Agenda item

To receive a report detailing the proposed merger of the North Middlesex University Hospital NHS Trust and the Royal Free London NHS Foundation Trust.

North Middlesex University Hospital (NMUH) and Royal Free London Group (RFLG):

Dr Nnenna Osuji - Chief Executive of NMUH.

Peter Landstrom - Chief Executive of RFGL.

The CEO of the Royal Free Trust Mr Landstrom introduced the topic. This was an update further to a Committee briefing in February. He stated that a decision was made to further explore the merger. The full business case was finalised. He explained that the business case was now with NHS England where appropriate testing and scrutinization will occur. After this, a recommendation for approval/refusal will be made to the Secretary of State. He emphasised that the merger was not for financial benefit but for the removal of barriers that prevented service delivery going further and faster for staff and patients. He stated that the Royal Free London Group (RFLG) covers several services and locations, however local leadership and identity remains strong. He wanted to reassure the Committee that the merger was designed to keep services local for residents.

Dr Osuji explained that the merger would provide benefits to both organisations, in terms of surgery, elective hubs, clearing the backlog from COVID as well as presenting advantages in terms of Research and Development. She used the example of Colo-rectal surgery. A larger number of Colo-rectal surgeries brought complex cases together. The merger meant that clinical practice could be standardised with training and innovative practices could also be used such as robotic surgery.

She emphasised that there were still internal conversations with staff and stakeholder engagement that was still ongoing. Work was continuing on the dedicated Terms and Conditions. Dr Osuji then invited feedback and questions from the committee.

Cllr Connor expressed apprehension that the NMUH would no longer be a ‘sovereign’ hospital but a ‘fourth health unit’ in the RFLG as per the terminology in the report. She speculated that this may influence staff morale and how patients saw the hospital. She felt that the terminology should reflect integration. She also wanted to know with what confidence it could be said that in a few years' time there would not still be a problem with getting the right treatment to a particular cohort of patients. She wanted assurance that the NMUH would still be a local hospital for local people.

Dr Osuji assured the Committee that the hospital would remain uniquely NMUH. She emphasised that the outcome of the merger would be the same – to have access to excellent care no matter where residents live and for the Group to have strong community links where they operate. Furthermore, she explained that they had looked at ‘warranted and unwarranted variation’ in statistics related to population and care. In response they had looked at representation in the corporate structure. The CEOs of all local health units would be represented at Board. They are considering expanding further local representation at Board, however non- execs and local units are still represented in sub committees and working groups. The role of ‘critical friends’ to her were also vital in getting things right.

Mr Landstrom emphasised that the RFLG is specialist but also very aware that it is made up from local hospitals and services and local priorities must remain.

Cllr Connor also raised that any future paper from the Panel should have a little more depth. She stated that she had confidence that the patients of NMUH would be represented well after talking further with the panel - however it would be beneficial to the Committee to see this in the report. She added that the Committee would like to know more about the lines of accountability and how subcommittees are going to feed into the Board. Also, more about how North Mid Governors and Staff reps can feed into the process of governance. ACTION

Cllr Milne then questioned the panel’s wording in the agenda pack presentation that ‘currently, the merger does not anticipate significant change.’ Mr Landstrom admitted that the service could change but that this was dependant on future issues not yet identified. He emphasised that engagement was key in this and if changes were to occur then the organisation would engage and consult properly with staff and patients alike. Dr Osuji also affirmed that she was not anticipating any changes but that if they did occur these would go through due process.

Cllr Milne then asked about the aim of the Group to become a World Class Cancer Centre. He asked how far NMH was from this currently, and what plans there were to share best practice with other hospitals such as the Royal Marsden. Mr Landstrom responded that, he believed the Group had all the ingredients to make this aim achievable, however there was still a long way to go. With the merger the RFLG would become the second largest Trust in the country. He highlighted that in North London cancer prognosis was good, however sometimes services were not seeing patients quickly enough. But he stated that diagnosis was improving. There were some further challenges in planning for growing demand in cancer care. He believed that working together with other hospitals was key and mentioned the Barnet Oncology Department as an example.

Cllr Milne then expressed surprise that the Electronic Patient Records (EPR) were not already amalgamated and national. He stated that he could see all his patient records on the NHS app and asked how this was the case if all patient records were not amalgamated.

Mr Landstrom responded that there is no national system even within hospitals, primary care, and secondary care. The records themselves are on different databases and are sometimes paper based. Integration of data has not been achieved. For Mr Landstrom it was critical for the Group to join up specialist input. Dr Osuji added that the systems are not the same and have different access permissions and ways in which databases talk to each other. However, the ultimate aim will be to ensure patient records are in patient hands. She stated that it also presented the group with lots of opportunities when it came to Research and Development. She used the example of the analysis of all those on the Cancer pathway – an integrated system would help clinicians find out whether they are diagnosing patients within 62 days. However, she stated that there will always be patients who come through the front doors of the hospital that are only caught in the late stages of cancer.

Cllr White then enquired about the risks associated with automatically integrating record systems into a new overall record. He emphasised the risk and asked the panel whether they had systems in place to mitigate this. Dr Osuji responded that they wanted to safeguard the sanctity of the EPR. There were various IT Project Management procedures that were being followed, such as putting the records in a test environment, however she emphasised that one system would mean in the future that records could be updated just once and securely. It would also mean opportunities for Research and Development.

Cllr Connor then interjected that accurate data on patient records, for her was critical. She asked that in future the Committee needed some clarity and confidence that inaccuracies were being monitored and acted on in a timely manner. She wanted to ensure that accuracy was not only for those who enter the correct pathways but also for those who turn up unexpectedly at reception. Dr Osuji responded that inaccuracies did not happen often. However, admitted that getting corrections done were a challenge. Patients should use the NHS App so that they could be in control of their records.

Cllr White interjected that he was impressed with the Diabetes services that the NMUH offers. He highlighted that the cost must be high to provide a preventative service, but in the long term would save the NHS money - as diabetics would be less likely to get heart disease, kidney dialysis etc. He wanted to know how the Panel would decide which was best – the more expensive preventative or the usual symptom-specific treatments.

Dr Osuji responded that the aim was that everyone should have access to seamless care, even if they are in the warranted or unwarranted variation groups. She added that there are seventeen levels of consensus needed for clinical practices. She stated that they must make sure that everyone should have access to new drugs and treatments However, Prevention is hardest to deliver.

Cllr Connor stated that it would be beneficial for the Committee to take a case study in the less obvious areas of care, to understand how care is delivered in the area; and see how it was monitored before, and after, any changes to service. She added that it would be useful to know what local priorities are and their impact on how clinical decisions are made in a particular area – also how this would affect warranted and unwarranted variation. ACTION

Discussion turned to Item 7 and the structure of corporate governance. Cllr James wanted more clarification regarding this. She added that it would be helpful to see an organisation chart after the merger about what the lines of accountability are. ACTION

Cllr Cohen then requested clarification on where Barnet patients should go once the merger has been finalised and what the longer-term plans are. Also, whether the Committee could see the plans to safely merge the EPRs. ACTION. He requested further information on whether the plans to unify the EPRs access would also include GPs so that they would know who to refer to at the Royal Free Hospital. Dr Osuji stated that one clinical conversation must happen about the patient no matter where they are. She added that GPs have their own pathway of referrals for specialist access and that will not change. However, how they refer onwards would be faster with the unified EPR. Ultimately the EPR would improve efficiency. She stated that it would take 18 months to implement to the new EPR system.

Discussion then turned to transport. Cllr Revah asked whether there would be a possibility of transport for patients to and from NMH and RFLG. Mr Landstrom responded that there were no planned changes to the configuration of transport, as it was felt that the demand was not there. He added that the Group had worked closely with Healthwatch and Oncology concerning this. He stated that if things were to change, they would plan a formal consultation. However, he added that there were issues with accessible access to the Group’s sites.

Cllr Milne then asked if there would be anything that would stop the merger from happening. Mr Landstrom replied that if NHS England did not recommend the merger after due process the merger would be scrapped.

Cllr Connor summed up and raised another point the panel was not able to discuss in depth – this was the financial risk. The NMUH was in surplus however the RFLG was in deficit. She wanted assurance that the debts of the RFLG would not affect the NMUH’s budget. Mr Landstrom admitted that there were issues with debt in the RFLG however there have been some successful measures to reduce that debt and there are plans to break even in a few years. However, he emphasised that this would not be a concern. Cllr Revah asked for an opportunity to talk further about this, as she was concerned as to the reasons why there was a deficit. ACTION

Cllr Connor also raised that it would be useful to the committee to have a future paper on what engagement has been carried out for the merger. She emphasised that there was not enough evidence presented to see what patient groups had been consulted. ACTION