59.1 To try to set the context for the debate on this matter the committee’s role in this process was explained. Unlike substantial/significant service change proposals the Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013 were silent on proposals for pilot schemes. The committee’s role therefore was that of critical friend. If the committee agreed that the pilot was not something that it could support this would not prevent the GHNHSFT from proceeding to plan for the pilot. If the committee was so minded it could decide to write to the Secretary of State for Health and Care with its concerns, but this also would not prevent the GHNHSFT from proceeding, unless he chose to intervene. (It was important to set the wider context to this issue in that the first that the committee knew of this proposal was following a leaked internal staff memo by a GHNHSFT staff member two days after the committee’s 11 September 2018 meeting. This was followed by 57 GHNHSFT consultants writing to all members of the GHNHSFT Board expressing views on the preferred model of care, and which was subsequently the basis for articles in the local media.)
59.2 The Chief Executive, GHNHSFT, assured members that this was a pilot and that no irreversible steps would be taken during the pilot’s timeline. She expected a robust debate with members of the committee today. She explained the timing for the different communications, noting that the approach for this proposal was identical for that previously taken for orthopaedics and gastroenterology and noted the timing of the Trust meeting and the HCSOC was unfortunate.
59.3 The Director of Strategy and Transformation at the Gloucestershire Hospitals NHS Foundation Trust (GHNHSFT) gave a detailed presentation on this proposal highlighting the benefits that were expected to be achieved, and the metrics that would be used in the evaluation of this pilot. Two consultant surgeons from GHNHSFT also explained to the committee what an average day in general surgery looked and felt like. (The presentation slides were uploaded to the council website and included in the minute book.)
59.4 In the discussion that followed, it was stated by members that this was just another step in the downgrading of Cheltenham General Hospital (CGH); that this meant that access to emergency surgery was not safe and quoted an anonymous consultant who had spoken on local radio that this proposal was not safe for patients.
59.5 Some members felt that the fact that this number of consultants (57) had written this letter and that to them this signified a high degree of concern; and also suggested that there was a culture of fear at the GHNHSFT whereby consultants were afraid to raise their concerns publicly. In response it was commented that as they had signed the letter this did not seem to indicate that they were afraid to raise their voice.
59.6 The Chief Executive, GHNHSFT, drew members attention to the wording of the letter which in fact set out support for the proposed direction of travel and did not raise concerns for safety. She stated that it was clear that there was clinical consensus on the proposals related to emergency surgery, and that this was confirmed by the consultant letter; where there was some dissonance related to the proposed model for the elective pathway. She stated that whilst the views of the 57 consultants were important and added value to the discussion it was necessary to place them in context and understand that they represented a minority of the overall number of consultants at the GHNHSFT (400). She also reminded the committee that similar letters had been received with regard to the trauma and orthopaedic pilot but that this has been a success and none of the articulated fears had ultimately been realised.
59.7 The Chief Executive further stated that she wanted to be clear that this proposal was in no way linked to the provision of A & E at Cheltenham General Hospital; of the 130 attendances per day at CGH A&E only around 5 related to general surgery in Gloucestershire. Furthermore, she did not recognise the view that there would be a deterioration in access to general surgery, access and quality would in all likelihood be improved by this change.
59.8 In response to criticism that the GHNHSFT had not brought this matter to committee earlier it was explained that the GHNNSFT were required to take any proposals through its clinical governance process and senior leadership team. The senior leadership team had signed off the proposal in principle on 13 September 2018 (two days after the committee meeting). This information was then shared with staff via an internal email. The email had been shared outside of the Trust by a member of staff which placed the GHNHSFT in the position of having to share information publicly earlier than it would have wished to given that much of the planning and preparation was still in process. The GHNHSFT would have shared this proposal with the committee in due course as it had with the trauma and orthopaedic and Gastroenterology pilot proposals.
59.9 In response to a question it was explained that whilst the service was safe now, the long term sustainability of the service was at risk and there was evidence that the current service was falling behind others and local patients were not receiving care in line with national standards. This proposal was also part of wider considerations linked to the system’s vision for the development of centres of excellence (CoE). One of the aims associated with the CoE proposals was the potential to bring back to Gloucestershire several areas of service where significant numbers of patients currently travel out of county for more specialist care. CoE were also expected to improve the training experience for clinicians and improve recruitment and retention in medical, nursing and other specialist areas of workforce.
59.10 Cllr Flo Clucas, Cabinet Member Healthy Lifestyles Cheltenham Borough Council, had asked to speak to the committee on this matter. At the discretion of the Chair this was allowed. Cllr Clucas reiterated other members concerns regarding the letter from the consultants, access to general surgery in an emergency situation, and that there was a culture of fear at the Trust. She also stated that she felt that all options should have been presented to this committee for consideration; she felt that the committee should have another meeting to discuss this matter.
59.11 The Chief Executive, GHNHSFT, the Director of Strategy and Transformation and the Chair of GHNHSFT, and the two consultants present informed the committee that they did not recognise this description of the Trust. It was reiterated that this was not an anonymous letter; the consultants had felt able to sign their names to it. All signatories to the letter had received a response from the Chief Executive, and this had been discussed openly at a GHNHSFT Board meeting. It was also stated that the letter indicated support for the proposed CoE model, including the centralisation of emergency care and dedicated elective centres.
59.12 Other members were of the view that this was an excellent proposal; that it was good to have specialist teams in place; and that sometimes pilots were the only way to identify the way forward. It would be important to be clear as to what the process would follow the completion of the pilot.
59.13 The Deputy Accountable Officer, GCCG, explained that the GCCG supported the pilot, that the report was clear on the work that has already been done to identify how this pilot would be measured, and that the GCCG and GHNHSFT were committed to a full evaluation.
ACTION Andrea Clarke
59.14 It was agreed that the committee would write to the GHNHSFT and GCCG Boards outlining its concerns. The committee would also hold an additional meeting to discuss this proposal to gain a better understanding of the detail of the proposal particularly the benefits for both staff and patients, what the implementation planning timeline looks like, including the decision points, and the frequency of updates to the committee.
59.15 The Chief Executive GHNHSFT indicated that she would support the committee’s proposed work on this matter; she would prefer to be in a position where the majority of members were supportive of the proposal. However her paramount concern was addressing the safety and sustainability of emergency general surgery. She was clear that the GHNHSFT would continue with its planning for this pilot; she was also clear that this was a pilot and should it become clear that it was not generating the expected outcomes this was reversible. It was reiterated that the proposal was addressing significant issues within the service and had been developed through a panel of external experts, chaired by the national lead for general surgery. She stated that she fully accepted the need for HCOSC support should the Trust propose a permanent change.