Agenda item

For the Committee to consider the detail of and rationale for changes in this area, the equality impact assessment, the approach to engagement and the travel analysis.

The presentation on the NCL Surgical Transformation Programme: Ophthalmology Surgical Hub Proposal was provided by Dilani Siriwardena, Deputy Medical Director at Moorfields Eye Hospital and NHS London Clinical Director for Ophthalmology, Jon Lear, Senior Operations Manager at Royal Free London NHS Foundation Trust, Marco Inzani, Deputy Director of Strategic Programmes for NCL ICB and lead for the Surgical Transformation Programme and Richard Dale, Executive Director of Performance and Transformation NCL ICB.

Marco Inzani explained that there were current more than a quarter of a million patients waiting for elective care in NCL. Ophthalmology was one of the higher volume specialities and the waiting lists had grown by 48% over the past seven years. There were also risks associated with waiting including health deterioration and increased complexity of care so this really affected people’s quality of life. It was not possible to keep up with demand in NCL despite initiatives including evening/weekend working, using capacity in the independent sector and Trusts offering mutual aid to each other.

Elective Orthopaedic Centres had previously been developed in NCL, at Chase Farm and at UCLH, and these had doubled the number of surgeries for hip and knees. The aim was therefore to replicate this in other specialities, beginning with ophthalmology. In developing the engagement work, the focus had been on what mattered to patients and a key finding was that patients were willing to travel further if this meant that they would be seen quicker and that the service was better.

Marco Inzani continued by explaining that the main proposals were to consolidate surgery from Whittington Health and Chase Farm Hospital to the Edgware Community Hospital and Royal Free Hospital. Outpatient appointments and tests would remain at all local hospitals so it was just the surgery that would move location, which would typically be only one or two appointments. Patients would still have a choice of three Trusts in NCL and it was expected that this would drive efficiency and productivity. There was expected to be an additional 3,000 procedures per year which could potentially help patients to be treated 10 weeks earlier. He explained that the downside was that some patients would have to travel further, estimated to be an additional 19 minutes by public transport on average. The maximum additional journey time (i.e. for someone who lived close to Chase Farm Hospital who needed to travel to the Edgware Community Hospital) would be 90 minutes but this would be for a very small proportion of patients. They would also continue to have the option of travelling to Potters Bar, which is closer but outside of the NCL border. 

Dilani Siriwardena added that ophthalmology would ideally involve two theatres running in parallel with senior supervision for all patients and a reduced likelihood of late cancellations. This was already the type of service provided by Moorfields and St Anns, but for Royal Free staff they may have to travel between sites during the day which reduced the number of patients that they could treat.

Jon Lear said that, from the perspective of the Royal Free, this development was clinically led and clinically supported. There would be two phases to the project – firstly moving the activity from the Whittington to Edgware and secondly moving activity from Chase Farm to Edgware. There were currently two operating theatres at Edgware, but only one of these was currently for ophthalmology and so the proposal was for both of these to be used for ophthalmology for four days per week. Staff worked compressed hours during this four-day week (Mon-Thurs) but there was the possibility of expanding capacity in the future by moving to a five-day week. Overall, the change would enable the consolidation of surgical resource, make best use of theatre staff, reduce travel time for surgeons and improve the flow of patients. With the current Chase Farm/Whittington arrangements, they would typically complete 5 to 6 operations on a half-day theatre list but, after the consolidation, this was expected to move up to 7 or 8 operations.

Marco Inzani concluded the presentation with slides about the Equality Impact Assessment (EqIA) which highlighted three groups – over 65s, BAME populations and the most deprived populations who were most impacted by the increased travel times. It would therefore be necessary to particularly engage with these groups during the consultation period, especially those who lived close to the Chase Farm or Whittington sites, to look at mitigations and additional support that could be offered. If this proceeded successfully then the implementation was expected in November/December 2023.

The NHS officers then responded to questions from the Committee:

·         Cllr Clarke queried the justification of significantly increased travel times when the increased number of surgeries would be marginally increased from 5-6 to 7-8. Jon Lear responded that there were currently five half-day sessions per week at Whittington so there would be increased capacity at Edgware, in addition to the improved efficiencies and productivity as a consolidated hub. He clarified that it was Royal Free surgeons who currently provided services at the Whittington Hospital with Whittington nursing and administration staff. Cllr Clarke expressed concern that this was a necessary arrangement. In terms of the increased number of surgeries, Marco Inzani, reiterated that this would amount to around 3,000 additional procedures per year overall. Richard Dale highlighted the additional capacity that would be freed up at the Whittington so there were other positive knock-on effects to be considered. Dilani Siriwardena added that ophthalmology could sometimes be deprioritised during the winter as nursing staff were needed elsewhere which would not be an issue in a specialised hub.

·         Cllr Clarke asked for clarification on the “potentially adverse impact in particular on those whose ethnicity coding is Unknown” relating to the proposed service changes at the Whittington as set out on Slide 13. Marco Inzani clarified that, when patients had been mapped as part of the EqIA process, this highlighted communities that were likely to be affected more in terms of travel times. This included the Unknown ethnicity coding, which included people who preferred not to state their ethnicity. Cllr James suggested that this category could include mixed race people who did not feel that they fit into any of the categories described on the forms. Richard Dale acknowledged that there were some limitations to demographic profiling and that it may be necessary to explore this issue further as part of the consultation in order to understand who could be adversely affected.

·         Asked by Cllr Clarke about timescales for the consultation, Richard Dale said that the JHOSC was being consulted early, but the consultation process would continue over the summer and then it may be helpful to speak to the JHOSC again in September about any changes or mitigations resulting from the feedback received.

·         Cllr Milne asked whether the 48% increase in the waiting lists over the past seven years had been a consequence of bottlenecks in the system or an increase in demand. Dilani Siriwardena acknowledged the issues with the system but said that a major cause for this was the aging population leading to more cases of cataracts, glaucoma and other conditions that required repeated treatment.

·         Asked by Cllr White about the difficulties of travelling from east to west across the NCL area, Richard Dale acknowledged that this was a key trade-off on which they were keen to engage the JHOSC and the wider community in order to build an understanding of what this would mean for patients. Marco Inzani added that any influence that Members could bring to the improvement of west-east transport links in NCL would be welcomed.

With a further update on this issue expected to the JHOSC in September 2023, Cllr Connor commented that the Committee wished to explore the following specific points further (ACTION):

·         The additional journeys times being asked of residents, balanced against the potential benefits of being treated earlier;

·         The potential impact on disadvantaged communities who could be disproportionately affected by the changes;

·         The financial implications, including knock-on effects (positive or negative) on other NCL hospitals.

·         What was learnt from the previous experience of developing surgical hubs in NCL for other types of treatments.