Agenda item

General Surgery Reconfiguration Pilot

The Committee are asked to note the report that was considered by the Health and Care Scrutiny Committee on 13 November 2018. At the meeting the committee agreed to 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.


Members are asked to refer to the Local Authority Health Scrutiny Guidance document at the link below:


Attached to the agenda is a letter from Cheltenham Borough Council.


3.1      At the Health and Care Scrutiny Committee on 13 November 2018, members agreed to hold an additional meeting to discuss the proposal around the General Surgery Reconfiguration Pilot. Members had requested more detail particularly around the benefits for both staff and patients, what the implementation planning timeline looked like, including decision points and the frequency of the updates to the committee going forward. Members were informed that the Committee had the role of a critical friend and could express views and concerns but that they did not have the power to refer to the Secretary of State as this was a pilot.


3.2      Cheltenham Borough Council had been in contact, asking for the Health and Care Scrutiny Committee to examine the proposals in detail and to allow an opportunity for the 57 consultants who had signed a letter raising their concerns to be able to address the meeting. The Committee had not received any contact from the signatories to attend the meeting. The Overview and Scrutiny Committee at Cheltenham Borough Council had considered the issue and heard from a representative and the draft minutes of that meeting had been circulated to members.


3.3      Peter Lachecki took the opportunity to update members on confirmation that the Trust had been graded by CQC as good a couple of weeks previously. There were many areas of outstanding practice identified in the report including an embedded systematic approach to quality improvement.


3.4      Members received a presentation from Sion Lanceley and consultants who were core members of the task and finish group that had worked up the options related to the model of emergency general surgery. It was explained that the current model of emergency general surgery did not meet national standards. It was important that there was a model of ensuring specialist teams were free to review new patients, that there was provision for ambulatory care services and consultant ward rounds. The current model allowed for patients to be admitted unnecessarily and to stay longer. It was recognised that 14 general surgeons agreed ‘do nothing’ was not an option and that all fourteen supported the centralisation of emergency general surgery to Gloucestershire Royal.


3.5      There was a majority clinical support for the proposed model of planned care, which it was explained was the only option which could be implemented in the short term. The pilot would be evaluated and, by its nature, was temporary; any substantive and permanent change would be subject to public consultation.


3.6      It was explained that general surgery comprises two abdominal specialities. It was broken down for the committee what emergency work included and what elective work included. 70% of emergency patients did not require an operation. It was explained that most of the work was completely independent; the first point of call if patients became unwell would be the team they were being looked after by. It was suggested that having surgery patients co-located made a lot of sense.


3.7      Members were informed centralising emergency general surgery would improve patient outcomes. Patients often waited to be reviewed by the surgical team and patients saw the right specialist less than 50% of the time. As part of the pilot, all patients would see a sub-specialist surgeon and patients referred by GP or ambulance would go directly to GRH. CGH walk in patients that need to be reviewed by the surgical team would be transferred directly to the GRH surgical assessment unit – they would not need to go via GRH Emergency Department. . If a patient was too ill to transfer, a GRH surgeon would go to CGH.


3.8      There was information around how changes to elective care would reduce cancellations as those with planned short-stay and daycase general surgery would be moved to Cheltenham General. As part of the pilot, three times the number of patients would have their operation at CGH.


3.9      Members noted the benefits for emergency care and planned care as detailed in the slide included two surgical teams being on duty providing 24/7 specialist colorectal and upper GI consultant cover and standardised care pathways and improved patient experience.


3.10    Since 2011there had been no clinical consensus around the reconfiguration of general surgery and so a task and finish process was established to deliver recommendations. All options were designed by clinical teams and all options included the centralisation of emergency general surgery at Gloucestershire Royal Hospital.


3.11    Referring to the letter signed by 57 colleagues, members were informed of the areas of support for centres of excellence and centralisation of emergency general surgery at GRH and long term strategy to centralise short stay surgical services at Cheltenham. The difference in opinion was on the preferred location of complex planned elective general surgery.


3.12    The Trust was in the implementation planning mode at the moment, but members were shown some of the pilot evaluation criteria as part of the presentation.


3.13    In March 2019 John Abercrombie would return to GHFT to look at how things had changed and give his view. The pilot would go live in September. There would be a 12 month monitoring programme in order to address seasonality. Updates would be shared with HOSC every three months.


3.14    Cllr Iain Dobie was invited to provide further feedback from the Cheltenham Borough Council meeting. The issue was considered at the Council meeting on 21 January 2019 and at Scrutiny on 11 February 2019. Concerns had been expressed that once the pilot had been implemented some of the changes would be irreversible, that not all the options for change had been properly assessed (with particular reference to Option 4 not being fully examined), and the potential aggravation of bed shortage issues at Gloucestershire Royal Hospital. A representative of the consultants who had signed the letter had suggested to the scrutiny committee that this was not a pilot but a major reconfiguration of services and emphasised the concerns already expressed. In addition the point was raised that where patients needed to be moved between sites this would compromise their recovery.


3.15    Responding to points raised by members, and noting the concerns from Cheltenham Borough Council, Simon Lanceley explained that it was not within the Trust’s gift to permanently enact change without public consultation. It was further explained that there would be a criteria to assess the pilot and to develop further. Option 4 was a full emergency and elective split but that could not have been implemented in the timescale. It was suggested that John Abercrombie had stated that this was 2-3 years away due to the staff numbers and workforce skillset required. On the perception of bed shortages, recently 12 gastroenterology beds had moved to Cheltenham General and a new Acute Medical Initial Assessment (AMIA) model implemented to reduce unnecessary admissions. The Trusts long term clinical strategy would address variation in bed occupancy between the two sites. By improving the access for patients to senior decision makers it would allow for quick decisions and rapid assessment that could reduce the requirements for beds.


3.16    Some members raised concerns about the potential impact of the Oncology Centre of excellence and how its reputation could be damaged. The example was given of consultants working together and how a splitting of teams could impact on that timely level of support. In response it was explained that under the pilot there would continue to be availability of emergency consultants to provide this support with one free to go and assess individuals. Most procedures as joint cases were planned operations and so the appropriate people would be on hand. Consultants emphasised that the reputation of the Oncology Unit would not be affected, with further detailed provided around the level of care provided which was in place pre and post surgery.


3.17    A specific concern was raised regarding the time it would take a surgeon to travel between Gloucester and Cheltenham if they were required. Members were informed that currently if a general surgeon was in surgery then there might be a 3 to 4 hour wait anyway. It was suggested that the pilot actually freed up surgeons to provide greater availability.


3.18    One member raised his dissatisfaction at the level of information provided. He had requested detail around the questions and points raised against each of the options considered, including the final outcome document. In addition he would have welcomed further information on the operation capacity at Gloucestershire Royal Hospital. He explained that national standards were not being met with regards to emergency surgery in Gloucester but that for complex elective surgery in Cheltenham, those standards were being met. He reiterated previous concerns regarding the bed base at Gloucester and on the concerns expressed regarding oncology, he suggested that Cheltenham’s reputation for safe complex surgery could be lost.


3.19    It was emphasised that Option 4 was not off the table with more detail to be produced with John Abercrombie in March. One member suggested that this had been a late consideration and asked whether if this was the long term direction, would the current pilot be a retrograde step in achieving that goal? In response, it was explained that there were advantages and disadvantages associated with all the options and that Option 2 was the one that could be implemented. It was emphasised that there would be no additional patient risk and that future planning, potentially around Option 4, would be informed by the pilot.


3.20    There was further discussion around the potential impact on the Oncology unit with one member suggesting that the assurances provided to members was disputed by other surgeons that had been in contact. It was suggested by some members that the changes would be a fundamental error and undermine the service. In particular there were questions regarding adequate consultant and junior doctor cover. In response to concerns it was clarified that there were continual interactions between staff across Gloucester and Cheltenham with a one hospital approach in place and . Cheltenham General would continue to have registrar cover at night. 


3.21    In response to a question it was stated that as part of an upgraded level of care SWAST ambulance would transfer patients between sites when required.


3.22    Members welcomed the opportunity to discuss the detail of the pilot and thanked all officers for their presentation and their responses to questions. Members felt that the most appropriate forum to explore the remainder of their questions and to best scrutinise the pilot would be through a scrutiny task group. A one page strategy would be developed setting out the aims, ambitions and timescale for the work and this would be circulated to members for comment.
ACTION                     Cllr Carole Allaway Martin/ Democratic Services



3.23    The Committee agreed to write a letter to the Secretary of State outlining their concerns around a lack of clarity on the role of Health Scrutiny in regards to a reconfiguration pilot.
ACTION                     Cllr Carole Allaway Martin/ Democratic


Supporting documents: