Agenda item

To receive an update on Start Well - a long-term change programme focusing on children & young people’s and maternity & neonatal services in a hospital context.

Report to follow.

Cllr Connor noted that, although the report covered the consultation approach, the papers did not include the consultation itself as this was not due to be launched until 11^th December.

Sarah Mansuralli, Chief Strategy & Population Health Officer at North Central London Integrated Care Board (NCL ICB), introduced the report, explaining that this built on previous briefings and provided the Committee with the opportunity to comment on the approach to consultation. As an Integrated Care System, there was an overall focus on inequalities, value for money and social/economic development. The Integrated Care Strategy identified Start Well as a priority with a focus on service improvement and pregnant women’s experience of care and the role of the workforce as being critical for population health.

Sarah Mansuralli explained that the Case for Change had been published in June 2022 with a strong evidence base for improving care at an early age having an impact on population health outcomes. The Start Well programme had commenced in November 2021 and had benefitted from extensive clinical and service user input with the development of best practice care models and understanding the case the changing the way that services were organised. In NCL the birth rate was declining but the complexities of births was increasing. There were high vacancy rates in birthing centres which could compromise the choice of services while there was imbalance of demand across services leading to an over/underutilisation of particular units. The number of deliveries at the Edgware Birth Centre was declining each year with just 34 deliveries in the previous financial year. In addition, the fabric of estates in NCL was not up to the standards required by best practice models.

The new models of care were designed to address these issues, making each unit clinically viable, maintaining choice and improving the patient experience. The documents provided to the Committee demonstrated that doing nothing was not an option as the existing model was no longer sustainable. The following changes were therefore proposed:

• To move to a model with four units providing maternity and neonatal care instead of five units.
• This would mean having three Level 2 units and one specialist Level 3 neonatal intensive care unit at University College London Hospital (UCLH).
• There would no longer be a Level 1 unit or a stand-alone birthing centre.
• Pathways for paediatric surgical care would be streamlined.

Anna Stewart, Programme Director for Start Well, set out details of the options being included in the public consultation:

• Option A involved the UCLH as the specialist Level 3 neonatal unit, with Barnet Hospital, North Mid Hospital and the Whittington Hospital as the three Level 2 units. Maternity and neonatal services at the Royal Free Hospital would be closed.
• Option B also involved the UCLH as the specialist Level 3 neonatal unit, with Barnet Hospital, North Mid Hospital and the Royal Free Hospital as the three Level 2 units. Maternity and neonatal services at the Whittington Hospital would be closed.
• Option A had been identified as the ICB’s preferred option. The reasons for this were set out in the report, but were mainly because this would mean fewer staff needing to move to a new location and because Option A would mean some patients going to hospitals in North West London where there was capacity for this, while Option B involved some patients going to hospitals in North East London where capacity was more limited.

Anna Stewart also outlined details of a second issue in the public consultation which concerned the proposed closure of Edgware Birth Centre due to low levels of demand.

The third main issue in the public consultation related to proposals on paediatric services which would involve:

• Local units (at Barnet, North Mid, Royal Free and Whittington Hospitals) continuing to provide most emergency surgery for children aged 3 or older, general/urology surgery for children aged 5 or older and ear/nose/throat/dentistry day surgery for children aged 3 or older.
• A centre of expertise at Great Ormond Street Hospital including a surgical assessment unit for emergencies for babies and young children and emergency surgery for children younger than 3 years old or for general/urology surgery for children younger than 5 years old.

Sarah Mansuralli and Anna Stewart then responded to questions from the Committee about the options and general approach to the consultation:

• Cllr Clarke welcomed the preferred option being the one that retained services at the Whittington Hospital due to the large catchment area that could be affected. However, she asked how concerns identified with the Whittington unit on page 12 of the report would be addressed including the unit not meeting with modern best practice building standards and risks around infection control. Sarah Mansuralli responded that this part of the report set out the clinical drivers for the proposed changes but that the changes would also involve capital investment to improve facilities on one of the two sites (Whittington or Royal Free depending on the option selected). Clare Dollery, Medical Director at Whittington Health NHS Trust, added that the unit had very caring, well-trained staff who worked to ensure that the deficiencies of the old Victorian estate did not impact on outcomes for patients. However, she acknowledged that the lack of en-suite facilities was an issue for patients and that investment was required to bring the estate up to the standard required. Mike Greenberg, Medical Director for Barnet Hospital (which managed the unit at the Royal Free), added that, as stated in the report, the Level 1 unit at the Royal Free was only 37% occupied in 2021/22. This impacted on the experience of the doctors and nurses in looking after sick babies, representing a clinical risk that was mitigated by the use of fixed term consultants but was not sustainable in the longer-term. He also reiterated the considerations about the additional staff disruption and patient flows associated with Option B. Clare Dollery and Mike Greenberg also highlighted the involvement of their staff in the stakeholder consultation group. Cllr Clarke welcomed these points but expressed the view that more information about the capital investment should be available and made clearer in documents relating to the consultation. (ACTION) Anna Stewart responded that the public consultation documents had not yet been approved by the ICB Board but, in their current form, explained that approximately £40m of capital investment would be provided for either option.
• Cllr Chowdhury expressed concern about the additional demand pressure on the Whittington unit and about potential difficulties with transport issues for patients going to the Whittington unit instead of the Royal Free unit. Michelle Johnson, Clinical Lead for the Start Well programme, said that not all patients from the catchment area would be going to the Whittington unit as a significant proportion would be going to hospitals in North West London (should Option A be chosen) and that the overall impact of the proposals would be to increase capacity and improve all maternity units.
• Asked by Cllr Connor about the monitoring of data on patient flows, Anna Stewart said that complex modelling had been carried out and that this was based on predictions about where patients would go. In most cases this would be their nearest unit, but patient choice was also considered. The model would need to be rerun as more information became available.
• Asked by Cllr Cohen for further details on the capital investment, Sarah Mansuralli explained that there was a technical document underpinning the pre-consultation business case that was linked to from the main report. Option A involved around £42m being provided to improve the Whittington unit while Option B involved around £39m being provided to improve the Royal Free unit. She added that the decision was clinically driven rather than financially driven, noting that the preferred option involved slightly more funding and that the proposed closure of the Edgware Birth Centre would not result in savings as the services would be offered elsewhere.

Chloe Morales Oyarce, Acting Assistant Director for Communications & Engagement at NCL ICB, then set out details of the public consultation itself which was proposed to launch from 11^th December 2023 and remain open for 14 weeks. She explained that there had already been extensive engagement through the Start Well programme and that the new public consultation would involve working with partners including local authorities, NHS Trusts, voluntary sector organisations and others. Clear information would be provided on how people could participate in the consultation with various formats available online and via printed documents to enable a high level of accessibility. There would also be some targeted engagement for certain groups including more deprived areas, BAME groups and geographical areas close to the units affected. Engagement with staff groups would also continue. More details about the consultation questionnaire and engagement techniques were included in the report to the Committee.

The Committee then asked further questions about the public consultation:

• Cllr Connor asked how realistically the direction of policy would be impacted if the feedback favoured Option B (or neither option) rather than the preferred Option A. Sarah Mansuralli said that both options were deliverable and that the proposals had been thoroughly tested by the London Clinical Senate in terms of clinical outcomes. Anna Stewart concurred with this and added that the consultation was not a referendum or vote but a more nuanced process where everything that was said and where these views were coming from would need to be carefully analysed with the detailed impact assessment updated as part of the process to reaching a decision.
• Asked by Cllr Connor how concerns about transport issues would be addressed through the consultation process, Sarah Mansuralli said that the ICB recognised that further mitigations may be needed but that these would need to be informed by the consultation.
• Cllr Connor commented that, as part of the consultation process, the public would need be made aware of the context that the Royal Free NHS Trust was in favour of Option A (which involved the closure of the existing unit at the Royal Free Hospital) as there was otherwise a risk of only the negative aspects of a unit closure being understood. Anna Stewart said that the consultation document would explain how the ICB conclusions had been reached and set out which organisations had been involved in that process. Sarah Mansuralli acknowledged that this might not necessarily be overtly clear to the public and so they would give this some further thought. (ACTION)
• Asked by Cllr O’Halloran about the potential pressure on hospitals in North East London under Option B, Anna Stewart said that, while both options were deliverable, the proposals under Option A were considered to be less disruptive both in terms of outflows and the expansion of the current neonatal unit.
• Cllr Clarke suggested that the graphic on page 16 of the agenda pack required further information about how units were being upgraded if it was to be included in the consultation. Anna Stewart responded that this illustrated what the outcome of either option would look like but reiterated that details of the capital investment would be included in the public consultation document and agreed to recheck how this would be framed. (ACTION)
• Cllr Connor queried whether details of any additional services that would be provided at the Royal Free or Whittington in the space vacated by a unit closure would be included in the consultation. Sarah Mansuralli said that it would be difficult to include this in the consultation as the Trusts had not yet reached decisions on this but acknowledged that there would be opportunities provided by the availability of new space. Mike Greenberg added that there was huge demand on space at the Royal Free Hospital, including the possibility for a number of specialist services to expand.
• Asked by Cllr Chowdhury about engagement with BAME and more deprived communities, Chloe Morales Oyarce reiterated the engagement with partners, that the ICB had good relationships with community groups who could help to facilitate engagement and that there would also be targeted engagement based on where people could be reached such as Childrens Centres. She added that any suggestions for community contacts from Committee Members would also be welcomed.
• Cllr Cohen suggested that the mitigations around travel times and costs may need to be strengthened, particularly in relation to more disadvantaged communities. Anna Stewart responded that work with partners had been carried out on mitigating the disbenefits, including potential eligibility for reimbursement for travel costs in some circumstances. She added that the current service model already involved long journeys in some circumstances, for example when more complex care was required than could be offered at the local unit. These issues would be tested and analysed further as part of the public consultation.

Cllr Connor then summarised the main recommendations of the Committee on the public consultation as follows:

• The need for the public to be made aware of the underlying support of NHS Trusts for the proposals, including Trusts directly affected by the potential closure of a unit as this was particularly relevant to any local debate on this issue.
• The importance of clarity over the capital funding being provided under either of the main two options and the need to address any potential risks over the longer-term of insufficient capital funding to support the ongoing cost of Start Well programme, including any possible hidden costs.
• To engage with residents over the development of mitigations for people who may be affected by additional transport costs.
• To closely monitor and report back to the JHOSC on the ongoing modelling of patient flows as current predictions may not necessarily match the choices that patients subsequently make in future years.
• That any ‘before/after’ graphics illustrating the two options in the consultations documents should make clear how units are being upgraded as part of that reconfiguration.