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STATUTORY JOINT HEALTH OVERVIEW & SCRUTINY COMMITTEE - A PICTURE OF

HEALTH FOR SOUTH EAST LONDON

Date and Time: Monday, 27 October 2008 6.45 pm

Venue: Committee Room 5, Greenwich Town Hall, Wellington Street,

Woolwich, London SE18 6PW Contact Officer:

Ade Adebola, Corporate Support Officer Telephone – 020 8921 6348; Ade.adebola@greenwich.gov.uk

LAMBETH Members: Councillor Robert Banks and Councillor Helen O'Malley

AGENDA

Page Nos.

1. Apologies for Absence and Substitutions

2. Disclosures of Interests and Dispensations

3. Items of Late Business

4. Minutes of the Meeting held on 10 September 2008

1 - 6

5. Matters Arising from the Minutes

6. Committee Referral to the Secretary of State for Health

7 - 28

7. Programme Update from the A Picture of Health Project Team

To follow.

8. Date of Next Meeting

Membership

Bexley Councillors David Hurt & Graham D’Amiral Bromley Councillors Roger Charsley & Charles Rideout Greenwich Councillors Janet Gillman & Mick Hayes Kent County Council Councillor Dr Tony Robinson Lambeth Councillors Robert Banks & Helen O’Malley Lewisham Councillors Chris Maines & Sylvia Scott Southwark Councillor Adedokun Lasaki & Martin Seaton

Please note that the local contacts for enquiries on the agenda items are:-

Bexley Louise Peek, Scrutiny Officer, louise.peek@bexley.gov.uk, 020 8294 6154

Bromley Graham Walton, Democratic Services Manager, graham.walton@bromley.gov.uk, 020 8461 7743

Greenwich Ade Adebola, Corporate Support Officer, Ade.adebola@greenwich.gov.uk, 020 8921 6348

Kent Paul Wickenden, Overview and Scrutiny Manager, 01622 69 4486, paul.wickenden@kent.gov.uk

Lambeth Elaine Carter, Interim Scrutiny Manager, ecarter@lambeth.gov.uk, 020 7926 0027

Lewisham Nike Shadiya, Head of Overview and Scrutiny, nike.shadiya@lewisham.gov.uk, 020 8314 7443

Southwark Shelley Burke, Head of Overview and Scrutiny, shelley.burke@southwark.gov.uk, 020 7525 7344

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Minutes of the meeting held in the Council Chamber, Bromley Civic Centre, Bromley

on Wednesday 10th September 2008 at 6.45pm In attendance Bexley Councillor David Hurt, Chairman of the Delivery of NHS Services Scrutiny Sub-Group and Health Scrutiny Committee Chairman Councillor James Spencer Louise Peek – Scrutiny Officer Bromley Councillor Charles Rideout, Adult and Community PDS Committee Councillor Roger Charsley, Vice-Chairman, Adult and Community PDS Committee Graham Walton, Democratic Services Manager Greenwich Councillor Janet Gillman, Chair of the Healthier Communities & Older People Scrutiny Panel Councillor Mick Hayes, Chair of the Overview and Scrutiny Committee Simon Froud, Assistant Director Alain Lodge – Corporate Support Officer Lambeth Councillor Helen O’Malley, Chair of the Health and Adult Services Scrutiny Sub Committee Councillor Robert Banks Elaine Carter, Lead Scrutiny Officer Lewisham Councillor Sylvia Scott – Chair of the Healthier Communities Select Committee and Chair of the Joint Committee Councillor Chris Maines – Vice-Chair of the Healthier Communities Select Committee Nike Shadiya – Head of Overview and Scrutiny

Statutory Joint Health Overview & Scrutiny Committee to review

‘A Picture of Health for Outer South East London’ (APOH)

Agenda Item 4Page 1

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Also in attendance: Michael Chuter - Chairman Joint Committee of PCTs, Greenwich Teaching PCT Oliver Lake - Communications and Engagement Lead (APOH) Other members of the APOH team, representatives of the press and members of the public 1. Apologies for Absence and Substitutions

1.1 Councillor Graham D’Amiral, LB Bexley – Councillor James Spencer substituting.

2. Disclosures of Interests and Dispensations 2.1 No disclosures were made.

3. Minutes of the meetings held on 20th and 27th May and 24th July

2008 and Matters Arising 3.1 The minutes of the meetings held on 20th and 27th May and 24th July

2008 were approved.

(Note: Councillor Robert Banks should have been listed as present at the meeting on 24th July 2008.)

3.2 Councillor Chris Maines raised a question about the procedural basis

for the London Borough of Bexley’s referral of the APOH proposals to the Secretary of State for Health. It was clarified that an individual overview and scrutiny committee could make a referral once the NHS bodys proposing the change had responded in full to the report of the JOSC.

4. Response to the Report of the Joint Health Overview and Scrutiny

Committee – APOH Project Team 4.1 Michael Chuter gave a presentation to the Joint Committee. This

covered –

• Why changes were needed;

• What changes were needed;

• How the Joint Committee of PCTs (JCPCT) had arrived at its decision;

• the benefits of the proposed changes;

• the impacts of the changes;

• the consequences of not making changes.

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4.2 He concluded that the JCPCT had taken into account all the relevant factors and the views of interested parties including clinicians, elected councillors and the public, and had come to a balanced decision. He stated that his Committee had responded to all of the JOSC recommendations, but had to take the correct decisions to achieve the best health outcomes and save lives. He also outlined the impact of any further delay on staff at the Trusts, suggesting that a referral to the Secretary of State for Health might take up to eight months to resolve, based on the recent referral in Barnet, Enfield and Haringey.

4.3 Councillor O‘Malley asked how GPs had responded to the proposals.

Mr Chuter responded that GPs were championing the proposed changes.

4.4 Councillor Maines asked about the capital budgets to fund building

improvements related to the proposals and whether any expenditure was proposed at Lewisham. Mr Chuter stated that a table of immediate expenditure was included in the JCPCT response – this did not use up all the £10.5m capital budget. A colleague confirmed that discussions were taking place with Directors of Finance in the Trusts and PFI partners. Some expenditure was proposed at Lewisham to provide the Urgent Care Centre, while at Queen Mary’s three new operating theatres would be needed.

4.5 After a short adjournment, the Chairman asked individual Members of

the Committee to summarise their views on the possibility of making a referral before the Committee took a formal vote – Cllr Maines – Felt that the consultation process had not been effective and in particular that the JOSC had not been given time to study the Integrated Impact Assessment. Concerned that recruitment might be affected by a referral, particularly at Lewisham, and that the JOSC needed to consider what it expected to achieve from referral. Cllr Gillman – Agreed that the consultation had not been successful, and although concerned about the effect of the proposals on social care budgets she was minded not to make a referral as she felt the proposals would offer safer, better quality services. She wanted the JOSC to remain constituted to review implementation alongside the scrutiny committees in each borough. Cllr Hayes – Felt that, despite the problems with the consultation, a case had been made for change, and would not support referral. Cllr Banks – Minded to refer as the JCPCT had not addressed all concerns raised by the JOSC. Concerned in particular that rising birth rates meant increasing pressure on services in Lambeth and Southwark. Cllr O’Malley – Accepted that there was some mitigation of the stress on trusts in Lambeth, but reservations about the financial modelling and the gap between the vision and the reality of the proposals. Cllr Charsley – Unhappy about the consultation and the impact of the A&E and maternity changes at Queen Mary’s – minded to refer.

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Cllr Rideout – Although this was outside the scope of APOH, concerned about the closure of surgical unit at Orpington Hospital. Concerned about the impact of changes at Queen Mary’s and unclear about the impact of Bexley’s referral. Cllr Spencer – Felt that the changes at Queen Mary’s meant that residents in Bexley were getting a raw deal. Cllr Hurt – Agreed that residents in Bexley would suffer from the loss of A&E, maternity and children’s in-patients services at Queen Mary’s. Cllr Scott – Concerns about transport and the extent of public engagement, given that although many events had been held it was often the same people attending.

4.6 Councillor Maines requested information from Bexley on the grounds of their referral and what outcomes they wanted from referral. Councillor Hurt summarised the issues raised by Bexley in their referral, which included consultation, the impact assessment, maternity and new-born care (they had hoped for a midwife led unit at Queen Mary’s), loss of in-patient children’s services, lack of clarity about planned/emergency surgery, travel (particularly as parking was difficult at the Princess Royal University Hospital and the Queen Elizabeth Hospital, and Darent Valley was too far away). By referring the proposals, Bexley was seeking a change of direction for Queen Mary’s, with A&E and maternity services retained.

4.7 Cllr O’Malley reported that the Government had just announced the

first five polyclinics in London, and she asked whether any PCTs were taking this approach to GP services in south east London. Cllr Hurt confirmed that there were proposals in Bexley for one practice to move to Queen Mary’s Hospital.

4.8 Michael Chuter stated that Darent Valley Hospital Trust had confirmed

that it could accommodate the additional patients it was likely to receive. He emphasised that the current configuration of hospitals was not delivering satisfactory services, and that the Royal College of Surgeons recommended that each A&E unit needed to cover a population of around 450,000 people so that clinicians developed and retained the skills and experience they needed. He concluded that the current arrangement of four fully admitting hospitals served the population of outer south east London badly.

4.9 AGREED that

(1) the JCPCT’s response to the Committee’s report be noted; (2) a referral be made to the Secretary of State for Health on the

following grounds -

• concerns over the consultation process, and the late receipt of the Integrated Impact Assessment;

• travel and accessibility;

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• lack of an assessment covering impact on services in Southwark and Lambeth;

• loss of Services at Queen Mary's Sidcup (A&E, maternity etc);

• concerns about financial modelling.

The voting was - For referral: Councillors Hurt and Spencer (Bexley), Charsley and

Rideout (Bromley) and Banks and O’Malley (Lambeth) Against referral: Councillors Gillman and Hayes (Greenwich) and Maines and

Scott (Lewisham) 5. Options for the Joint Committee 5.1 The Committee received a report setting out options for the future of

the Joint Committee. As the Committee had decided to refer the APOH proposals it would remain formally constituted for the time being.

5.2 Michael Chuter confirmed that although the Joint Committee of PCTs

had technically ended it had been decided that some form of joint committee would continue.

5.3 The Committee’s next meeting would be held at Greenwich (date to be

agreed). The meeting ended at 8.15pm.

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The Right Honourable Alan Johnson, MP

Secretary of State for Health

Department of Health

Richmond House

79 Whitehall

London SW1A 2NS

Dear Secretary of State,

Re: A Picture of Health for Outer South East London

I am writing to you on behalf of the Joint Health Overview & Scrutiny Committee (JHOSC) to

advise you of our decision to exercise the Committees’ power to refer NHS proposals for

substantial change to local health services to you for independent review.

This referral is made pursuant to regulation 4 (5(a)) and 4 (7) of the Local Authority

(Overview & Scrutiny Committee Health Scrutiny Functions) Regulations 2002 (S.I. 2002 No

3048), made under s.7 of the Health and Social Care Act 2001 (now consolidated in s.244 of

the National Health Service Act 2006).

As the Primary Care Trusts responsible for commissioning health services in these areas

formed a Joint Committee, it was necessary for a JHOSC to be established in accordance

with the Department’s Directive. The JHOSC was established to consider the consultation

and proposals outlined in the NHS consultation document ‘A Picture of Health for Outer

South East London’ and is made up of members from the following local authorities:

Bexley, Bromley, Greenwich, Lambeth, Lewisham, Southwark and Kent County.

The JHOSC undertook an extensive programme of gathering evidence in order to

understand the financial, clinical, access and staffing issues driving these proposals as fully

as possible, and to hear the views of the public and stakeholders on the options presented

by the Joint Committee of Primary Care Trusts (JCPCT).

At the JHOSC meeting on 10th September 2008, the Committee resolved that the

consultation process was inadequate and some of the decisions made by the JCPCT at its

meeting on 21st July 2008 are not in the interests of the health service in the areas affected.

At that meeting the JHOSC made it clear that the reasons for the referral were as follow:

• The consultation process was flawed;

• The late completion of the Integrated Impact Assessment;

• Loss of Services at Queen Mary’s Hospital;

Cllr Sylvia Scott Chair Joint Health Overview & Scrutiny Committee Lewisham Town Hall Catford London SE6 4RU direct line 0208 314 7443 fax 020 8314 3111 xx October 2008

Agenda Item 6Page 7

• Inadequate Financial Modelling;

• Lack of Integrated Impact Assessment for the geographical areas covered by

Lambeth and Southwark Councils.

The JHSOC has not taken this decision lightly and is aware that difficult decisions do have to

be made about the configuration of NHS services, however these decisions need to take

place with the full information available to local people and other stakeholders.

The JHOSC is particularly dissatisfied with elements of the consultation documentation and

the availability of that material, particularly the poor distribution of the documents to each

household and the overcomplicated setting out of the options in the consultation document.

I should like to point out that the purpose of this referral is not merely to highlight the

concerns of the JHOSC regarding the process, but to express the JHOSC’s concerns about

the wider impact on the effectiveness of this public consultation process. The JHOSC is

anxious to ensure that public consultation is effective and that all people who may be

affected by the proposals have had a real opportunity to engage in this debate.

The JHOSC considered the delay which would be caused if it made a referral and the impact

this would have locally. However, given the evidence, the level of concerns presented to the

JHOSC and the response of the JCPCT, the decision to refer was 6 to 4 in favour.

Since its meeting on 10th September 2008 the JHOSC has met in private and public to

discuss the basis of this referral, and following an assessment of the evidence considered

and the views of our constituent local authorities, we are requesting that you challenge only

those decisions which impact the ‘outer’ areas of the sub region.

This referral is not seeking a review of the decisions made about the configuration and

delivery of services at Greenwich and Lewisham. The JHOSC is of the view that the

improvements secured for University Hospital Lewisham must proceed to implementation

without delay and that an Integrated Impact Assessment must be completed for Lambeth and

Southwark as part of implementation.

Whilst the JHOSC has voiced many concerns about the content of the consultation process,

we understand that the minimum requirements outlined by the Department of Health and the

Cabinet Office were probably adhered to and welcome the recent publication of the

Department’s ‘Changing for the Better – Guidance when undertaking major changes to NHS

services’ document which will improve the quality of consultation materials and ensure

meaningful public and stakeholder engagement in health service reconfiguration. It is

unfortunate that this document was published after the close of the consultation on the A

Picture of Health proposals.

The JHOSC has serious concerns about the recent decision of Bromley Hospitals Trust

(BHT) to relocate surgical services from the Orpington Treatment Centre to the Princess

Royal University Hospital. This option was not included in the consultation document for the

A Picture of Health Proposals. BHT took this decision without prior consultation with the

public or the local overview and scrutiny committee despite the decision taken by the JCPCT

on 21st July 2008 to move these services to Queen Mary’s, Sidcup.

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The JHOSC is not against change where it is necessary, and in our report we expressed the

view that it is wrong not to change services when they currently are not the best they could

be and we accepted the need for change in the location and delivery of health services in

South East London. However, the JHOSC is of the view that some of the decisions arrived

at by the JCPCT do not represent the right decision for ‘outer’ South East London and there

are potential alternatives which should be fully considered.

The JHOSC asks that you give careful consideration to this request that the decisions of the

JCPCT which affect the geographical area covered by Bexley and Bromley Councils be

subject to full review, taking account of the specific issues the Committee has raised.

I enclose detailed evidence to support this referral. In providing this evidence I have

endeavoured to provide you with a clear statement of the grounds for the referral and the key

examples of the evidence to support each point. I have not provided you with all of the

supporting evidence as this runs to volumes of A4 leaver arch files. However, if you would

like any additional information to support the referral or have queries about specific aspects

of the evidence, I would of course be happy to supply additional material.

I look forward to hearing from you.

Yours sincerely,

Councillor Sylvia Scott

Chair,

Joint Health Overview & Scrutiny Committee

cc. Members of the Joint Health Overview & Scrutiny Committee

Michael Chuter, Chair of the Joint Committee of Primary Care Trusts

Oliver Lake, Interim Programme Director, A Picture of Health

Anthony Mckeever, Chief Executive Bexley Care Trust

Will Tuckley, Chief Executive, Bexley Council;

Doug Patterson, Chief Executive of Bromley Council

Simon Robbins, Chief Executive of Bromley Primary Care Trust and Senior Responsible

Officer for A Picture of Health

Mary Ney, Chief Executive, Greenwich Council

Jane Schofield, Chief Executive, Greenwich Teaching Primary Care Trust

Paul Carter, Chief Executive, Kent County Council;

Derek Anderson CBE, Chief Executive Lambeth Council

Kevin Barton, Chief Executive Lambeth Primary Care Trust

Mayor Sir Steve Bullock, Mayor of Lewisham

Gill Galliano, Chief Executive Lewisham Primary Care Trust

Barry Quirk CBE, Chief Executive Lewisham Council

Annie Shepperd, Chief Executive, Southwark Council

Susanna White, Chief Executive Southwark Primary Care Trust

Enclosures:

1. Table of evidence supporting the referral – October 2008

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2. The full report of the JHOSC

3. The full response of the JCPCT to the JHOSC report

4. London Borough of Bexley Overview & Scrutiny Committee referral to the Secretary

of State for Health

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Joint Health Overview & Scrutiny Committee established to consider A Picture of Health for Outer South East London The Joint Health Overview & Scrutiny Committee (JHOSC) was established by the London Boroughs of Bexley, Bromley, Greenwich, Lambeth, Lewisham, Southwark and Kent County Council to consider and respond to the proposals and consultation outlined in the NHS document entitled ‘A Picture of Health for Outer South East London’. The JHOSC met on x occasions between [insert date] and [insert date] and considered issues relating to: [list JHOSC agenda items] The JHOSC considers that the health needs and populations of ‘inner’ South East London – the area covered by Greenwich, Lambeth, Lewisham and Southwark Councils is different to those of ‘outer’ South East London – the area covered by Bexley and Bromley Councils and Kent County (specifically West Kent). The table below outlines the basis on which the JHOSC considers, in recognition of the impact and effect of the proposals on the residents of Outer South East London, that the decision taken for the geographical areas covered by Bexley and Bromley Councils are not in the interests of the health service in Outer South East London.

JHOSC Ref:

Evidence Source

Extracts from relevant Legislation/Guidance

Views expressed by the JHOSC Likely Impact

A – Integrated Impact Assessment

JHOSC Meeting Local Authority Regulations 2002 Statutory Instrument 2002 No.3048 – Paragraph 5 (1): ‘subject to paragraph (3) it shall be the duty of the local NHS body to

The JHOSC consistently requested that the Integrated Impact Assessment be made

Consultees were asked to make judgements on

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provide an Overview and Scrutiny Committee with such information about the planning, provision and operation of health services in the area of that committee’s local authority as the committee may reasonably require in order to discharge its functions’

available for the public during the consultation period so as to ensure the public was able to make an informed judgement on the options presented by the NHS in the consultation document. The JHOSC requested that the Integrated Impact Assessment was made available for the JHOSC to consider ahead of submitting its final report for the JCPCT. The JHOSC further requested that this was made available in sufficient time so as to allow members adequate time to consider the content and potential implications of the assessments completed. This request was not met. The proposals do not stipulate how the new arrangements will address health inequalities The failure to complete an Integrated Impact Assessment for the geographical area covered by Lambeth and Southwark Councils means that a decision has been taken without an adequate assessment of the full implications and impact (good and bad) on all affected residents in South East

the options presented without access to the full range of information available. The JHOSC was unable to adequately scrutinise the contents of the Integrated Impact Assessment. Consultees were asked to make judgements on the options presented without access to the full range of information available and potential implications.

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London. It is the position of the JHOSC that the involvement of the Academic Health Science Centre (AHSC) necessitates a full Integrated Impact Assessment of for Lambeth and Southwark as part of the implementation of these proposals

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B. Consultation

Pre-Consultation Process Department of Health Guidance July 03, Chapter 10, Duties placed on NHS bodies, Paragraph 10.1.2: ‘At this point there should also be a discussion about how consultation will be undertaken. This latter discussion should include agreement about the length of time consultation will last and methods to be used taking into account local needs. Cabinet Office Code of Practice on Consultation, Criterion 1, Paragraph 1.2: ‘ It is important to identify proactively relevant interested parties and those whom the policy will be likely to affect. These groups should be contacted and engaged in discussion as early as possible in the policy development process’.

The JCPCT did not consult with the JHOSC on the content of the consultation document. Best practice indicates that JHOSC’s can make a meaningful contribution to consultation materials. The JHOSC is not convinced that all relevant and interested parties were involved in the development of the options consulted on and the materials used to support the consultation process.

Lack of involvement has meant that members of the JHOSC have had to spend much of the consultation period seeking to understand and explain the proposals and their implications to constituents. This has prevented effective scrutiny input prior to the formal launch of the consultation. The JHOSC could have explained and evidenced the need for a much simpler

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Paragraph 1.3: ‘Informal consultation with these stakeholders should be conducted prior to the written consultation period’ During formal consultation Cabinet Office Code of Practice on Written Consultations Criterion 3, Paragraph 3: ‘documents should be clearly focussed. They should be set out in plain language, as free as possible of jargon. Technical detail may be unavoidable, indeed central to the issues; but documents should be as widely understandable as possible. Worked examples may help in examining technical concepts to lay people. A guinea pig audience may be helpful in developing or testing a draft document’

The presentation of the options in pages 13 + 14 of the consultation document was extremely poor and the APOH team had to produce an ‘easy to understand’ version of the document during the consultation period. The consultation document did not achieve the Crystal Mark for plain English and the questionnaire was produced separately from the consultation document. Consequently the questions listed in the questionnaire did not sit alongside the contents of the consultation document.

presentation of the options. X

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Paragraph 1: ‘Respondents may have a great deal many documents to deal with, and lack time from their everyday work to study a comprehensive paper. But their views may be of great value, and everyone should be helped to identify quickly if they are affected, and if so to contribute productively. That is why clarity, and a summary, are important’. Cabinet Office Code of Practice on Written Consultations Criterion 6, paragraph 4 ‘it is desirable to keep as full an account as possible of both formal and informal responses to

Conducting formal consultation alongside ‘Consulting the Capital’ for Healthcare for London was ill-advised and the case for doing so was not convincing or proven. This is illustrated by the fact that a key decision of the JCPCT is pending the outcome of further work and consultation as part on Healthcare for London. This has resulted in significant concern about the future of local maternity services The distribution of the main consultation document was patchy and not every house-hold in the areas affected received a copy. Consultation with ‘hidden’ and hard to reach communities was not a full as it should have been and no events were held in Southwark or Lambeth. It was not at all clear when consultation on the proposals ended. The JHOSC is aware that the public consultation ended on X

Lower response rate to the consultation; confusion around the options and limited understanding of how these issues are inter-related. Limited opportunity to respond to the consultation. No opportunity to comment on the consultation. Public perception of bias and unfair advantage.

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consultations; both to ensure everyone’s view is fairly considered, but also, in line with the reasoning of the Neill Committee, to help address any allegation of privileged access’. Cabinet Office Code of Practice on Written Consultations Criterion 6, paragraph 6 ‘If significant new options emerge from consultation, it may be right to consult again on them (though a shorter consultation period may be justified)’

April and was advised by the APOH team that consultation with others would continue beyond this date. The JHOSC saw little evidence that the APOH team engaged with the AHSC at an early stage. Had this happened it is potentially the case that a different modelling may have evolved for public consultation. The failure to engage early with the AHSC partners and undertake a robust assessment of the implications on those trusts’, there is no evidence to suggest that any impact assessment has been undertaken on the implications of change for residents of Lambeth and Southwark. The committee would argue that the population covered by the proposed changes explicitly includes residents of those two boroughs since the anticipated transfer of activity from the two outer

An alternative option which better addresses the health needs of ‘outer’ South East London might have been identified and consulted on. Southwark and Lambeth residents had very limited opportunities to participate in the consultation.

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London boroughs to the acute and community Trusts in Lambeth/Southwark will affect capacity and reduce access for local residents. Yet the views of Lambeth/Southwark residents were not sought as part of the public consultation

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C- Travel and Accessibility

Local Authority Regulations 2002 Statutory Instrument 2002 No.3048 – Paragraph 5 (1): ‘subject to paragraph (3) it shall be the duty of the local NHS body to provide an Overview and Scrutiny Committee with such information about the planning, provision and operation of health services in the area of that committee’s local authority as the committee may reasonably require in order to discharge its functions’

The APOH team did not meet this requirement. The JHOSC consistently requested that the Integrated Impact Assessment be made available for the public during the consultation period so as to ensure the public was able to make an informed judgement on the options presented by the NHS in the consultation document. The JHOSC requested that the Integrated Impact Assessment was made available for the JHOSC to consider ahead of submitting its final report for the JCPCT. The JHOSC further requested that this was made available in sufficient time so as to allow members adequate time to consider the content and potential implications of the assessments completed. The APOH decision will mean that residents will need to travel longer distances for core services, impacting on families as well as the patient themselves.

Patients and their families have been given insufficient information on the transport implications and there needs to be further work undertaken to inform residents and ensure that risks are mitigated as far as possible. Patients continue to travel to their nearest acute service as opposed to those

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There will be an increased reliance on public transport to hospital sites from areas not having existing direct links. Parking provision on sites is already costly and inadequate. These issues will not only impact upon patients, but also their families and hospital staff. These factors will make health provision less accessible to residents The Committee expressed a number of concerns on the impact of these proposals on the London Ambulance Service. The Committee remains unconvinced that the London Ambulance Service will be adequately resourced to meet this new role. Additional evidence requested by the committee on A&E performance was contrary to the evidence provided at the meeting. The Alberti review recognised that transport is a key factor to the successful implementation of many of the proposed changes and the Alberti report stressed the importance of close examination of the impact on the London Ambulance Service and public transport.

outlined in the A Picture of Health proposals. Additional pressure of services delivered at St Thomas’ and Kings College Hospitals’. X Inability to meet the national A&E targets – none of the hospitals in the sector met the 4 hour waiting target in 2007.

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D – Financial Modelling

X The JHOSC remains concerned that the financial modelling to support the project does not provide sufficient assurance that the proposals will produce the required efficiencies in the region, that they are not driven by financial considerations at the expense of patient care, that they will not lead to further changes forced by financial circumstances. The financial pressures that exist in South East London are acknowledged on all sides, particularly related to the Private Finance Initiative (PFI) schemes that have funded new hospitals in Bromley (the PRUH) and Greenwich (the QEH), and a new block at Lewisham. The difficulties of changing the long-term PFI contracts associated with these developments means that there is much less scope to reduce or reconfigure services on these sites than at Queen Mary’s, Sidcup, the only major acute site in the four boroughs not affected by PFI. The JHOSC remains concerned that major services are being removed from QMS for these reasons, rather than any reasons

Changes are not implemented as consulted upon and agreed; Services are changed in an unplanned manner, without adequate scrutiny

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relating to patient care. These financial pressures have been exacerbated by national policy changes such as payment by results and the move towards providing more care closer to home in community or primary care settings. The JCPCT has always accepted that there was a strong financial case for change, but has stressed that the clinical case for change was indisputable and the principal driver for change. The JHOSC remains concerned that financial considerations had an undue bearing on the initial choice of the three options consulted upon, and on the final option chosen on 21st July 2008. The pre-consultation business case allocated £10.5m for any capital requirements of implementing the proposals. The JHOSC has not seen evidence that this figure is sufficient, or that any detailed costings have been carried out. The potential costs of implementing APOH include –

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• Re-modelling of existing facilities at the four acute facilities;

• Cost of providing Urgent Care Centres at Bromley, Greenwich and Lewisham;

• Additional patient flows out of the area (to Kings College, Guys and St Thomas’s, Darent Valley and Mayday, Croydon);

• Provision of an additional ambulance by London Ambulance Service;

• Transition costs associated with the workforce.

• Development of out of hospital care and impact on local authority care services.

The Financial Analysis to Support JCPCT Decision Making document (Enc 2F in the papers for the meeting on 21st July 2008) sets out the overall assumptions behind the options presented for decision. Conclusions are based on the top-down assessments of costings, and also indicate some areas where savings or capital receipts might be achieved. However, the document admits that further work is needed to asses more detailed bottom-up costings, and while there is some consideration of the impact

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on other acute trusts there is little or no assessment of potential impacts on other interested organisations such as local authorities. The JHOSC is still concerned that financial modelling may not adequately reflect the true costs of implementing the proposals. The JHOSC has challenged the APOH team on whether patient safety and choice really are the key drivers of change, rather than the need to respond to financial crisis. While there have been repeated assurances and statements that although finance has to be taken into account, the principal driver for change is clinical and related to patient care, the JHOSC concludes that concerns about PFI commitments have effectively determined the configuration of services, and that financial modelling has been geared towards this purpose.

E – Loss of Services and Queen Mary’s

Please refer to Enclosure 4 – London Borough of Bexley Local Overview & Scrutiny referral.

The JHOSC supports the commentary that relates to the loss of services at Queen Mary’s.

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F – Lack of Integrated Impact Assessment for Lambeth and Southwark

Following a review by the Office of Government Commerce in early July 2007, the focus of APOH was narrowed to address the acute financial and clinical issues facing the four outer South East London boroughs. The governance arrangements for the project were consequently restructured and as a result the process to develop the pre-consultation business case including option appraisal did not directly involve Lambeth and Southwark nor the organisations comprising the AHSC. The pre-consultation business case acknowledged that the three APOH options to reconfigure services in Bexley, Bromley, Greenwich and Lewisham included changes that will increase demands on certain Lambeth and Southwark based services, to an extent in some cases that would require significant extra capacity and new build. However, as late as April 2008 and in its response to the consultation the AHSC highlighted that ‘the AHSC partners are very keen to discuss the implications of the options in relation to Princess Royal, Queen Elizabeth and Queen Mary’s

In omitting Lambeth and Southwark residents from the Integrated Impact Assessment the committee does not consider that this issue has been sufficiently evidenced. In the absence of any refined modelling on the Option 2 Plus decision we are still seeking assurance that where NHS trusts anticipate an increase in activity they are able to provide for this without any detriment to current and future Lambeth/Southwark patients.

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hospital.’ In particular the AHSC noted that Option 3 was untenable and that to accommodate projected patient flows would have serious implications for bed capacity. In particular we are concerned that the health inequalities assessment undertaken by Matrix did not include reference to Lambeth and Southwark communities. The health inequalities aspect is key as the APOH proposals are predicated on service changes improving the overall quality, safety and access to health services.

Additional Commentary made by the JHOSC in support of the decision to make a referral to the Secretary of State for Health: a) The Integrated Impact Assessment did not adequately cover the geographical area covered by Bromley and demonstrated a

lack of local knowledge in relation to travel; b) The JHOSC was not informed about the development of Academic Health Science Centre and the potential inclusion of

University Hospital Lewisham; c) Assurances received from Guys and St Thomas’ and Kings College Hospitals’ do not sufficiently address the concerns of the

JHOSC and should in no way substitute for a completed Integrated Impact Assessment;

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d) The JHOSC is of the view that the APOH team should have found appropriate mechanisms to ensure the involvement of

clinicians during the identification of sites; f) The decision making meeting was poorly planned and communicated. The JHOSC finds it unacceptable that the JCPCT

proceeded to make a decision at a meeting which provided members of the public and interested stakeholders limited opportunity to attend and ask questions on the actual series of decision taken. The decision papers fill an A4 Arch lever file and the JHOSC does not believe that interested stakeholders were provided adequate and reasonable time to digest the decisions in advance of the meeting. The JHOSC does not accept the rationale for making the decision on 21st July 2008 with only 3 days notice.

g) The relocation of the Orpington Treatment Centre at Orpington Hospital to Princess Royal was not outlined as an option in

the consultation document. The JHOSC finds it completely unacceptable that Bromley Hospital Trust has taken a unilateral decision without local consultation on the development of the options or the decision taken. This feeds into the public perception that consultation is a meaningless and futile exercise and weakens the business case for Queen Mary’s Hospital.

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