wish to consider the following areas:

· Key principles/criteria adopted to guide reconfiguration plans;

· The extent to which proposals are in keeping with

o Strategic direction set by the Minister;

o The views of local populations

· How consultation undertaken to date has taken place;

· How responses to consultation have been gathered, analysed and taken into account to date;

· How responses to consultation received to date may impact the proposals as originally presented;

· The role and relationship with the National Clinical Forum;

· Further information about the next steps for the proposals;

This briefing document is structured around these key headings.

Together with this briefing, a number of pieces of key evidence are embedded in Annex 1 – including:

· Our final Board paper in July 2012 summarising the review outcomes and proposals for change;

· A summary of the Board’s decisions in July 2012

· Our consultation document – “Healthcare in North Wales in Changing”;

· Our consultation questionnaire;

· Our consultation leaflet.

These formal documents are supported by a large volume of evidence and technical papers, impact assessments, strategy documents and wider documents relating to our service reviews. These documents cover the breadth of the challenges facing the NHS in North Wales as we seek to develop high quality and sustainable services. These technical documents are published in the public section of our website under each service review, via: http://www.wales.nhs.uk/sitesplus/861/page/42847

2. Background to Consultation

The Health Board entered a period of formal public consultation on 20th August 2012, and this will run until 28^th October 2012. The consultation continues a process of service reviews across North Wales that has been ongoing for the three years since the Health Board was formed, and has included very extensive clinical, professional and stakeholder engagement.

The proposals under consultation are those relating to:

· Community and Locality services – proposals to implement enhanced care at home, supporting people in their own homes, avoiding hospital admission. Proposals to enhance the range of services delivered at a local level through changes to the network of  community hospitals and supporting services, and;

· Older Peoples Mental Health services;

· Neonatal Intensive Care services;

· Vascular services – including complex arterial surgery;

The Health Board has also been undertaking reviews in other areas, notably Non-Elective General Surgery, Trauma and Orthopaedics, and Women’s and Children and Young Peoples services. In these areas, the  Board determined, with the agreement of the Community Health Council, that our proposals to change and enhance these services in a sustainable way, do not constitute substantial change that requires formal consultation. We plan to maintain these services on all three of our acute DGH sites, with stronger networking across the region. Work is ongoing with these areas to identify how professional and clinical standards will be delivered sustainably.

In all of these service areas the levels of engagement with stakeholders, patients and their representatives has been very high throughout our discussions. Our approach to continuous engagement was presented to the Health & Social Care committee at its meetings on 17^th November 2010 and again in early 2011.

The objective of our consultation is to continue the dialogue we have established with our stakeholders over the past three years, and to allow patients, staff, partners and the wider public to contribute their views on the Board’s proposals for service change.

This dialogue and engagement is a meaningful process that the Health Board, as a clinically-led organisation is fully committed to. It has led to the proposals that we are consulting on

3. Key Principles

Our clinical vision, set out in our summary board paper, and in our consultation document in Annex 1 is that:

· The local population will enjoy health, well-being and independence equal to the best;

· Supporting people to take responsibility for maintaining their own well-being in their own homes is our main aim as a practising public health organisation, with primary and community services working in close collaboration with third sector and community groups; 

· Out of hospital services should be accessible and available at convenient times, which are consistent and reliable wherever patients live;

· We want to make sure that when acute hospital care is needed, our hospital services can deliver the highest quality clinical outcomes; 

· When urgent or specialist care is needed, providing this safely and reliably for the whole population builds community confidence that services are consistently available, safely staffed and that quality standards will be achieved, all in order to deliver the best outcomes for patients.  Building on our three main acute hospitals, this may involve networking some services to provide a reliable response for the whole population;

· Our services will be delivered by an appropriately trained and skilled workforce, with the opportunities to maintain and improve their clinical skills, supported by the necessary infrastructure;

Our aim throughout has been to ensure that we develop services that are fit for the medium and long term – that provide the people of North Wales with affordable, high quality, safe and sustainable services. Services that are built around clinical teams and skills, rather than tied to buildings. Services that meet the needs of patients, and are capable of adapting to our changing demographic and technological profiles.

In considering our consultation, it is important to understand the extensive process of service reviews which has led to those proposals being made.

The service reviews and the proposals we are consulting on have been developed using a methodology based upon the Institute of Healthcare Improvement’s 3-cycle process of service improvement. This ensures that proposals for change have a rigorous evidence base and are grounded in multiple stages of detailed stakeholder engagement, leading to successive cycles of refinement of solutions.

We have placed professional standards and clinical guidance at the core of or work, with safety our overriding principle.

Each service review has been conducted separately to ensure that the most appropriate sustainable configurations for that service were developed, before the different streams were brought together to consider the range of interdependencies that exist between and within services. Services have also been designed to reflect the differing needs of urban and rural communities in North Wales. This was critical to building sustainable solutions from the bottom-up.

Through dialogue with stakeholder groups, patients and agreement with the Community Health Council, we have developed a set of non-financial criteria against which all of our proposals are assessed:

ü Quality of care, including clinical safety

ü Deliverability

ü Accessibility

ü Sustainability

ü Acceptability

ü Transparency

Each of these headline criteria has a number of assessment factors which add further differentiation to consideration of the proposals.

Each of the service reviews assessed these criteria for suitability with their own local stakeholders, and in some cases these have been adapted to enable a more appropriate appraisal of proposals.

In additional to the non-financial criteria, a fundamental principle for each of the service reviews has been to develop solutions that address issues of sustainability  including financial, clinical, operational and workforce sustainability.

In setting out our proposals, we have been careful to ensure we can describe them fully in terms of financial impact, capital requirements, the types of staffing rotas and training opportunities they would entail, and how they would impact upon recruitment and retention of clinical and professional staff.

A further guiding principle throughout our work has been to provide services in North Wales (or to bring services back in to North Wales) where it made clinical and economic sense to do so. This helps build the resilience and sustainability of local services, as well as reducing travelling times for many of our patients, their families and carers.

4. Strategic Fit

4.1 National Strategy

As well as the Welsh Government’s strategic direction, we have also paid particular regard to nationally published clinical and professional standards – for example, those set out by the British Association of Perinatal Medicine, All Wales Neonatal Standards, Birth Rate Plus, All Wales Dementia Action Plan, The Provision of Services for Patients with Vascular Disease.

All of these set the foundations for our work on future service models, and have been underpinned by the evidence base and messages from the literature in relation to each of the service areas.

We have summarised our proposals’ alignment with this national direction in our consultation document as:

“In North Wales we will:

ü Support you to manage your own health and wellbeing

ü Offer planned care closer to home or in centres of excellence

ü Offer urgent care within a safe time and within a reasonable distance”

4.2 Local Views

Given the geography of North Wales, we have spent considerable time with stakeholders discussing the issues of rurality and transport. Whilst not everyone agrees, we have found a broad consensus amongst patients and carers that they are prepared to travel longer distances to ensure access to high quality or specialist services. This balanced by a desire to ensure we increase the scope of services provided within local communities.

The ability of relatives and cares to visit patients is important to stakeholders, and we are working closely with Community Transport providers, as well as Local Authority partners to improve the transport networks currently in place.

Stakeholders expressed concerns about possible communications difficulties as services change, and as a result we are developing single points of contact for referrals, and information with social services as part of our proposals.

Patients on the borders of our area – for example in South Meirionnydd - have told us they have concerns between our service change proposals and those of neighbouring health boards. We have worked with Hwyel Dda and Powys LHBs to ensure that patients who live within the BCULHB area but access services from Hwyel Dda (specifically Bronglais Hospital) are fully considered in both Health Boards’ proposals. Similar discussions have also been held with English providers including the Countess of Chester Foundation NHS Trust and the Robert Jones and Agnes Hunt NHS Trust.

The views of patients and residents during our engagement events for Trauma and Orthopaedics, Women’s and Children and Young People services and Non-Elective General Surgery were important in shaping our proposals to network these key services across all three of our DGHs.

5. Consultation Process

5.1 Continuous Engagement

A wide range of individuals and community group representatives, as well as partner organisations in the third sector and statutory services were involved in the engagement work to develop the North Wales Clinical Services Strategy. This process was independently evaluated and was found to comply with the interim guidance on consultation and engagement.

Since then we have continued to involve stakeholders in the further development of our proposals for service change.  Each service review has undertaken a number of discussion events at which stakeholders have been invited to contribute their views on the area in question.  This has been augmented by regular update briefings being widely disseminated, including through the media.  We have established 14 locality stakeholder groups which will have shaped the planning and development of their health services, working with the Locality Leadership Teams.

We have briefed major stakeholders on a monthly basis through a “Key Issues” update and we have held a series of briefing events for AMs, MPs, Local Authorities, Third Sector, Primary Care representatives and the Community Health Council.

We have talked to our main advisory groups – the Stakeholder Reference Group, Healthcare Professional Forum and the Local Partnership Forum – on a regular basis.

A series of stakeholder events have been held on specific service areas.  We have also held drop in sessions which have been targeted at particular community and patient groups where we have needed more feedback from those groups which are likely to be affected.  Our work on equality impact assessment of our proposals has highlighted some of the protected characteristic groups as needing further engagement and we are working on this as part of the formal consultation exercise.

We have used existing forums such as voluntary sector networks organised by the County Voluntary Councils, and forums of town and community councils, to present the issues and discuss concerns and views of these forums.

Overall, a very wide range of representatives, patient and community groups have been able to hear about the issues we have been considering and give us their views. 

An overview of the detailed engagement activities/dates undertaken by each service review is contained within the final papers present to the Health Board in July 2012: http://www.wales.nhs.uk/sitesplus/861/page/62235. It is summarised in Annex 2.

5.2 Formal Consultation

The Guidance requires Health Boards to undertake a two stage process in relation to consultation, when it appears likely that formal consultation should take place.  The first stage is to undertake extensive discussions with key stakeholders to explore the issues, refine the options and agree on the approach to questions.

We have included the key stakeholders identified in this part of the guidance in our engagement processes, and included a specific formal approach under the terms of this part of the guidance.  This included presentation to the Stakeholder reference Group; the Healthcare Professional Forum; the Local Partnership Forum and the Community Health Council.  A presentation was made to an all-North Wales LSBs’ meeting on the potential options and the approach to consultation.

A scoping document for the consultation was presented to the Community Health Council and agreement reached on the issues to be covered.  The scoping document has also been signed off by the Consultation Institute, together with the project plan.

Our consultation was launched with a media briefing (print and broadcast) that coincided with the delivery of an information leaflet to every household in North Wales.

The consultation runs from 20^th August until 28^th October 2012, and anyone with an interest in our proposals can have their say by:

· Attending any of our 48 formal public meetings held in 16 different locations across North Wales – the dates/locations are set out on p39 of our consultation document.

· Writing to us via our Freepost address or dedicated email address.

· Phoning our free telephone helpline

· Completing the formal questionnaire – either in print or online via our consultation website: www.bcuhbjointhedebate.wales.nhs.uk

· Contacting the Community Health Council - with whom we have worked closely in designing our consultation process.

ORS have been commissioned to undertake a number of small discussion groups and household surveys to capture more targeted feedback to complement that received directly through the Health Board’s activities.

5.3 Analysis of Consultation Responses

Responses are primarily received via the formal questionnaire. Loggists are also capturing all responses made via public meetings, letters and emails, to feed into the ORS analysis.

ORS will produce a standalone summary of the responses, as well as a full report on the consultation findings.

5.4Impact of Responses on Plans to Date

We have set out above how feedback during our continuous engagement phases has been key in helping to shape our proposals – particularly around transport, the development of centres of excellence supported by a network of acute services across all three acute DGH sites, and the development of locality hubs.

It is too early in our formal consultation to make an assessment of responses received to date on the proposals we are considering. However, where responses have related to the presentation of material or the organisation of events, these have resulted in appropriate changes being made. Where demand has been high for public meetings we have amended our arrangements to accommodate more attendees.

Any alternative proposals that are suggested during the consultation will be considered, and subjected to the same non-financial and financial assessment criteria set out above. They will also be considered in terms of the Triple Aim and the objectives of delivering safe, affordable, high quality and sustainable services.

6. National Clinical Forum

During the February visit, the Health Board presented the clinical case for change from each review work stream, focussing on issues of safety, standards and sustainability. Particular attention was paid to the sustainability of medical staffing rotas and medical training, as well as the delivery of national clinical standards set in the local North Wales context of geography and demography.

In June 2012, the Health Board presented the draft proposals to address the issues raised in the clinical case for change. The Forum’s detailed response is shown in Annex 3. Broadly, the forum were supportive of the proposals being put forward as clinically safe and appropriate responses to the case for change. They raised questions relating to the clinical interdependencies between a number of services, which were fed into our final proposals.

7. Next Steps

The consultation period closes on 28^th October 2012. A period will follow to allow ORS to complete their analysis, and for service reviews and clinical teams to consider the consultation report and any alternative proposals that have been made. We will also take account of the views of the Community Health Council and any views they have heard.

The supporting technical documents will be updated and developed to reflect the outcomes of the consultation.

The Health Board will then decide, in the light of the consultation and other information gathered, whether to proceed with the proposals as set out or to amend them in light of the consultation feedback. We anticipate that this decision will be taken at a public meeting of the Health Board in December 2012.

Implementation will follow in early 2013. We will aim to have completed the changes by 2016.

Annex 1

Library of key documents to support this briefing paper:

July 2012 Board Paper

Summary of Board Decisions, 19 July 2012

Our Consultation Document

Our Consultation Questionnaire

Our Consultation leaflet – link unavailable

Our 5 Year Plan

Our Consultation website

Our Service Reviews website

Link to all of our July 2012 Board papers

Annex 2

Summary of the detailed engagement activities/dates undertaken by each service review

A:      Extract from Locality & Community Services final Board Paper, July 2012:

“Particular areas of work which have supported this Review include:

· Health, Social Care and Well-Being Strategies for each county area

· The creation of 14 localities across North Wales each with a multi-agency Locality Leadership Team and Locality Stakeholder Group (see Appendix 1)

· The Llangollen Hospital project

· The Llandudno Hospital project

· North Denbighshire Project

· Meetings with GPs and hospital doctors in the evenings and at Grand Round meetings

· Presentations to Local Authority Scrutiny Committees

· Specific forums eg. Flintshire County Forum, Ffestiniog Development Group,

· Meetings with the Local Medical Committee

In addition the Chronic Conditions pathfinder work has been completed in Gwynedd and South Wrexham, as a Demonstrator site for Wales, which has also influenced our review, with evidence of engagement to support a number of priority areas. 

A major conference was held in May 2011 bringing together about 120 people from our Clinical Programme Groups, Local Authorities, Voluntary Sector and Primary care contractors to identify priority themes for the development of locality working.   This identified widespread support for the development of integrated community based services within localities. Participants reflected upon the learning and successes of existing service models which included the improved integration of health and social care services, delivery of intermediate care and CCM Demonstrator projects.

On the 9th November 2011 an engagement event was held with around 100 stakeholders to consider further how we prioritise the work required to deliver the model of care in our local communities.  In particular the participants considered 3 key priority areas, namely prevention, enhanced care at home and moving services from acute hospitals to local communities.  Comments and themes raised by participants have been recorded and where used in the development of further locality engagement meetings. 

From January to June 2012 further significant engagement has been undertaken at a locality level.  Locality Stakeholder Groups have been established with a wide spectrum of local representation including, locality based community staff, County, Town and Community Councillors, Hospital League of Friends representatives, local voluntary sector groups, social services, GP practices and the Community Health Council.

A series of three meetings were held with each Locality Stakeholder Group to:

1)  Present and agree the Case for Change and the 3 priority areas,

2)  Present and agree a Generic Locality Model of Care

3)  Present and discuss various scenarios at a local level in implementing the Locality Model of Care

Around 240 stakeholders attended each set of meetings held across North Wales, with an average of 40 people for each local meeting.  The North Denbighshire stakeholders group has been in place for a longer period and have been considering the service needs of that Locality with a particular focus on the Glan Clwyd Hospital Project.”

B:       Extract from Older People’s Mental Health Services final Board Paper, July 2012:

“Internal and external engagement commenced in July 2011 and to date the following events have been held for all stakeholders including staff:-

Date	Venue
20^th September 2011	Porthmadog
22^nd September 2011	Llangefni
6^th October 2011	Wrexham
13^th October 2011	Deeside
19^th October 2011	Rhyl
24^th October 2011	Llandudno Junction
3^rd April 2012	Pwllheli
5^th April 2012	Dolgellau
17^Th April 2012	Mold
24^th April 2012	Rhyl
26^th April 2012	North Powys
10^th April 2012	Llangefni
18^th April 2012	Wrexham
25^th April 2012	Colwyn Bay
16^th May 2012	West,  North and Central Wrexham
18^th May 2012	Arfon  and Anglesey
22^nd May 2012	Meirionnydd  and Dwfor
18^th May 2012	Conwy East  and West
25^th May 2012	Flintshire
25^th May 2012	Central and south Denbighshire
22^nd May 2012	North Denbighshire

Throughout the review updates have been provided to the following:-

· Healthcare Professional Forum, Stakeholder Reference Group and Local Partnership Forum, Updates at Older Peoples Forums, Locality Leadership Meetings, GP Practice Managers Meetings”

C:       Extract from Vascular Services final Board Paper, July 2012:

“The review commenced after the other acute service reviews, and internal and external engagement commenced in January 2012. To date the following actions have been undertaken:-

Internal and external briefings following key stages agreed in the project board (eg commencement of review, following the first clinical workshop, when the case for change was adopted).	Multiple dates
A clinical workshop for all clinicians involved in delivering the service.	20^th March 2012.
Update to Health Professionals Forum.	11^th June 2012
Update to Stakeholder Reference Group.	11^th June 2012
Updates to Inter-CPG Group (multiple sessions);	May-July 2012
A dedicated CHC briefing session for the project board representative	16^th April 2012.
Presentation of the case for change and service models being developed to the National Clinical Forum.	27^th June 2012
Inclusion in briefings and other stakeholder events as appropriate – eg CHC briefing sessions, Town & Community Council scrutiny meetings, and the series of non-elective general surgery stakeholder events;	Multiple dates

D:      Extract from Paediatric & Child Health and Maternity, Gynaecology  & Neonatal Services final Board Papers, July 2012:

“Internal and external engagement commenced in July 2010 and was undertaken jointly with the Maternity, Gynaecology and Neonatal work stream. To date the following events and actions have been undertaken:-

Summary of engagement events

9^th September 2010: Stakeholder Event (Llandudno)

September 2010: Interviews with service users – Paediatrics & Neonatal

27^th September – 3^rd October: Interview with service users – Women’s

5^th October 2010: Stakeholder Event (Llandudno)

2^nd November 2010: Discussion Forum for GPs

1^st March 2011: GP Focus Group Llandudno

2^nd March 2011: GP Focus Group Holywell

18^th & 19^thApril  2011: Paediatric Consultant Focus Group

26^th & 28^TH April 2011:  Women’s Consultant Focus Group

8^th May 2011: Drop in session YG

14^th May 2011:  Drop in session WMH

11^th May 2011: Drop in session Central (Faenol Fawr)

19^th May 2011: Young People’s consultation Event

11^th July 2011: BCU Drop in session (West)

19^th July 2011: county stakeholder event, Porthmadog

21^st July 2011: county stakeholder event, Wrexham

2^nd August 2011: BCU Drop in session (East)

4^th August 2011: county stakeholder event, Llangefni

9^th August 2011: BCU Drop in session (Central)

11^th August 2011: County stakeholder event, Mold

17^th August 2011: County stakeholder event, Ruthin

18^th August 2011: Local Authority and Third Sector stakeholder event, Faenol Fawr, Bodelwyddan

23^rd August 2011: County stakeholder event, Colwyn Bay

2^nd September 2011: Summer Briefing for AMs, CHC, on all the reviews

7^th September 2011: Women’s CPG Focus Group

7^th November 2011: Update on Reviews

8^th May 2012: BCU Drop in session (West)

14^th May 2012: BCU Drop in session (East)

11^th May 2012: BCU Drop in session (Central)

On line questionnaire

The above has been supported by:-

· Bi-monthly CPG drop in sessions and team meetings

· Updates to Children and Young People’s Partnerships

· Local Midwifery Liaison committee

· Stakeholder Reference Group

· Health Professional Forum

· Local Partnership forum

· BCU Briefings following every project board meeting

· Monthly update to partners via the Key Issues document “

E:       Extract from Non-Elective General Surgery service final Board Paper, July 2012:

“There has been significant engagement with stakeholders and particularly clinicians.

A summary of the engagement events is as follows:

Date	Event
1 September 2010	Briefing for clinicians (St Asaph)
28 September 2010	Briefing for consultant surgeons and anaesthetists – open session (Bodelwyddan)
12 October 2010	Stakeholder briefing (Wrexham)
13 October 2010	Stakeholder briefing (Bangor)
14 October 2010	Stakeholder briefing (Bodelwyddan)
15 October 2010	Stakeholder workshop (St Asaph)
2 November 2010	Primary Care Discussion Forum (joint, Bodelwyddan)
3 November 2010	Discussion forum for surgeons, anaesthetists and radiologists (Bodelwyddan)
5 November 2010	Second stakeholder workshop (St Asaph)
1 April 2011	Clinical engagement, general surgery consultants
5 July 2011	Clinical engagement, general surgery consultants
18 August 2011	Clinical engagement, general surgery consultants
6 September 2011	Clinical engagement, general surgery consultants
8 November 2011	Stakeholder workshop (Colwyn Bay)
13 January 2012	Clinical engagement, general surgery consultants
14 May 2012	Stakeholder drop in session, Colwyn Bay
21 May 2012	Stakeholder drop in session, Rhyl
25 May 2012	Stakeholder drop in session, Wrexham
28 May 2012	Stakeholder drop in session, Connah’s Quay
29 May 2012	Stakeholder drop in session, Caernarfon
30 May 2012	Stakeholder drop in session, Dolgellau
31 May 2012	Stakeholder drop in session, Anglesey
14 June 2012	Combined service reviews primary & secondary care session, Wrexham
19 June 2012	Combined service reviews primary & secondary care session, Bangor
20 June 2012	Combined service reviews primary & secondary care session, Bodelwyddan

Information briefings have been released to the media, to project board members and staff and their representatives and placed on the website after significant project board meetings and at key points during the project.”

F:       Extract from Trauma & Orthopaedic services final Board Paper, July 2012:

“The work to develop a 5 year clinical services strategy for orthopaedics commenced with a series of internal and external stakeholder briefings in summer 2010.

To date the following engagements events have taken place:

A series of internal and external briefings following key stages agreed in the project board (eg commencement of review, following stakeholder/clinician workshops, when the case for change was adopted by BCU Board).	Multiple dates
4 internal/external stakeholder events with attendance from approximately 300 stakeholders and partners in total – coinciding with the 3 cycles of the review and formal feedback periods on all review documentation	30th July 2010 3^rd September 2010 22^nd October 2010 10^th November 2011
4 secondary care clinician workshops – 23/09/10, 20/10/10, 05/05/11, 20/10/11);	23^rd September 2010 20^th October 2010 5^th May 2011 20^th October 2011
A series of update briefings with other service reviews at key points during the work;	Multiple dates.
Publication on the internet/intranet, and circulation to all stakeholders of all draft project documentation with a defined formal feedback period before documents were adopted.	Ongoing.
Regular updates to Health Professionals Forum, Stakeholder Reference Group, Local Partnership Forum, and Inter-CPG Group;	Multiple dates, most recently 11^th June 2012
Inclusion in briefings and other stakeholder events as appropriate – eg CHC briefing sessions, General Surgery stakeholder events;	Multiple dates throughout the review.
Presentation of the case for change and service models being developed to the National Clinical Forum in February and June 2012;	February 2012 27^th June 2012

Feedback from stakeholders informally or via feedback sheets from events has been very positive about the process and levels of engagement – particularly with patients, patient representatives and carers.”

Annex 3

Feedback from National Clinical Forum