Minutes for Health Overview & Scrutiny Committee meeting, Dec 11 2009, 10.00AM official page

Apologies were received from Mr Hedley Cadd and Mr Paul Rogerson.  Mr Polhill substituted for Mr Cadd and Mr Egleton substituted for Mr Rogerson.

There were no changes in membership.

To declare any personal and prejudicial interests

Mr Polhill declared an interest in agenda item 5 as he is the Member for Buckingham North.

of the meeting held on Friday 13 November 2009 to be confirmed as a correct record.

The minutes of the meeting held on Friday 13 November were agreed as a correct record.

The Chairman will take questions from the public and refer them to health representatives for a response.  Recipients of public questions will be requested to provide an initial written response within 28 days.

A member of the public expressed concern over the closure of clinics at Amersham with patients being transferred to Wycombe Hospital for treatment.  This has resulted in additional help being needed to get to hospital appointments.  The member of the public asked the Chairman to pass on these concerns to the Buckinghamshire Hospitals Trust.

The Chairman responded by saying that the date for implementing the changes is imminent and there has been correspondence between the hospital trust and the Chairman.

The Chairman clarified the situation regarding responding to public questions as there had been some queries regarding the procedure.  He said that both written and verbal questions are forwarded to the relevant health organisations with a request for a written response from them within 28 days.  The Chairman stressed that the role of the Overview and Scrutiny Committee does not allow it to impose sanctions on health agencies if they do not co-operate.  However, he said that in the interests of maintaining a co-operative working relationship the expectation would be for the trusts to adhere to this requirement.  He went on to say that the Committee can remind trusts of this agreement if they fall foul of the timescales.

As a result of the September 2009 Committee meeting, an independent review was commissioned to assess whether the new contract for the provision of medical cover for patients at Buckinghamshire PCT’s Community Hospitals would result in a significant variation to patient care.  Previously in-patient care had been provided by GP practices local to the hospitals, but since September 2009 this service has been provided by The Practice plc after a successful bid for the new contract.

Members of the Committee requested that the review clarified the requirement for the current level of GP cover and clearly demonstrated whether patients were being adversely affected by the new arrangements or not.  The Committee emphasised the importance of taking patients and carers views into account.

Members will have the opportunity to hear and debate the findings of the review and make any further recommendations.

Stewart George, Chairman, Buckinghamshire PCT

Other members of the review panel and PCT representatives will be there in support.

The Chairman started by explaining that all Members had received a significant volume of reading material, including the independent review and the correspondence from interested parties in response to the review panel’s report and there had been one very late submission the day before the Committee meeting.

The Chairman asked members of the public to indicate whether they wished to speak as he explained that 10 minutes would be allocated for public speaking.  Five people requested to speak and were allocated 2 minutes each.

Dr Duncan Keeley from the Rycote Practice spoke first.  He urged the Committee not to accept the review panel’s report due to factual inaccuracies.  He said that the petition which was handed to the Committee at the September meeting which had 2,000 signatures now has over 5,000 signatures.  He handed the petition to the Chairman.

Dr Richard Harrington, also from Rycote Practice, explained that the Rycote Practice has 3 partners with over 60 years’ experience and they are all committed to providing the highest quality NHS services.  He said that the Rycote Practice is located next to the Community Hospital which makes accessibility to patients very easy.

Mr Frank Donlon from the League of Friends in Buckingham challenged the panel review process as he said that the four community hospital sites should have been considered separately as they have very different needs and amalgamating the needs has created a hypothetical situation rather than the reality of what is actually taking place at each hospital.  He went on to say that Dr Elaine Robb was in attendance at the meeting to represent the local GPs in Buckingham.

Ms Sarah Taylor from the League of Friends in Thame explained that the Community Hospital is very much part of the community and local residents have been fundamental in raising funds for the Hospital.  She went on to say that everyone who works at the hospital has a key role to play (nurses, therapists, cleaners, etc) and the local GPs know the needs of the patients and they are key to shaping the healthcare services provided at the Hospital.  She said that morale at the Hospital is at its lowest and she has no confidence in NHS Buckinghamshire.

Mr Roger Edwards from North Bucks Health Action Group expressed grave concerns over the way the whole process has been handled. He said it has been the worst consultation and change process that he has ever seen.  He explained that in Buckingham Community Hospital, there should be 16 beds and this has been reduced to 8 beds.

The Chairman thanked the members of the public for their statements and explained to Members that they are required in its deliberation and from the evidence they have received to consider the effect on patient outcomes.  He understood the concerns expressed over how the whole process has been undertaken but the role of the Committee is to consider what effect the changes have had on patient outcomes.

The Chairman invited Stewart George, Chairman of NHS Buckinghamshire to make an opening statement before taking questions relating to the independent review.

Mr George explained that Andrew Passmore, one of the panel members, had sadly passed away last Saturday.  He said that he had sent condolences to his family.  He said that Mr Passmore gave selflessly of his time.

Mr George gave apologies on behalf of David Lunn who lead the panel review.  Mr Lunn is a non-executive director on the PCT Board.

Mr George said that he understood the passion and ownership which local people and GPs felt over the issue of medical cover at Community Hospitals.  He went on to say that the PCT has a duty to make the provision of medical cover as effective as possible.  He accepted that the PCT did not do enough with regards to public consultation and apologised for the way in which the process had been handled.  Mr George accepted responsibility for this and said it would not happen again.  He acknowledged that the PCT needs to do more to engage with the public and stakeholders.  He stressed that patients are not being adversely affected by the new arrangements and, in some cases, improvements have been made.  He said that the Practice plc would have been awarded the contract based on either the higher or lower number of hours.  Mr George said that he would look at the scoring process to see whether the scoring results could be made public.

Action: Mr Stewart George

Mr George explained that the PCT is looking to strengthen relationships with the League of Friends and the local GPs.  There is a concerted effort by the PCT to provide better information so that people know what services are on offer and where to go for certain services.  He said that the PCT is determined to do better in future.

Mr George introduced John Wrigley, Chairman of the League of Friends in Buckingham and, an independent member on the review panel.  Mr Wrigley explained that there were 6 people on the panel – 2 members from the PCT (who were not involved in the procurement process), 2 independent professionals (a GP from Berkshire and a GP from a Community Hospital in Oxfordshire) and 2 independent members (Mr Wrigley and Mr Passmore).

Mr Wrigley explained to Members that he started the review process as cross, angry and perplexed over the PCT’s original decision as many people in the public seating area.  He said that the review panel looked at the evidence without pre-conceived ideas and considered why the contract was necessary in the first place and why it was awarded to The Practice plc.  He explained that there had been a lot of information to look at and to digest.  He said that at the first meeting in November, the panel invited a number of people along to be interviewed, including people from the procurement team, the League of Friends in Thame and Bucks Action Group.  He said that a Buckingham GP was unable to attend in person but was interviewed over the telephone.  He pointed out that the interviews covered a broad spectrum of people and the interviews were all recorded.  There were 2 further meetings and a report was circulated for comments at each stage.  At the third and final meeting, the panel considered the draft report which then became the final report which was presented to the Board.

The Chairman thanked Mr Wrigley on behalf of all the Committee Members and emphasised that the Committee must consider whether the review adequately demonstrates how the medical cover was delivered in the past and how it differs from the planned delivery under the new arrangements.

During discussions, the following questions and issues were raised.

A Member asked how many GPs were part of The Practice plc and where were they based.  The Member also asked whether the GPs had to travel some distance to visit patients in the Community Hospital.

Mr George responded by saying that he did not know how many GPs were part of The Practice plc but he knew that they have a foothold in Buckinghamshire but he said that they have GPs across the County.

A Member asked whether the GPs were paid per visit or whether it is a block contract.

Mr George said that it is a block contract.

A Member expressed concern over the rapid expansion of The Practice plc and felt that perhaps the PCT had been exposed to an aggressive marketing campaign by the company.

Mr George said he was not aware of an aggressive marketing campaign by The Practice plc and emphasised that all GP practices are businesses.  He said that The Practice plc should not be vilified for being a successful business and he believes that they are a sustainable option.

A Member asked whether The Practice plc provides out of hours cover or is it provided by Harmoni.

Mr George explained that out-of-hours cover is provided by a consortium of GPs in conjunction with Harmoni.  He said it is not part of The Practice’s contract to provide this service.

A Member asked whether The Practice plc can provide a consistent level of cover.

Mr George explained that 1 GP covers Amersham, Marlow and Thame and I GP covers Buckingham.  He mentioned that in 2010, the Practice plc would have a base in Milton Keynes and this would provide GP cover for Buckingham.

A Member asked for clarification over what constitutes a substantial variation rather than a significant change.  For example, 16 beds rather than 8 beds.

Mr George responded by saying that the number of GP hours is not about the number of beds in the Community Hospital.  He said that the contract was not awarded on the basis of the number of beds.

A Member said that the general consensus appears to be that if the public has been consulted at an earlier stage, then the public would not feel so railroaded by the PCT.

Richard Mills, from the PCT, explained that any permanent substantial changes to Community Hospital beds would require a public consultation.  As yet, no changes have been made permanent but he said if the situation changes then a public consultation would take place.

Dr Harrington explained that the quality of patient service has been cut in half and he asked the Committee to agree with this.

A Member directed the Committee to page 31 of the agenda pack which summarises the differences in service before and after 1 September 2009 and said that it would have been helpful to have a quantitative and qualitative set of outcomes which could have been used to ascertain whether the costs associated with the differences in service are justifiable and the costs in terms of patient outcomes are acceptable.

Mr George explained that there has been a financial saving as a result of the differences in service but this was not the main objective.  The main aim emanated from concerns about the consistency of care across Buckinghamshire and the PCT felt that they were not in control.

At this point, Mr George introduced his colleague, Rachael Corser representing Community Health Bucks, the provider arm of Bucks PCT.

A Member asked who is responsible for monitoring the quality and level of patient care.

Ms Corser explained that there are national quality standards in place which the PCT are measured against.  The Practice plc has a copy of the performance measures set out as part of the contract and these are reviewed every two weeks.

A Member said that they were hoping to see the performance measures included in the report and asked whether there has been an improvement in patient care.

Ms Corser responded by saying that there has been no decrease in the quality of care.

A Member asked what happens when a GP goes on holiday or is unable to provide the patient care required.

Ms Corser said that there are GPs available to support time-off by the main GP.

Nick Carter, from Oxfordshire County Council, explained that the PCT is not in control of County-wide medical cover and there is substantial feeling that local GPs know the needs of local people.  He went on to say that he feels we have a bureaucratic system now where one size fits all and local judgement has been removed.  Mr George said that the quality of care is now consistent across the Buckinghamshire PCT’s geographical area.

Mr Carter went on to say that bureaucratic control has led to a standardised tendering process.  Local GPs felt that 5 hours was not adequate medical cover and therefore they did not enter the bidding process due to their professional judgement that 5 hours was not enough.

Mr Carter said that the hours of medical cover has changed since the contract was awarded and other shifts have occurred.  He felt that the contract was awarded on the basis of no clinical judgement.  Mr George said that all the practices who wished to tender did tender and the review report states that The Practice plc would have been awarded the contract irrespective of the change to the number of hours.

A Member commented that the independent review process requested by the OSC has helped to get a very poor procurement process back on track.  The Member felt that there was a need to make good the gaps in the process and asked for more information about the nurse-led model.

Ms Corser explained that the GPs work closely with the nurses and the transition to a fully nurse-led service will require additional training in the short term.

A Member asked whether the training contract which was, in the past, funded by the Deanery of Oxford could be reinstated as it is very beneficial.

Ms Corser said she would look into this as The Practice plc is a training practice so it could be brought back.

Action: Ms Rachael Corser

A Member asked how long the training takes and asked who would supervise the nurses throughout their training.

Ms Corser explained that nurses are already working in a nurse-led environment and the PCT are supporting nurses in identifying additional training needs.  She said that training is on-going and the PCT will continue to develop their staff.  She went on to say that all nurses have supervision and access to support their practice.  She went on to say that the PCT needs to be able to be flexible in the number of hours of medical cover which are required in the Community Hospitals as there are variations in bed numbers and patient dependency throughout the year.   This view was further endorsed by Mr George who said that any variations in the contract are determined by patient need and not by costs.  He agreed with Ms Corser that the level of patient care will vary.

A Member asked whether it is The Practice plc’s responsibility to train the nurses.

Ms Corser explained that Community Health Bucks is responsible for training nurses who work in the Community Hospitals.  She went on to say that there is a Personal Development Plan (PDP) for each nurse and agreed to provide evidence of this to a future OSC meeting.

Action: Ms Rachael Corser

A Member asked for clarification about whether the Committee has the power to ask the PCT to re-tender the contract.  The Chairman clarified that the Committee can only recommend that the PCT re-tenders the contract.  Mr George explained that the contract is a commercial contract and there are clauses in the contract relating to breaking it.  A Member stated that the Committee does not know the full details of the contract and the review report states that the contract would still have been awarded whether the hours of medical cover were higher or lower than those in operation now.  The Member commented that the priority is to ensure the highest level of patient care and there is no evidence to show whether this has been achieved.

Mr Carter then stated that he felt it was not a level playing field and the contract which was awarded to The Practice plc has changed considerably from the one which was initially presented to GPs at the outset.  He felt that the contract should be re-tendered in light of the changes made to the contract since it was awarded.

The Committee spent some time debating the recommendations included in the review panel’s report.  In terms of the first recommendation, which related to developing a joint toolkit that could be used in cases of substantial variation, the Committee said that this would require further discussion.  The Committee expressed particular concern about the temporary period of increased GP cover to accommodate the training of the nursing staff.  Members asked for clarification about how the interim period will be managed, risk assessed and the impact this will have on patients.

The Committee agreed that all the recommendations in the report require further information, including an action plan with timescales and dedicated responsibility for each action.  It was agreed that the further information and progress on the action plans would be provided by the end of March 2010 and the PCT would present to the OSC at the April meeting.

The Chairman asked the Committee to vote on whether the level of medical cover provided by The Practice plc after 1 September 2009 is substantially different to the medical cover provided before this date.

5 Members voted that it was a substantial change.

6 Members voted that it is not a substantial change.

The officer informed Mr Carter that, as supported by the constitution, he does not have voting rights as he is a guest on the Committee whilst this issue is discussed, it was noted that he believed it is a substantial change. 

For noting - this would not have influenced the vote had he had voting rights as the Chairman would have used his casting vote and the final decision would have been the same.

The Chairman agreed to write to Mr George and set out the concerns of the Committee regarding how the process has been handled and to set out the plans for future reporting to the OSC on the recommendations in the report.

Action: Chairman and Policy Officer

The meeting was adjourned for 5 minutes (from 11.55 to 12.00).

Dr Keeley handed a petition to the Chairman which contained 5,178 signatures from local people regarding Thame Community Hospital.

As part of their implementation support programme for scrutiny committees, NICE will run a scrutiny development session for Members.

The aims of the session are:

• To raise Members awareness of NICE guidance and the role it plays in health and healthcare
• To encourage discussion on evidence, different types of evidence and how it might be used in scrutiny
• To consider a specific piece of guidance relating to diabetes and to come up with a series of questions which lay people might usefully ask of professionals
• To consider diabetes in pregnancy within the context of health inequalities.

This item will provide a useful background to the Committee’s forthcoming review into health inequalities.

Chris Connell, Implementation NICE Consultant

Steve Sparks, Associate Director, NICE Field Team

Please note there will be a short break for lunch during the working session.

The Chairman introduced Chris Connell, Implementation NICE consultant and Steve Sparks, Associate Director, NICE field team.

Mr Connell gave a presentation to Members on the work of NICE and explained that NICE produces 600 pieces of guidance.  He led Members into a discussion on evidence and the different types of evidence and how it might be used in scrutiny.  Members were also asked to consider a specific piece of guidance relating to diabetes which has been produced by NICE.

The Chairman thanked Mr Connell and Mr Sparks for their presentation and said that the Committee is now much better appraised of what NICE can offer.

Margaret Aston, Avril Davies, David Polhill, David Watson, Tim Butcher, Nick Carter and Maureen Royston left the meeting.

At the November meeting of the Committee, Members agreed that a future review into health inequalities should look in detail at the management of a long-term condition.  After a debate, the short list included the following conditions:

• Heart disease
• Cancer
• Stroke
• Diabetes.

Members will decide which condition will be the focus of the review.

This item has been deferred until the February meeting.

The Committee will discuss written submissions only during Committee update.

The Chairman told Members that he and Angela have met Julie Burgess, the chief executive at Wexham Park Hospital, who has indicated that the hospital is entering a two year programme to get itself back to financial balance as they are currently dealing with some major issues.  He said that Julie Burgess is keen to attend a future Committee meeting and will be invited in the New Year.

Action: Angela Macpherson

Angela Macpherson, policy officer, explained that she is arranging for a programme of Members visits to the NHS trusts in the New Year.  She has been given possible dates from the Hospitals trust and asked Members to let her know their availability on 18 January, 1 February, 4 February, 8 February and 11 February.  She explained that there are limited places available on the visit so it will be first come, first served.

Action: Members

The next meeting will take place on Friday 12 February 2010 in Mezzanine Room 1, County Hall, Aylesbury.

Future meetings:

12 March 2010 (Mezzanine Room 1)

9 April 2010 (Mezzanine Room 1)

14 May 2010 (Mezzanine Room 1)

11 June 2010 (Mezzanine Room 1)

9 July 2010 (Mezzanine Room 1)

10 September 2010 (Mezzanine Room 1)

8 October 2010 (Mezzanine Room 1)

12 November 2010 (Mezzanine Room 1)

10 December 2010 (Mezzanine Room 1)

The next meeting will take place on Friday 12 February 2010 in Mezzanine Room 1, County Hall, Aylesbury.

Future meetings:

12 March 2010 (Mezzanine Room 1)

9 April 2010 (Mezzanine Room 1)

14 May 2010 (Mezzanine Room 1)

11 June 2010 (Mezzanine Room 1)

9 July 2010 (Mezzanine Room 1)

10 September 2010 (Mezzanine Room 1)

8 October 2010 (Mezzanine Room 1)

12 November 2010 (Mezzanine Room 1)

10 December 2010 (Mezzanine Room 1)