Shaping a healthier future Decision making business case · 2015-10-20 · Shaping a healthier future . Decision making business case . Volume 3 . Appendix A Programme governance

Shaping a healthier future Decision making business case

Volume 3 Appendix A Programme governance membership until February 2013 Appendix B Stakeholder engagement record (pre-consultation) Appendix C Activities undertaken during consultation Appendix D Case for Change Appendix E Literature review of available relevant clinical evidence Appendix F Ipsos MORI consultation analysis report

Edition 1 12 February 2013

North West London

Notes

NHS North West London

Shaping a healthier future Decision making business case

Edition 1

12 February 2013

Volume 3 of 7

Appendix A – Programme governance

Appendix A – Programme governance

Shaping a healthier future Decision making business case Volume 3

Edition: 1.0

12 February 2012

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APPENDIX A – Programme governance A.1.1 Key governance principles

Key principles underpinning Programme governance arrangements:

Key decisions will be made by commissioners (with CCG chairs, as the leaders of commissioners of the future)

This decision can only be taken by a legal entity. In NW London this is a Joint Committee of Primary Care Trusts (JCPCT). The JCPCT is constituted of the eight PCTs in NW London plus representatives from Camden, Richmond & Twickenham and Wandsworth PCTs. These three PCTs have chosen to join the JCPCT because they believe the proposals may significantly impact all or part of their population

Early the lifetime of the programme commissioning responsibilities will transition to CCGs:

- As of February 2013 all eight NW London CCGs have been established and are progressing through the authorisation process. Seven NW London CCGs have been authorised with or without conditions by the NHS National Commissioning Board. Hillingdon CCG is progressing through Wave 4 of the authorisation process and is on track to be authorised by 1 April 2013

- For decisions taken prior to April 2013, whilst the CCGs are authorised they are able to take on delegated responsibilities from PCTs but they will not be a legal entity. Therefore the JCPCT will need to retain decision making responsibility for reconfiguration until the end of March 2013

- In addition, prior to April 2013, the PCT Boards take advice from the Professional Executive Committee (PEC), which includes the CCGs and the PEC Chair (currently the Medical Director for NHS NW London)

- Based upon the Secretary of State’s “four tests” and the NHS London Reconfiguration Guidance, the programme also plans to ensure that CCGs have provided written evidence of their support for any service reconfiguration before it is launched

- From April 2013 commissioning responsibilities will transfer from PCTs to CCGs. Although this is expected to take place after formal decision-making, implementation will be beginning at this stage

- The programme governance has therefore been designed to involve CCGs from the outset to ensure they are bought in and continue to consider it a commissioning priority.

Providers have no legal role in the decision-making process but it is very important that they are engaged with and supportive of the process, particularly as they will be tasked with the proposals. The Programme has a Programme Board with provider representation, to provide strategic oversight of the Programme and to report to the JCPCT

The Programme Board and its supporting groups act in an advisory role to the JCPCT. This is also consistent with legal advice that double delegation of formal decision-making is not possible (i.e. the Cluster Board – which has decision-making authority delegated from the PCTs – cannot delegate decision-making further)

Clinical leadership of the programme must be facilitated and senior local clinicians (Medical Directors and equivalent) given the opportunity to influence the development of solutions, ensuring that they are clinically sound

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Local providers must have the opportunity to influence decision-making and involve their staff in the development of informed solutions that reflect actual provider circumstances (e.g. productivity targets, capital implications of changes)

Regular opportunities must be provided for key external stakeholders (e.g. OSCs, the public) to influence and inform the development of solutions

Programme leadership will transition to commissioners during this time and will need to maintain a single point of accountability via the SRO throughout.

A.1.2 Governance arrangements

The programme governance structure has been designed around the principles set out above and is summarised in figure A.1 below.

Figure A.1: Programme Governance

A.1.3 The JCPCT has formal decision-making responsibility for the programme. This includes responsibility for:

Taking the final decision on whether to proceed to consultation (undertaken based on PCBC)

Ultimately, taking the final decision on whether to proceed with proposed service changes.

A.1.4 The Programme Board has responsibility for:

Overseeing delivery of the programme in line with the scope, aims and timescales set out by the Cluster Board; in particular managing cross-organisational issues, risks and dependencies

Comms & Engagement Working Group

Programme Board

JHOSC(Representatives of all 11 OSCs and neighbouring

OSCs)

Clinical Board Transformational Group

Programme Executive

Finance & Business Planning Working Group

Paediatrics Clinical Implementation Groups

Emergency & Urgent Care Clinical Implementation

Group

Chair: Programme medical directors x 2

Members: Lead clinicians for relevant service, director of public health, local GPs, external clinical experts, PPAG rep/specific patient groups, Mental Health rep.

Chair: Programme Medical Director(s)

Members: Nominated Clinical leaders for each NWL provider, nominated CCG representative, PPAG representatives and/or patient experts, NHS NWL Director of Nursing, reps from Camden, Richmond and Wandsworth

Chair: SRO

Members: NWL Provider CEOs, NHS NWL Directors, sub-cluster, CEOs, CCG Chairs, programme Medical Directors PPAG rep.

Attendees: NHS London, SWL & NCL Clusters, NHS CB, NHS TDA, Imperial College

Chair: Cluster CEO

Members: SRO, Medical Director, SRO programme Delivery, Comms lead, NHS London rep. DSU lead, Other w/s leads

Chair: Abbas Khakoo, Consultant Paediatrician

Members: Lead clinicians for relevant service, Director of public health, local GPs, external clinical experts, PPAG rep/specific patient groups, Mental Health rep.

Chair: SaHF Communications Lead

Members: Commissioner & Provider Communication Directors, PPAG rep.

Chair: CCG (designate) Director of Finance x 2

Members: Commissioner and Provider Finance Directors, COOs/Estates leads, PPAG rep where necessary.

Key……. Provide views_____ Line of accountability

Formal decision making body

ClusterClinical Executive

CommitteeCluster

Executive TeamJoint Committee

of PCTs

AdvisoryPPAG

Travel Advisory Group

Equalities Steering Group

Expert Clinical Panel

Maternity Clinical Implementation Group

Chair: Gubby Ayida, Consultant Obstetrician & Gynaecologist and Pippa Nightingale, Head of Midwifery

Members: Lead clinicians for relevant service, Director of public health, local GPs, external clinical experts, PPAG rep/specific patient groups, Mental Health rep.

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Overseeing development of programme deliverables

Ensuring appropriate links are made with other strategic programmes and groups within NHS NW London ; in particular the Ealing / NWL merger team and the Imperial / West Middlesex project team

A.1.5 The Transformational Group has responsibility for:

Steering programme delivery in line with the scope, aims and timescales set out by the Cluster Board when the programme was commissioned in November 2011.

A.1.6 The Programme Executive has responsibility for:

Managing programme delivery in line with the scope, aims and timescales set out by the Cluster Board when the programme was commissioned in November 2011.

A.1.7 The Clinical Board has responsibility for:

Providing clinical leadership to the programme, ensuring the programme develops robust clinical proposals and making clinical recommendations to the Programme Board and JCPCT. Specifically:

- Review and agree the case for change for NW London - Develop and agree quality standards for services – including standards for

primary, community and acute care in these areas. - Develop and agree models of care which will ensure delivery of these standards

across the whole of NW London - To re-evaluate the assessment of options for the future configuration of services

in light of consultation responses and other inputs to the programme

In addition the Board is also required to:

- Provide expert clinical advice on other programme deliverables - Ensure there are clinical advocates for proposals in each relevant service area.

A.1.8 The Finance & Business Planning Working Group has responsibility for:

Developing a financial model to capture baseline activity and financials for all acute providers across NW London, and project forward activity and financials under status quo and a range of configuration options

Developing high level estimates of capital expenditure requirements for configuration options

Planning, managing and quality assuring input to programme deliverables relating to: - Modelling assumptions - Financial projections & impact - Financial criteria for assessment - Activity & capacity projections & impact - Analysis of impact on travel times - Workforce planning - Expected benefits in terms of finance, workforce, capacity, travel / access.

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Ensuring programme deliverables have appropriate input from provider leads for finance, capacity / estates planning and workforce.

A.1.10 The Communications & Engagement Working Group has responsibility for:

Planning and coordinating programme communications & engagement activities, ensuring statutory requirements are met at each stage

Ensuring consistency of communications between commissioners and providers, as part of managing internal communications

Coordinating engagement with PPAG, OSCs / JHOSC etc. as required by programme

Coordinating broader engagement with clinicians, GP practices, patients and public.

A.1.10 Emergency and Urgent Care Clinical Implementation Group has responsibility for:

Ensuring the robustness of proposals and modelling underpinning the emergency and urgent care aspects of the programme.

Ensuring alignment between the plans for implementing changes to emergency and urgent care and the agreed clinical standards.

Leading the implementation of relevant recommendations made by the National Clinical Assessment Team (NCAT) and the Office of Government Commerce (OGC) review reports.

Providing information to the Programme Board, and its groups, to support the implementation of changes to the configuration of services in NHS North West London.

A. 1.11 Maternity Clinical Implementation Group has responsibility for:

Ensuring proposals and modelling underpinning the maternity services are clinically robust.

Ensuring alignment between the plans for implementing changes to maternity services and the agreed London commissioning standards.

Leading the implementation of relevant recommendations made by the National Clinical Advisory Team (NCAT) and the Office of Government Commerce (OGC) review reports.


A. 1.12 Paediatrics Clinical Implementation Group has responsibility for:

Ensuring the robustness of proposals and modelling underpinning the paediatric

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services aspects of the programme.

Ensuring alignment between the plans for implementing changes to paediatric services and the agreed clinical standards.

Leading the implementation of relevant recommendations made by the National Clinical Advisory Team (NCAT) and the Office of Government Commerce (OGC) review reports.


A.1.13 The Joint Health Overview & Scrutiny Committee (JHOSC) has responsibility for:

Bringing together representatives of each OSC in the area and, if necessary, in neighbouring areas

Considering the 'Shaping a Healthier Future” consultation arrangements - including the formulation of options for change, and whether the formal consultation process is inclusive and comprehensive

Considering and responding to proposals set out in the 'Shaping a Healthier Future” consultation with reference to any related impact and risk assessments or other documents issued by or on behalf of NHS North West London in connection with the consultation

Terms of reference have been developed for these groups except the JHOSC (which is managed and supported by Local Authorities).

A.1.14 Advisory Groups

The Programme will be advised by a number of specific advisory groups.

PPAG. The North West London PPAG will advise the programme about appropriate ways to keep patients and the wider public involved in and informed about future strategic service change.

Travel Advisory Group. Advise the programme on the travel implications / opportunities associated with different options for change; including identifying the impact on particular patient groups

Equalities Steering Group. To advise on, inform and approve Equalities Impact Assessment activities and provide expert equalities, travel, public health, and patient input to the programme.

Expert Clinical Panel. Asked to advise the Programme Medical Directors / Clinical Board as necessary. (see Appendix A.3.1 for membership details)

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APPENDIX A2 – Programme Governance: Terms of Reference for Programme bodies

Contents

• Programme Board Terms of Reference ToR

• Transformational Group

• Programme Executive ToR

• Clinical Board ToR

• Finance & Business Planning Working Group ToR

• Comms & Engagement Working Group ToR

• Emergency and Urgent Care Clinical Implementation Group ToR

• Maternity Clinical Implementation Group ToR

• Paediatrics Clinical Implementation Group ToR

• List of JCPCT Members

• JCPCT establishment agreement

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A.2.1 NW London Reconfiguration Programme Board Terms of Reference

Purpose of the Programme Board

• The Programme Board is an advisory body to the JCPCT which will decide on the option(s) for future configuration of services upon which to consult and commission.

• The Programme Board will ensure that the best possible options are developed in a robust, open and transparent manner and that Programme Board members are given the opportunity to influence each stage in the development, shortlisting and refinement of options to secure the best solution for patients in NWL – and the NHS – as a whole.

• The Programme Board is constituted to bring together local commissioners and local providers to inform and influence the development of the programme. It is not responsible for commissioners’ or providers’ decision making.

• The Programme Board will made recommendations to the NWL JCPCT/ Cluster Board and in particular advise it on:

– Delivery of the programme in line with the scope, aims and timescales set out by Cluster Board

– Development of programme deliverables and progress against agreed timescales, in particular the management of cross-organisational issues, risks and dependencies

Responsibilities

• In order to achieve its purpose, the Programme Board has responsibilities to: – Oversee development of programme deliverables and approve these as

ready to go forward to the JCPCT/ Cluster Board for approval. This should include:

• Case for service change in NWL • Process for options development and appraisal • The Pre-Consultation Business Case • Option(s) for change for public consultation and consultation material • Report on consultation findings and the programme’s proposed

response; and • Decision Making Business Case setting out final recommendations for

the future configuration of services in NWL – Assure itself of the continuing validity of the Vision, the Programme benefits,

and the Programme plans to deliver this Vision and these benefits – Ensure appropriate links are made with other strategic programmes and

groups within NHS NWL, in particular the Ealing/NWLH merger programme team

– Ensure appropriate links are made with other strategic programmes and organisations outside NHS NWL, including NHS SWL, NHS NCL, NHS London, London Health Programmes

Constitution, Decision-making and Behaviours

• The NWL Reconfiguration Programme Board is established by the NWL Cluster Board and has no powers other than those included in its terms of reference.

• The Programme Board will seek to reach consensus in deciding its recommendations. Where consensus cannot be reached, views which are divergent

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from the majority view will be recorded and presented with the report/advice to the NWL Cluster Board.

• Members are expected to act as ambassadors for the Programme and engage their organisations in the development of the Programme. Programme Board members are expected to act in the best interests of local patients and the NHS in North West London as a whole.

• Each Programme Board member is expected to act as a representative of their organisation. Where an organisation’s board raises concerns about the recommendations or progress of the Programme, the Programme Director shall support the member in engaging their organisation in addressing the concerns.

• Due to the large size of the Programme Board, the Programme Chair/SRO or Programme Director will engage members in agreeing innovative methods to ensure that all parties are able to express their views.

• Members are expected to provide information to the Programme Board, and its groups, to support the undertaking of accurate analysis and well informed decision-making.

• The Programme Board will be advised by • NWL local Health Overview and Scrutiny Committees (HOSCs) and/or a Joint

Health Overview & Scrutiny Committee (JHOSC) • The NWL Patient and Public Advisory Group (PPAG) • NWL shadow Health & Wellbeing Boards

• The Clinical Board will act as the single route for making clinical recommendations to the Programme Board

• The Programme Board shall be dissolved when the Cluster Board confirms that the service configuration option has been decided, and any formal reviews or challenges of that decision have been completed or at any other time when a significant change to either the programme or existing governance arrangements makes it necessary.

Authority

• The Programme Board is authorised: to instigate any activity within its terms of reference and to seek information as necessary; to obtain outside legal or other independent professional advice; to secure the attendance of such persons, including outsiders with relevant experience and expertise, as it considers necessary.

Chair and Senior Responsible Owner

• The NHS NWL Director of Strategy and Chief Officer Designate CWHH CCGs shall be the Programme Board Chair and the Senior Responsible Owner for the Programme

• If the Chair is unable to attend a meeting, the SRO for Programme Delivery will deputise

Quorum

• Where the Chair has determined – and has given two weeks’ notice to Programme Board members – that a key decision will be made, then the quorum shall include members (or their proxies) of all organisations that the Chair determines should be present unless that organisation has instead chosen to make a written submission.

• For other meetings, the Programme Board will be quorate when at least two weeks’ notice has been given of the meeting and the Chair (or a Proxy) and three other members (or their proxies) are present.

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Membership

• The membership of the Programme Board shall be: – Chair and Senior Responsible Owner: NHS NWL Director of strategy and

Chief Officer Designate CWHH CCGs – Programme Medical Director(s) – CEOs of the provider trusts located in NWL:

• North West London Hospitals NHS Trust • Ealing Hospital NHS Trust and ICO • Hillingdon Hospitals NHS Foundation Trust • West Middlesex University Hospital NHS Trust • Imperial College Healthcare NHS Trust • Chelsea & Westminster Hospital NHS Foundation Trust • Royal Marsden NHS Foundation Trust • Royal Brompton & Harefield NHS Foundation Trust • Central and North West London NHS Foundation Trust • West London Mental Health NHS Trust • Hounslow & Richmond Community Healthcare • Central London Community Healthcare NHS Trust • London Ambulance Service NHS Trust

– Chair of each Clinical Commissioning Group in NWL and neighbouring boroughs:

• Central London CCG • Hounslow CCG • West London CCG • Hammersmith & Fulham CCG • Ealing CCG • Hillingdon CCG • Brent CCG • Harrow CCG • Richmond CCG • Camden CCG • Wandsworth CCG

– Chief Officer Designate for Brent and Harrow, Ealing and Hillingdon CCGs – NHS NWL Directors – NHS NWL sub-cluster CEOs – PPAG representative

• In addition, the following shall be invited to attend: – NHS London – South West London PCT Cluster – North Central London PCT Cluster – NHS Commissioning Board – NHS Trust Development Authority – Imperial College –

• The Programme Director and Programme Manager shall also attend Programme Board meetings.

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Programme Board Support

• Support and advice to the Programme Board will be provided by the Programme Director and by the Programme Manager as Board Secretary. This support shall include:

– Agreement of the agenda with the Programme Board Chair – The proper and timely preparation and circulation of papers – Keeping a proper record of the meetings and all decisions and actions to be

taken forward – Advising the Programme Board and its Chair on matters of process and

procedure

Meetings

• The Programme Board will meet monthly, and more frequently if required to consider matters in a timely manner, e.g. to approve key deliverables.

Reporting

• A report of the work of the Programme Board and progress of the Programme shall be submitted to each meeting of the NHS North West London JCPCT/ Cluster Board.

Review

• The Programme Board shall keep its membership and responsibilities under review in the light of the development of the Programme, and make any recommendations to the NHS North West London JCPCT/ Cluster Board on changes to its membership or responsibilities.

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A.2.2 Transformational Group

Purpose of the Transformational Group

• For NHS NW London CEO to steer programme delivery in line with the scope, aims and timescales set out by the Cluster Board

• To provide cluster level assurance of Programme Activities

Responsibilities

• In order to achieve its purpose, the Programme Executive has responsibilities to: – Review progress of programme activity – Ensure that risks are being appropriately escalated to Cluster level, in line

with the Board Assurance Framework – Ensure the programme remains appropriately resourced to deliver

Chair

• The CEO of NHS NW London will chair the Transformational Meeting.

Membership

• The membership of the Transformational Group shall be: – Chair: CEO Cluster – Programme Director – Programme Manager – Director Delivery Support Unit – Programme Medical Directors – Programme Finance Directors – Programme Communications Director – Head of NWL Corporate Affairs

• A PPAG representative shall be invited to attend this meeting on a monthly basis.

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A.2.3 Programme Executive ToR

Purpose of the Programme Executive

• To advise on, inform and approve workstream activities and deliverables • To manage programme delivery in line with the scope, aims and timescales set out

by the Cluster Board

Responsibilities

• In order to achieve its purpose, the Programme Executive has responsibilities to: – Track and manage progress of programme activity; ensuring that issues are

acted on rapidly – Ensure that risks are being appropriately managed, in line with the

programme risk register – Plan and scope each phase of work and ensure the programme remains

appropriately resourced to deliver – Engage with Programme Board members and other stakeholders as

appropriate in between programme boards to support day-to-day decision-making


• The Programme Executive is established by the Cluster Board to advise the Reconfiguration Programme Board, and has no powers other than those included in its terms of reference.

• The Programme Executive will seek to reach consensus in deciding its recommendations. Where consensus cannot be reached, views which are divergent from the majority view will be recorded and presented with the report/advice to the Programme Board.

• Members are expected to act as ambassadors for the Programme and engage their organisations in the development of the Programme. Where an organisation’s board raises concerns about the recommendations or progress of the Programme, the Programme Director shall support the member in engaging their organisation in addressing the concerns.

• Members are expected to provide information to the Programme Executive to support the undertaking of accurate analysis and well informed decision-making.

• The Programme Executive shall be dissolved when the Cluster Board confirms that the future service configuration has been decided, and any formal reviews or challenges of that decision have been completed.

Authority

• The Programme Executive is authorised to instigate any activity within its terms of reference and to seek information as necessary; and is authorised to obtain outside legal or other independent professional advice.

Chair

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• The Workstream Lead for Programme Delivery shall be the Chair.

Quorum

• Where the Chair has determined – and has given one week’s notice to Programme Executive members – that a key decision will be made then the quorum shall include members (or their proxies) of all organisations that the Chair determines should be present unless that organisation has instead chosen to make a written submission.

• For other meetings, the Programme Executive will be quorate when at least two days’ notice has been given of the meeting and the Chair (or a Proxy) and two other members (or their proxies) are present.

Membership

• The membership of the Programme Executive shall be: – Chair: Workstream Lead for Programme Delivery – Programme Director – Programme Manager – NHS London – Programme Medical Directors – Sub-cluster Chief Executives – Workstream leads

Support to the Programme Executive

• The Programme Management Team shall provide support to the Executive, including:

– Agreement of the agenda with the Programme Executive Chair – The proper and timely preparation and circulation of papers – Keeping a proper record of the meetings and all decisions to be taken forward – Advising the Programme Executive and its Chair on matters of process and

procedure Meetings

• The Programme Executive will meet fortnightly, and more frequently if required to consider matters in a timely manner.

Reporting

• A report of the work of the Programme Executive shall be submitted to each meeting of the Programme Board.

Review

• The Programme Executive shall keep its membership and responsibilities under review in the light of the development of the Programme, and make any recommendations to the Programme Board on changes to membership and responsibilities.

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A.2.4 Clinical Board ToR

Purpose of the Clinical Board

• To provide clinical leadership to the programme, ensuring the programme develops robust clinical proposals and making clinical recommendations to the Programme Board. Specifically it will:

– Review and agree the case for change for NW London – To develop and agree quality standards for services, with a particular focus

on urgent care, children’s services, and long term conditions – including standards for primary, community and acute care in these areas

– Quality standards to include clinical outcomes, patient experience and access (journey time) to care

– To develop and agree models of care which will ensure delivery of these standards across the whole of NW London

– To develop options for the future configuration of acute services – To develop and recommend criteria for the assessment of options for the

future configuration of services to the programme board – To re-evaluate the assessment of options for the future configuration of

services in light of consultation responses and other inputs to the programme – To ensure Out of Hospital care will deliver against the standards required

• In addition the Board will also: – Provide expert clinical advice on other programme deliverables; including

expected clinical benefits – Ensure there are clinical advocates for proposals in each relevant service

area • To establish Working Groups where required to take forward short, focussed work to

finalise clinical service models

Responsibilities

In order to achieve its purpose, the Clinical Board has responsibilities to:

Engage with clinicians within the sector to identify the clinical evidence base underpinning the case for change in NWL

Set out standards for high quality care, particularly in the areas outlined above Agree the resulting vision and clinical service models Recommend the criteria to be used to assess service options and service models to

the programme board Identify a clinical benefits framework for the programme Support the development of clinically appropriate options for acute service

configuration and the definition of decision making criteria to appraise these options Ensure proposals for Out of Hospital care will enable the service standards to be met Engage with external expert clinicians and clinical advisory bodies, in particular the

NCAT, to clinically assure the service models and proposed configuration options. Engage with other local clinicians to test and refine clinical proposals


• The Clinical Board is established by the Cluster Board to advise the Reconfiguration Programme Board, and has no powers other than those included in its terms of reference.

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• The Clinical Board will seek to reach consensus in deciding its recommendations. Where consensus cannot be reached, views which are divergent from the majority view will be recorded and presented with the report/advice to the Programme Board.

• Members are expected to act as ambassadors for the Programme and engage clinicians within their organisations in the development of the Programme. Where clinicians raise concerns, the Programme team shall support the member in engaging relevant clinicians in addressing the concerns.

• Members are expected to provide information to the Clinical Board to support the undertaking of accurate analysis and well informed decision-making.

• The Clinical Board shall be dissolved when the Cluster Board confirms that the future service configuration has been decided, and any formal reviews or challenges of that decision have been completed.

Authority

• The Clinical Board is authorised to instigate any activity within its terms of reference and to seek information as necessary. The Clinical Board is authorised by the Cluster Board to secure the attendance or advice of such persons, including outsiders with relevant experience and expertise, as it considers necessary.

Chair

• There will be four Programme Medical Directors – two representing primary care and two representing acute care.

• The Programme Medical Directors shall act as joint Chairs of the Clinical Board. Each will be particularly responsible for ensuring the robustness of deliverables and clinical ownership in the respective clinical areas.

Quorum

• Where the Chair has determined – and has given two weeks’ notice to Clinical Board members – that a key decision will be made then the quorum shall include members (or their proxies) of all organisations that the Chair determines should be present unless that organisation has instead chosen to make a written submission.

• For other meetings, the Clinical Board will be quorate when at least two weeks’ notice has been given of the meeting and the Chair (or a Proxy) and three other members (or their proxies) are present.

Membership

• The membership of the Clinical Board shall be: – Chairs and Senior Responsible Officers: Programme Medical Directors (as

above) – Nominated Clinical leaders for each NWL Provider organisation – Nominated CCG representatives – PPAG representative(s) and/or patient experts – Director of Public Health, NHS NWL – Director of Nursing, NHS NWL

• The Programme Manager shall also attend Clinical Board meetings. • Where relevant, the OOH workstream lead will also be invited to attend

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Clinical Board Support

• Support and advice to the Clinical Board will be provided by the Programme Manager and the Programme Management Team. This support shall include:

– Agreement of the agenda with the Board Chair – The proper and timely preparation and circulation of papers – Keeping a proper record of the meetings and all decisions to be taken forward – Advising the Board and its Chair on matters of process and procedure

Meetings

• The Clinical Board will meet every two weeks and more frequently if required to consider matters in a timely manner.

Reporting

A report of the work of the Clinical Board shall be submitted to each meeting of the Programme Board.

Review

• The Clinical Board shall keep its membership and responsibilities under review in the light of the development of the Programme, and make any recommendations to the Programme Board on changes to membership or responsibilities.

Advisory support

The Clinical Board will be advised by:

- The NWL Clinical Senate (once established) - An expert advisory group of external clinicians with specific expertise

who will be asked to act as “critical friends” at key stages

Short term clinical groups established to quickly finalise service models that need further work

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A.2.5 Finance & Business Planning Working Group ToR

Purpose of the Finance & Business Planning Working Group

To advise on, inform and approve workstream activities and deliverables To provide expert financial, capital, estates, productivity and workforce input to the

programme; in particular to: – Develop a financial model to capture baseline activity and financials for all acute

providers across NW London, and project forward activity and financials under status quo and a range of configuration options

– To include high level estimates of capital expenditure requirements for configuration options

– Ensure programme proposals and deliverables, in particular the options development and appraisal, are based upon robust modelling and assumptions

– Ensure that modelling assumptions and data are agreed amongst all providers and commissioners

– Ensure the financial, capital, estates, activities and workforce implications of proposals are fully understood, for the sector as a whole and at site level and that provider CEOs are fully sighted on these implications

– Ensure programme deliverables have appropriate input from provider leads for finance, capacity / estates planning and workforce

Responsibilities

In order to achieve its purpose, the Finance & Business Planning Working Group has responsibilities to:

Ensure the robustness of assumptions and modelling underpinning expectations of financial and business planning benefits

Identify the financial and business planning dependencies and implications of implementing the clinical vision

Plan, manage and quality assure input to programme deliverables relating to: – Baseline financials – Modelling assumptions – Financial projections & impact – Activity & capacity projections & impact – Analysis of impact on travel times – Workforce planning – Expected benefits in terms of finance and capacity requirements, workforce, ,

travel / access • Specifically, to:

– Produce financial model to capture baseline activity and financials for all acute providers across NW London, and project forward activity and financials under status quo and a range of configuration options; to include high level estimates of capital expenditure requirements for configuration options

– Ensure that modelling assumptions and data are agreed amongst all providers and commissioners

– Ensure the financial, capital, estates, activities, travel and workforce implications of proposals are identified


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• The Finance & Business Planning Working Group is established by the Cluster Board to advise the Reconfiguration Programme Board, and has no powers other than those included in its terms of reference.

• The Finance & Business Planning Working Group will seek to reach consensus in deciding its recommendations. Where consensus cannot be reached, views which are divergent from the majority view will be recorded and presented with the report/advice to the Programme Board.


• Members are expected to provide information to the Finance & Business Planning Working Group to support the undertaking of accurate analysis and well informed decision-making.

• The Finance & Business Planning Working Group shall be dissolved when the Cluster Board confirms that the future service configuration has been decided, and any formal reviews or challenges of that decision have been completed.

Authority

• The Finance & Business Planning Working Group is authorised to instigate any activity within its terms of reference and to seek information as necessary. The Finance & Business Planning Working Group is authorised by the Cluster Board to secure the attendance of such persons, including outsiders with relevant experience and expertise, as it considers necessary.

Co-Chairs

• The CCG Designated Directors of Finance will be the co-chairs.

Quorum

• Where the Chair has determined – and has given two weeks’ notice to Finance & Business Planning Group members – that a key decision will be made then the quorum shall include members (or their proxies) of all organisations that the Chair determines should be present unless that organisation has instead chosen to make a written submission.

• For other meetings, the Finance & Business Planning Working Group will be quorate when at least two weeks’ notice has been given of the meeting and the Chair (or a Proxy) and three other members (or their proxies) are present.

Membership

• The membership of the Finance & Business Planning Working Group shall be: – Chair: CCG Designated Directors of Finance as above – Commissioner and provider Finance Directors – Provider estates leads – Commissioner and provider workforce leads (or a representative) – The Programme Director and Programme Manager shall also attend Finance

& Business Planning Group meetings.

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Finance & Business Planning Group Support

• Support and advice to the Finance & Business Planning Working Group will be provided by the Programme Management Team. This support shall include:

– Agreement of the agenda with the Group Chair – The proper and timely preparation and circulation of papers – Keeping a proper record of the meetings and all decisions to be taken forward – Advising the Group and its Chair on matters of process and procedure

Meetings

• The Finance & Business Planning Working Group will meet not less than monthly, and more frequently if required to consider matters in a timely manner.

Reporting

• A report of the work of the Finance & Business Planning Working Group shall be submitted to each meeting of the Programme Board.

Review

• The Finance & Business Planning Working Group shall keep its membership and responsibilities under review in the light of the development of the Programme, and make any recommendations to the Programme Board on changes to its membership and responsibilities.

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A.2.6 Communications & Engagement Working Group ToR

Purpose of the Communications & Engagement Working Group

To advise on, inform and approve workstream activities and deliverables To ensure that the programme plans and undertakes appropriate engagement with

relevant stakeholders at each stage To ensure that the programme delivers sufficient levels of awareness or,

understanding about and support for service change across NWL among key target audiences

To ensure regular opportunities are provided to engage with key target audiences, both before, during and following formal consultation

To ensure audience engagement and consultation is facilitated through high-quality, credible communications channels and messages

To ensure support among target audiences is benchmarked and tracked over time, both before and after consultation

To ensure that statutory requirements to engage stakeholders in the programme are met

To ensure consistency of communications between commissioners and providers, as part of managing internal communications.

Responsibilities

The workstream will run six strands:

Firstly, editorial (core script, key messages, proactive and reactive content) Secondly, stakeholder management (segmentation, prioritisation, targeting, ownership,

recording) Thirdly, marketing services (branding, multi-media channels, delivery, consultation

management) Fourthly, stakeholder insight via an opinion tracker (from start of 2012) Fifthly, stakeholder impact (Integrated Impact Assessment, Travel Advisory Group); and Sixthly, independent analysis of the post-consultation results

In order to achieve its purpose, the Comms & Engagement Working Group has responsibilities to:

Establish programme branding and key messages at each stage of the programme Plan and coordinate programme communications & engagement activities, ensuring

statutory requirements are met at each stage Ensure programme leaders, particularly clinicians, are supported in undertaking

programme communications and engagement activities Lead the formulation and communication of messages to the range of stakeholders

to support delivery of the Programme Map programme stakeholders and maintain a stakeholder engagement plan Support other parts of the programme in planning appropriate engagement of

stakeholders in the development of deliverables Pay particular attention to how Traditionally Under-represented Groups are engaged Ensure the effect of the consultation solution(s) on the travel options for patients and

carers is communicated effectively

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In particular, the Working Group will:

• Coordinate engagement with PPAG, OSCs / JOSC etc as required by programme manager

• Coordinate broader engagement with clinicians, GP practices, patients and public


• The Communications & Engagement Working Group is established by the Cluster Board to advise the Reconfiguration Programme Board, and has no powers other than those included in its terms of reference.

• The Communications & Engagement Working Group will seek to reach consensus in deciding its recommendations. Where consensus cannot be reached, views which are divergent from the majority view will be recorded and presented with the report/advice to the Programme Board.


• Members are expected to provide information to the Communications & Engagement Working Group to support the undertaking of accurate analysis and well informed decision-making.

• The Communications & Engagement Working Group shall be dissolved when the Cluster Board confirms that the future service configuration has been decided, and any formal reviews or challenges of that decision have been completed.

Authority

• The Comms & Engagement Working Group is authorised to instigate any activity within its terms of reference and to seek information as necessary. The Communications & Engagement Group is authorised by the Cluster Board to secure the attendance of such persons, including outsiders with relevant experience and expertise, as it considers necessary.

Chair

• The NHS NWL Director of Communications shall be the Chair.

Quorum

• Where the Chair has determined – and has given two weeks’ notice to Communications & Engagement Working Group members – that a key decision will be made then the quorum shall include members (or their proxies) of all

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organisations that the Chair determines should be present unless that organisation has instead chosen to make a written submission.

• For other meetings, the Communications & Engagement Working Group will be quorate when at least two weeks’ notice has been given of the meeting and the Chair (or a Proxy) and three other members (or their proxies) are present.

Membership

• The membership of the Comms & Engagement Working Group shall be: – Chair: NHS NWL Director of Communications – Commissioner and provider Communications Directors or equivalents – A communications representative of each sub-cluster – The Programme Director and Programme Manager shall also attend Comms

& Engagement Working Group meetings.

Support for the Comms & Engagement Working Group

• Support and advice to the Comms & Engagement Working Group will be provided by the Programme Management Team. This support shall include:

– Agreement of the agenda with the Group Chair – The proper and timely preparation and circulation of papers – Keeping a proper record of the meetings and all decisions to be taken forward – Advising the Group and its Chair on matters of process and procedure

Meetings

• The Comms & Engagement Working Group will meet monthly – and more frequently if required to consider matters in a timely manner.

Reporting

• A report of the work of the Comms & Engagement Working Group shall be submitted to each meeting of the Programme Board.

Review

• The Comms & Engagement Working Group shall keep its membership and responsibilities under review in the light of the development of the Programme, and make any recommendations to the Programme Board on changes to membership and responsibilities.

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A.2.7 Emergency and Urgent Care Clinical Implementation Group Terms of Reference Context

• Any changes to the configuration of services in North West London will have an impact on how clinicians lead and deliver services.

• As the reconfiguration programme progresses, plans for implementing changes to clinical services will be developed. The input and expertise of patients and local clinicians and patients are essential for planning the implementation of these changes.

Purpose of the Clinical Board

• To ensure the reconfiguration programme develops robust implementation plans for emergency and urgent care.

• To ensure that implications for emergency and urgent care are communicated and fully understood at local level, and that clinical colleagues are kept informed.

• To ensure that the plans for implementing changes to emergency and urgent care receive appropriate input from clinicians and patients.

Responsibilities

In order to achieve its purpose, the Clinical Board has responsibilities to:

• To ensure the robustness of proposals and modelling underpinning the emergency and urgent care aspects of the programme.

• To ensure alignment between the plans for implementing changes to emergency and urgent care and the agreed clinical standards.

• To lead the implementation of relevant recommendations made by the National Clinical Assessment Team (NCAT) and the Office of Government Commerce (OGC) review reports.

• To provide information to the Programme Board, and its groups, to support the implementation of changes to the configuration of services in NHS North West London.

Constitution and Authority

• The Emergency and Urgent Care Clinical Implementation Group is established by the Clinical Board to advise the Clinical Board, and has no powers other than those included in its terms of reference.

• The EUC CIG will develop a work plan which will be submitted for approval to the Programme Board. Once agreed it will be decided whether it will be appropriate for the group to assist with implementation of the model.

• The Emergency and Urgent Care, Maternity and Paediatric Clinical Implementation Groups will act as advisory and implementation groups, submitting reports to Clinical Board.

• The Clinical Implementation Groups are authorised to instigate any activity within its terms of reference and to seek information as necessary. They are authorised by the Clinical Board to secure the attendance of relevant persons, including representatives of external organisations, as it considers necessary.

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Co-Chairs

Two of the Programme Medical Directors, Tim Spicer and Susan La Brooy, as Programme Leads for Acute Care, will chair the meetings.

Membership

The Co-Chairs, as Programme Medical Directors and Programme Leads for Acute Care.

The NHS North West London Workstream Lead for Programme Delivery. Director, NHS North West London Delivery Support Unit. At least one patient representative, to be drawn from the membership of the Patient

and Public Advisory Group. Medical, nursing and surgical representatives from all sites within NHS North West

London that currently have an Emergency Department. GPs, as commissioners of care and leads for 111. Clinical representatives of local urgent care centre providers A representative of NHS London / London Health Programmes A representative of the London Ambulance Service (LAS) Clinical representative from local Mental Health service providers Representatives from local GP our of hours service providers A representative from the London Local medical Committee (LMC) A Local Authority representative

Clinical Board Support

• Support and advice to the Clinical Board will be provided by the Programme Manager and the Programme Management Team. This support shall include:

– Agreement of the agenda with the Board Chair – The proper and timely preparation and circulation of papers – Keeping a proper record of the meetings and all decisions to be taken forward – Advising the Board and its Chair on matters of process and procedure

Meetings

The Emergency and Urgent Care Clinical Implementation Group will meet monthly until the completion of the decision-making period.

The Emergency and Urgent Care Clinical Implementation Group may be asked to meet more frequently if required to consider matters in a timely manner.

Reporting

The Emergency and Urgent Care Clinical Implementation Group will report to the Clinical Board.

Review

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• The Clinical Board shall keep its membership and responsibilities under review in the light of the development of the Programme, and make any recommendations to the Programme Board on changes to membership or responsibilities.

Advisory support

The Clinical Board will be advised by:

- The NWL Clinical Senate (once established) - An expert Advisory group of external clinicians with specific expertise

who will be asked to act as “critical friends” at key stages

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A.2.8 Maternity Clinical Implementation Group Terms of Reference

Context



Purpose

• To ensure the NW London Reconfiguration Programme develops robust implementation plans for the delivery of safe and secure maternity services.

• To ensure effective joint working and communication between acute services and maternity services in NW London.

• To ensure that the plans for implementing changes to maternity services receive appropriate input from clinicians and patients.

Responsibilities

• To ensure proposals and modelling underpinning the maternity services are clinically robust.

• To ensure alignment between the plans for implementing changes to maternity services and the agreed London commissioning standards.

• To lead the implementation of relevant recommendations made by the National Clinical Advisory Team (NCAT) and the Office of Government Commerce (OGC) review reports.


Constitution and authority

• The Maternity Services Clinical Implementation Group is established by the Clinical Board to advise the Clinical Board, and has no powers other than those included in its terms of reference.

• The work plan of the Maternity Services Clinical Implementation Group is currently limited to work required to support the programme through consultation and decision making. However, work will be required to take forward the implementation of these implementation plans following decision-making and it may be appropriate for this to sit with the Clinical Implementation Group. The future form of the Clinical Implementation Group will therefore be reviewed after programme decision making.

• The Maternity Services Clinical Implementation Group will act as an advisory and implementation group, submitting reports to Clinical Board.

• The Maternity Services Clinical Implementation Group is authorised to instigate any activity within its terms of reference and to seek information as necessary. It is authorised by the Clinical Board to secure the attendance of relevant persons, including representatives of external organisations, as it considers necessary.

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Co Chairs

• The group will be chaired by Ms Gubby Ayida (Obstetrics) and Ms Pippa Nightingale (Midwifery)

Membership

• The Co Chairs • The members of the North West London Maternity Network • The NHS North West London Workstream Lead for Programme Delivery. • At least one patient/carer representative, to be drawn from the membership of the

Patient and Public Advisory Group. • A neonatal representative from the North West London Perinatal Network • Supervisor of midwives • A representative from the Obstetric Anaesthesia Association • A representative of NHS London / London Health Programmes • We agreed Associate members • Minutes to go to Associate members and attendance may be required for specific

meetings: a) Representative RCM b) Representative RCOG c) Deanery representative d) Lay representative

Frequency of meetings

• The Maternity Services Clinical Implementation Group will meet fortnightly until the completion of the decision-making period.

• The Maternity Services Clinical Implementation Group may be asked to meet more frequently if required to consider matters in a timely manner.

Administration and facilitation

• The Reconfiguration Programme Office will provide administrative support for meetings, including agreement of the agenda with the Maternity Services Clinical Implementation Group Chair; timely preparation and circulation of papers; keeping a record of the meetings, decisions and actions; registering risks and issues.

• Where the Chair considers this necessary members of an external organisation may be invited to facilitate meetings

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A.2.9 Paediatrics Clinical Implementation Group Terms of Reference

Context



Purpose

• To ensure the reconfiguration programme develops robust implementation plans for the delivery of paediatric services.

• To ensure that implications for paediatric services are communicated and fully understood at local level, and that clinical colleagues are kept informed.

• To ensure that the plans for implementing changes to paediatric services receive appropriate input from clinicians and patients/ carers.

Responsibilities

• To ensure the robustness of proposals and modelling underpinning the paediatric services aspects of the programme.

• To ensure alignment between the plans for implementing changes to paediatric services and the agreed clinical standards.

• To lead the implementation of relevant recommendations made by the National Clinical Advisory Team (NCAT) and the Office of Government Commerce (OGC) review reports.


Constitution and authority

• The Paediatrics Clinical Implementation Group is established by the Clinical Board to advise the Clinical Board, and has no powers other than those included in its terms of reference.

• The work plan of the Paediatrics Clinical Implementation Group (CIG) is currently limited to work required to support the programme through consultation and decision making. However, work will be required to take forward the implementation of these implementation plans following decision-making and it may be appropriate for this to sit with the Clinical Implementation Group. The future form of the Clinical Implementation Group will therefore be reviewed after programme decision making. The North West London Paediatric Network will continue to function once the Paediatric Clinical Implementation Planning Group has ended.

• The Paediatrics Implementation Group will act as an advisory and implementation group, submitting reports to Clinical Board.

• The Paediatrics Clinical Implementation Group is authorised to instigate any activity within its terms of reference and to seek information as necessary. It is authorised by the Clinical Board to secure the attendance of relevant persons, including representatives of external organisations, as it considers necessary.

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Chair

• The Chair of the Paediatric Network in North West London, Abbas Khakoo, will chair the meetings.

Membership

• The Chair. • The members of the North West London Paediatric Network • The NHS North West London Workstream Lead for Programme Delivery. • At least one patient/ carer representative, to be drawn from the membership of the

Patient and Public Advisory Group. • Medical, nursing and surgical representatives from all sites within NHS North West

London that currently have a Paediatrics Department. • A representative of NHS London / London Health Programmes

Frequency of meetings

• The Paediatrics Clinical Implementation Group will meet fortnightly until the completion of the decision making period.

• The Paediatrics Clinical Implementation Group may be asked to meet more frequently if required to consider matters in a timely manner.

Administration and facilitation

• The Reconfiguration Programme Office will provide administrative support for meetings, including agreement of the agenda with the Paediatrics Clinical Implementation Group Chair; timely preparation and circulation of papers; keeping a record of the meetings, decisions and actions; registering risks and issues.

• Where the Chair considers this necessary, members of an external organisation may be invited to facilitate meetings.

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A.2.10 JCPCT Membership

The JCPCT is a joint committee established by NHS Brent, NHS Ealing, NHS Hammersmith & Fulham, NHS Harrow, NHS Hillingdon, NHS Hounslow, NHS Kensington & Chelsea, NHS Westminster, NHS Camden, NHS Wandsworth and NHS Richmond.

Members

Jeff Zitron (JZ) Chairman

Trish Longdon (TL) Non Executive Director

Elizabeth Rantzen (ER) Non Executive Director

Fergus Cass (FC) Non Executive Director

Sarah Cuthbert (SC) Non Executive Director

Arif Kamal (AK) Non Executive Director

Chandresh Somani (CS) Non Executive Director

Martin Roberts (MR) Non Executive Director

Anne Rainsberry (AR)

Chief Executive NHS NWL

Daniel Elkeles (DE)

Rob Larkman (RL)

SRO, Shaping a Healthier future

Chief Officer designate BEHH CCGs

Mark Spencer (MSp) Medical Director, Shaping a healthier future*

Andrew Howe (AH)

Jonathan Webster (JW)

Director of Public Health*

Acting Director of Nursing*

Stephen Hickey (SH)

Ellen Schroder (ES)

Marilyn Plant (MP)

Clare Parker (CP)

Jonathan Wise (JWi)

Nominated Representative of Wandsworth PCT

Nominated Representative of Camden PCT

Nominated Representative of Richmond PCT*

Director of Finance, CWHH CCGs/PCTs

Director of Finance, BEHH CCGs

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A.2.11 JCPCT Establishment Agreement

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33

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APPENDIX A3 – Programme Governance: Membership for Advisory Groups

A.3.1 Expert Clinical Panel

The Expert Clinical Panel was coordinated to provide external assurance and advice to the programme. The table below covers those who attended these meetings.

First Name Surname Role (Context of SaHF)

Ken Aswani GP NHS Waltham Forest

John Coakley Intensive Care Consultant - Homerton Hospital NHS Trust

Simon Eccles Clinical Director of Paediatrics and Consultant Craniofacial Plastic Surgeon - Chelsea & Westminster Hospital NHS Foundation Trust

Donal Hynes PEC Chair - NHS Somerset

Abbas Khakoo Medical Director and Consultant Paediatrician – The Hillingdon Hospital NHS Trust

Derek Bell Prof. Acute Medicine - Imperial College Healthcare NHS Trust and Chelsea & Westminster Hospital

Andrew Hobart Consultant Emergency Medicine - South London Healthcare NHS Trust

Marilyn Plant PEC Chair - NHS Richmond

Ganesh Suntharalingham Clinical Director, Critical Care, NW London Hospitals NHS Trust

Alison Pointu Director of Quality & Safety at North Central

Patrice Donnelly Quality and Safety – NHS London

Programme Medical Directors, Mike Anderson, Susan LaBrooy and Mark Spencer also attended the meetings of the ECP.

The papers for all Expert Clinical Panel meetings were sent to a wider audience, to present clinicians with the opportunity to provide out of committee comments. These additional clinicians are listed in the table below.


Caroline Alexander Physiotherapist and Research – Imperial College Healthcare NHS Trust

Jacqueline Dunkley-Bent Dir. Midwifery - Imperial College Healthcare NHS Trust

Robin Evans Consultant Radiologist - Croydon Healthcare NHS Trust

Stewart Findlay Chief Clinical Officer Designate - Durham Dales Easington and Sedgefield CCG

Shane Gordon Chief Officer North East Essex CCG

Celia Ingham-Clark Medical Director - The Whittington Hospital Trust

Gavin Marsh Orthopaedic Consultant - Croydon Healthcare NHS Trust

Mike Lane Joint Clinical Lead Wandle Locality & GP Wandsworth

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Andy Mitchell Medical Director - NHS London

Emma Saunders Lead Clinical Research Nurse - Lewisham Healthcare NHS Trust

Matt Thompson Prof. Vascular Surgery - St Georges Healthcare NHS Trust

Jane Wilson Consultant Obstetrician and Gynaecologist - Kingston Hospital NHS Trust

Trish Morison-Thompson

Chief Nurse, NHS London

Appendix B – Stakeholder engagement record (pre-consultation)

Appendix B – Stakeholder engagement

record (pre-consultation)


Edition: 1.0

12 February 2012

Shaping a healthier future Pre-consultation responses

Document Cover Sheet Document information

Document Title: Pre-consultation responses Programme: Shaping a healthier future Date: 15 June 2012 Owner: Luke Blair Author: Luke Blair Content input: Comms and engagement team

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NHS NWL Reconfiguration Programme Pre-consultation responses

1.0 Purpose of this document The Shaping a Healthier Future programme has undertaken substantial engagement with a wide range of stakeholders since it commenced in November 2011. With the programme approaching the planned date for consultation this document provides a baseline of the responses the programme has received during this period and explains how they have informed the development of the proposed consultation options.

2.0 Introduction The NHS looks after nearly two million people in North West (NW) London and has the highest aspirations for the way they are cared for and the services they receive. But it is facing substantial challenges including a growing and ageing population, of working from inadequate NHS facilities, and of working within an increasingly tight financial envelope. These challenges need to be met – or the NHS and its services in NW London will deteriorate. Shaping a healthier future (SaHF) is being led by eight Clinical Commissioning Groups (CCGs), who are made up of GPs representing NW London’s eight Primary Care Trusts (PCTs). They have worked with hospital doctors, nurse leaders, providers of community care such as mental health services, social services organisations, and others, to develop a programme to address these challenges. Throughout the pre-consultation period, the programme has undertaken detailed conversations with other local clinicians, healthcare providers, patients and the public as part of initiatives to establish the future vision for care and work up proposals for change in more detail. Following this phase, a formal consultation on options for improved healthcare will take place over a 14 week period from 2 July 2012. The pre-consultation stakeholder engagement work builds on similar work carried out with Clinical Working Groups and other stakeholders in previous years. The programme carried out a systematic and wide-ranging programme of engagement based on an agreed set of principles and an understanding of who our stakeholders are and how they should be engaged. It is important that the programme demonstrates to those stakeholders engaged how their input has been used to inform and shape the development of the consultation options. Furthermore Shaping a healthier future depends heavily on successful communications and engagement in order to meet its objectives, and particularly the ‘four tests’, namely:

I. support from GP commissioners II. patient and public engagement III. clarity about clinical evidence base IV. patient choice

3.0 Method The programmed has structured its engagement around three key groups during the pre-consultation phase:

1. Public and patient engagement, 2. Clinical and provider engagement, and 3. HOSC/ JHOSC, H&WB Board and wider political engagement.

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Engagement with these groups is carefully planned and coordinated by the programme. A number of tools are used to track and manage stakeholder contact:

• A comprehensive database – with stakeholder contact details and records of correspondence and engagement activity (reviewed weekly)

• An intelligence log – a snapshot of intelligence and information about key stakeholders’ relationships with and attitudes to the programme (updated as often as needed)

• A stakeholder management diary – a log of all upcoming meetings and events and record of programme attendance

• A borough heat map – to track the status of each borough as a whole with regard to their attitude toward the programme

• Engagement log – a template for programme leaders and representatives to fill in to report any stakeholder engagement activity. This is then fed into the tools listed above.

• Daily monitoring – of local, regional and national media, parliamentary activity, City Hall activity and local political activity

This report summarises the following:

• Engagement that has occurred with each of these three groups, • Key themes that have emerged during this engagement, and • How this feedback has been used by the programme to develop proposals.

4.0 Summary of engagement, themes and responses 4.1 Patient and public engagement Three major stakeholder engagement events took place during the pre-consultation period; a summary of each event is contained in the table below. 15 February stakeholder engagement Lord’s Cricket Club

200+ attendees: - Representatives from all eight Local Involvement Networks (LINks) patient groups

from across North West London - Representatives from all eight local authorities in North West London, including

elected councillors - Patient groups including AgeUK, Mencap, MIND and the Patients Association - GPs from across North West London including those from the new Commissioning

Consortia in each borough - Clinicians representing every NHS NWL service provider, including hospitals and

community health services Covered: - Case for change - Clinical standards (acute and Out Of Hospital (OOH)) - Evaluation criteria

23 March stakeholder engagement Lord’s Cricket Club

180+ attendees: - Representatives from all eight LINks groups - Representatives from patient groups such as MIND, Hammersmith and Fulham

Disability Forum, Age UK and Community Voice - Representatives from all eight Clinical Commissioning Groups in NW London - Representatives from North West London Local Authorities - Representatives from eight provider trusts as well as NW London’s community and

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mental healthcare providers - GPs and CCG leads from across North West London Covered: - Long list to medium list process - Local vision and plans for out of hospital care - Evaluation criteria

15 May stakeholder engagement Satavis Pattidar Centre

180+ attendees: - representatives from six of the eight LINks groups - representatives from patient groups such as BME Health Forum, Breathe Easy

Brent, West London Citizens, Hanwell Neighbourly Care Scheme and Age UK - Councillors and/or officers from six of the eight North West London councils - representatives from the Clinical Commissioning Groups in NW London - representatives from six acute provider trusts as well as NW London’s community

and mental healthcare providers - GPs from across NW London Covered: - Programme update and timeline - Medium list to short list process - Patient pathways now and in the future - Consultation plans

The programme has also attended the following patient and public meetings since January: 24 Jan Patient and Public Advisory Group (PPAG) – to share Case for Change and

arrangements for stakeholder events. 27 Jan PPAG and LINks workshop – to brief interested members more fully on the

programme. 31 Jan LAUNCH - all stakeholder sent launch newsletter including case for change. 21 Feb PPAG – review of recent stakeholder event and general programme update 23 Feb West London Citizens – Ealing Emergency Assembly. Programme was present on the

panel. Clinicians presented the Case for Change, early work on options development, and discussed specific questions relating to Ealing hospital and other local services. The event was well organised with some speakers subsequently attending the 23 March event held by the programme.

6 March PPAG – to update on programme. 27 March PPAG - to update on programme. APRIL Meetings postponed due to pre-election period. 9 May Ealing Citizens public meeting. Programme was present on panel and presented.

Programme leaders including local GPs presented an update on the programme. The audience were very engaged and appreciative of the programme being open and transparent about latest progress.

9 May Westminster LINk – to discuss programme with steering group. 22 May PPAG – to discuss consultation plan. The key themes and the programme’s responses to these are detailed in the table below:

Event/group Key themes and messages How the programme has incorporated these messages into our proposals

15 February Overall, the Case for Change was very well Clinical leaders have used the feedback

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NHS NWL Reconfiguration Programme Pre-consultation responses event received and the need to address the issues

it raises was widely recognised. Attendees also told us they were pleased to be involved in the discussions at this early stage in the programme. Key themes for OOH care included: o Issues with continuity of care in the

community o Communication between settings,

specialties and health and social care o Improved coordination of care o Better information sharing systems to

facilitate joint working o Issues with access to care in the

community. Key themes for acute care included: o Clinical quality most important criteria.

from the event to inform: o The clinical standards – particularly out-

of-hospital care standards o The ongoing development of visions and

plans for out-of-hospital care in each borough

o The development of a medium list of options for change

o The identification of potential criteria to use to assess the medium list of options in order to establish a shortlist for public consultation in the summer

o The agenda for the next event on 23 March and our planning for other events in May and through public consultation

23 March event Delegates voted to indicate how well they understood the options development process which described how the programme has moved from a long-list of options for change to a medium-list. 85% of patient and public representatives and clinicians voted positively to say they understood this. Key themes for OOH included: o Strategies well received. o Changes should reflect better care not

cost reduction. o Adequate resources to deliver success o Integration of health and social services o Information systems that support care

delivery across settings. Key themes about options for change: o Consider access more widely. o Focus on clinical case for change. o Consider population density and

neighbouring areas.

The programme’s leaders built feedback from the event into their plans, specifically: o Working with local clinicians to agree

our shortlist of options for change. o Working with local clinicians, local

authorities and others across the eight NW London boroughs to refine the local visions for out-of-hospital Care.

o Programme undertook engagement events to give a wider body of local patient representatives and local clinicians the opportunity to hear about the programme and influence it.

o Undertaking detailed travel analysis, an equalities review to look at access, and convening a Travel advisory Group.

o Liaising with neighbouring PCTs and providers to ascertain the likely impacts of the NW London reconfiguration.

o OOH strategies consider IT systems and funding has been included in the modelling, ICP pilot demonstrated requirement for integrated IT systems.

o Programme engaging with H&WB Boards to explore links between health and social care.

15 May event Key themes for developing options for change included: o Emphasising that this isn’t cost driven. o Clarifying the role of Urgent Care

Centres (UCCs). o Ensuring the programme addresses the

Following feedback from this event, programme leaders are: o Working with local clinicians to further

develop the three recommended options for consultation

o Working with local clinicians, local

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equalities challenge. Key themes for developing patient pathways included: o More detail about patient pathways o Further consideration given to mental

health and the elderly o Improved capacity and capability in the

community o Better access to GPs o Improved communication.

authorities and others across the eight NW London boroughs to refine the local visions for out-of-hospital care

o Setting up CIGs which will work with primary and secondary care clinicians to clarify pathways including workforce, urgent care centres, etc.

o Holding ongoing discussions with local patient representatives on our Patient and PPAG - which has representatives on each of our working groups

o Running more engagement events to give a wider body of local patient representatives and local clinicians the opportunity to hear about the programme and influence it

o Further developing our consultation plans and refining this with the North West London Joint Health Overview and Scrutiny Committee (JHOSC) and PPAG.

LINks sessions Some members of the relevant LINks expressed concerns that travel analysis based on information from Transport for London (TfL) was not robust.

In order to address these concerns, the programme is establishing a travel advisory group which will involve input from council transport leads, TfL and PPAG LINks representatives.

PPAG PPAG have provided input into the following: o Consultation document and questions. o PCBC o Consultation plan Feedback received included: o Emphasising improvements to access

through the delivery of OOH strategies. o Ensuring MH services are considered. o Concerns about the impact of the

financial position of some boroughs and the need for clear communication of key messages during the consultation period.

o Concerns re. integration with social services.

This feedback has been used as follows: o MH was included in OOH strategies: o A meeting was offered with the

programme’s finance lead to address the first concern and the PPAG will be involved in reviewing and informing the development of messages used in consultation materials.

o The programme has used input from PPAG to create revised drafts of the key consultation documents and Pre Consultation Business Case (PCBC).

o Ensuring OOH borough strategies provide a coherent story for patients.

o Ensuring OOH strategies provide details of the integration between health and social care.

West London Citizens event

The key themes emerging from the event were: o Access was the main concern among the

residents of Ealing. o Programme will need to address

transport concerns. o Case for Change was well received,

o Reconfiguration programme made an offer to come back and have a more discursive event to hear about what else could be there.

o Ensure continued focus on engagement with Ealing.

o Detailed consideration of travel

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especially the vision ‘Specialise, Localise, and Integrate’.

implications for Ealing residents.

For further details of the feedback received at the three stakeholder engagement events please refer to Appendix 1. Seldom heard groups As part of the SaHF programmes wider consultation and engagement work, the communications and engagement team will be undertaking work to engage and consult groups, communities that are seen as seldom heard and traditionally under represented, this will include groups such as refugee’s communities, the elderly, faith groups, BME communities and women from within these communities. This element of the work will ensure that these groups are aware of the possible changes to NHS services within their local area and how these may affect them as an individual or as a community, we will also be looking to ensure that any concerns or views they have on the reconfiguration of services are captured and used to help determine the future provision of NHS services. The focus of this work will be to link in with existing networks and forums within the eight boroughs, this will include work with local authority colleagues who support voluntary and community sector networks, voluntary sector organisations including the CVS network and small community organisations who work with the key target groups and meeting with faith groups who are able to access a large number of community members through the work they undertake. The work will compliment the larger formal consultation taking place and will also link in with future Equalities Impact Assessment (EqIA) work which will form the basis of ensuring that the impact of changes to services does not have an adverse impact on potential groups.

4.2 Clinical and provider engagement Clinical engagement during the pre-consultation period was essential in order to develop options for reconfiguration. A key construct of the programme’s governance structure is the Clinical Board. The Programme Medical Directors worked closely with the Clinical Board (which consisted of medical directors from each provider in NW London and clinical representatives from each CCG) to develop the main deliverables from the pre-consultation phase, including:

• The Case for Change • Clinical Vision • Clinical standards • Service delivery models • Medium list of options • Shortlist of options • Recommended options

The Clinical Board makes recommendations to the Programme Board which then makes final recommendations to the Joint Committee of Primary care Trusts (JCPCT). The inputs, discussions and decisions of the Clinical Board are well documented through papers and minutes and so aren’t included here. Neither have discussions undertaken by the Expert Clinical Panel, which is a group of clinicians from outside NW London who meet regularly to peer review the proposals of the Clinical Board. Similarly, the inputs and outputs of this group are thoroughly documented in papers and minutes. This document focuses on clinical engagement that has occurred outside these two groups.

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NHS NWL Reconfiguration Programme Pre-consultation responses The Programme Medical Directors (MDs) have been continuously committed to supporting stakeholder engagement by attending and presenting at meetings to enable the clinical messages to be given accurately to other clinicians and for audience feedback to be gathered and considered throughout the proposals development process. To ensure wider clinical engagement, direct engagement has been focused on two core groups; senior provider clinicians and local GP Practice staff. The programme has engaged with clinicians and managers across the providers in NW London, with the main focus on acute providers and community care providers. These have included:

The programme has also attended the following clinical engagement meetings since January:

Wider clinical engagement

The programme was aware that we reached only clinical leaders through the clinical board and regular programme meetings and that there was a need to engage with the wider clinical community. This was done by Programme Medical Directors using standing events such as regular consultant meetings and GP forums to present the progress of the programme and to answer questions.

Multi-laterals with each acute provider in NW London

At this meeting, provider chief executives and medical directors met with senior members of the programme, their local CCG Chair, and Sub-Cluster chief executive. The meetings covered the latest view on service reconfiguration options, the implications for the provider and what additional work could be carried out to enhance the evaluation or design of the options. The record of the multi-lateral meetings can be found in Appendix 2.

15 February, 23 March and 15 May events

Clinicians representing every NW London service provider, including hospitals and community health services and GPs attended three stakeholder events where they were able to discuss and inform the programme’s work on:

• The case for change • Rationale for options development • Out of Hospital visions and strategies • Consultation options • Plans for consultation

Newsletters Programme newsletters have been shared with all GPs. Communications and Engagement working group

In addition to these activities, the programme ran a monthly working group. This consisted of programme communications staff and directors of communications from each of the providers. This enabled us to ensure alignment of activities between the programme and providers and gave the opportunity to share progress and gain feedback on considerations for the programme. It enabled us to disseminate material and messages and also for the provider teams to request tailored material from the programme. Between each meeting we shared relevant materials including the development of options, post event reports and newsletters that provider communications leads have then been able to distribute to provider staff. This has resulted in wider stakeholder engagement.

Chelsea & Westminster Open forum event

17 Apr 12-1pm, Chelsea and Westminster - 12 - 1pm Hospital boardroom. All staff invited to attend (clinical and non-clinical) - Medical Directors open forum event. Around 50 attendees, clinicians and other staff

Harrow GP Forum 18 April, attended by over 60 GPs. Royal Brompton and Harefield

20 Apr 9-10am, Harefield Hospital, Concert Hall, Harefield Site. Audit day - Medical Directors (20-25 consultants expected)

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The key themes and the programme’s responses to these are detailed in the table below: Event/group Key themes and messages How the programme has incorporated

these messages into our proposals

Local clinical engagement events during March – May 2012.

The key areas discussed with this group were: o Consultation options. o National Clinical Advisory Team (NCAT)

review. o Need to explore protected groups within

Southall and Central Ealing population and how that will be serviced.

o Development of UCCs. o OOH will have to be functioning prior to

services moving. o Support for UCC/Emergency

Department (ED) Working Group. o Provide evidence of CCG support for

process. o Providing clear narrative about patient

flows and pathways, especially in Ealing.

o The first area of focus was on the quality standards, service models and influencing the options development process. Clinical input has driven the development of the standards and service models.

o The second area of focus has been on the NCAT review, refining the options for consultation and understanding the site-specific implications in more detail. A wide range of clinicians had input into the NCAT process. The NCAT review was broadly supportive of the programme.

o Programme has created CIGs to explore the development of UCCs.

o Programme undertaking detailed implementation planning, led by CIGs.

o Programme has sought letters of support from providers and CCGs.

Royal Brompton and Harefield

20 Apr 11-12pm, Royal Brompton, Part of CHGD day - Medical Directors. Clinical audit days at both sites –Approx 40 attended at each. Mix of senior clinicians, nurses and other.

Ealing GP Event 24 Apr 8pm, Ealing, MS spoke with GPs regarding OOH strategies Chelsea & Westminster Grand round

3 may, event well attended.

Royal Marsden Hospital

08 May 5.30pm, Royal Marsden Hospital, Slot medical advisory committee. Senior clinicians invited to a specific briefing.

Ealing CCG 08 May 7.10pm, Trailfinders Sports Club, Ealing, 20 minutes presentation followed by questions. Ealing wide GPs to attend. This was a meeting of GPs in general with about 60 of them there to discuss practice issues.

North West London Hospitals

14 May 4.45-5.45pm, Room SR3, Medical Education Offices, HA1 3UJ, slot part of medical advisory committee. Medical staff committee meeting:

• Approx 30 attended & mix of consultants • Video link to Central Middlesex from NPH • Case for change presentation + 30mins discussion.

Ealing Hospital NHS Trust

16 May 5.15pm-6.30pm, Board Room, Main Hospital, update on SAHF. 30 consultants present.

West Middlesex University Hospital

22 May 12-1pm, Education Centre, Twickenham Road, Isleworth, Middlesex TW7 6AF, Update on SaHF. Approximately 35 people attended, mix of nurses/admin/consultants.

West Middlesex University Hospital

23 May 5pm, Education Centre, Twickenham Road, Isleworth, Middlesex TW7 6AF, Update on SAHF. 15 people – majority consultants and several nurses.

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o Programme producing Borough information packs for consultation describing the changes for specific Boroughs.

o Consultation materials written to provide a clear story.

GPs o Southall GPs sought assurances about access to services

o GPs in North West London received the Case for Change and each of the programme newsletters.

o They were also invited to each of the three pre-consultation stakeholder engagement events with strong representation at each one.

o Broad support for changes invested at NPH. Accident & Emergency (A&E) and intensive care surgeons planning extra activity which will be coming their way.

o Programme developed engagement plans for Southall GPs and public around what service configuration in and out of hospital would be required for this population.

4.4 HOSC/ JHOSC, H&W Board and wider political engagement Various stakeholder engagement events and activities took place during the pre-consultation period; a summary for each group is presented in the tables below. HOSC / JHOSC engagement

See APPENDIX 3 - Ongoing OSC / JHOSC/ Council engagement for more details. H&WB Board engagement Throughout the pre-consultation period, the Health and Wellbeing Board (H&WBB) have been in various stages of maturity. As such, there have been individual meetings with some of the more established HWBBs including two meetings with Hammersmith and Fulham, one with Ealing and one with Brent.

6 December 2011 Anne Rainsberry wrote to the nearly 100 members of the various Health Overview and Scrutiny Committees (HOSCs) in the eight relevant NW London boroughs so that their duties to form a Joint HOSC could be considered in good time.

16 January 2012 An informal briefing meeting was attended by scrutiny chairs, vice chairs, and/or officers from all eight relevant HOSCs.

29 February 2012 A second meeting of all relevant HOSC members was held to reinforce the need for them to form a Joint HOSC in April in order for the programme to proceed as planned.

4 April 2012 Full JHOSC meeting (in Shadow Form). 17 May 2012 Full JHOSC meeting (in Shadow Form). 12 June 2012 Full JHOSC meeting (in Shadow Form).

24 May 2012 Principal stakeholder attendees at this North West London H&WBB engagement event included:

• CCG chairs

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Wider political engagement MP engagement - All NWL MPs have received: 23 Dec Introductory letter with offer of a meeting Early Jan Follow-up call to reiterate meeting offer 1 Feb Case for Change and Newsletter #1 21 March Newsletter #2 14 May Newsletter #3 In addition the following meetings have taken place: 7 February Meeting with Seema Malhotra MP (Feltham and Heston) 13 February Meeting with Gareth Thomas MP (Harrow West) 27 March Meeting with Mark Field MP (Cities of London and Westminster) and Karen Buck MP

(Westminster North) (representing Andrew Slaughter MP(Hammersmith)) 29 March Meeting with Greg Hands MP (Chelsea and Fulham) 17 May Meeting with Angie Bray MP (Ealing Central and Acton) Mayor and Assembly Member engagement - All Assembly Members, the Mayor and key GLA officers have received: 23 December Introductory letter 1 February Case for Change and Newsletter #1 21 March Newsletter #2 14 May Newsletter #3 As appropriate Briefings have also been provided ahead of Mayor’s Question Time, People’s Question

Time and key meetings as appropriate. Local political engagement - All NW London Council leaders, Cabinet Members and key officers have received: 1 February Case for Change, introductory letter and Newsletter #1 21 March Newsletter #2 14 May Newsletter #3 15 February 23 March 15 May

All NW London local authorities have been invited to send representatives to all three stakeholder events. Representatives from all eight attended the first event. Representatives from six of the eight attended the other two.

14 May Meeting with programme representatives and Tri-Borough Leaders: Cllr Stephen Greenhalgh (Hammersmith & Fulham (H&F)) Cllr Joe Carlebach (H&F)

• HWBB chairs • Borough Directors • DPHs, and • Other shadow H&WBB members.

Covered a briefing on: • OOH strategy • Acute services reconfiguration and implications.

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Derek Myers (Joint CE RB Kensington & Chelsea K&C and H&F) Cllr Sir Merrick Cockell (RB Kensington & Chelsea) Cllr Fiona Buxton (RB Kensington & Chelsea) Cllr Rachael Robathan (Westminster City Council (WCC)) Mike Moore (CE WCC) Cllr Philippa Roe (WCC)

Further ad-hoc meetings have taken place throughout – see log at Appendix 1 The key themes and the programme’s responses to these are detailed in the table below: Event/group Key themes and messages How the programme has incorporated

these messages into our proposals

HOSC o HOSC members agreed to form the JHOSC in shadow form until formal meetings of the relevant councils could officially agree which councillors should be members of the full JHOSC.

o Engagement with individual HOSCs has been ongoing in parallel with JHOSC engagement. There has been regular attendance by the programme at as many HOSC meetings as possible in every borough. Key feedback from HOSCs includes: o Welcomed the proposals to have

more integrated care and more care in a community setting.

o Sought reassurance that all patient groups would benefit

o Reassurance that GPs support the proposals

o That it would create a financially viable future for the NHS

o That carers would get support; workforce development

o That there would be no financial or service imbalance across the NWL cluster

o Parking/access and impact on blue badges and cross borough travel

o Need to emphasise what the different types of hospitals are.

o Need to look at travel/speak to local transport people.

o Need to do more about why things failing now and how they will improve.

o Maternity provision.

o The programme confirmed its commitment to continuing to engage with individual borough HOSCs as well as the JHOSC.

o The programme is also committed to providing responses to HOSCs and the JHOSC within 28 days and meeting monthly, 8 to 10 days prior to Programme Board meetings.

The programme has used this feedback in the following ways: o Undertaking an equalities review to

ensure groups are not disproportionally impacted.

o Sought written support from GPs. o Undertaken substantial travel analysis

and convened a travel advisory group (TAG).

o Used peak morning travel times for the analysis to present a worst case scenario.

o Create robust financial models to develop the consultation options and articulate how reconfiguration creates financial stability and sustainability for the NHS in NW London.

o The financial models looked at sites and trusts to ascertain a micro and macro picture of the financial position as a result of various reconfiguration options.

o Developed clear service models for the different hospital types and the core and additional services provided at each type before and after reconfiguration, with patient stories giving the service models context.

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o Developed a detailed narrative about what happens if the NHS ‘does nothing’, i.e. the quality, clinical, patient experience, and financial implications.

o Developed maternity standards and used this to define the number and types of units post reconfiguration, convened the Clinical Implementation Groups (CIGs) to develop maternity services.

JHOSC (Shadow)

The full JHOSC has now met three times (in Shadow Form) and they have: o JHOSC has input into the PCBC and the

consultation document, including comments about the consultation questions and the narrative.

o Throughout the pre-consultation engagement period, the JHOSC and some individual HOSCs requested various pieces of information from the programme including detailed travel analysis and estates work, which has been provided where possible.

o Ealing OSC requested a presentation on local out-of-hospital providers which was subsequently provided by representatives of the Ealing CCG. Requested information on the technical aspects of the travel time data.

o The programme discussed the consultation timeline with the JHOSC and agreed a two week extension to the standard period to accommodate summer holidays and the Olympics (resulting in a 14 week consultation duration).

o The programme discussed the most appropriate day to commence consultation and agreed the 2 July.

o The programme followed up with the relevant transport official from the borough, the programme convened a Travel Advisory Group and this has representatives from the Boroughs.

o The programme has used the input from the JHOSC to develop both the PCBC and the consultation document.

o We undertook further detailed analysis on travel time analysis (12 June), also covering the equalities review and impact on protected groups.

H&WB Board (Shadow)

Shaping a healthier future/ OOH: o There were queries about schedules and

some concern that strategies need to be more closely integrated.

o It was recognised that OOH & SaHF have very significant implications for Borough’s JHWS for some years.

o H&WBB roles and current development There was discussion about the HWBB’s role in relation to OOH and the balance between it being regarded as a stakeholder verses a partner and the extent to which there was a real opportunity to shape the strategies.

o Engagement to date with OOH and reconfiguration

o It was noted that board away days had

The Programme has woven the following key messages into the narrative of the PCBC: o The urgency of the challenge we face o The inevitability of system failure if we

don’t deliver a planned reconfiguration o The programme has also considered the

resources that can be made available to Boroughs to model health and social care impacts

The programme undertook the following in response to the H&WBB: o Consider how to address care for the

elderly and those with LTC, children’s services, wider determinants, i.e. will a phased approach be adopted or look to advance each consecutively.

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proved productive and suggested that boards should avoid overly full business agendas since they need time to explore system transition together.

Challenges and solutions: o It was recognised that the question of

the impact of plans on social care has been raised a number of times already and that whilst everyone recognises this issue nobody appears to have modelled the impact at a local level. This is an area where HWBBs need to assume leadership. NHS NWL might consider how it can support HWBBs to make progress in this area.

o It was noted that Children’s services are given relatively little attention in OOH strategies and that this involves greater consideration to prevention services and wellbeing.

o It was suggested that HWBBs will not be able to achieve system transformation without working with other boroughs.

o Established the paediatric CIG which will work over the next 6 months to consider implementation issues in greater detail.

o Urgent and emergency care CIG will consider implementation issues in greater detail.

o In discussion with NHS NWL Delivery Support Unit (DSU) on how this fits with implementation support for OOH and engagement with social care.

o Programme exploring the requirement for a further engagement with the Accountable Officers.

NWL MPs o Some MPs expressed concerns about the proposed closure of an A&E in their area.

o The programme offered follow up meeting to help address these concerns and provide additional information about the proposals.

Tri-Borough Leaders

o Challenge that NHS has not opted out of European Working Time Directive (EWTD).

o Need to avoid ‘winners and losers’ and also be transparent.

o Don’t trust transport figures from TFL and so you need to talk to H&F transport people.

o People understand what an A&E is but not a UCC.

o Parking and blue badge co-ordination will also be an issue.

o How will people know the best place to go if it is not the A&E?

o Need to do what stroke and care consultation did.

o Should you consult in Nov/Dec instead?

o Most of the questions here were answered in the session by Programme Representative

o Commitments were made to follow up with H&F transport officials, including points on blue badge and parking.

o Programme has established a Travel Advisory Group which meets regularly to provide guidance and oversight of programme travel issues.

Local Councils Some Councillors expressed concerns around the following issues: o Parking / access and impact on blue

badges holders. o Impact on transport and patient travel

o The programme offered follow up meeting to help address these concerns and provide additional information about the proposals.

o Programme has established a TAG which

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across borough. o Explain the different types of hospital

proposed. o Current situation and why it needs to

improve.

meets regularly to provide guidance and oversight of programme travel issues.

o The programme has ensured the PCBC contains adequate detail about the case for change and what would happen under ‘do nothing’.

5.0 Next steps This paper will be shared with the Programme Board for information. Meetings and activity will continue until and throughout public consultation. During public consultation an intensive schedule of engagement events and activity is planned (see full consultation plan for detail). The contents of this document will be used in conjunction with feedback gained through consultation to inform the refinement of the proposed reconfiguration options.

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APPENDIX 1 Feedback received at engagement events 15 February event Specific examples of how the feedback from the event has been used are in the table below: WHAT DELEGATES SAID: WHAT WE DID: Out-of-hospital care – bringing care closer to patients Shaping a healthier future’s proposals for the transformation of out-of-hospital services were positively received by both patient representatives and clinicians. The patient journey and challenges described certainly seemed familiar and attendees were quick to describe current out-of-hospital services (like GP services) as inconsistent and uncoordinated.

Feedback incorporated into the out-of-hospital standards: “Everyone who has a care plan will have a named ‘care coordinator’ who will work with them to coordinate care across health and social care. The role of the care coordinator will be clearly defined and understood by the individual and those involved in providing care. Clinical accountability will remain with the patient’s GP.”

References to ‘continuity of care’ were common and many patients said that they are not able to see one GP on a consistent or regular basis and so often had to repeat their story.

Additional investment will be made in primary care that will improve access. There will be occasions when you may not be able to access your own GP (unless you are prepared to wait a little longer). However, the Care Planning core standard specifies that everyone who has a care plan will have a named ‘care coordinator’ (see above).

Many felt that communication is a key area for improvement; between patients and clinicians, between clinicians in different disciplines and fields and between the health and social care systems

Improved communication is integral to the out-of-hospital standards. Specifically, they say that; “Any previous or planned contact with a healthcare professional should be visible to all relevant community health and care providers, in particular, when a patient is admitted or discharged from hospital. This should ensure that care providers are aware of any planned or outstanding activities required for the individual.”

Linked to this, many felt that there would be a significant impact on patient experience if healthcare was better coordinated and the patient placed at the centre. Many suggested that there should be one person with responsibility for coordinating the care of each patient.

Care planning core standard has been updated: “Care plans will be agreed with individuals (i.e. patients, users, carers) and will: • Be co-created, kept up-to-date and monitored by the individual and appropriate professional(s); • Include a carer’s assessment where appropriate; • Be available in the format suited to the individual, with the relevant sections shared amongst those involved in delivery of their care; • Include sources of further information to help patient’s decision-making and choice about treatment and self-care.”

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Clinicians in particular said that integrated IT systems are essential in order to facilitate this type of joint working and recognise that this will present a significant practical challenge

Our information and communications core standard says that: “With the individual’s consent, relevant information will be visible to health and care professionals involved in providing care. This should be available electronically and in hard copy.”

This was also linked to a need for a more transparent and accountable system whereby records and information are shared between clinicians and their patients more easily

The Information and Communications standard specifies that: “Any previous or planned contact with a healthcare professional should be visible to all relevant community health and care providers, in particular, when a patient is admitted or discharged from hospital. This should ensure that care providers are aware of any planned or outstanding activities required for the individual.”

Access was also a raised as a major area of weakness at the moment, particularly the ease with which a patient can get an appointment or speak to a healthcare professional. This is seen as a major factor in why a patient may choose to visit A&E even though a visit to their GP or other out-of-hospital service may be more appropriate. We agree that better access to primary and community care is a priority for OOH improvement. This is embedded as a core standard and also forms an important element in the emerging borough strategies.

The access, convenience and responsiveness standard specifies that “Out-of-hospital care operates as a seven day a week service. Community health and care services will be accessible, understandable, effective and tailored to meet local needs. Service access arrangements will include face-to-face, telephone, email, SMS texting and video consultation”. Overall, these comments were shared with the Out-of-Hospital Care Working Group and our Clinical Commissioning Group (CCG) Chairs to inform the development of the Out-of-Hospital care standards.

Acute hospital care: urgent and emergency care, maternity and paediatrics Attendees discussed the criteria and ranked them in order of importance. In general, clinical quality was considered the most important criteria for evaluating options for change by both patient and public representatives and clinicians.

This feedback was shared with our Clinical Board and Programme Board and was used to inform the selection of criteria.

A small proportion of attendees also suggested some new criteria.

Additional criteria suggested have been reviewed, and where appropriate, included in the evaluation process.

23 March event Specific examples of how the feedback from the event has been used are in the table below: WHAT DELEGATES SAID: WHAT WE DID: Local out-of-hospital plans presented by Clinical Commissioning Groups (CCGs) chairs (morning session only) Delegates felt that, in general, the out-of-hospital strategies are logical and sensible

Clinical Commissioning Groups recognise the need to continue actively engaging their local populations to continue to build understanding of their strategies and ensure they work for all patients

Changes must reflect improved care not just cost reduction

The new out-of-hospital standards outline how improved access, convenience and

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responsiveness, better coordination of care and improved patient experiences are key priorities for out of hospital transformation.

Adequate resourcing will need to be in place to ensure success

We agree and are planning for additional investment for out- of-hospital care services. Recognising the general pressure on healthcare funding, existing services will also need to demonstrate that they are cost effective as well as clinically effective

Integration of health and social services will be critical in achieving high quality long-term care

A combined health and social care approach absolutely offers the greatest potential for improving clinical results and patient experience. Each Clinical Commissioning Group will continue to work closely with partners in social care to jointly plan and deliver improvements. The out-of-hospital standards specify that pooled funding and resources between health and social care will be included in commissioning plans to ensure that efficient, cost effective and integrated services are provided.

Patients should be able to see a noticeable improvement in their care after changes have taken place

The out-of-hospital standards set ambitious targets for improved healthcare and patients should both feel the effect of these raised aspirations and feel empowered to let us know if they feel they are not being met. To this end, the standards specify that patients will also be offered greater opportunity to take control of their own care through better, more accessible information and education and more active involvement in their own care-planning together with their local community health and care services.

IT systems that are comprehensive, up-to-date and accessible by all relevant health professionals will be critical to improve coordination of care

One of the new out-of-hospital standards is about improved information and communication. The standards specify that with an individual’s consent, relevant parts of their health and social care record will be shared between care providers. Monitoring will identify any changing needs so that care plans can be reviewed and updated by agreement. By 2015, all patients will have access to their own health records.

You want to be closely involved in the process to develop local improvement plans, especially to understand what changes mean for you at a local level

Clinical Commissioning Group Chairs have stated their intention to continue to work with patients and healthcare professionals on their strategies and ensure that all views are considered.

Developing options for change Delegates broadly agreed with the process, the content shared so far and the approach There was a lot of information presented and more time was needed to reflect on it

The presentation slides used at the event were loaded onto the programme website and paper copies were posted to delegates who requested

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these. The programme email address and free phone number were also shared in case delegates had specific questions to raise after the event.

You were concerned that the options analysis was largely driven by travel times and that it should also take into account access more generally as well as the financial case. Clinicians in particular thought that there should be a greater focus on the clinical case for change rather than the transport implications.

The options analysis was driven by a number of factors with the Case for Change being the starting point. The options development process focussed on; • ensuring high quality care • access to services • the timescales and financial impact of each

option • patient volumes • the effect on the clinical workforce • the fact that some services rely on others and

require clinical support • minimising disruption to existing services, • geographic distribution of major hospitals to

minimise the impact of changes on local borough residents.

Taking on board this feedback, we have looked at the way we describe the options development process to ensure that in future we make it clear to patients that all of the above factors are part of that process.

Having said that, you were also keen to understand more of the detail and background data with regard to travel time analysis

Additional detail and background data was made available at the subsequent engagement event on 15 May 2012. In addition, an interactive map is being developed for the programme website which will allow patients and the public to enter their postcode and view exactly how proposed changes will affect travel times.

The population density and the number of tourists and workers should be considered, especially with the regard to sites nearer to central London

Clinical leaders have considered these factors as part of the process of evaluating options for change.

You wanted to understand the impact of the programme beyond North West London and also to understand the impact of other programmes on Shaping a healthier future

We are ensuring that we provide clear information about the impact of other programmes on Shaping a healthier future and how proposed changes will impact on neighbouring boroughs.

15 May event

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NHS NWL Reconfiguration Programme Pre-consultation responses Specific examples of how the feedback from the event has been used are in the table below: WHAT DELEGATES SAID: WHAT WE DID: Developing options for change Delegates accepted and understood the challenges being faced by the health service Delegates were concerned that the proposals are driven by the need to make cuts in services

These proposals are being driven by the need to improve the quality of healthcare across North West London.

Delegates were concerned that Urgent Care Centres (UCCs) will not be able to offer the full range of emergency services that should be provided at a hospital site. Using the example of Ealing Hospital, where A&E admissions have not reduced since its UCC was set up, delegates said that UCCs should not be seen as a simple replacement of an A&E

The range of services offered at UCCs means that patients will continue to go there for around 75% of the services they currently access at an A&E (outpatients, diagnostics and urgent care centre). As currently happens, if a patient presents to a UCC with a condition that cannot be treated on the site they will be transferred to the appropriate care facility. For example, if they have a serious eye injury they may need to be referred to a specialist Eye Hospital.

Delegates highlighted the importance of overcoming the equalities challenges of the proposals. This means making sure that the options do not disproportionately impact on patients from poorer, more deprived and BME backgrounds and older people. In particular delegates highlighted specific areas of NW London such as Harlesden, Southall and Ealing that need to be closely considered.

We agree that this is vital - tackling health inequalities (for example reducing variations in life expectancy across boroughs) is one of the core goals set out in the proposals. An Equalities Impact Assessment has been commissioned and is due to report in mid June.

Patient pathways Delegates liked some aspects of the stories and what they might mean for patient care in the future • The patient stories have a clear vision in theory but

delegates wanted more detail on how they would work in practice

• Delegates liked some aspects of the stories and what they might mean for patient care in the future

• It is difficult to use representative patient stories given the range of different services with different standards and in some places the ‘future’ situation is already happening, or the ‘current’ scenario would not occur

• Delegates think that the patient stories describing major injury, planned care and an asthma attack are the most feasible. The future scenarios describing care for someone with a mental health issue and for elderly confusion were highlighted as being the most difficult to achieve due to the need

Patient pathways will be used throughout the formal consultation period as a key way to communicate the vision for how health services could work in the future. Feedback received from delegates about the patient pathways is being considered as we prepare our consultation document and other materials to be used during the formal consultation period.

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to join up primary care with community, mental health and social care services

• Delegates think that it will be vital to improve the capacity, resources and knowledge of community services and community based professionals in order to make the pathways work

• In particular if GPs are to be the key link in this, access to GPs needs to be improved, as well as more training and up-skilling of community resources such as community nurses. This has funding implications and delegates were concerned about where the funding for this would come from

• There is a need to improve communication in the health service for these patient stories to work in the future as they rely on good joint working

• Delegates want to see more focus on the holistic nature of health conditions. For example, more explanation about the links between health and other services such as social services, the Local Authority, housing etc.

• Delegates highlighted a number of other scenarios that they wanted to see included in future patient stories such as paediatrics, maternity, outbreak/pandemics, learning disability, drink-related disorders, diabetes, home care etc. Attendees at the event also wanted to understand the patient experience when there are co-morbidities.

• Delegates wanted to see more detail about the facts and figures of current patient experience such as the percentages of current patients experiencing the system as described, and who would be affected in the future. Also, more data about the cost savings as a result of these changes.

• Delegates suggested that patients should be involved in producing the pathways and these should be formalised so that patients and clinicians are aware of them.

Consultation plan Principles and approach: • Delegates want the consultation approach to be

focussed on listening to all parts of the community and involve patients upfront, for example in developing the consultation questions and designing other materials. This should be wider than just consultation with the Programme’s

The plans for consultation are being shared in detail with PPAG to help inform the development of; the consultation document, a timetable of events across NW London, the programme website and other materials. In addition to this, 8 focus groups are being held

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Patient and Public Advisory Group (PPAG) • Key messages about the case for change and the

motivation behind the programme should be strengthened and simplified

• Delegates reinforced the consultation aims as being important, such as the need for plain English, an Easy Read version of the consultation document, use of different languages for different community groups.

prior to consultation, one in each borough. These will include participants from harder to reach groups, faith groups, young people, protected groups, those with particular health needs and those in more deprived areas. We are working on ensuring our messages are clear and strongly agree that we will need to use plain English and provide alternative formats of the consultation document when requested.

Methods used during consultation: • The spread of channels and approaches for the

consultation felt fairly comprehensive to delegates • A number of different routes of accessing patient

and public views were highlighted by including GP practice meetings, supermarket, schools/colleges, Twitter and Facebook, outpatient clinics, children’s centres, youth parliaments, colleges, local festivals, pensioners forums, faith groups, charity organisations for particular groups (e.g. homelessness, drugs, alcohol), young mothers groups, pharmacies, carers groups, housing associations

• You suggested the use of key roles in the community to act as champions and advocates for the consultation process, such as GPs and pharmacists, community group leaders, community ambassadors and culturally recognised leaders

• Another key role is frontline NHS staff being involved in the consultation to give the ‘insider’ view on the proposals

• Delegates liked the plan to have road shows, and wanted more local meetings as well as larger public meetings specifically focussed on options 5, 6 and 7

• You wanted the consultation to use social media and technology creatively, for example an interactive aspect to the website as well as an introductory video that local groups and charities could show their members and users to encourage responses, or a ‘viral’ video for the internet.

We are considering all feedback received from the event about consultation methods as we prepare our detailed plans. In particular, we are investigating suggested venues for consultation events and reviewing community groups that were recommended to be involved. The programme will soon launch a comprehensive website which will include an interactive map which allows people to enter their postcode and view exactly how proposed changes will affect travel times. There will also be videos available on the site which clearly explain the Case for Change and the vision for healthcare in the future.

Ensuring the consultation is wide ranging: • You want to see a robust consultation process that

ensures good representation across the general public and ‘hard to reach’ groups

• There should be specific and extra consideration of the equalities impact of the changes, especially in

A key part of the consultation will be engaging and involving ‘hard to reach’ groups or individuals from within the 8 boroughs on their views of any potential changes to NHS services within NW London.

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relation to deprived parts of different boroughs and those that already find it difficult to access services

• You wanted to see more public, patient and voluntary sector involvement in the delivery of consultation activities and in developing materials and making decisions, in particular BME groups, faith groups and young people, who may be under-represented in the consultation responses

• Delegates suggested greater and more random sampling of the public’s views on the proposals

• The consultation also needs to involve the Royal Colleges and explore the views of the teaching hospitals.

This work will link closely with the PPAG and existing networks and stakeholders to ensure that the consultation is as inclusive as possible and achieves involvement from traditionally under-represented groups and communities.

Information to be included as part of consultation: • Some of you felt the decision making process used

to get to the medium list was unclear and you wanted more information about how future decisions will be made. In particular, you wanted to understand how results will be analysed given the different responses from people in different parts of NW London, as well as how the consultation responses affect the final decision by the JCPCT

• The JCPCT will make the final decisions – what if they do not like the result of the public consultation?

• You wanted to have a greater understanding of how needs and incidence of disease across the boroughs link to the level and location of where services are or should be through, for example, population and needs maps

• You would like more analysis and explanation of what services will be needed in the community after changes are made and how to ensure they are adequately resourced and trained. Detailed business plans and cost analysis would be helpful

• Delegates wanted to have a clearer picture of the amount of consultation already undertaken and planned to be carried out

• Delegates wanted to hear more about the role of the focus groups and how they fit in with consultation responses

• You wanted more information about how each local area will be specifically affected by the proposals, and even having localised equalities Impact Assessments.

As we prepare materials for consultation, we are reviewing all requests for additional information and any areas where delegates have suggested our messages could be made clearer.

Page 23 of 41


APPENDIX 2 Multilateral events Programme/Provider/CCG Multi-lateral Meetings – 3 rounds Meetings are conducted between:

o Provider Chief exec (or deputy) o NWL Exec o CCG Chair o Provider Medical director(s) o NWL Programme Medical Director

Round 1 Round 2 Scope: Options Development Process: Clinical vision and acute standards Service delivery models & service

interdependencies

Scope: Consultation Options: Proposed approach to Long/Medium/Short

list development

Provider Date Provider Date West Middlesex Imperial Chelsea & Westminster Royal Brompton Ealing Northwest London Hospitals

14 Feb 2012 14 Feb 2012 13 Feb 2012 13 Mar 2012 7 Mar 2012 -

West Middlesex Imperial Chelsea & Westminster Royal Brompton Ealing Northwest London Hospitals

- 3 April 2012 3 April 2012 - 5 April 2012 2 April 2012

Round 3

Scope: Options short listing: Financial modelling Short list

Provider Date

West Middlesex Hillingdon

1 May 1 May

Page 24 of 41


APPENDIX 3 Ongoing OSC / JHOSC/ Council engagement 25 May 2012 The following engagement log outlines all stakeholder engagement to date (19 April 2012) with OSCs, Council Leaders, Council Officers and Cabinet Members for each of the eight North West London boroughs (Harrow, Hillingdon, Hounslow, Ealing, Brent, Hammersmith and Fulham, Kensington and Chelsea, and Westminster). Details of all interaction with OSCs are grouped by borough and include: * Meeting purpose * Key attendees * Details of relevant correspondence * Other interaction e.g. Media It should be noted that alongside the engagement with individual boroughs listed below the following meetings have taken place to date: • 16 January – informal briefing for OSC chairs and officers hosted by programme • 29 February - informal briefing for OSC chairs and officers hosted by programme • 4 April – First meeting of shadow JHOSC attended by programme • 1 May – Second meeting of shadow JHOSC postponed due to pre-election period • 17 May – Second meeting of shadow JHOSC attended by programme NB. There is in some cases a gap in meetings attendance during the latter half of April – this was due to the pre-election period. Borough Type of engagement /

meetings/events attended Correspondence Other interaction

with programme (media interviews)

Brent OSC • 16/01/12 – OSC chair

attended first NHS NWL briefing session re programme and formation of JHOSC

• 06/02/12 – Brent OSC:

attended by Rob Larkman to discuss programme

• 29/02/12 – Vice Chair

attended second briefing session (scrutiny officer also attended)

• 27/03/12 – Health

Partnerships OSC. Attended by Marcel Berenblut, Rob Larkman

OSC • 06/12/11 – To: Chair/officer

– letter sent re: JOSC creation

• 01/02/12 – To: Chair/officer -

HOSC briefing paper, newsletter, CFC hard copy/email

• 17/02/12 – To: Chair/officer

– letter sent re: JOSC creation, second briefing session

• 29/02/12 – To: Chair – email

invitation to 23 March engagement event

Page 25 of 41


Cabinet Member • 23/03/12 – Brent Cab Mbr

for health attended engagement event

• 05/03/12 – To: Chair/officer – letter sent re legal case for JOSC, briefing session slides


– second newsletter

• 26/03/12 – To: Chair/officer – letter re: NCAT review

• 02/04/12 – To: JHOSC

nominees and officers – background briefing for first shadow JHOSC mtg

• 27/04/12 – email invitation to

15 May engagement event • 15/05/12 - To: Chair/officer

– third newsletter Council leader • 6/12/11 - cc'd into OSC intro

letter, JOSC creation • 30/01/12 - Update letter from

sub-cluster CEO, invite to 15 Feb engagement event

• 01/02/12 - Newsletter, cover

letter, CFC hard copy

• 29/02/12 – email invitation to 23 March engagement event

• 5/3/12 - cc'd into OSC briefing following NHS NWL session with OSC chairs and officers (29/02/012)

• 21/03/12 – Second

newsletter

• 27/04/12 – email invitation to 15 May engagement event

• 15/05/12 – third newsletter Council officers (executive) • 01/02/12 – stakeholder

newsletter, cover letter, CFC hard copy

Page 26 of 41


• 21/03/12 – Second

newsletter


• 15/05/12 - third newsletter

Cabinet member • 30/01/12 - Update letter from


• 01/02/12 – Stakeholder

newsletter with link to CFC cover letter


23 March engagement event

• 21/03/12 – Second newsletter


• 15/05/12 – third newsletter

Ealing OSC • 16/01/12 – Chair attended

first OSC briefing session re programme and formation of JHOSC (scrutiny officer also attended)

• 29/02/12 – Chair attended

second briefing session (scrutiny officer also attended)

• 08/03/12 – Ealing Adult

Health and Social Care OSC. Attended by Duncan Stroud, Susan Labrooy, Jenny Durrant, Jo Murfitt

• 23/03/12 – Chair, vice-chair

and officer attended engagement event










– letter sent re legal case for JOSC, briefing session

Council Leader • 10/02/12 – Cllr

Julian Bell was quoted in Ealing Gazette in MS interview story - "This is the first public statement by an NHS official that actually begins to come clean on the secret plans the Tory-led government has to close hospitals and accident and emergency wards in North West London..."

Page 27 of 41


Council leader • 23/02/12 – Cllr Bell on

panel at West London Citizens meeting re: changes to health services in Ealing

slides

• 21/03/12 – To: Chair/officer – second newsletter


– letter re: NCAT review • 30/3/12 – To: Chair/officer –

response re: JHOSC formation and support

• 30/3/12 – To: Chair – letter re: Northwick Park extra funding

• 02/04/12 – To: JHOSC nominees and officers – background briefing for first shadow JHOSC mtg


• 15/05/12 - To: Chair/officer – third newsletter

Council leader • 6/12/11 - cc'd into OSC intro

letter • 30/01/12 - Update letter from

sub-cluster CEO, invite to 15/02 event





• 21/03/12 – Second

newsletter



Page 28 of 41


Council officers (executive) • 01/02/12 – stakeholder



• 21/03/12 – Second

newsletter





• 01/02/12 – stakeholder







Hammersmith & Fulham

OSC • 16/01/12 – Scrutiny officer

attended first OSC briefing session re programme and formation of JHOSC

• 22/02/12 - HOSC meeting –

Attended by Jeff Zitron, Dr Mark Spencer, Dr Tim Spicer, Tim Tebbs, Andrew Pike. Discussed programme.

• 29/02/12 – Scrutiny officer

attended second briefing session








invitation to 23 March

Council leader • 10/02/12 – Cllr

Greenhalgh quoted in K&C Chronicle "Over a long period of time we have already seen the downgrading of Charing Cross by stealth without any meaningful consultation or vision. Now is the time for clarity on what

Page 29 of 41


• 17/04/12 – HOSC meeting - Attended by Jeff Zitron, Dr Mark Spencer, Dr Tim Spicer, Tim Tebbs, Andrew Pike. Discussed programme.

Council leader • 16/01/12 – Cllr Greenhalgh

met with Sub-cluster CEO Sarah Whiting

• 14/05/12 – Programme briefing for tri-borough leaders

engagement event • 05/03/12 – To: Chair/officer

– letter sent re legal case for JOSC, briefing session slides





15 May engagement event • 02/04/12 – To: JHOSC


• 15/05/12 - third newsletter Council leader • 6/12/11 - cc'd into OSC intro











newsletter, cover letter, CFC

the plans are for the future of hospital services."

• 30/03/12 – Cllr Greenhalgh quoted in Evening Standard, “The piecemeal dismantling of hospital services is set to continue across west London without long-term vision and site strategy for specialist services being in place. For years I have warned that Charing Cross Hospital was being downgraded and facing closure by stealth. Removing all A&E services in my borough makes no sense when Hammersmith and Fulham is set for dramatic growth in its three ‘Opportunity Areas’ at Earls Court, White City and Park Royal.

• 13/04/12 – Cllr Greenhalgh quoted in H&F, K&C and Westminster Chronicles – exact quote that ran in ES 30/3 (above)

Page 30 of 41


hard copy


• 21/03/12 – Second

newsletter












Harrow OSC • 16/01/12 – Vice Chair

attended first OSC briefing session re programme and formation of JHOSC (scrutiny officer also attended)



• 07/02/12 – Harrow OSC –

Attended by Daniel Elkeles, Marcel Berenblut. Discussed creation of JOSC, programme, ICP.








invitation to 23 March

OSC • 19/4/12 – OSC

meeting held and not attended by the programme as the focus was on the FBC for NWLHT/ EHT merger and Harrow OSC did not request a programme update or report.

Page 31 of 41


DE requested they form a JOSC.

• 13/03/12 - Health and

Social Care sub-committee OSC – MEETING CANCELLED and moved to 19 April

• 23/03/12 – Officer attended

engagement event

• 19/04/12- Health and Social Care sub-committee OSC –No attendance (13 March meeting rearranged to 19 April)

Council leader • Meets Rob Larkman /

Borough Director regularly

Cabinet member • Meets with borough director

regularly

engagement event • 05/03/12 – To: Chair/officer





• 02/04/12 – To: JHOSC



15 May engagement event • 15/05/12 - third newsletter Council leader • 6/12/11 - cc'd into OSC intro







• 21/03/12 – Second

newsletter


• 15/05/12 - third newsletter Council officers (executive) • 01/02/12 – stakeholder

Page 32 of 41




• 21/03/12 – Second

newsletter


• 15/05/12 - third newsletter Cabinet member • 30/01/12 - Update letter from









Hillingdon OSC • 16/01/12 – Chair of External

Services OSC and Chair of Social services OSC attended first OSC briefing session re programme and formation of JHOSC

• 29/02/12 – Chair of External

services OSC attended second briefing session

• 15/02/12 – Cllr White

(External OSC) attended 15 Feb engagement event

• 28/03/12 – External

Services Scrutiny


(both OSCs) – letter sent re: JOSC creation







Page 33 of 41


Committee OSC. Attended by Duncan Stroud, Sharon Daye, Ian Goodman, Paul Wood, Mark Spencer






• 02/04/12 – To: JHOSC










• 21/03/12 – Second

newsletter




Page 34 of 41




• 21/03/12 – Second

newsletter • 27/04/12 – email invitation to

15 May engagement event










Hounslow OSC • 16/01/12 – Chair of External

Services OSC and Chair of Social Services OSC attended first OSC briefing session re programme and formation of JHOSC

• 29/02/12 – Chair of External

services OSC attended second briefing session


attended 15 Feb engagement event

• 20/03/12 – OSC. Attended

by Duncan Stroud, Nick Relph

OSC • 06/12/11 – To: Chairs/officer


• 01/02/12 – To: Chairs/officer

- HOSC briefing paper, newsletter, CFC hard copy/email

• 17/02/12 – To: Chairs/officer





Page 35 of 41






• 02/04/12 – To: JHOSC



15 May engagement event


Council leader • 6/12/11 - cc'd into OSC intro







• 21/03/12 – Second

newsletter





Page 36 of 41















Kensington & Chelsea

OSC • 16/01/12 – Chair attended

first OSC briefing session re programme and formation of JHOSC



• 14/03/12 – Health,

Environmental Health, Adult Social Care Scrutiny Committee OSC. Attended by Andrew Pike, Sarah Whiting, Frankie Lynch, Mark Sweeney, Aumran Tahir

• 23/03/12 – OSC members










Page 37 of 41


health attended engagement event

Leader • 14/05/12 – Programme

briefing for tri-borough leaders





• 02/04/12 – To: JHOSC



• 15/05/12 - third newsletter Council leader • 6/12/11 - cc'd into OSC intro











newsletter, cover letter, CFC

Page 38 of 41


hard copy


• 21/03/12 – Second

newsletter











Westminster OSC • 16/01/12 – Scrutiny officer

attended briefing session re programme and formation of JHOSC

• 06/02/12 – Westminster

OSC: Chair raised concerns re JOSC creation – would prefer a tri-borough OSC. Programme attendance by Dr Mark Spencer, Karen Broughton, Westminster Borough Director, Dr Melanie Smith, Andrew Pike


attended second briefing









Page 39 of 41


session • 15/02/12 – Scrutiny officer

attended 15 Feb engagement event

Leader • 14/05/12 – Programme

briefing for tri-borough leaders

• 05/03/12 – To: Chair/officer – letter sent re legal case for JOSC, briefing session slides




• 30/3/12 – To: Chair/officer –

response re: JHOSC formation and support

• 02/04/12 – To: JHOSC


• 3/4/12 – To: Chair – letter

addressing concerns re: HOSC engagement, patient flow data, site visits









• 21/03/12 – Second

newsletter • 27/04/12 – email invitation to

Page 40 of 41


15 May engagement event • 15/05/12 - third newsletter Council officers (executive) • 01/02/12 – stakeholder



• 21/03/12 – Second

newsletter












Page 41 of 41

Appendix C – Activities undertaken during consultation

Appendix C – Activities undertaken

during consultation


Edition: 1.0

12 February 2012

1

Report: Activities undertaken during consultation

12 November, 2012

The following report outlines key activities undertaken during public consultation (2 July - 8 October, 2012) for the NHS North West London Shaping a Healthier Future Programme (SaHF). These include: document distribution, event delivery and media activities Please note. This is the final draft of the document to be submitted to the 20 November Programme Board and will subsequently be submitted for approval at the 6 December JCPCT meeting

2

Contents

Contents............................................................................................................................................ 2

1. Introduction .................................................................................................................................. 4

1.1 Background ............................................................................................................................. 4

1.2 What we planned to deliver during Consultation ..................................................................... 5

2. Consultation document, supporting materials and distribution ...................................................... 6

2.1 Consultation document ........................................................................................................... 6

2.2 Additional consultation materials produced............................................................................. 7

2.3 Other communication materials used during the consultation ................................................. 8

2.3.2 Website ............................................................................................................................ 9

2.3.3 Press adverts .................................................................................................................. 11

2.3.4 Social media ................................................................................................................... 14

2.4 Media coverage ..................................................................................................................... 14

2.4.1 Press releases ................................................................................................................. 15

2.4.2 Media coverage .............................................................................................................. 16

2.4.3 Key interviews ................................................................................................................ 17

2.4.4 Letters to editors ............................................................................................................ 18

2.5 Distribution of consultation materials .................................................................................... 18

2.5.1 Distribution summary for individual copies of the consultation document ...................... 18

2.5.2 Distribution summary of bulk consultation materials ...................................................... 19

3. Engagement activities during consultation ................................................................................... 20

3.1 Roadshows ............................................................................................................................ 20

3.2 Focus groups ......................................................................................................................... 21

3.3 Hospital events ...................................................................................................................... 21

3.4 Events and meetings.............................................................................................................. 22

3.5 Key stakeholders met during consultation (HOSCs, JHOSC, PPAG and MPs) ........................... 22

3.6 Engagement with hard to reach (h2r) communities and ‘protected’ groups ........................... 25

3.6.1 Our approach in detail .................................................................................................... 25

3.6.2 Highlights of our engagement......................................................................................... 27

3.6.3 Summary - Key learnings ................................................................................................ 29

3.7 Provider trusts & other third party engagement .................................................................... 29

3.7.1 Key highlights in provider trust engagement ................................................................... 30

4. Engagement in boroughs ............................................................................................................. 31

4.1 Brent ..................................................................................................................................... 32

4.2. Ealing.................................................................................................................................... 34

4.3. Hammersmith & Fulham ....................................................................................................... 36

4.4 Harrow .................................................................................................................................. 38

3

4.5 Hillingdon .............................................................................................................................. 40

4.6 Hounslow .............................................................................................................................. 42

4.7 Kensington & Chelsea ............................................................................................................ 44

4.8 Westminster .......................................................................................................................... 46

4.9 Neighbouring boroughs: Camden, Richmond and Wandsworth ............................................. 48

5. Consultation response unit (CRU) ................................................................................................ 50

5.1 Overview of CRU activity ....................................................................................................... 51

5.2 Key themes ............................................................................................................................ 52

6. Appendix ..................................................................................................................................... 54

4

1. Introduction

Public consultation for the NHS North West (NW) London Shaping a Healthier Future (SaHF) Programme began on 2 July and closed on 8 October. At its meeting on 25 June, the Joint Committee of Primary Care Trusts (JCPCT) was informed of the purpose of consultation Note. This paper can be found at: http://www.healthiernorthwestlondon.nhs.uk/sites/default/files/documents/03purposeofconsultationv3.pdf) The purpose of this paper is to describe how the consultation was carried out in order for the JCPCT to be satisfied that it was delivered appropriately.

1.1 Background The Pre-Consultation Business Case (PCBC) described both:

The stakeholder activity that had taken place – with evidence of the correspondence and discussions that took place with over a thousand clinicians, patients and members of the public from around the area (PCBC Volume 07 / Appendix B); and

The communications plan for consultation (PCBC Volume 05). The JCPCT agreed (25 June, 2012) to put into the public domain all relevant material to enable the public to provide properly informed responses, by publishing materials via the web-site www.healthiernorthwestlondon.nhs.uk; setting up a freephone telephone number for the programme; making hard copies available in public places such as libraries and on request; and using public meetings and other events to put information in the public domain.

(Note. The PCBC can be accessed at http://www.healthiernorthwestlondon.nhs.uk/document-downloads?term=127) Overall, during the consultation the programme:

Attended over 200 meetings and met over 5,000 people through roadshows, hospital site events, hard to reach engagement and other events such as; public debates.

Advertised and inserted the summary leaflet consultation document in newspapers in NW London (that have a circulation of 412,886) during the first two weeks of August. Then with additional circulation in total we distributed 555,298 summary leaflets

Recorded over 16,000 visits to the website

Attracted over 17,000 responses on the paper or online consultation response form, and tens of thousands of other responses in letters, comments, petitions and other formats

Midway through the consultation the Consultation Institute was asked to independently review the progress of the programme and make recommendations (http://www.consultationinstitute.org/) to improve the consultation as necessary. The Institute assessed the activities and efforts made and subsequently made a number of recommendations which have been addressed by the programme. The programme believes a certificate of compliance will be forthcoming from the Consultation Institute in late November.

http://www.healthiernorthwestlondon.nhs.uk/sites/default/files/documents/03purposeofconsultationv3.pdf

http://www.healthiernorthwestlondon.nhs.uk/sites/default/files/documents/03purposeofconsultationv3.pdf

http://www.healthiernorthwestlondon.nhs.uk/

http://www.healthiernorthwestlondon.nhs.uk/document-downloads?term=127

http://www.healthiernorthwestlondon.nhs.uk/document-downloads?term=127

http://www.consultationinstitute.org/

5

1.2 What we planned to deliver during Consultation The Joint Health Overview and Scrutiny Committee (JHOSC) considered a draft plan for the consultation in June, 2012. This continued to be developed and discussed both in the programme team and at subsequent JHOSC meetings. Alongside this the communications plan was also shared with the Public and Patient Advisory Group (PPAG) twice (both at May and June meetings) to incorporate feedback. The plan was also shared with the JCPCT. The plan has been delivered in full with additional activities included during consultation to accommodate different challenges and opportunities that arose during the consultation (see table 1.2.1).

What the plan proposed What we delivered

General publicity: paid advertising in local media, posters displayed across NW London, postcards available widely, a social media campaign, as well as publicity via NHS organisations and established stakeholder channels such as LINks and local voluntary networks

As described

Materials distribution: distribution across NW London and neighbouring boroughs of the consultation document, summary leaflet version and other relevant materials such as; borough sheets

As described

Public meetings: any invitation to attend a public meeting to be considered and, within reason, accepted

As described

Roadshows: Two road shows to be held in each NW London borough; one road show in Camden, Richmond and Wandsworth

As described

Focus groups: Eight focus groups being held pre-consultation (one in each borough); Eleven focus groups being held towards the end of consultation (including the three focus groups for three neighbouring boroughs).

As described

GP events As described Staff events As described

1:1 meetings with key stakeholders As described

Comprehensive website As described Press releases and interviews As described

Telephone and freepost response mechanisms As described

Additional to plan What we delivered

Consultation document: Alternative formats to be produced on demand. To include translations, easyread, Braille, and audio. This was changed to print multiple copies and languages as a matter of course

As described

Special focus groups: For those with physical disabilities, mothers with children under two years and, young people 16-18 years

As described

Public debate meetings: Attended and/or organised public debate meetings offering the public a chance to question the SaHF programme team. Included debate meetings in Ealing, H&F and Westminster

As described

Table 1.2.1: Key activities that were outlined in the consultation communications plan prior to consultation start and those that were added during consultation

6

2. Consultation document, supporting materials and distribution

A key part of the consultation in ensuring that public and other stakeholders were aware and informed of the proposals were the consultation document and supporting materials that were shared. Details of these materials are outlined in the following sections. Note. Please see the www.healthiernorthwestlondon.nhs.uk for all documents discussed in this section.

2.1 Consultation document

The consultation document was developed with input from the SaHF Programme Board and Clinical Board including GPs representing the eight NW London Clinical Commissioning Groups (CCGs) and all provider NHS Trusts. The JHOSC and NW London Patient and Public Advisory Group (PPAG) reviewed the document and their feedback was considered and actioned appropriately. The document and plans for the consultation were then signed off by the JCPCT and NHS London. The consultation document was also reviewed and approved by the Plain English Campaign to ensure that it was easily understandable by as many people as possible and, as a result of this, was awarded the Crystal Mark. Note. The response form was developed and tested independently by Ipsos MORI. The consultation document was available online from 2 July and was on the same day sent to key stakeholders via email and hard copy format (see section 2.5 for details). The full print run of 100,000 consultation documents and associated response forms and freepost envelopes were available from 11 July 2012 (section 2.5.2 for a list of those who were sent documents proactively). The consultation document was also available both online in PDF format and in hard copy, printed format on request. Enclosed within the hard copy consultation document was the response form and freepost envelope. A fully online version of the response form was also available on a special section of the programme website hosted by Ipsos MORI (Further details are as below). The consultation document and response form were produced in:

Braille

Large print

Easy read

Audio In addition to the facility on the website that could translate all documents into one of 65 languages, the consultation document was also translated and produced in nine different languages:

Arabic

Bengali

Hindi

Polish

Punjabi Somali

Swahili

Tamil

Urdu

http://www.healthiernorthwestlondon.nhs.uk/

7

A summary version of the consultation document was produced to provide a short overview of the proposals to a much wider audience and to steer them towards the website, the full consultation document, and response form. The summary document was available in large print, easy read format, and in 15 languages:

Arabic

Bengali

Farsi

French

Gujarati

Hindi

Mandarin

Pashto

Polish Punjabi

Somali

Swahili

Tamil

Tigrinya

Urdu. The summary document was available on request, online on the SaHF website and at consultation events from 24 July, 2012. A wider distribution occurred during the first two weeks of August with an insertion into twelve local papers (reaching approximately 412,000 readers).

2.2 Additional consultation materials produced In addition to the consultation document and summary, a range of additional materials were produced to further publicise and provide information about the consultation. Below we outline the documents which were available on the website. Printed copies were taken to public meetings and events

Frequently asked questions during the consultation were compiled, distributed at events and made available online

Standard slide deck outlining consultation background and proposals was used at events, and made available online

8

Exhibition boards that summarised key sections of the consultation document were used at public events such as roadshows

Two sets of borough-based factsheets were produced for each borough o The first set of factsheets summarised how the different options proposed would

affect that borough. The second set was produced to provide information specifically on the out of hospital proposals for each borough

o The second set of factsheets were provided in response to the SaHF team becoming aware that at many events and meetings, a large number of people were only aware of the changes being proposed to their local hospital

Local hospital factsheet provided information on what services would be available under the definition of a ‘local hospital’ as proposed by the programme. These were distributed at meetings and events

Postcards and posters were distributed across NW London, for example at roadshows, stakeholder meetings and public events

To make information more accessible, three videos were produced. These were: o The case for change o Out of hospital care o End of consultation

After a number of public events, a mythbuster factsheet was produced to address common misconceptions about the programme.

2.3 Other communication materials used during the consultation In addition, to the materials produced for consultation, other materials were produced such as: newsletters and adverts in the press that were sent to stakeholders and a website by which stakeholders could learn more about the proposals to gain access to information. For example, an infographic on the website allowed users to calculate travel times to and from hospitals. These tools are discussed in detail below.

9

2.3.1 Newsletters Consultation newsletters were produced and sent to stakeholders regularly to provide updates on the consultation programme. The newsletters also provided website links to consultation materials as well as information on how to get in touch with questions and/or request further information. Newsletters were also sent to members of the public who had contacted the programme, patient groups, pre-consultation event attendees, elected officials and NHS NW London staff. Individually tailored letters based on similar material were sent to elected officials (e.g. MPs, Assembly Members) instead of the newsletter. In total, three newsletters were distributed during the consultation period (out of a total six produced to date). In summary the consultation newsletters covered the following: 2 July, Newsletter

Detailed aim of the consultation and associated timescales. Introduced readers to the consultation website, encouraged them to read the consultation document, and provided a link to the response form. Information was provided on the roadshow events and on how to get involved. The newsletter encouraged those receiving it to forward it on to any other individuals or groups in NW London.

26 September, Newsletter

Provided an update on the consultation, highlighting the upcoming debates and other events taking place. It also included a reminder on the upcoming end of consultation and encouraged people to send in their responses.

9 October, Newsletter

Informed stakeholders that the consultation was closed, explained how the results were being analysed and explained what the next steps in the process would be.

2.3.2 Website

The dedicated ‘Shaping a healthier future’ website was launched on 2 July, 2012 hosted at the following address: www.healthiernorthwestlondon.co.uk The website aimed to provide up-to-date information on the consultation including events, the consultation document (and alternative formats) along with additional useful materials. Specifically the website made available:

A full explanation of the proposals and their potential impact on patients and public

A link to the full downloadable consultation document

A link to the online response form (hosted by independent analysis organization Ipsos MORI)

All contact details for the consultation team including how to request hard copy materials, ask questions and provide feedback

A detailed events calendar outlining all consultation activity including roadshows and meetings

A regularly updated news page Glossary of terms to help ensure NHS language was accessible

http://www.healthiernorthwestlondon.co.uk/

10

A documents library including meeting papers, the full PCBC, the case for change document, various formats of the consultation document and other information about the programme

Information about the programme leaders, NHS NW London and the JCPCT A Google translate function so that individual pages could be translated into 65 languages

A font size increase tool for those with sight impairments The website was developed with input from the PPAG as well as an expert web design agency to ensure it was easy to navigate and met disability and discrimination act requirements. Throughout the consultation, the website continued to be updated and improved with key additions including:

The introduction of an interactive travel infographic tool which allowed users to calculate travel times to and from hospital sites. Specifically, they were able to enter their postcode and see how they might be affected by the proposals in terms of distances and estimated journey times to local health services, at each site, under each option.

Borough-specific web pages which were added to the site with factsheets and information relevant to each individual borough.

On the 9 October (the morning after consultation closed) the website was amended to highlight the close of consultation and provide more information on what happens next in the coming weeks. Over the consultation period over 16,000 people visited the website. Specific statistics are as below:

Total website visits: 24,405

Unique visitors: 16,591

Total page views: 79,049

Average page views per visit: 3.24

Average time on site: 3minutes 37seconds As indicated in figure 2.3.2.1 below, the majority of people (68%) visited the website once. Of those returning to the website, 22% of people visited between 2 and 5 times.

Figure 2.3.2.1: Visitors to the website during consultation Figure 2.3.2.2 below shows how people arrived at the website. 14.5% of people came to the website directed from a search engine and 43% directly entered the website address. Of those who came via a search engine, the most popular search terms were ‘healthier north west London’ and ‘shaping a healthier future’ demonstrating that nearly 58% of people visiting the site were already familiar with the name of the programme from other sources. The remaining 42% were referred from another website. The top five other website referrers to the SAHF website were: northwestlondon.nhs.uk, Ealing Council, 38degrees, the NHS NW London intranet and Hammersmith & Fulham council.

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Figure 2.3.2.2: How visitors were directed to the SaHF consultation website The top five most popular pages on the website, by percentage of page views, were:

Home page: 27%

Document downloads: 10.7%

Have your say: 8%

Consultation document: 7.7%

Events: 7% The bounce rate, that is the percentage of visitors who left after viewing only the page they arrived on, was 35%. A large number of people arrived at the home page which included a link to the response form hosted on the Ipsos MORI site. There were 8,648 downloads from the document library on the website by 6,152 visitors. In addition, 446 visitors used the Google translate function to view the website in a different language.

2.3.3 Press adverts

Four types of press advertisements were placed during the consultation. These are discussed below but were: generic adverts, roadshow adverts, public meeting adverts and a letter from clinicians to the public. Roadshow adverts Ahead of each public roadshow, a half page advert was placed in the relevant local paper to raise awareness and encourage attendance. Details can be seen in table 2.3.3.1 below and figure 2.3.3.1 shows example adverts.

Roadshow adverts - (half page adverts)

No. of adverts

Brent & Kilburn Times 4 Ham & High 2 Harrow Time 4 Wandsworth Guardian 2 Richmond &Twickenham Times 2 Ealing Gazette 4 Hounslow Chronicle 3 Uxbridge Gazette 2 Hammersmith & Fulham Chronicle 4 Kensington & Chelsea Chronicle 4 Westminster Chronicle 4

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Roadshow adverts - (half page adverts)

No. of adverts

Harrow Observer 4 Wembley Observer 4 The Brent Magazine 1 Harrow People 1 Around Ealing 1 Westminster 1

Table 2.3.3.1: Newspapers in NW London in which adverts for roadshow events were placed

Figure 2.3.3.1: Examples of adverts for roadshow events placed in NW London newspapers Public meeting adverts Ahead of both public meetings arranged by NHS NW London, quarter page adverts were placed in the local papers to raise awareness and encourage attendance. Details can be seen in table 2.3.3.2 and figure 2.3.3.2

Public debate adverts - 1/4 page ads

Hammersmith &Fulham Chronicle Ealing Gazette

Table 2.3.3.2: Newspapers in NW London in which public debate adverts were placed Figure 2.3.3.2: Example advert placed in newspapers to promote public debate events

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Letter from NW London clinicians Following the widespread public debate provoked by the consultation exercise, a letter from leading clinicians in NW London was published, outlining the reasons for change, the proposals and also setting out the answers to common misconceptions, based on the ‘mythbuster’ document referred to above. This ran as a double-page advert once in each of the local NW London newspapers in the week commencing 10 September. Details of which newspapers this advert was published in can be seen in table 2.3.3.3 below and figure 2.3.3.3 highlights the advert itself.

Clinical letter advert

Ham & High Brent & Kilburn Times Harrow Times Wandsworth Guardian Richmond & Twickenham Times Ealing Gazette Hounslow Chronicle Uxbridge Gazette Hammersmith & Fulham Chronicle Kensington &Chelsea Chronicle Westminster Chronicle Harrow Observer Wembley Observer

Table 2.3.3.3: Newspapers in NW London where the letter from clinicians was published

Figure 2.3.3.3: Double-page advert that was published mid-consultation with a letter from clinicians and mythbusters

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Generic advert An advert was placed in three publications which were not borough or event specific but were to raise awareness of the consultation. The newspapers in which these were placed can be seen in table 2.3.3.4 along with an example of the advert in figure 2.3.3.4.

Newspaper

Advert Placed

Hillingdon People 1 Hounslow Matters 1 Royal Borough News 1

Table 2.3.3.4: Newspapers in which the generic advert to raise awareness of the ongoing consultation was placed Figure 2.3.3.4: An example of the generic advert that was placed in newspapers by which to raise awareness of the ongoing consultation

2.3.4 Social media

The SaHF programe used two Twitter accounts to publicise the consultation and roadshow events to Twitter users who followed these accounts. These were the corporate Twitter account for NHS NW London (@NHS_NWLondon) and a dedicated one for SAHF (@SAHFinNWL). A total of over 70 tweets were sent out from these two accounts, promoting the road show events, publicising the consultation in general, and responding to individual queries that were made using Twitter. We encouraged local authorities, community groups and hospitals to 'retweet' our tweets on the roadshows to their followers, thus significantly extending the visibility of our tweets on the consultation, and encouraging people to follow our accounts directly in order to receive our tweets on the consultation. In addition, many community leaders including politicians, activists and clinicians used Twitter to publicise events and their views on the SAHF programme. Having our own Twitter accounts enabled us to contribute to the debate in this forum, and monitor and respond to comments made on Twitter about the proposals.

2.4 Media coverage Over the consultation period the programme ensured presence in the media through a number of press releases and was featured in the press, on television, radio and online.

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2.4.1 Press releases

All press releases went to regional and local papers and other key media outlets and were posted on the SAHF website. 23 press releases were sent at key milestones in the programme and to local papers ahead of each borough roadshow. Full details can be seen in table 2.4.1.1 below.

Title of press release

Date

Subject

Shaping a healthier future launched 2 July Launch of consultation Hillingdon residents to have their say on the future of NHS services

12 July 14 July roadshow

Hounslow residents to have their say on the future of NHS services


Ealing residents to have their say on the future of NHS services


Westminster residents to have their say on the future of NHS services


Hammersmith & Fulham residents to have their say on the future of NHS services


Harrow residents to have their say on NHS services 23 July 26 July roadshow

Kensington & Chelsea residents to have their say on the future of NHS services


Brent residents to have their say on the future of NHS services


Hounslow residents to have their say on the future of NHS services

14 Aug 18 August roadshow

Harrow residents to have their say on the future of NHS services.

20 Aug 25 August roadshow

‘Shaping a healthier future’ public consultation on proposals to improve healthcare for two million people in NW London

24 Aug Half way through - this is what we’ve done so far

Hillingdon residents to have their say on the future of NHS services

28 Aug 5 September roadshow

Camden residents to have their say on the future of NHS services


Roadshow for Wandsworth residents on the future of NHS services


Ealing residents to have their say on the future of NHS services

5 Sept 11 September roadshow

Kensington & Chelsea residents to have their say on the future of NHS services


Hammersmith & Fulham residents to have their say on the future of NHS services


Two public debates planned on the future of NHS services

20 Sept Public debates

Brent residents to have their say on the future of NHS services


Last chance to have your say on NHS changes in your area

25 Sept 2 weeks until the close of consultation

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Title of press release

Date

Subject

Westminster residents to have their say on the future of NHS services

4 Oct 6 October roadshow

Shaping a healthier future consultation ends 9 Oct Close of consultation – what happens next

Table 2.4.1.1: Press releases by the SaHF programme to promote awareness of the consultation

2.4.2 Media coverage

Throughout the course of the consultation we are aware of at least 411 articles which have discussed the SaHF consultation programme. Exact details of these articles by publication per media type can be seen in table 2.4.2.1. The appendix shows a list of number of articles per newspaper.

Media type

No. of articles

Print 261

National print 23

Local print 225 Trade print 13

Broadcast 11

TV 3

Radio 1 Broadcasters websites 7

Online 139

Stakeholder sites 40 National papers 19

Local papers 66

Trade 14 Table 2.4.2.1: 411 articles discussing the SaHF programme during the consultation period grouped by media type Over the course of the consultation the programme plotted the number of website visitors and programme communication either though contact with the Consultation Response Unit (CRU) or mentions in the media. Figure 2.4.1 below indicates high levels of activity throughout the consultation but particular peaks of activity at consultation launch, and towards the end of consultation. This was in line with press adverts published to ensure the public knew of consultation launch and were reminded of the consultation close drawing near.

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Figure 2.4.1: Media, website and CRU activity plotted on a week by week basis during consultation to monitor usage and communication in NW London regarding the consultation

2.4.3 Key interviews

The consultation was launched to the media at a press briefing on Monday 2 July. Dr Mark Spencer, Dr Tim Spicer and Daniel Elkeles represented the programme. Journalists from the local, regional, national and trade press were invited to attend and the following journalists and publications were present:

Max Walters – Brent & Kilburn Times (on behalf of Tara Brady)

Greg Burns - Fulham & Hammersmith Chronicle and also on behalf of Ealing Gazette, Kensington & Chelsea Chronicle, Westminster Chronicle, Harrow Observer, Hounslow Chronicle

Karl Mercer - BBC London Farah Abdulkadir - Kasmo newspaper (Somali), covering Brent, Harrow, Camden and Barnet

Along with ongoing media relations work to provide reactive statements and comments, a number of proactive and reactive interviews were arranged with media throughout the consultation period. These were with the:

Evening Standard - Dr Mark Spencer was interviewed by Ross Lydall, Chief News reporter, on 10 July. The subsequent article appeared on Wednesday 11 July

Ealing Gazette - Dr Mark Spencer was interviewed by the Ealing Gazette on 18 July

Nursing Standard - Jonathan Webster, Director of Nursing (NHS NW London) on 16 August

BBC London - Dr Mark Spencer was interviewed on 12 September for a piece that was broadcast on 13 September

Financial Times - Dr Mark Spencer was interviewed by Sarah Neville but an article was never published

Inside Out - the ‘SaHF’ team contacted the journalists working on Inside Out after learning that they had been filming at public events. This led to on-air and off-air interviews with Dr Mark Spencer as well as an interview with Dr Mike Anderson

BBC London Radio - Dr Mark Spencer, 25 October

Nursing Standard - Jonathan Webster, Director of Nursing for NHS NW London - 16 August

Consultation

launch

Nearing consultation

close

Letter from clinicians advert in press

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Brent & Kilburn Times – Dr Mark Spencer with Max Walters

Fulham & Hammersmith chronicle

2.4.4 Letters to editors

A number of reactive letters in response to published articles were sent to editors by the programme. In addition, at key milestones in the programme, proactive letters to editors were sent from the programme to all local papers in NW London. Details of these proactive letters can be seen in table 2.4.3.1 below.

Date Audience Subject

27th July All NWL Launch of consultation letter from CCG Chairs encouraging participation

13th July All NWL Letter from Dr Spencer to confirm that all responses will be considered

10th October All NWL Close of consultation and what happens next Table 2.4.3.1: Proactive letters that were sent to editors for publication at key milestone points in the consultation

2.5 Distribution of consultation materials In the initial outline consultation plan developed in early 2012, the programme set out the draft plan for distribution of materials across NW London. The plan of work completed, as laid out in this report, was refined and reviewed following consultation with the PPAG, JHOSC and, other key stakeholder groups as indicated. Subsequent to this, from consultation launch onwards, a robust programme of materials distribution was put in place to raise awareness of the consultation across NW London.

2.5.1 Distribution summary for individual copies of the consultation document

The full consultation document and response form were sent to:

The Chairs of each of the eight CCGs in NW London

The Chairs of each of the neighbouring borough CCGs in Richmond, Wandsworth and Camden

The NHS NW London Non-Executive Board Directors (NEDs)

Members of the JCPCT

All members and officers of the NW London JHOSC

Other HOSC officers in NW London that were not covered by the JHOSC

NHS NW London senior management team and programme leads

Chief Executives, chairs, medical directors and NEDs of each of the NHS provider trusts in NW London

Representative members of the NW London PPAG and Local Involvement Networks (LINks) for both NW London and neighbouring boroughs

Council leaders, Chief executives and cabinet members of each of the councils in NW London and the neighbouring boroughs; Richmond, Wandsworth and Camden

Members of Parliament (MPs) in NW London and neighbouring boroughs

Assembly Members and senior GLA (Greater London Assembly) officers including those covering London-wide, NW London and neighbouring boroughs

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NW London borough directors

NHS London senior management

Communications leads in each of the NW London NHS provider trusts

Chief executives of neighbouring PCTs and NHS provider trusts

Chairs and communications leads for neighbouring PCTs

2.5.2 Distribution summary of bulk consultation materials

The following materials were distributed:

Consultation documents

Generic postcards

Generic posters

Tailored postcards advertising relevant roadshow dates

Tailored posters advertising relevant roadshow dates and summary leaflets These materials were distributed to:

All 413 GP practices in NW London

118 libraries in NW London, Richmond, Wandsworth and Camden

All eight LINks offices in NW London

All 18 key hospital sites in NW London (including specialist and community locations)

The communications lead at each of the eight Councils in NW London as well as Richmond and Camden (Wandsworth Council requested that all materials be distributed directly to libraries only)

83 GP practices in Wandsworth and Richmond were sent:

Consultation documents

Tailored postcards

Posters advertising relevant roadshow dates

Summary leaflet

38 GP practices in Camden were sent: Consultation documents

Generic postcards

Generic posters

Summary leaflets

3 LINks offices in Wandsworth, Richmond and Camden were sent:

Consultation documents Tailored postcards

Posters advertising relevant roadshow dates

6 neighbouring hospital sites in the boroughs of Wandsworth, Richmond and Camden were sent: Consultation documents

Generic postcards

Generic posters Consultation documents were also sent to London Ambulance Service (LAS) and each of the PCT offices in NW London as well as Richmond, Wandsworth and Camden. Consultation documents and generic posters were sent to 507 pharmacies in NW London.

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In many cases, such as local libraries and GP surgeries, we monitored supplies of consultation documents at these locations and, where necessary, replenished these during the consultation period. This was conducted by both proactive phone calls and through requests coming into the programme office and CRU. Other distribution of materials A range of distribution options and costs were considered in order to reach the majority of households across the boroughs. Following extensive discussion with the JHOSC, PPAG and at programme meetings, it was decided that it would be most cost effective to print more than 400,000 copies of the summary leaflet and distribute these as an ‘insert’ into local newspapers in all NW London boroughs as well as Richmond, Wandsworth and Camden (as noted above). In addition, materials were also distributed to individuals and organisations upon request via the CRU (see section 5 for more details). Consultation documents and other materials were also handed out in large quantities at consultation events including roadshows, meetings and public debates. Total number of materials distributed:

5,533 posters

199,010 postcards

555,298 summary leaflets

73,086 consultation documents

3. Engagement activities during consultation To ensure an effective public consultation which spanned NW London and surrounding boroughs we ensured a number of activities. Below we outline the key meetings/events delivered and discuss in addition to this the hard to reach engagement and the activities of provider trusts, councils and other organisations. In parallel there was extensive activity through distribution of consultation materials and press activity.

3.1 Roadshows

During the consultation period 19 roadshow events were held across the NW London area. Two were held in each of the eight NW London boroughs and one in each of Camden, Richmond and Wandsworth. For each borough one roadshow was held on a Saturday and one on a weekday in different parts of the borough. In most cases, the Saturday roadshows ran from 10-4pm and the weekday ones from 2-8pm.

The roadshows were static in design in that they were held in buildings such as church halls, town halls and community centres. The venues were selected on the basis that they should be easily accessible and in areas of high footfall. Each roadshow consisted of exhibition boards which showed people the SaHF journey from the case for change to the three options proposed in the consultation document. Clinicians were available most of the time to respond to any questions people might have. Other staff were available throughout each event to help as needed.

At each roadshow there was a minimum of one, but in most cases two, question time sessions where attendees were able to ask clinicians from the SaHF programme any questions they had. This more formal Q&A format allowed people to question clinicians in public and listen to questions from others.

Laptops were also available at each roadshow event so that attendees were able to complete the consultation questionnaire at the venue if they preferred.

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Table 3.1.1 shows attendance at roadshows. Collectively, data indicates that over 800 people attended. The full list of roadshow dates and venues can be found in the appendix (meetings calendar).

Borough Attendance Round 1 Attendance Round 2

Hillingdon 40 47

Hounslow 11 20

Ealing 80 63

Westminster 12 23

Harrow 23 40

H&F 200 55

K&C 15 60

Brent 35 35

Camden N/A 11

Richmond N/A 17

Wandsworth N/A 15

Total Attendees 416 386

Table 3.1.1: Number of individuals that attended the roadshow events during consultation

3.2 Focus groups

14 focus group sessions were held during consultation. There was one session in each of the eight NW London boroughs, one in each of Camden, Richmond and Wandsworth and the remaining three sessions were targeted at specific groups where it was felt there was a gap in engagement during the consultation. Specifically, these were for: mothers of children under two years, individuals with physical disabilities and, for young people aged 16-18 years.

Each workshop had between 15-20 participants and lasted two and a half hours. Participants were recruited by a market research agency to a specific quota sample. The samples were based on groups identified by the Equalities Impact Assessment (EqIA) as being most likely to be affected by any changes to health services. Additionally, recruiting people in this way allowed the opportunity to engage with people who may not have attended a roadshow or other event hence, were thus able to hear more about the consultation. Focus groups were an integral part of our engagement plan ensuring we heard a broad range of opinion.

The structure of the workshops and sampling profile can be found in the appendix.

3.3 Hospital events 14 staff events were held by the programme on hospital sites (in addition the hospitals themselves arranged events, see section 3.8 for further details). At least one event was held at each district general hospital. Additional ones were held upon request.

The design of these meetings was flexible, responding to the advice of people at each site. Mostly they consisted of a series of one hour meetings held over the course of a day to ensure that as many staff as possible were able to attend. Note. One ‘event’ means multiple one hour meetings, typically three.

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Each one hour meeting started with a presentation by a clinician from the SaHF programme and was then opened up into a Q&A session.

Table 3.3.1 shows the attendance at each of these events (Full details can be seen in the appendix, meetings calendar). Data collectively indicates ~700 people were met and does not include the extended engagement activity provider trusts carried out on their own. It is important to note that staff were encouraged to spread awareness of the proposals in their teams.

Hospital Numbers

Chelsea and Westminster (Event 1) 126 Chelsea and Westminster (Event 2) 32 Charing Cross 53 Hammersmith 59 Ealing 70 West Middlesex 68 St Marys 67 Western Eye 43 Hillingdon 100 Mount Vernon 17 Central Middlesex 27 Northwick Park 37 Total 699

Table 3.3.1: Numbers of individuals that attended the hospital sites events run during consultation

3.4 Events and meetings Our full extensive engagement meetings calendar can be viewed in the appendix. The programme organised and/or participated in over 200 meetings. As well as the roadshows, hospital site events and focus groups there was additional engagement with local community, hard to reach and protected groups, which are outlined in section 3.6. We ensured a robust approach to our meetings and events ensuring that we engaged with a wide range of stakeholders and in a number of ways such as: through holding public debate meetings and attending community events and fairs.

3.5 Key stakeholders met during consultation (HOSCs, JHOSC, PPAG and MPs) During the consultation we met with key stakeholders to keep them informed and to seek their ongoing views. This included meeting the:

Public and Patient Advisory Group (PPAG): Patient representatives that were able to ensure views of the public were heard

Joint Overview & Scrutiny Committee (JHOSC): This scrutiny body was able to comment on the proposals across NW London

MPs and Assembly Members (AMs): Who were able to represent views of their constituents

HOSCs: Scrutiny bodies at a borough level who were able to comment on the proposals Full details of the meetings can be seen in the appendix, however we highlight some of these below. PPAG engagement The SaHF programme has continually engaged the PPAG to ensure the views of patients are heard. Prior to the consultation PPAG offered feedback on the pre-consultation process. Their letter is at:

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http://www.healthiernorthwestlondon.nhs.uk/sites/default/files/documents/120622%20Letter%20to%20Mr%20J%20Zitron%20from%20PPAG%20%28LINKs%20chairs%29_2.pdf During the consultation period the programme met with PPAG three times. Timely views were sought and updates provided at consultation launch, mid-consultation and, as consultation was nearing its close (table 3.5.1).

Meeting date What was discussed

10 July

Consultation launch

Website launch Upcoming events

Materials distribution

5 September

Consultation update

Ongoing materials distribution Events progress

Hard to reach engagement

JHOSC update

3 October

Consultation closing No. of responses received thus far

JHOSC update

Post-consultation plans Table 3.5.1: Details of PPAG meeting dates and what was discussed at each meeting JHOSC, HOSC and council engagement Formal engagement between the programme and the eleven local authorities impacted (eight in NW London and three neighbouring boroughs) was via the JHOSC and individual OSCs. On 2 July, a letter was sent to all council leaders, cc’d to council chief executives, letting them know that consultation had started, the different ways in which they could learn more and how they could get further information. A briefing meeting with Anne Rainsberry (NHS NW London, Chief Executive) was also offered. On 11 July, all HOSC chairs and officers (including those on JHOSC), council leaders, chief executives and cabinet members for health and social care were sent a printed copy of the consultation document with a covering letter providing more information. On 12 July, a copy of the consultation document and covering note was sent to council communications leads. On 8 September a letter was sent to all council leaders and HOSC chairs, members and officers letting them know that a double page advert about the programme would be appearing in their local paper, that the consultation was to close on 8 October and that more information could be found online. During the consultation period the programme met with the JHOSC five times focussing on key aspects of the programme in order to enable the JHOSC to develop a full response to the consultation. Note. A focussed additional short meeting also took place with some of the JHOSC members during consultation to discuss financial aspects of the programme.

http://www.healthiernorthwestlondon.nhs.uk/sites/default/files/documents/120622%20Letter%20to%20Mr%20J%20Zitron%20from%20PPAG%20%28LINKs%20chairs%29_2.pdf

http://www.healthiernorthwestlondon.nhs.uk/sites/default/files/documents/120622%20Letter%20to%20Mr%20J%20Zitron%20from%20PPAG%20%28LINKs%20chairs%29_2.pdf

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Additional to the JHOSC meetings we regularly attended individual borough HOSC meetings to provide updates on consultation progress. Details of what was discussed at the five key JHOSC meetings can be seen in table 3.5.2 below.

Meeting Date What was discussed

12 July

Consultation launch General programme update

Communications update Consultation update and documents

2 August

Risks and underlying assumptions

Analysing the risks associated with the Implementation of 'SaHF' proposals

Underlying assumptions behind 'SaHF' proposals Demographics drivers for the 'SaHF’ case for change

Consultation progress update

4 September

Clinical case for change

Core change proposals and centralisation of care Proposals on urgent care centres and accident and

emergency provision Impact on local populations

Out of hospital care - community and service preparedness

Levels of professional support for proposals

6 September

Transport and Equalities Methodology

Impact on local populations

Proposed mitigations

26 September Consideration of JHOSC

Committee draft report

Q&A Table 3.5.2: Details of JHOSC meeting dates and what was discussed at each meeting

MP engagement

The MPs who represent the constituencies within the eleven boroughs impacted by the proposed changes were engaged as part of the consultation process. MPs were offered multiple opportunities to engage with the programme and were invited to contact us as needed. For example:

On 29 June a letter was sent to all MPs in NW London informing them of consultation launch on 2 July along with the ways in which they could get further information. A briefing meeting with Anne Rainsberry was also offered.

On Friday 6 July an email was sent to all NW London MPs offering them the opportunity to

meet with Anne Rainsberry on 11 July at the Houses of Parliament.

On 11 July, all NW London MPs were sent a printed copy of the consultation document along with a covering letter letting them know how to access further information.

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On 8 September a letter was sent to all MPs letting them know that a double page advert on the consultation would be appearing in their local paper, that consultation was to close on 8 October and that more information could be found on our website.

The Mayor and the London Assembly While the Mayor and the London Assembly have no formal jurisdiction over NHS services, they do have a formal role around public health and equalities and as a key local stakeholder and influencer, they were thus kept informed on programme progress.

On 11 July, all London Assembly members, the Mayor of London and his senior officers were sent a printed copy of the consultation document along with a covering letter letting them know where they could find out more and offering them a meeting with Anne Rainsberry.

On 8 September a letter was sent to all Assembly Members letting them know that a double

page advert would be appearing in their local paper about the programme which would include a letter signed by clinicians, that consultation was to come to an end on 8 October and that more information could be found on our website.

Dr Mark Spencer (Programme Medical Director) met with Murad Qureshi (London Assembly member on 5 September to discuss the SaHF proposals. Further, Anne Rainsberry and Mark Spencer (Programme Medical Director) also recently met (30 October) with the London Mayor to provide an update on the SAHF consultation and discuss next steps post-consultation.

3.6 Engagement with hard to reach (h2r) communities and ‘protected’ groups A key facet of the engagement programme was to ensure engagement with residents/other stakeholders from hard to reach (h2r) communities and protected groups who may have specific healthcare needs and views on the SaHF proposals. Particularly this was important in cases where opinions would not be heard unless deliberative pro-active engagement was undertaken. To support development of an engagement programme for the consultation we started to engage h2r communities and protected groups pre-consultation. For example; we identified in NW London Hammersmith & Fulham has the largest Polish community in the UK, that Ealing has the largest Somali community in the UK and Black & Minority Ethnic (BME) groups in Brent now make up the majority of the population1. Work enabled us to understand the wide range of groups that would form part of our engagement and alert groups early that we would engage them during consultation. The work has focused on developing links and engaging groups through discussing the Case for Change and in particular, the proposals. Views have been incorporated into the consultation response feedback. In the following section we discuss our approach to this work.

3.6.1 Our approach in detail The engagement work used a number of methods to ensure coverage of as many communities and organisations across NW London. This included:

1 54.7%, 2001 Census figures

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Working through existing voluntary and community networks within the area, such as the voluntary services councils, health & wellbeing boards, refugee/ BME groups and others

Developing links with individual groups and communities interested and possibly affected by the proposed changes such as; the stroke association, sickle cell society, integrated neurological services and other long-term condition groups.

Using local authority forums and existing meetings to engage groups and communities

Commissioning organisations and groups to help us engage with their groups and service users such as; the learning disabilities, BME and elderly communities.

Through our engagement we found that most groups wanted information and discussion on the proposals. Key to this was ensuring that we provided information/useful materials that could be taken away and reviewed to enable an informed view on the proposals. Mid-consultation review & gap analysis Mid-consultation we carried out a review to ensure that our engagement programme with h2r and protected groups was inclusive of the groups and communities identified in the EqIA. Note: The EqIA work was independently carried out through Mott McDonald. During this review we carried out a robust gap analysis in conjunction with third party OPM. Table 3.6.1.1 below highlights the high level groups that were identified as gaps in the engagement programme and subsequently the individual groups that were to be engaged.

Group identified as potential gap in engagement

Individual groups identified to fill gap

Children (under 16) Queen’s Park Rangers football club

Fulham football club - Through community scheme

Young people (16-25 years)

QPR football club - Through community scheme

West London mela - Gunnersbury park

Focus group - Young people (16-18 Years)

Elderly

Ealing senior citizens action group

Brent older people’s forum

K&C older people’s forum

H&F older people’s forum

Disabled people

MENCAP - H&F

Learning disability advocacy project

Note. Also addressed through participant selection in focus groups during consultation

South Asian community Singh sabah temple - Hounslow

Asian women’s resource centre - Brent

Pregnant women and new mothers

West Middlesex maternity liaison services committee

Barham park children’s centre Focus group - Mothers with children <2 Years

Lesbian, Gay, Bisexual and Transgender (LGBT) community

West London LGBT network

Rain trust (HIV Service Users)

Deprived wards within boroughs (high socio-economic deprivation)

Dalgano neighbourhood trust

Southall community alliance

South Acton community forum

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Group identified as potential gap in engagement

Individual groups identified to fill gap

Afghan & Somali communities

K&C Somali network

Community interpreting and access service

Afghan women’s project, Hillingdon

Recent migrants (From post 2004 EU accession states)

The Refugee council (NW London)

Polish homeless community - H&F

Table 3.6.1.1: Organisations identified for engagement during consultation (to ensure gaps

identified in the hard to reach engagement gap analysis were filled)

3.6.2 Highlights of our engagement Overall, through our h2r and protected groups work we engaged with over 2,000 people from over 50 groups and organisations across NW London (see table 3.6.2.1 and the appendix, the consultation meetings calendar). Note: This does not include the engagement outlined earlier in this document nor that undertaken by provider trusts or other organisations such as councils and the community & voluntary sector. In particular, we attracted a considerably large number of attendees at the following meetings/events (>100 attendees):

1. Al manaar islamic centre ~600 attendees 2. West London mela (Gunnersbury Park) ~300 attendees 3. Hounslow singh sabah temple ~300 attendees 4. Ealing senior citizens action group ~120 attendees 5. Kensington & Chelsea older people’s forum ~100 attendees

Lastly, we received over 400 response forms in a variety of community languages other than English. Note: We believe that 193 of these responses were in part due to the fact that we commissioned the Community Interpreting and Access Service (CITAS) to assist in the engagement with North London communities for whom English was a second language. We held a briefing session for 25 multi-lingual staff members to walk them through the consultation document so that they could provide further onward support within communities.

Pan NW London Borough specific

Age concern UK

Community interpreting and advocacy service

Kensington & Chelsea Somali network (Tri-borough)

Migrant and refugees community forum

NW London sickle cell forum

Queens park rangers football club (youth community scheme)

Refugee council

Sickle cell society NW London

The Rain trust HIV service user group

Advocacy project - Westminster

Afghan women’s project - Hillingdon

Al-hasaniya women’s project - North Kensington

Al-manaar islamic community centre -North Kensington

Barham Park children’s centre

Bosnian community association - Brent

Brent Asian women’s resource centre

Brent council partnerships team Brent community and voluntary sector

health forum

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Pan NW London Borough specific

Tri borough BME health forum -Westminster, K&C, H&F

West London mela

West London voluntary sector network

Brent multi faith forum

Brent pensioners forum

Brent voluntary sector forum

Dalgarno neighbourhood trust (health network in deprived area of K&C)

Getting involved event South Acton -Oaktree community centre

Gurdwara singh sabah – Hounslow

Hammersmith & Fulham community and voluntary sector - Fulham

Hammersmith & Fulham local area forum (Shepherd Bush )

Hammersmith & Fulham stroke association

Harlesden area forum

Harrow community and voluntary sector

Harrow refugee week

Hillingdon voluntary sector forum Hillingdon women’s refugee

Homeless broadway project polish community

Integrated neurological services - Richmond

Kensington & Chelsea older people’s forum

Kensington & Chelsea social council health & well being forum

Kilburn & Kensal area forum

Kingsbury & Kenton area forum

Learning disability event - Ealing

Marylebone Bangladeshi society

MENCAP - Hammersmith & Fulham

People in partnership Hillingdon

Refugees in effective action - Hillingdon

Senior citizens action group - Ealing

South Acton community forum

Southall community alliance

Southall trinity church Stable way travellers - Kensington &

Chelsea

Support for living project - Ealing

West London network

Willesden area forum West London lesbian, gay, bisexual and

transsexual (LGBT)

West London network

Willesden area forum

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Table 3.6.2.1: Table of all organisations and groups visited pre- and post- consultation as part of the hard to reach engagement programme (these have been categorised by those that were borough specific versus pan NW London)

3.6.3 Summary - Key learnings

Success of the work to engage h2r and protected groups is due to a number of factors:

1. Engaging through existing voluntary and community established networks worked well avoiding duplication of information and consultation fatigue

2. Ensuring we attended meetings at community organisation locations “we went to them we did not invite them to us” making engagement easier for them

3. Commissioning special interest groups such as; the learning disability community and those that work with the elderly to further engage in a lead role with members of their groups

4. Providing materials and information that could be easily understood which included; translated materials, an easy read summary version of the consultation document and for learning disabilities groups an easy read slide deck

5. Conducting a mid-consultation review of consultation and engagement work in conjunction with the EqIA scoping work to close any perceived gaps in engagement in the last couple of months of consultation

3.7 Provider trusts & other third party engagement We have already outlined in previous sections direct engagement by the programme. Alongside this, it is important to consider that a significant amount of activity was also carried out on our behalf by provider trusts and by councils, community & voluntary sector organisations. Note. As it would be a major undertaking to both capture and document in detail the full extent to which the SaHF programme has been discussed we have summarised our understanding of the engagement entered into by the NW London provider trusts. The programme engaged consistently during consultation with provider trusts through interaction with communications leads, hospital site events, meetings and through interaction with clinicians and other staff who attended our roadshows and programme meetings. Through this interaction we were able to ensure ambassadors of the programme were able to provide onward programme information, key messages and answer questions on the consultation for other staff and public. As the consultation began the programme provided launch information to all provider trusts including the link to the SaHF website. We encouraged all provider trusts to provide a link to the SaHF website and basic background information on their main website and intranet. Further, we encouraged them to provide information in their newsletters and regular communications internally particularly, as a reminder for staff and the public to complete response forms. We have seen provider trusts engage other staff and public in a number of ways including:

Internal meetings incl. management and trust board meetings

Posters/flyers

Newsletters/bulletins/magazines

Website/intranet postings

Other materials; banners, screensavers, t-shirts, slide decks

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Additionally, we observed the majority of borough council and LINks websites such as Kensington & Chelsea, Hammersmith & Fulham and Harrow provide information on their websites on the SaHF consultation. As an example, to appreciate the extent of engagement carried out on behalf of the programme, Hillingdon LINk outlined their engagement in their consultation response. They explained they had:

Engaged with Hillingdon stakeholders including the general public by means of post, email and website information and surveys, public events, workshops, forums, briefings and focus groups. Interacting with organisations such as:

Age UK EMAP Group

Afghan Community Group

Assembly for people with disabilities

Hillingdon association residents associations

Hillingdon citizens advice fair

Mental health forum Mount Vernon hospital

Refugees in effective and active partnership

The Community voice

Tamil Community group

The Hillingdon hospital

Duplicated the display board information available at the SaHF public events within their shop premises, making the consultation document and further information readily available to the general public.

Distributed the consultation document and made it available for download from their website

Displayed the SaHF consultation prominently on the front page of their website. Their website received 300,000 hits during the consultation period

3.7.1 Key highlights in provider trust engagement

The majority of provider trust organisations including; Imperial, Chelsea & Westminster, West Middlesex, Hillingdon, NW London Hospitals in NW London provided information on SaHF on their websites. In addition, many providers including; Imperial, Chelsea & Westminster, West London Mental Health, NW London Hospitals and Central London Community Healthcare discussed SaHF in at least one (if not more) newsletter communications during the consultation period. Through both the website and newsletter-type communications we are confident that we reached a large number of patients, public and clinical staff who use our hospitals. Chelsea & Westminster Hospital activity: Chelsea and Westminster Hospital ran a campaign (‘Safe in our hands’) to encourage Foundation Trust members, local residents and staff to support Option A to designate Chelsea & Westminster as a major hospital with a full A&E service. More than 11,000 people completed a postcard in support of the campaign - of these 11,000 supporters, almost 10,000 gave Chelsea & Westminster consent to complete the ‘official’ Shaping a Healthier Future consultation response form on their behalf. This accounted for roughly two-thirds of all completed consultation response forms.

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In addition, more than 6,500 people completed an online petition in support of the ‘Safe in our hands’ campaign which was organised by Foundation Trust Governors – elected representatives of patients, members of the public and staff. Chelsea and Westminster also generated significant national media coverage of its campaign in support of Option A - including articles in the Daily Telegraph, Mail on Sunday and Evening Standard. Further, examples of promotional material included printed T-shirts, posters, pop-up banners, desktop icons and postcards. Imperial Hospital activity: Imperial held their own staff events such as: open hours during the consultation where they spoke about the proposals as an avenue to inform others. Further, they discussed the consultation regularly in their newsletters placed on their website. North West London Hospitals: NWLH featured a screensaver for the programme for staff in the hospital. They promoted the consultation in their internal staff communications and spoke about it at their internal meetings e.g. board meetings. West Middlesex University Hospital: WMUH shared with us their engagement log of where the programme had either been discussed or was part of a larger meeting agenda. The log contained over 50 meetings throughout the consultation period.

4. Engagement in boroughs As discussed earlier in this document, a large amount of engagement activity was undertaken during the consultation period. In the following sections we outline specific activities in each borough. Please note that this is not additional engagement – it is the previously described engagement repurposed for ease of reference so that readers can understand the efforts made in each borough. Borough sheets can be found in the following order

4.1 Brent 4.2 Ealing 4.3 Harrow 4.4 Hammersmith & Fulham 4.5 Hillingdon 4.6 Hounslow 4.7 Kensington & Chelsea 4.8 Westminster 4.9 Neighbouring boroughs: Camden Richmond and Wandsworth

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4.1 Brent General engagement across NW London including in Brent Throughout the consultation period we conducted a robust engagement programme across NW London. This included attending and organising a series of meetings/events across NW London. Alongside this to ensure increased awareness of the programme there was ongoing press activity, a regularly updated website and, distribution of a wide range of materials. Materials distributed included (refer to section 2.5 for further details):

Consultation document - Distributed to provider trusts organisations, GP practices, libraries, at meetings/events and supplied on request to the programme consultation response unit

Summary consultation document - Distributed as borough newspaper inserts and at meetings/events

Other versions consultation document - Translated, easy read, audio and Braille Local hospital factsheet - Available on SaHF website and distributed at meetings/events

Local borough factsheets - Two for Brent available on the SaHF website and distributed at local borough meetings/events

Newsletters - Three distributed during the consultation: launch, mid and, on close

Mythbusters, posters and postcards In addition to the specific activities summarised below Brent residents were represented by:

Membership of the JHOSC and PPAG

Residents attending 1:1 and public meetings

Involvement on special groups: Three focus groups covered mothers with children less than two years, those with physical disabilities and young people 16-18 years

There were generic press releases sent across NW London:

Consultation launch - 2 July

Last chance to have your say - 28 September

Consultation ends - 9 October Brent borough specific activities

Two focus groups in Brent - Pre and post consultation

Two roadshow events - in Patidar house and Harlesden Methodist church

Hospital site events at Central Middlesex hospital

We also attended area community forums which were council led consultative forums which looked at local issues for residents of a given area. We attended these in:

o Harlesden o Kilburn o Kingsbury o Wembley o Willesden

As part of our hard to reach engagement programme we identified key groups/organisations in each borough that we could engage with to ensure a wide and broad reach. For Brent this included us engaging with the:

o Bosnian Herzegovinian society o Multi-faith forum o Pensioner’s forum o Sickle cell society o Asian women’s resource centre

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o Children’s centre o Community & voluntary sector forum

Additionally, we attended: o Health, overview & scrutiny committee meetings o An all council meeting

A Brent specific press release was sent to local papers ahead of each of the roadshows in the borough and there was regular engagement with local media including Brent & Kilburn Times, Wembley & Willesden Observer and Wembley Matters. There were specific Brent press releases:

Brent roadshow (31 July) - 24 July

Brent roadshow (29 September) - 24 September Adverts were also placed in the press:

Upcoming borough specific roadshows o Brent & Kilburn Times o Wembley Observer o The Brent Magazine

Clinical letter & mythbusters mid-consultation o Brent & Kilburn Times o Wembley Observer

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4.2. Ealing General engagement across NW London including in Ealing Throughout the consultation period we conducted a robust engagement programme across NW London. This included attending and organising a series of meetings/events across NW London. Alongside this to ensure increased awareness of the programme there was ongoing press activity, a regularly updated website and, distribution of a wide range of materials. Materials distributed included (refer to section 2.5 for further details):




Local borough factsheets - Two for Ealing available on the SaHF website and distributed at local borough meetings/events


Mythbusters, posters and postcards In addition to the specific activities summarised below Ealing residents were represented by:







Consultation ends - 9 October Ealing borough specific activities

Two focus groups - Pre and post consultation

Two roadshow events in the Dominion centre and Ealing town hall

Hospital site events at Ealing hospital and the West London mental health trust

We also attended area community forums which were council led consultative forums which looked at local issues for residents of a given area. We attended the:

o West Ealing centre neighbourhood forum

Further, as part of our hard to reach engagement programme we identified key groups/organisations in each borough that we could engage with to ensure a wide and broad reach. For Ealing this included us engaging with the:

o Southall community alliance o West London training & employment network o West London citizens o AgeUK o TreatMeRight learning disabilities o Gunnersbury Park mela

Additionally, we attended and/or organised: o Three GP events

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o Health, overview & scrutiny committee meetings o Ealing public debate o Clinical Commissioning Group (CCG) public engagement event o Health & wellbeing board meeting

An Ealing specific press release was sent to local papers ahead of each of the roadshows in the borough and there was regular engagement with local media including Ealing Gazette There were specific Ealing press releases:

Ealing roadshow (21 July) - 16 July

Ealing roadshow (11 September) - 5 September Adverts were also placed in the press:

Adverts to alert in local borough papers of upcoming borough specific roadshows o Ealing Gazette o Around Ealing

Clinical letter & mythbusters mid-consultation o Ealing Gazette

Public meeting adverts o Ealing Gazette

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4.3. Hammersmith & Fulham General engagement across NW London including in H&F Throughout the consultation period we conducted a robust engagement programme across NW London. This included attending and organising a series of meetings/events across NW London. Alongside this to ensure increased awareness of the programme there was ongoing press activity, a regularly updated website and, distribution of a wide range of materials. Materials distributed included (refer to section 2.5 for further details):




Local borough factsheets - Two for H&F available on the SaHF website and distributed at local borough meetings/events


Mythbusters, posters and postcards In addition to the specific activities summarised below H&F residents were represented by:







Consultation ends - 9 October H&F borough specific activities


Two roadshow events in the town hall and Fulham Broadway methodist church

Hospital site events at Chelsea & Westminster, Charing Cross and Hammersmith hospitals

We also attended area community forums which were council led consultative forums which looked at local issues for residents of a given area. We attended the:

o Hammersmith & Fulham forum

Further, as part of our hard to reach engagement programme we identified key groups/organisations in each borough that we could engage with to ensure a wide and broad reach. For H&F this included us engaging with the:

o QPR community scheme o H&F elders forum o Community, interpreting, translation & access service o Shepherd’s Bush town centre network o Fulham football Club o MENCAP o Homeless Polish community o Stroke association

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Additionally, we attended and/or organised: o All council public meeting o Public debate o Health, overview & scrutiny committee meetings o LINKs hospital working group o Clinical Commissioning Group board meeting (CCG) and CCG members event o Hammersmith diabetes event

A H&F specific press release was sent to local papers ahead of each of the roadshows in the Borough and there was regular engagement with local media including H&F Chronicle. There were specific H&F press releases:

H&F roadshow (28 July) - 23 July H&F roadshow (19 September) - 13 September

Adverts were also placed in the press:

Adverts to alert in local borough papers of upcoming borough specific roadshows o H&F Chronicle

Clinical letter & mythbusters mid-consultation o H&F Chronicle

Public meeting adverts o H&F Chronicle

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4.4 Harrow General engagement across NW London including in Harrow Throughout the consultation period we conducted a robust engagement programme across NW London. This included attending and organising a series of meetings/events across NW London. Alongside this to ensure increased awareness of the programme there was ongoing press activity, a regularly updated website and, distribution of a wide range of materials. Materials distributed included (refer to section 2.5 for further details):



Other versions consultation document - Translated, easy read, audio and Braille

Local hospital factsheet - Available on SaHF website and distributed at meetings/events Local borough factsheets - Two for Harrow available on the SaHF website and distributed at

local borough meetings/events


Mythbusters, posters and postcards In addition to the specific activities summarised below Harrow residents were represented by:







Consultation ends - 9 October Harrow borough specific activities


Two roadshow events at Bernay’s hall and the methodist church

Hospital site events at Northwick Park hospital

Additionally, we attended: o Health, overview & scrutiny committee meetings

A Harrow specific press release was sent to local papers ahead of each of the roadshows in the borough and there was regular engagement with local media including Harrow Times and Harrow Observer. There were specific Harrow press releases:

Harrow roadshow (26 July) - 23 July

Harrow roadshow (25 August) - 20 August Adverts were also placed in the press:

Adverts to alert in local borough papers of upcoming borough specific roadshows

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o Harrow Times o Harrow Observer o Harrow People

Clinical letter & mythbusters mid-consultation o Harrow Times o Harrow Observer

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4.5 Hillingdon General engagement across NW London including in Hillingdon Throughout the consultation period we conducted a robust engagement programme across NW London. This included attending and organising a series of meetings/events across NW London. Alongside this to ensure increased awareness of the programme there was ongoing press activity, a regularly updated website and, distribution of a wide range of materials. Materials distributed included (refer to section 2.5 for further details):




Local borough factsheets - Two for Hillingdon available on the SaHF website and distributed at local borough meetings/events


Mythbusters, posters and postcards In addition to the specific activities summarised below Hillingdon residents were represented by:


Residents attending 1:1 and public meetings Further, we conducted special focus groups which covered mothers with children less than two years, those with physical focus disabilities and young people 16-18 years There were generic press releases sent across NW London:



Consultation ends - 9 October Hillingdon borough specific activities


Two roadshow events in the Methodist church and the Great barn

Hospital site events at Mount Vernon and Hillingdon hospitals

We also attended a Health and wellbeing forum run by the CVS (Community & Voluntary Sector) for its members which focussed on health issues. This was the:

o Hillingdon voluntary sector forum Further, as part of our hard to reach engagement programme we identified key

groups/organisations in each borough that we could engage with to ensure a wide and broad reach. For Hillingdon this included us engaging with the:

o People in partnership o Voluntary sector forum o Older people’s assembly o West London network steering group o Afghan women’s association

Additionally, we attended and/or organised: o Health, overview & scrutiny committee meetings

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o Joint public event with SaHF and Hillingdon council A Hillingdon specific press release was sent to local papers ahead of each of the roadshows in the borough and there was regular engagement with local media including Uxbridge Gazette There were specific Hillingdon press releases:

Hillingdon roadshow (14 July) - 12th July

Hillingdon roadshow (5 September) - 28 August Adverts were also placed in the press:

Adverts to alert in local borough papers of upcoming borough specific roadshows o Uxbridge Gazette

Clinical letter & mythbusters mid-consultation o Uxbridge Gazette

Generic advert o Hillingdon People

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4.6 Hounslow General engagement across NW London including in Hounslow Throughout the consultation period we conducted a robust engagement programme across NW London. This included attending and organising a series of meetings/events across NW London. Alongside this to ensure increased awareness of the programme there was ongoing press activity, a regularly updated website and, distribution of a wide range of materials. Materials distributed included (refer to section 2.5 for further details):




Local borough factsheets - Two for Hounslow available on the SaHF website and distributed at local borough meetings/events


Mythbusters, posters and postcards In addition to the specific activities summarised below Hounslow residents were represented by:







Consultation ends - 9 October Hounslow borough specific activities


Two roadshow events in the Montague hall and Feltham library

Hospital site events at West Middlesex hospital

Further, as part of our hard to reach engagement programme we identified key groups/organisations in each borough that we could engage with to ensure a wide and broad reach. For Hounslow this included us engaging with public at the:

o Gurdwara Singh Sabah Hounslow Additionally, we attended:

o Health, overview & scrutiny committee meetings o Clinical Commissioning Group (CCG) public stakeholder engagement event o Clinical Commissioning Group (CCG)board meeting o Council public community Fair

A Hounslow specific press release was sent to local papers ahead of each of the roadshows in the borough and there was regular engagement with local media including Hounslow Chronicle. There were specific Hounslow press releases:

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Hounslow Roadshow (17 July) - 12 July

Hounslow Roadshow (18 August) - 14 August Adverts were also placed in the press:

Adverts to alert in local borough papers of upcoming borough specific roadshows o Hounslow Chronicle

Clinical letter & mythbusters mid-consultation o Hounslow Chronicle

Generic advert o Hounslow Matters

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4.7 Kensington & Chelsea General engagement across NW London including in K&C Throughout the consultation period we conducted a robust engagement programme across NW London. This included attending and organising a series of meetings/events across NW London. Alongside this to ensure increased awareness of the programme there was ongoing press activity, a regularly updated website and, distribution of a wide range of materials. Materials distributed included (refer to section 2.5 for further details):




Local borough factsheets - Two for K&C available on the SaHF website and distributed at local borough meetings/events


Mythbusters, posters and postcards In addition to the specific activities summarised below K&C residents were represented by:







Consultation ends - 9 October K&C borough specific activities


Two roadshow events in the Unitarian church and then Old town hall

Hospital site events at Imperial, Western Eye, St Mary’s and Royal Brompton hospitals

We also attended a Health and wellbeing forum run by the K&C social council (community & voluntary sector) for its members which focussed on health issues. This was the:

o K&C health & wellbeing voluntary sector forum

Further, as part of our hard to reach engagement programme we identified key groups/organisations in each borough that we could engage with to ensure a wide and broad reach. For Hillingdon this included us engaging with the:

o The rain trust (HIV service Users) o AgeUK o Westway travellers group o K&C LINK elders group o Westminster nurses practice o Advocacy project o Al Mannar Muslim community o Healthworks project

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Additionally, we attended: o Health, overview & scrutiny committee meetings

A K&C specific press release was sent to local papers ahead of each of the roadshows in the borough and there was regular engagement with local media including K&C Chronicle. There were specific K&C press releases:

K&C Roadshow (30 July) - 24 July

K&C Roadshow (15 September) - 12 September Adverts were also placed in the press:

Adverts to alert in local borough papers of upcoming borough specific roadshows o K&C Chronicle

Clinical letter & mythbusters mid-consultation o K&C Chronicle

Generic advert o Royal Borough News

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4.8 Westminster General engagement across NW London including in Westminster Throughout the consultation period we conducted a robust engagement programme across NW London. This included attending and organising a series of meetings/events across NW London. Alongside this to ensure increased awareness of the programme there was ongoing press activity, a regularly updated website and, distribution of a wide range of materials. Materials distributed included (refer to section 2.5 for further details):




Local borough factsheets - Two for Westminster available on the SaHF website and distributed at local borough meetings/events


Mythbusters, posters and postcards In addition to the specific activities summarised below Westminster residents were represented by:


Residents attending 1:1 and public meetings Further, we conducted special focus groups which covered mothers with children less than two years, those with physical focus disabilities and young people 16-18 years There were generic press releases sent across NW London:



Consultation ends - 9 October Westminster borough specific activities


Two roadshow events in the central hall and methodist church

We also attended a council forum chaired by the council. For Hounslow, this was the Maida Vale area forum. Further, we attended the Westminster senior citizen’s forum for members of the public

Further, as part of our hard to reach engagement programme we identified key groups/organisations in each borough that we could engage with to ensure a wide and broad reach. For Westminster this included us engaging with the:

o Bangladeshi society o Learning disability advocacy project

Additionally, we attended and/or organised: o Westminster public debate o Health, overview & scrutiny committee meetings o Clinical Commissioning Group (CCG) board meeting

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A Westminster specific press release was sent to local papers ahead of each of the roadshows in the borough and there was regular engagement with local media including Westminster Chronicle. There were specific Westminster press releases:

Westminster Roadshow (24 July) - 18 July Westminster Roadshow (6 October) - 4 October

Adverts were also placed in the press:

Adverts to alert in local borough papers of upcoming borough specific roadshows o Westminster Chronicle o Westminster

Clinical letter & mythbusters mid-consultation o Westminster Chronicle

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4.9 Neighbouring boroughs: Camden, Richmond and Wandsworth General engagement across NW London including neighbouring boroughs Throughout the consultation period we conducted a robust engagement programme in NW London and in boroughs neighbouring NW London. This included attending and organising a series of meetings/events in Camden, Richmond and Wandsworth. Alongside this to ensure increased awareness of the programme there was ongoing press activity, a regularly updated website and, distribution of a wide range of materials. Materials distributed included (refer to section 2.5 for further details):



Other versions consultation document - Translated, easy read, audio and Braille

Local hospital factsheet - Available on SaHF website and distributed at meetings/events


Mythbusters, posters and postcards Additional, to engagement activities summarised for each borough below we also ensured engagement with:

Key stakeholders - Attendance at five JHOSC and three PPAG meetings along with other 1:1 and public meetings

Special Groups - Three specific focus groups that covered mothers with children less than two years, those with physical disabilities and young people 16-18 years




Consultation ends - 9 October Neighbouring borough specific activities

One roadshow event in each of the neighbouring boroughs which took place in: o Camden Friends house o Richmond Green united reformed church o Wandsworth civic suite

One focus group session in each of the neighbouring boroughs

Further, as part of our hard to reach engagement programme we identified key groups/organisations in each borough that we could engage with to ensure a wide and broad reach. We visited the:

o Integrated neurological services association

Additionally, we attended: o Richmond Health & overview scrutiny committee meetings o Richmond Clinical Commissioning Group (CCG) meetings o Wandsworth CCG board meetings and member-wide forums

Further, specific press releases were sent with details as below:

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Camden A Camden specific press release was sent to local papers ahead of the roadshow in the borough and there was engagement with local media including the Ham & High. Specific press release:

Camden Roadshow (1 September) - 29 August Adverts were also placed in the press:

Adverts to alert in local borough papers of upcoming borough specific roadshows o Ham & High

Clinical letter & mythbusters mid-consultation o Ham & High

Wandsworth A Wandsworth specific press release was sent to local papers ahead of the roadshow in the borough and there was engagement with local media including Wandsworth Guardian. Specific press release:

Wandsworth Roadshow (8 September) - 28 August Adverts were also placed in the press:

Adverts to alert in local borough papers of upcoming borough specific roadshows o Wandsworth Guardian

Clinical letter & mythbusters mid-consultation o Wandsworth Guardian

Richmond Adverts were placed in the press:

Adverts to alert in local borough papers of upcoming borough specific roadshows o Richmond & Twickenham Times

Clinical letter & mythbusters mid-consultation o Richmond & Twickenham Times

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5. Consultation response unit (CRU) The Consultation Response Unit (CRU) was operational for the duration of the formal consultation period. The CRU was established to be the primary contact point for public enquiries relating to the SaHF programme. The CRU was further responsible for ensuring that all requests from members of the public were actioned appropriately, including obtaining specialist information or advice from across the wider programme team as necessary. Queries were received by the CRU in one of four ways:

1. Directly via the 0800 881 5209 phone number 2. Directly via the [email protected] email address 3. Indirectly via the FREEPOST SHAPING HEALTHIER FUTURE CONSULTATION address (which

were in turn scanned, encrypted and emailed to the email address above by Ipsos MORI) 4. Indirectly via enquiries made to an individual member of the wider programme team.

Each new enquiry was individually logged and archived by a CRU Administrator according to a standardised process. Individual enquiries were also differentiated by type at this stage. Separate protocols were then used for progressing enquiries based on their allocated classification. Each class of CRU request (and its subsequent management protocol) can be examined separately: Requests for materials All requests for materials were processed immediately and distributed directly by the CRU team based at 15 Marylebone Road, London. Any large requests (more than 10 items) were ordered and dispatched from our bulk print supplier DST (provided sufficient stock was available, bulk orders were routinely distributed within one working day). Materials distributed by the CRU (and DST) included, but were not limited to:

The Shaping a healthier future consultation document

Translated versions of the Shaping a healthier future consultation document. In addition to English, the consultation document and response form were also available in Punjabi, Urdu, Somali, Hindi, Swahili, Polish, Tamil, Bengali and Arabic. It was further available in Braille, large print or as an audio CD.

The ‘What do you think?’ summary leaflet

A translated version of the summary leaflet. In addition to English, the summary leaflet was also available in Punjabi, Urdu, Somali, Hindi, Swahili, Polish, Tamil, Bengali, Arabic, Gujarati, Farsi, Pashto, French, Mandarin and Tigrinya.

The Pre-Consultation Business Case

Hard copies of miscellaneous other documents available online from the www.healthiernorthwestlondon.co.uk website, for example Borough Factsheets, Out of Hospital Factsheets, Roadshow event Calendars and Mythbusters.

Processing of queries The CRU would seek to remedy any issue raised by a member of the public as soon as possible. However, for instances where specialist expertise or assistance was required, the relevant request was forwarded directly to the relevant member of programme team for resolving. These types of enquiries were generally processed within one working day. If further assistance was required, this was requested from the wider programme team and resolved as quickly as possible. Generally, these types of enquiries were generally processed within one working day.

mailto:[email protected]

http://www.healthiernorthwestlondon.co.uk/

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Issues reported regarding the consultation process Some feedback raised specific issues arising from how the consultation undertaken by NHS NW London was executed. Such issues were subcategorised as being one of five distinct types:

1. Issue with document distribution 2. Issue with roadshow events and/or information about roadshows 3. Technical issue with website, infographic travel tool, online response form, email or phone

number 4. General comment on meaningfulness, resourcing or adequacy of consultation process 5. Issue with response time of CRU in responding to queries

We dealt with each issue individually, responding to peoples concerns and resolving issues where appropriate..... Feedback received on the ‘Shaping a healthier future’ consultation

Many enquiries used the [email protected] email address to provide detailed feedback on the reconfiguration proposals. For enquiries where no specific questions were asked, a standard response thanking the submitter for their comments was sent in reply, and feedback was forwarded on to Ipsos MORI for inclusion in their official submission analysis. These types of enquiries were generally processed within one working day. “Complex” requests

“Complex” requests can involve elements of making comments on the content of the discussion documents, or the consultation process but also ask specific questions that require a bespoke response. These were either answered directly by the CRU or another member of the project team as appropriate. Content was sourced from expertise within the project team and each enquiry was answered as quickly as possible, preferably within 20 working days. Given the complexity and number of queries this timescale was not always achievable and some responses were replied to outside the 20 working days.

Freedom of Information Act requests

Freedom of Information (FOI) Act requests were received directly by the CRU via one of the media outlined above, or alternatively were forwarded by the NHS NW London Cluster FOI Lead. All FOI enquiries identified as relating to the SaHF programme were managed in the same way as “Complex” requests (see above) according to the statutory 20-working day deadline as stated in the FOI Act. As discussed above this deadline was not always able to be met.

5.1 Overview of CRU activity The table and pie graph in figure 5.1.1. below demonstrates total activity (1,438 enquiries) as at 16 October 2012 by borough and by each of the six classes described above:

mailto:[email protected]

52

Figure 5.1.1: The bar chart plots number of queries received by the consultation response unit against individual boroughs. The pie chart indicates the proportion of queries received by type of query

5.2 Key themes A qualitative analysis of the 221 “Complex” requests received by the CRU illustrated the emergence of several recurring lines of enquiry. Such queries were aggregated into ten key themes and each theme alongside example questions is outlined in table 5.2.1.

Key Themes Questions asked through the Consultation Response Unit

Document distribution

How, when and where will we distribute information about the consultation? How often?

How will we make sure we target everyone?

What will we do about hard to reach groups?

Why was there no documentation in GP's surgeries, libraries and council offices as promised? Why was there a delay in distribution of information?

0

50

100

150

200

250

300

350

400

Request for materials

Comments for Ipsos MORI

Complex question

Event information

Issue with consultation process

FOI request

53

Key Themes Questions asked through the Consultation Response Unit

Consultation Methodology

Why were there not more local events to discuss consultation?

Why were roadshow events scheduled to coincide with the Olympics and the summer holidays?

How do healthcare professionals inform patients about the consultation?

Why were different versions (community languages, Braille, easy read etc) of the consultation document not more readily available? Will the consultation be extended?

Are petitions being taken into account? A&E and UCC's What is the difference between A&E and UCC?

What will happen to patients who have to be transferred from UCC's to a major hospital?

Are there lists of conditions that can or cannot be treated? Is there a UCC exclusion list?

Travel Will more bus routes be provided to link major conurbations with new major hospital sites?

Will there be any extra parking provision? How long will it take people to reach hospitals further away by public transport?

How will “blue light” journeys be affected by ambulances having to travel longer distances?

Clinician buy in How many local clinicians support the proposals? How can this be evidenced?

Workforce impact

How many more or less people will it take to staff these new proposals?

Out of Hospital Investment

How much are we going to invest locally?

Will land no longer required be sold off to the private sector?

What will happen to the money raised from land disposal? Where will the new hubs be located?

Specialist Services

How are other specialist services (such as maternity, mental health) being affected by the proposals?

Cost of programme

How much money has been spent on outside agencies? How much has been spent on advertising?

Evidence base Where is the evidence base to support the proposals?

What evidence do we have to show that specialism and centralisation will save lives?

Is this reform simply all about saving money? Will it lead to greater privatisation of the NHS?

Table 5.2.1: Questions asked through the consultation response unit divided by key question themes

54

6. Appendix Number of articles published in newspapers or through other media channels during consultation

Name of outlet No. of articles

BBC Inside Out 1 BBC London News 1

BBC London News, online 6

BBC Radio London 1 BBC Sunday Politics Show 1

Brent & Kilburn Times 20

Brent & Kilburn Times, online 8 Brentford Today, online 1

Brentford TW8, online 1

British Medical Association, online 1

Camden New Journal 1 Chiswick W4, online 1

Daily Mail, online 6

Daily Mirror 1 Daily Telegraph 3

Daily Telegraph, online 1

Ealing and Acton Gazette 24 Ealing Gazette 21

Ealing Gazette, online 10

Ealing Times, online 3 Ealing Today 1

Ealing Today, online 1

Evening Standard 18 Evening Standard, online 3

Financial Times 1

French Tribune 1

Fulham and Hammersmith Chronicle 25 Fulham and Hammersmith Chronicle, online 11

Greenford and Northolt Gazette 17

Guardian 2 Guardian society 1

Guardian, online 4

Ham & High 1 Harrow Observer 17

Harrow Observer, online 5

Harrow Times 1 Harrow Times, online 3

Health Service Journal 8

Health Service Journal, online 10 Hounslow Chronicle 12

iHarrow, online 1

Kensington and Chelsea Chronicle 21

55

Name of outlet No. of articles

ITV, online 1

Kensington and Chelsea Today 1

Kensington and Chelsea Today, online 1 Local Government Chronicle 2

London Guardian, online 2

Londonist 1 Mail on Sunday 6

Morning Star 1

Morning Star, online 1 National Health Executive 1

New Statesman 1

Nursing Standard 1

Observer 1 Planning 1

Private Eye 1

Public Service, online 1 Pulse, online 2

Richmond and Twickenham Times 3

Richmond and Twickenham Times, online 1 Richmond Guardian, online 1

Snipe London, online 2

Shepherds Bush W12, online 1 Socialist Worker, online 5

Sunday Telegraph 1

Sunday Times 1 Independent 1

Independent, online 2

The People 1

This is local London, online 1 Uxbridge and West Drayton Gazette 4

Uxbridge Gazette 4

Uxbridge Gazette, online 2 Wembley and Willesden Observer 5

Wembley Matters 2

Wembley Matters, online 6 West End Extra 1

Westminster Chronicle 22

Westminster Reporter 1 Wood and Vale 3

*coverage on stakeholder websites not included in this table

56

Key meetings and events attended and/or organised by the SaHF programme during consultation

Meeting Category

Meeting Type Meeting Name Borough/ Location Date/ Time

Council HOSC Hounslow HOSC Committee Room 1 Civic Centre Lampton Road, TW3 4DN

02-Jul 7pm

Public Forum Kilburn & Kensal ACF Kensal Rise Primary School Hall, Harvist Rd, Kilburn, NW6

03-Jul 7pm

Hard to Reach

Hard to Reach Healthworks Project Dalgarno Neighbourhood Trust

03-Jul

Clinician Hospital Royal Brompton Hospital Meeting Royal Brompton 04-Jul

Public Forum Hammersmith & Fulham Forum Sir Oswald Foundation 04-Jul 10am

Council HOSC K&C HOSC - Health, Environmental Health and Adult Social Care Scrutiny Committee

K&C, Committee Rm 1, The Town Hall

04-Jul 6.30-8.30pm

Public Forum Wembley ACF

Patidar House, 22 London Road (Off Wembley High Road), Wembley, HA9

04-Jul 7pm

Public Forum Southall Community Alliance Southall Town Hall 04-Jul 7pm

Hard to Reach

Hard to Reach Marylebone Bangladeshi Society 19 Stamford St., London

05-Jul

Public Forum Public meeting on the SAHF programme

Hanwell Methodist Church, Ealing

05-Jul 7pm

Clinician BMA BMA event

British Medical Association, BMA House, Tavistock Square, London, WC1H 9JP - Murrell Barnes Suite

05-Jul 6-9pm

Council HOSC Westminster HOSC - Adult & Health Policy Scrutiny Committee

Westminster, Committee Rooms 5, 6 & 7, 17th Floor, City Hall, Victoria Street, SW1

05-Jul 7pm

Clinician Hospital C&W Hospital Site Event Chelsea & Westminster Hospital

05-Jul

Council JHOSC JHOSC Briefing Westminster 06-Jul 10.30-1pm

Other Local Network

West London Training & Employment Network meeting

Ealing, Hammersmith & West London College, Gliddon Road, Barons Court

06-Jul 1-4pm

Hard to Reach

Hard to Reach Bosnian Herzegovinian Society 108 High Rd, Willesden 09-Jul 7.30pm

Council HOSC Harrow HOSC - Health and Social Care sub-committee

Harrow 09-Jul 7.30pm

Hard to Reach

Hard to Reach Integrated Neurological Services 82 Hampton St, Twickenham

10-Jul 1pm

Clinician CCG Harrow Formal CCG Board Harrow 10-Jul 3.30-5.30pm

Public PPAG PPAG (Patient and Public Advisory West Ealing 10 July 4-6pm

57

Meeting Category


group)

Clinician CCG Hounslow CCG Stakeholder event 4-7pm

The Conference Centre (Civic Centre), Lampton Road, Hounslow, TW3 4DN

10-Jul

Public Forum Willesden ACF College of NWL, Denzil Rd, Willesden, NW10

11-Jul 7pm

Clinician CCG Brent CCG Board Brent 11-Jul 2-5pm

Clinician Hospital Clinical Engagement WLMHT

The Chapel, St Bernard’s Hospital, West London Mental Health Trust, Southall, UB1 3EU

11-Jul 9.30-10.30am

Clinician Hospital Imperial Faculty of Medicine Meeting

Council Room, 58 Princes Gate, S Kensington (off Exhibition Road)

12-Jul 8.30-9.30am

Other Internal C&E Working Group Internal meeting 12-Jul 10-12pm

Clinician Hospital NWLH Open Day NWLH 12 Jul 5.45 - 7.15pm

Council JHOSC First Public JHOSC

The Small Hall, Kensington Town Hall, Hornton Street, London W8 7NX

12-Jul 7-9pm

Public Forum People in Partnership, Hillingdon West Drayton 13-Jul

Public Forum Revd. Mike Bolley - West London Citizens

Holy Trinity Church, Southall

14-Jul

Public Roadshow Hillingdon Roadshow

Hillingdon, Methodist Church Hall, Hayes - 4, Station Road, Hayes, Middlesex UB3 4DA

14-Jul 10-4pm

Public Forum QPR community Scheme QPR Loftus Road 16-Jul

Council HOSC Westminster HOSC visit to St. Charles Centre of H&WB

St Charles 16-Jul 5-6.30pm

Public Forum Kingsbury & Kenton ACF Kingsbury High School, Princes Avenue, Kingsbury, NW9

17-Jul 7-9pm

Public Roadshow Hounslow Roadshow

Hounslow, Montague Hall off Hounslow High Street, Montague Rd, Hounslow, TW3 1LD

17-Jul 2-8pm

Clinician Hospital Charing Cross Hospital Site Event

Charing Cross Hospital, Mary Cochrane Lecture Theatre, Education Centre

17-Jul 1-2pm

Clinician Hospital West Middlesex Hospital AGM

Education Centre, West Middlesex Hospital, Twickenham Road, Isleworth, Middlesex, TW7 6AF

17-Jul 3-4.30pm

Council HOSC H&F HOSC -Housing, Health And Adult Social Care Select Committee

H&F Town Hall, King Street London W6 9JU

17-Jul 7pm (pre-brief 6.45pm)

Public Forum Hillingdon Voluntary Sector Forum Hillingdon Civic Centre 18-Jul 10am

Clinician CCG Richmond CCG Richmond /Twickenham

18-Jul am

58

Meeting Category


Clinician CCG Ealing CCG Board Ealing 18 Jul 1.30 - 4pm

Council HOSC Brent HOSC-Health and Social Care Sub-committee

Committee Rms 1 & 2, Brent Town Hall, Forty Lane, Wembley, HA9 9HD

18-Jul 7pm

Public Forum Westminster (Maida Vale) Area Forum

Westminster, Paddington Academy on Marylands Road, W9

18 Jul 6.30-8.30pm

Clinician Hospital Hammersmith Hospital Site Event

Hammersmith Hospital, Oak Suite, Hammersmith Conference Centre, DuCane Rd, W12 0HS

19-Jul 1-2pm

Clinician Hospital Western Eye Hospital Site Event

Western Eye Hospital Postgraduate Centre, Western Eye Hospital, 153-173 Marylebone Rd, NW1 5QH

20-Jul 8.30-9.30am

Clinician Hospital St Mary's Hospital Site Event

St Mary's Hospital, Wolfson Lecture Theatre, Education Centre, Praed St., W2 1NY

20-Jul 1-2pm

Hard to Reach

Hard to Reach Al Mannar - Muslim community Goldbourne Rd, Kensington

20-Jul 2pm

Public Roadshow Ealing Roadshow

Ealing, Dominion Centre in Southall, 112 The Green, Town Centre, Southall, UB2 4BQ

21-Jul 10-4pm

Public Forum H&F Elders Forum St. Paul's Church, Queen Caroline St., London, W6 9PJ

24-Jul 10.30am

Clinician CCG Hounslow CCG Board Hounslow 24-Jul 9-2pm

Clinician CCG H&F CCG Board Hammersmith Town Hall, Committee Room 1

24-Jul 1-4.30pm

Clinician CCG Harrow CCG Board Harrow 24-Jul 3.30-5.30pm

Public Roadshow Westminster Roadshow

Westminster, Central Hall, Storeys Gate, Westminster, SW1H 9NH

24-Jul 2-8pm

Public Forum Harlesden ACF (Brent)

All Souls Church, Station Rd (next to Lloyds TSB), Harlesden, NW10

24-Jul 7pm

Hard to Reach

Hard to Reach Community interpreting, translation and access service

1 Dalling Rd, London 25-Jul

Clinician CCG Brent CCG Board Brent 25-Jul 2-5pm

Clinician GP Brent & Harrow GP event - CANCELLED

Brent & Harrow - Sattavis Patidar Centre, 40 Park Avenue, Wembley Park, HA9 9PE

25-Jul 7-9pm

Clinician Hospital West Middlesex Hospital Site Event West Middlesex 25-Jul 8-9am and

59

Meeting Category


Hospital, Conference Room/Education Centre, Twickenham, Middlesex, TW7 6AF

12-1pm

Clinician CCG H&F CCG Members Event Queens' Club, Palliser Road, London, W14 9Eq

25-Jul 6.30-9pm

Council HOSC Ealing HOSC Ealing Town Hall, New Broadway, Ealing, W5 2BY

26-Jul 7pm (Pre-briefing 6.30pm at venue)

Public Roadshow Harrow Roadshow Harrow, Bernays Hall, 25 The Broadway, Stanmore, HA7 4DA

26-Jul 2-8pm

Public Roadshow H&F Roadshow H&F, Assembly Town Hall, King St., Hammersmith, W6 9JU

28-Jul 9-2.30pm

Public Roadshow K&C Roadshow

K&C, Unitarian Church, 112 Palace Gardens Terrace, Notting Hill, W8 4RT

30-Jul 2-8pm

Other Chief Exec Chief Execs meeting (including NWLHT and Council)

Harrow 30-Jul

Public Roadshow Brent Roadshow

Patidar House, 22 London Road, Wembley, Middlesex HA9 7EX

31-Jul 2-8pm

Council JHOSC Public JHOSC Harrow TBC 02-Aug 9.30-11.30am

Other Internal C&E Working Group Internal meeting 02-Aug 9.30-11.30am

Public Forum Learning Disability Advocacy Project Unit 215 Buspace Studios, Conlan St., London, W10 5AP

07-Aug

Hard to Reach

Hard to Reach The Advocacy Project Kensington & Chelsea 10-Aug 10.30am

Clinician Hospital Mount Vernon Hospital Site Event

Postgraduate Centre, Mount Vernon Hospital, Rickmansworth Rd, Northwood, HA6 2RN

14-Aug 10-11am

Clinician Hospital Hillingdon Hospital Site Event

Hillingdon Hospital, Education Centre, Pield Health Rd, Uxbridge, UB8 3NN

14-Aug 1-2pm, 3-4pm

Clinician LMC LMC London 14-Aug 2-3.30pm 408

Clinician CCG Richmond CCG Richmond 15-Aug

Clinician GP Ealing GP event

Trail Finders, Phoenix Room, Trail finders sports Club, Vallis Way, West Ealing, London, W13 0DD

15-Aug 6.30-9pm

Public Forum Age UK Ealing Town Hall, New Broadway, Ealing, W5 2BY

17-Aug 11-3pm

Public Roadshow Hounslow Roadshow Feltham Library, The Centre, High St.,

18-Aug 10-4pm

60

Meeting Category


Feltham, TW13 4GU

Public Forum Gunnersbury Park Mela Gunnersbury Park 19-Aug 10-6pm

Hard to Reach

Hard to Reach CITAS meeting 1 Dalling Rd, White City, London, Greater London W6 0JD

23rd August 12.30-3pm

Public Roadshow Harrow Roadshow

North Harrow Methodist Church, Pinner Rd, Harrow, HA2 6EQ

25-Aug 10-4pm

Clinician Hospital K&C Westminster Practice Nurses Forum

St Charles Hospital 30-Aug 1-2pm

Public Forum Brent CVS Health Consultation Details TBC 30-Aug

Public Forum The Rain Project POSTPONED Canal side House, 383 Ladbroke Grove, London

30-Aug

Public Roadshow Camden Roadshow Camden, Friends House, 173 Euston Road, NW1 2BJ

01-Sept 1-7pm

Council JHOSC Public JHOSC

Committee Room 1 -Hammersmith Town Hall, King Street, Hammersmith, London W6 9JT

04-Sept 10-11am

Clinician Hospital C&W Foundation Trust Members Public Meeting

Postgraduate Lecture theatre, Lower ground floor, Chelsea & Westminster Hospital, 369 Fulham Road, London, SW10 9NH

04-Sept 5.30-6.30pm

Clinician CCG NHSCL CCG

Paddington Green Health Centre, 4 Princess Louise Close, London, W2 1LQ

04-Sept 6.30-9pm

Council Public Brent All Council Meeting Brent Town Hall, Forty Lane, Wembley, Middlesex, HA9 9HD

04-Sept 7-9pm

Hard to Reach

Hard to reach Brent Multi-Faith Forum TBC 04-Sept 3-4pm

Council Hospital Councillor visit to Chelsea & Westminster Hospital

Chelsea & Westminster Hospital

05-Sept 9.30-11am

Public Forum Shepherd's Bush Town Centre Network

Charecroft Estate Community Hall, Shepherds Bush Green, Shepherd's Bush, London, W12 8PQ

05-Sept 10-12.30pm

Council HWB Hounslow H&WB Committee Room 3, Civic Centre, Lampton Road, TW3 4DN

05-Sep

Public Roadshow Hillingdon Roadshow Hillingdon Great Barn, Bury St., Ruislip, HA4 7SO

05-Sept 2-8pm

Public PPAG PPAG (Patient and Public Advisory group)

London 05-Sept 4-6pm

Clinician GP Ealing GP event Trail Finders, Phoenix Room, Trail finders sports Club, Vallis Way,

05-Sept 6.30-9pm

61

Meeting Category


West Ealing, London, W13 0DD

Council HOSC

K&C Health, Environmental Health and Adult Social Care Scrutiny Committee visit to St Charles Hospital

St Charles 06-Sept 2pm

Other Internal C&E Working Group Internal meeting 06-Sept 9.30-11.30am

Political AM Meeting Mark Spencer & Murad Qureshi (Assembly Member)

Marylebone Rd, London

06-Sept 10-11am

Clinician Hospital Ealing Hospital Site Event

Postgraduate Lecture Theatre Level 3, Ealing Hospital, Ealing Hospital NHS Trust, Uxbridge Road, Southall, Middlesex, UB1 3HW

06-Sept 12-1pm, 1-2pm

Council JHOSC Public JHOSC Ealing Town Hall, New Broadway, Ealing, W5 2BY

06-Sept 7.30-9.30pm

Council HWB Ealing H&WB Ealing Town Hall, New Broadway, Ealing, W5 2BY

06-Sept 6-8pm

Public Forum Hammersmith Diabetes Event Awaiting details 08-Sept 10-1pm

Public Roadshow Wandsworth Roadshow Wandsworth Civic Suite, High St., London, SW18 2PU

08-Sept 10-4pm

Hard to Reach

Hard to Reach Gurdwara Singh Sabah Hounslow Alice Way, Hanworth Road, Hounslow TW3 3UA

09-Sep

Hard to Reach

Hard to Reach Brent Pensioners Forum Brent Town Hall, Forty Lane, Wembley, Middlesex, HA9 9HD

10-Sept 2-4pm

Hard to Reach

Hard to Reach Lesbian Gay Bi-sexual and Transgender Group

The Lido, 63 Mattock Lane, London, W13 9LA

10-Sept 6-8pm

Hard to Reach

Hard to Reach Sickle cell Society 54 station road NW10 4UA

10-Sept 6-8pm

Council HOSC Nick Botterill and co. visit to Charing Cross and Hammersmith Hospital

Charing Cross & Hammersmith Hospitals

11-Sept

Public Roadshow Ealing Roadshow

Victoria Hall, Ealing - Room G09, Ealing Town Hall, New Broadway, Ealing, W5 2BY

11-Sept 2-8pm

Council HOSC Hounslow HOSC - NO ATTENDANCE REQUIRED

Committee Room 1 at the Civic Centre on Lampton Road, TW3 4DN

11-Sept 7-9pm

Council HOSC K&C HOSC - Special meeting of Health, Environmental Health and Adult Social Care Scrutiny Committee

The Small Hall 1, K&C Town Hall, Hornton Street, London, W8 7NX

11-Sept 6.30-8.30pm

Clinician CCG Wandsworth CCG Board

Meeting Rooms 2/3, 3rd Floor, Wimbledon Bridge House, Hartfield Road, Wimbledon

12-Sept 10-11am

62

Meeting Category


SW19 3RU

Political LA London Assembly's Health and Environment Committee

Marylebone Rd, London

12-Sept 2.30pm

Hard to Reach

Hard to reach Fulham Football Club The lighthouse Ladbroke Grove

12-Sept 4pm

Clinician CCG Wandsworth-wide CCG Members’ Forum

Wimbledon Park Golf Club. (Near to Wimbledon Tennis Club)

12-Sept 7pm

Public Forum K&C Link Elders Sub-group K&C Town Hall, Hornton Street, London, W8 7NX

12-Sept 2-4pm

Clinician Hospital Hillingdon Hospital Public Meeting Hospital Education Centre, Pield Health Rd, Uxbridge

12-Sept 7-9pm

Hard to Reach

Hard to Reach Travellers Group Westway Travellers site

13-Sept 11-12.30pm

Hard to Reach

Hard to Reach MENCAP Hammersmith & Fulham Stamford Brook Centre, London

13-Sept 6pm

Public Forum H&F Links Hospital working Group

St Pauls Church Queen Caroline St London W6 9PJ

13-Sept 3-5pm

Council CCG Hounslow CCG meeting

Harlequins Rugby Ground, Twickenham Stoop Stadium, Langhorn Drive, Twickenham, Middlesex, TW2 7SX

13-Sept 1-3pm

Clinician Hospital Event for Council of Governors meeting - Request from C&W Hospital

C&W Hospital 13-Sept 3-5pm

Council HOSC Westminster HOSC - Adult & Health Policy Scrutiny Committee

Westminster, Committee Rooms 5, 6 & 7, 17th Floor, City Hall, Victoria Street, SW1

13-Sept 7-9pm

Clinician CCG H&F CCG Members Event H&F 13-Sept 7-9pm

Council HOSC Hillingdon HOSC - Council External Affairs Scrutiny Panel

Committee Rm 6, Civic Centre, High St., Uxbridge, UB8 1UW

13-Sept 6-8pm

Clinician Hospital C&W Hospital Site Event

Board Room, lower Ground floor, Chelsea & Westminster Hospital, 369 Fulham Road, London, SW10 9NH

14-Sept 8-8.45am, 12-12.45pm, 12.50-1.30pm

Public Forum All day protests Ealing, Brent and Greenwich

15-Sept (All day)

Public Roadshow K&C Roadshow Old Town Hall, Kings Road, SW3 5EE

15-Sept 10-4pm

Council Public H&F Council Public Meeting

Assembly Hall, Hammersmith Town Hall, King Street, Hammersmith, London W6 9JT

18-Sept 7-9pm

63

Meeting Category


Public Forum Residents of H&F and K&C Event (AgeUK)

K&C Town Hall, Hornton Street, London, W8 7NX

19-Sept 2-4pm

Public Forum Westminster Senior Citizens Forum 97-113 Marylebone Road, NW1 5PT

19-Sept 2-4pm

Clinician Hospital Central Middlesex Hospital Site Event Central Middlesex Hospital, Acton Lane, Park Royal, NW10 7NS

19-Sept 8-9am, 12.30-1.30pm, 3.30-4.30pm

Public Roadshow H&F Roadshow

Fulham Broadway Methodist Church, 452 Fulham Rd, SW6 1BY (Near Wandsworth Place)

19-Sept 2-8pm

Clinician CCG Ealing CCG Public Engagement Event Greenford Hall, Ruislip Rd, Greenford, UB6 9QN

19-Sept 7-9pm

Council HOSC Harrow HOSC -Special meeting of Health and Social Care Scrutiny Sub-Committee

Committee Rm 6, Harrow civic centre, Harrow Council, Station Road, Harrow, HA1 2XY

19-Sept 7.30-9pm

Public Forum TreatMeRight Learning Disability Consultation

Prince's Room, Ealing Town Hall, New Broadway, Ealing, W5 2BY

20-Sept 10-12.30pm

Clinician BMA BMA event

British Medical Association, BMA House, Tavistock Square, London, WC1H 9JP - Murrell Barnes Suite

20-Sept 7-9pm

Council HOSC Ealing HOSC ATTENDANCE NOT REQUIRED

Ealing Town Hall 20-Sept 7-9pm

Hard to Reach

Hard to Reach Integrated Neurological Services Group

82 Hampton Rd, Richmond, London

21-Sept 1-2.30pm

Focus Groups

Focus Group Wandsworth: Focus Group Wandsworth TBC 21-Sept

Focus Groups

Focus Group Richmond: Focus Group Richmond TBC 21-Sept

Public Roadshow Richmond Roadshow

Richmond Green United Reformed Church, Quadrant Road, Richmond, Surrey, TW9 1DH

22-Sept 10-4pm

Public Forum Hounslow Council Public Event - Community Fair

Lampton Park, Hounslow, TW3 4DN

22-Sept 10-4pm

Public Forum West Ealing Centre Neighbourhood Forum

N/A 24-Sept 5.15-6pm

Clinician Hospital Mount Vernon Hospital Site Open Day

Mount Vernon Hospital, Rickmansworth Rd, Northwood, HA6 2RN

24-Sept 2-5pm

Public Links Brent LINk event The Stonebridge Centre, 6 Hillside NW10 8BN

24-Sept 6-8pm

64

Meeting Category


Council HOSC H&F HOSC

Courtyard Room, Hammersmith Town Hall, King Street, Hammersmith, London W6 9JT

24-Sept 7-9pm

Hard to Reach

Hard to Reach K&C Health & Wellbeing Voluntary Organisations Forum

K&C Town Hall, Hornton Street, London, W8 7NX

25-Sept 11-1pm

Public Forum Hillingdon Older People's Assembly Uxbridge Civic Centre, 25-Sept 3.30-4.30pm

Clinician Hospital Northwick Park Hospital Site Event Northwick Park Hospital, Watford, Rd, Harrow, HA1 3UJ

25-Sept 8-9am, 12.30-1.30pm, 3.30-4.30pm

Clinician GP Ealing GP event

Trail Finders, Phoenix Room, Trail finders sports Club, Vallis Way, West Ealing, london, W13 0DD

25-Sept 6.30-9pm

Other Hospital Board

Imperial Board Meeting

The Boardroom Clarence Wing St Mary's Hospital Paddington

25-Sept 10-11am

Council JHOSC Public JHOSC Brent Town Hall, Forty Lane, Wembley, Middlesex, HA9 9HD

26-Sept 10-12pm

Council Local Council Joint Public Consultation Event on SAHF with Hillingdon Council

Hillingdon Civic Centre, High Street, Uxbridge, Middlesex UB8 1UW

26-Sept 10-12pm

Focus Groups

Focus Group Hounslow: Focus Group

Oriel Community Resource Centre, Cresswell Rd, Feltham, TW13 6YQ

26-Sept

Focus Groups

Focus Group K&C: Focus Group Westway Sports Centre, 1 Crowthorne Rd, London, W10 6RP

26-Sept

Focus Groups

Focus Group Brent: Focus Group

Bridge Park Community Leisure Centre, Harrow Rd, Stonebridge, NW10 0RG

26-Sept

Hard to Reach

Hard to Reach Homeless Polish community The Broadway Centre, 13 Market Lane (Off GoldHawke Rd)

26-Sept 11-12am

Public Forum Public Debate - Ealing

Victoria Hall, Ealing Town Hall, New Broadway, Ealing W5 2BY

26-Sept 7-9pm

Focus Groups

Focus Group Ealing: Focus Group Southall Sports Centre, Beaconsfield Rd, Southall, UB1 1DP

27-Sept

Focus Groups

Focus Group Camden: Focus Group Camden TBC 27-Sept

Hard to Reach

Hard to Reach The Rain Trust (HIV Service Users) Canalside House, 383 Ladbroke Grove, London, W10 5AA

27-Sept 5.30-6.30pm

65

Meeting Category


Council HWB Ealing H&WB Ealing Town Hall, New Broadway, Ealing, W5 2BY

27-Sept 6-8pm

Council HOSC K&C HOSC - Health, Environmental Health and Adult Social Care Scrutiny Committee

K&C, Committee Rm 1, The Town Hall

27-Sept 6.30-8.30pm

Council HOSC Richmond HOSC York House, Richmond Road, Twickenham, TW1 3AA

27-Sept 7-9pm

Hard to Reach

Hard to Reach Hammersmith & Fulham Stroke Association

Trillington House, 241 Uxbridge Road, Shepherds Bush, London W12 9DL

28-Sept

Focus Groups

Focus Group Harrow: Focus Group

Savoy Court Community Centre, 49 Savoy Court, Station Road, Harrow, HA2 6BU

28-Sept

Public Forum H&F Stroke Association

Trillington House, 241 Uxbridge Road, Shepherds Bush, London W12 9DL

28-Sept 12-2pm

Public Forum Public Debate - H&F

Phoenix High School, The Curve, Shepherds Bush, London, W12 ORQ

28-Sept 7-9pm

Public Roadshow Brent Roadshow Harlesden Methodist Church, 25 High Street, Harlesden, NW10 4NE

29-Sept 10-4pm

Public Forum West London Network Steering Group Committee

Hillingdon Association of Voluntary Services, Key House, 106 High Street, Yiewsley, Middlesex, UB7 7BQ

01-Oct 10-12pm

Public Forum Public Debate - Westminster

Westminster Academy, The Naim Dangoor Centre, 255 Harrow Road, London, W2 5EZ

01-Oct 6-8pm

Public Forum Willesden ACF College of NWL, Denzil Rd, Willesden, NW10

02-Oct 7-8.30pm

Focus Groups

Focus Group Westminster: Focus Group

Marylebone Bangladesh Society, 19 Samford St., London, NW8 8ER

02-Oct

Hard to Reach

Hard to Reach Afghan Women's Association Nestle Children's Centre

03-Oct

Focus Groups

Focus Group Hillingdon: Focus Group

Yiewsley & West Drayton CC, Harmondsworth Rd, West Drayton, UB7 9JL

03-Oct

Public PPAG PPAG (Patient and Public Advisory group)

The Lido Centre, Mattock Lane, West Ealing

03-Oct 4-6pm

Public Forum Hounslow Links Public Meeting tonight - Quiz the Professionals

Hounslow Civic Centre, Lampton Road

03-Oct 7-9pm

66

Meeting Category


Hard to Reach

Hard to Reach Asian Womens Resource Centre (Brent)

108 Craven Park, Harlesden, London

04-Oct 11-1pm

Other Internal C&E Monthly Provider Comms Working Group

Internal meeting 04-Oct 9.30-11.30am

Focus Groups

Focus Group Young People 16-18: Focus Group Ealing 04-Oct 6pm

Focus Groups

Focus Group H&F: Focus Group Irish Cultural Centre, Blacks Road, Hammersmith, W6 9DT

05-Oct

Focus Groups

Focus Group Mothers with Children <2yrs: Focus Group

Brent 05-Oct 10am

Hard to Reach

Hard to Reach Brent Children’s Centre Barham Library, Harrow Road, Wembley, HA0 2HB

05-Oct 12-1pm

Public Forum All day protests Hammersmith 06-Oct (All day)

Public Roadshow Westminster Roadshow

Hinde Street Methodist Church, 19 Thayer Street, Westminster, W1U 2QJ

06-Oct 10-4pm

Public Forum Presenting petition March

Outside the Department of Health in Whitehall, then to NHS NW London HQ in Victoria St

08-Oct 12.30pm

Focus Groups

Focus Group People with physical disabilities: Focus Group

Brent or H&F TBC 08-Oct 10am

Hard to Reach

Hard to Reach Brent Children’s Centre Curzon Crescent, Harlseden, London, NW10 9SD

08-Oct 2-3pm

67

Sample recruitment profile and discussion guide for focus groups conducted during consultation Recruitment: participant profile for focus groups

Categories Numbers to be recruited

Brent Ealing Harrow Hillingdon

Hounslow

Hammersmith & Fulham Kensington & Chelsea Westminster Camden Wandsworth Richmond

Gender

Male

7 7

Female

8 8

Age

16-24 6 6

24-65 2 2

65+ 7 7

Ethnic Group

White (British, Irish, other – see

recent migrants)

White

6 At least 5

Asian or Asian British (Indian,

Pakistani, Bangladeshi), Asian Other

India

Sri Lanka

Bangladesh

5 At least 2

Black or Black British (Caribbean,

African, other)

Jamaica

Somalia

Kenya

4 At least 1

Recent migrants (e.g. Eastern

European, Tamil, etc)

PLEASE EXCLUDE RECENT MIGRANTS

FROM DEVELOPED ENGLISH

SPEAKING COUNTRIES, E.g. Australia,

8

On-street or via

local groups

5

On street or via local groups

68

United states

Afghanistan (Ealing, Hounslow,

Harrow, Brent)

Somalia (Ealing, Hounslow, Harrow,

H&F, Hillingdon)

Eastern European particularly Polish,

Romanian & Lithuanian (Ealing,

Hounslow, Harrow, Brent)

Single parent

One family and no others: Lone

Parent Households ALL

At least 1 At least 1

Socio-economic Status

D At least 3 At least 3

E At least 3 At least 3

Health situation

Disability physical or sensory

disability


Long term condition At least 4 At least 4

Access to private transport

Households without car or van At least 5 At least 5

Use of specific services in last year

Maternity and new born At least 1 At least 1

Urgent, unscheduled and emergency

care

Including close relatives / carers of

service users


Hammersmith and Fulham - White City, Wormholt, Edward Woods, Charecroft and Clem

Atlee Westminster - Churchill ward, Westbourne ward, Church Street/Regent's Park wards and

Queen's Park/Harrow Road wards Kensington and Chelsea - Norland, Colville, St. Charles Notting Barns and Golbourne. Earl’s

Court, Redcliffe and Cremome also include areas of disadvantage Camden - St Pancras and Somers Town, Cantelowes, Kilburn, Kentish Town, Kings Cross

Wandsworth - St Mary’s Park, Queenstown, Latchmere, Shaftesbury

Richmond - Barnes, Mortlake & Barnes Common, North Richmond (western part), Heathfield, Whitton

69

Discussion Guide

Objectives

Set out the case for change and understand and capture participants’ reactions are to it

Set out the vision for the future and models of care and see what reactions are

Present the options and gauge reactions

Understand what concerns people have about the preferred option and what can be done to

reassure them? (e.g. patient transport)

Note: the materials used at the focus group will be based on the boards being used at the

roadshows

Timings Session details

9.00am - 9.30am OPM venue set up and briefing

9.30am - 10.00am Arrival and coffee

10.00am - 10.05am Welcome and purpose of the day, agenda and housekeeping – 5 mins

Brief introductions

First names

Tell me a little bit about yourself

10.05am - 10.15am Reflecting on the challenges facing health services in North West

London

Session aims and outputs:

To understand participants’ views on the challenges facing

healthcare in NW London

To explore how far people agree there is a need to change services

How the session will work:

Short presentation on the case for change – 5 mins (handout

roadshow board ‘1. The need for change’)

Table discussion (two groups) – 5 mins

Thinking about the challenges facing healthcare in NW London –

what are your views on these challenges?

Probes on challenges:

o Which ones were you already aware of?

o Do you see them all as equally important and impacting on

level of care?

o Which ones are new or surprising?

o How far do you accept / question them?

o What concerns do you have about them? How could these

be addressed?

o What opportunities might they present?

Any questions they would like to ask or other information needed

70

10.15am –

11.30am

Exploring the vision for the future and the model for the future


To understand participants’ views on the vision for how future health

services should be delivered, given the challenges already discussed

To explore participants’ views on the model for the future.


Short presentation - 5 mins (handout roadshow board ‘2. Our vision

for healthcare in North West London):

Table discussion (two groups – 10 minutes)

Immediate responses

How do they feel about this?

Which aspects are most / least appealing and why?

Short presentation – 5 mins (handout roadshow board ‘3. Proposals

for where care will be provided in the future’:

Table discussion (10 mins) of the elements of the model covering:

Overall understanding

Initial reactions, likes/ dislikes

Concerns and opportunities presented by this model

Impact on service delivery and how it might affect them in terms of

using the service

How well does the vision and model seem to meet the challenges

outlined earlier


for delivering care outside hospitals’):

Table discussion (10 mins)

Immediate responses



Short presentation – 5 mins (handout roadshow board ‘5. Our

recommendations for local hospitals’):


Immediate responses




for elective hospitals and specialist services’):


Immediate responses



71

11.30am –

12.30pm Five major hospitals and the 3 options


To understand participants’ views on 3 options, particularly the

preferred option


Short presentation – 5 mins (handout roadshow board ‘7. Five major

hospitals for NW London’ and borough specific handout)


Overall understanding

Initial reactions, likes/ dislikes

Short presentation: 5 mins (handout roadshow board ‘8. The three

options for major hospitals – option A’)


Immediate responses



What would need to happen for this option to be acceptable to local

people?’

Short presentation: 5 mins (handout roadshow board ‘8. The three

options for major hospitals – options B and C’)


Immediate responses



Of the three options which is your preferred one and why?

12.30pm Final comments

Any other comments and close

Appendix D – Case for Change

Appendix D – Case for Change


Edition: 1.0

12 February 2012

NHS North West London

Case for Change

9 February 2012

NHS North West London | Case for Change Page 2

Contents

Erratum:

Note that this edition of the Case for Change contains one correction to a figure from the 30th January 2012

version of the Case for Change on Page 11. The estimated number of deaths in NW London prevented by the new approach to the provision of stroke services is 100. This change is also reflected in the Executive Summary on

Page 5.

Executive Summary 4

1. Demands on the NHS in NW London are changing 7

2. The NHS in NW London has also been changing 11

3. But more change is still needed 14

3.1…..to prevent ill health in the first place 14

3.2…..to provide easy access to high quality GPs and their teams 15

3.3…..to support patients with long term conditions 16

3.4…..to enable older people to live more independently 17

4. Hospitals in particular need to change 19

4.1…..to improve patient and staff satisfaction 19

4.2…..to make high quality more consistent 19

4.3…..by providing 24/7 access to specialist emergency care 21

4.4…..and by providing access to specialised care 23

5. Providers face significant estates and financial challenges 26

5.1 NW London’s NHS hospital estate needs £150m investment 26

5.2 Our hospitals face extreme financial pressures 27

6. Rising to the challenge 30

Appendix 32


OUR COMMITMENT

As clinical leaders in North West London, we believe that the case for making changes to how we deliver services in North West London is compelling and places a clear responsibility on us now to deliver better healthcare for our patients in years to come. We believe that increasing the amount of care delivered closer to the patient’s home will enable better co-ordination of that care, ensure the patient has access to the right help in the right setting and improve quality of care and value for money. We will take on that challenge. Its scale should not be underestimated, but neither should we underestimate the rewards of getting this right – better healthcare, more lives saved, more people supported and a system that is more efficient. As the current and future commissioners of services in North West London and the leaders of the programme to deliver this change, we have made four key commitments. These underpin our vision for how services should work in the future and though there will be difficult decisions to make, these commitments are, we think, obvious, uncontroversial aspirations for any world-class healthcare organisation. We would add one final pledge – to listen to our patients and staff throughout the process of change and make sure that we are always working to create a system that works, first and foremost, for them. Dr Ethie Kong - Brent GP Federation CCG Chair Dr Ruth O’Hare - Central London CCG Chair Dr Mohini Parmar - Ealing CCG Chair Dr Nicola Burbidge - Great West Commissioning Consortia Chair Dr Tim Spicer - Hammersmith & Fulham CCG Chair Dr Amol Kelshiker - Harrow CCG Chair Dr Ian Goodman - Hillingdon CCG Chair Dr Mark Sweeney - West London CCG Chair


Executive Summary

The health needs of the people of North West London are changing; demands on our health services are increasing; the way we have organised our hospitals and primary care in the past will not meet the needs of the future.

Therefore the way we deliver health care services must change.

The population of North West London (“NW London”) is facing major changes in its health needs and these are placing ever greater demands on the local NHS. People are living longer, the population as a whole is getting older, and there are more patients with chronic conditions such as heart disease, diabetes and dementia.

More needs to be done to improve care and prevent ill health, and improvements need to be made to ensure better, consistent access to high quality care. For example, when people are worried about their health, their first point of call is often NHS primary care – usually their GP. But patients in some parts of NW London cannot get a GP appointment, or access their GP and related services, very easily. Patient surveys suggest six of the eight boroughs in NW London are in the bottom 10% nationally for patient satisfaction with out-of-hours GP services. More should also be done to support the growing number of people in NW London who are elderly, or suffer from long term conditions. These patients need support to manage their condition, and help to stay as independent as possible. Providing suitable care will mean providing more proactive services in the community and spending proportionately more on those services in local communities, and less on hospitals. Doing so could result in 20-30% of patients who are currently admitted to hospitals in NW London as emergencies being more effectively cared for in their community. These challenges are not unique to NW London. We have made progress but there is more to be done. It is up to the NHS, in partnership with carers, the voluntary sector and social care to continue to focus on tackling these challenges. Initiatives to provide enhanced levels of care outside hospitals such as the Short Term Assessment, Rehabilitation and Reablement Service (“STARRS”) and the “Integrated Care Pilot”, will prevent 2,000 people being admitted to NW London hospitals in 2012-2013. These schemes proactively plan the care for people to prevent them getting more seriously ill, combining primary, acute and mental health. If we rolled out these kinds of initiatives across the whole of NW London, up to 10,000 admissions to hospital could be avoided each year, leading to better care and more available resources. But more needs to be done by the NHS: primary care and hospitals need to change how they deliver care. People needing hospital care must be sure of receiving the best possible services. This is not happening consistently across NW London. There are big differences in the quality of care patients receive depending on which hospital they visit and when they visit. Recent analysis across London has shown that people attending and admitted to hospital during evenings, nights or at the weekend are more likely to die than people admitted at times when more senior staff are available. Around 130 lives could be saved in NW London every year if mortality rates for admissions at the weekend were the same as during the week.


NW London also has more hospital floor space per head of population than in other parts of the country, and uses a greater proportion of the NHS budget on hospital care than average – but the productivity of NW London hospitals is lower than in other regions. This is not the best use of resources – resources which could be better used to help people to stay well in the community – and makes it even more important to change hospital services. If the NHS is to provide more consistent high quality hospital care in NW London, it needs to ensure that senior doctors and teams are available more often, seven days a week, 24 hours a day. Again, much progress has been made – for example, in centralising heart attack care, major arterial surgery and stroke care in hospitals. This new approach to stroke care has already saved about 100 lives over the last year in NW London – but more needs to be done. The physical condition of hospital buildings needs to improve. Despite having three relatively newly built hospitals (Central Middlesex, Chelsea and Westminster and West Middlesex), NHS buildings in NW London are generally in a poor state. Three quarters of hospitals require significant work to meet modern standards, at an estimated cost of £150m.

And all these challenges need to be met at a time of unprecedented economic pressure, which affects all of us, not just the NHS. Hospitals in NW London will have significant financial challenges even if they become as efficient as they can be.

The demand for health services in NW London will continue to grow and, given the economic pressure, the NHS needs to focus even harder on improving quality, safety, outcomes and experience, whilst also providing care in the most effective way.

In essence this means health services need to be localised where possible, centralised where necessary. This will mean we will need to review the current pattern of hospitals in NW London. In all settings, care should be integrated across health, social care and local authority wherever that improves seamless patient care.

The impact on providers of the Commissioning Strategy Plan


In short, the NHS in NW London needs to redesign services, so that

• You can be supported to take better care of yourself, lead a healthier lifestyle, understand where and when you can get treatment if you have a problem, understand different treatment options and better manage your own conditions with the support of healthcare professionals if you wish;

• When you have an urgent healthcare need, you can easily access a primary care clinician 24 hours a day, seven days a week by telephone, email and face-to-face consultations in local, easily accessible facilities;

• If you need to see a specialist or receive support from community or social care services, this will be organised in a timely way and GPs will be responsible for co-ordinating the delivery of your healthcare;

• If you need to be admitted to hospital, it will be to a properly maintained and up-to-date facility where you receive care delivered by highly trained specialists, available seven days a week, with the specific skills needed to treat you.

This document sets out how the NHS might achieve this change. We will be working with a number of NHS partners over the next few months to identify options to deliver our vision for change. There are plans to launch a major public consultation in June 2012. This will genuinely seek patient and public views and offer real choices about how their services can be better delivered.


1. Demands on the NHS in NW London are changing

The NHS in NW London includes eight London boroughs: Brent, Ealing, Hammersmith and Fulham, Harrow, Hillingdon, Hounslow, Kensington and Chelsea, and Westminster, each with its own clinical commissioning group1. NW London has a population of nearly two million people on which the NHS spends approximately £3.4 billion each year. There are nine acute and five specialist hospital sites and 423 GP practices. In addition, there are 505 pharmacies, two mental health and four community care providers delivering services from multiple sites, including people’s homes2.

This population is growing and life expectancy is improving. NW London is expected to increase by approximately 113,000 people (5.9%) growing from 1.9 million to 2.0 million in the next 10 years. This represents a significant pressure on the NHS. Thanks to earlier diagnosis and improved treatments, fewer people are dying prematurely from diseases such as cancer, heart disease and strokes. Since 2001, the number of people under 65 dying from cancer has dropped by 15%, the number dying from heart disease has dropped by 38%, and the number dying from stroke has dropped by 36%3. These improvements mean people are living longer and, as a result, the population as a whole is getting older. Ten years ago life expectancy in NW London was 76.8 years for men and 81.9 years for women but it is now about three years longer – 80 years for men and 84.5 years for women4,5.

1 CCGs are closely to aligned to the boundaries of local authorities 2 NHS Choices 3 NHS Information Centre 4 GP registered population figures used to calculate population weighting of each NW London PCT. Life expectancies associated

with each NW London PCT then multiplied by weighting to produce ‘average’ life expectancy for NW London 5 NHS Information Centre


For the NHS, this is hugely significant because older people are more likely to develop long term conditions such as diabetes, heart disease and breathing difficulties and are more at risk of strokes, cancer and other health problems. Three out of every five people aged over 60 in England suffer from these kinds of conditions and, as the population ages, there will be more people with age-related diseases. Some 300,000 – nearly 1 in 6 – of people all ages in NW London, have one of the following five conditions: diabetes, asthma, coronary heart disease (CHD), chronic obstructive pulmonary disease (COPD), and cystic fibrosis disease (CFD)6. Adding to these pressures, modern lifestyles are creating problems. In particular, unhealthy eating and lack of exercise is resulting in increasing rates of obesity and diabetes. In Westminster, 29% of 10 to 11-year-olds are obese compared to only 12% in Richmond7. Diabetes prevalence in NW London rose from 3.6% to 5.7% between 2004/5 and 2010/118; obesity prevalence (in adults) in London rose from 18.2% to 23.2% between 1998 and 20089.

It is estimated that roughly one in five people smoke10 and the number is higher in more deprived areas. Smoking (and other forms of tobacco consumption) are the UK’s single greatest cause of preventable illness and early death. A recently published paper estimated that around 107,000 people died in 2007 from smoking-related diseases11. In addition, alcohol abuse is leading to increasing rates of liver disease and other associated conditions.

Fortunately our ability to prevent, diagnose and treat medical conditions is constantly improving. New treatments emerge as the boundaries of medical science and technology change. These offer new ways of tackling old problems leading to increased rates of survival from life-threatening illnesses. For example, heart attacks used to kill 73,000 people a year in 1993 but now only kill 25,000 annually12. In just eight years between 2002 with 2010, mortality rates fell by 50% in men and by 53% in women13. This is due to a combination of factors, for example fewer people smoking, and the introduction of procedures such as percutaneous coronary intervention (PCI) – where a fine tube is inserted through a blood vessel and a tiny balloon is inflated to unblock arteries in the heart. However, only a few of our hospitals can provide this as the delivery of PCI as an emergency treatment for heart attacks requires that specialists are available 24/7. Instead of going to any hospital, patients needing PCI are directed to hospitals such as Hammersmith or Harefield. With 86% of patients receiving PCI within 150 minutes of calling for help, this technology is measurably saving lives14.

6 QOF, Proportion of the GP registered population in NW London who are on the CHD, COPD, CFD, diabetes and asthma

registers 7 Prevalence of Childhood Obesity by Borough, 2006-2010, Greater London Authority 8 QOF prevalence tables 9 NCHOD 10 Based estimates of current smoking, 2003–2005 by SWL PCT (Source: Household Survey for England (HSfE) 2006 11 Peto, R et al, Mortality from smoking in developed countries 1995,2007 (2010 12 Mortality from Acute Myocardial Infarction in England: 1993 – 73,824, 2009 – 25,264, NCHOD 13 Determinants of the decline in mortality from acute myocardial infarction in England between 2002 and 2010: linked national database study, BMJ 2012;344:d8059 doi: 10.1136/bmj.d8059 (Published 25 January 2012) 14 MINAP Public Report, 2010


This kind of advanced medical treatment depends on better technology and equipment, operated by more specialised clinicians. The general surgeon of 20 years ago effectively now no longer exists. Instead, surgeons now specialise in different conditions and different parts of the body. There are currently 24 professional associations and expert groups that represent the interests and set standards for the varying surgical specialties, techniques and patient groups15. Until recently cardiology did not even exist as a specialty – now it is a major clinical specialty with a number of sub-specialties. This in turn means the traditional ways of organising care in the NHS have had to change. A recent report by The King’s Fund16 has underlined how advances in medicine and surgery have led clinical staff and equipment to become more specialised, leading to specialist teams brought together into fewer, larger hospital sites so that skills can be maximised and patient outcomes improved. Medical advances also mean fewer hospital beds are needed. Most routine surgery is now done in just one day (“day surgery”) and 80% of all patients have stays in hospital of fewer than three days17. Not surprisingly therefore, the number of hospital beds in NW London has fallen by about 9% over the last five years18. As medicine and surgery continue to become more specialised, and new techniques allow people to go home even earlier, or avoid going to hospital at all, the number of hospital beds will reduce even more. The rise of the internet, mobile communications, and ‘telehealth’19 all provide other new ways for patients to access advice about their health and communicate with health and social care professionals. This creates more opportunities to support patients in their own homes and receive services, traditionally based in a hospital, through more local facilities such as GP surgeries. So services will be moved closer to patients’ own homes. Although the Government’s pledge to protect health budgets meant they fared well compared to some other areas of public spending, analysis suggests expenditure will only be increasingly very slightly in real terms in the years up to 201520. Against this, the financial pressures caused by the increasing age of the population, the increased burden of more ill health and the need to keep pace with new technology would need growth of 5%21 each year unless we change the way services are delivered. As a result, the 2010 Spending Review committed the NHS to finding £20bn in productivity improvements by 2015 to reinvest in services to meet increasing demand.

15 http://www.rcseng.ac.uk/media/spec_assocs.html 16 Reconfiguring Hospital Services, 2011 17 Hospital Episode Statistics 18 Department of Health 19 Using technology such as the internet to remotely monitor and care for people’s conditions 20 Where next for the NHS reforms? The case for integrated care, The King’s Fund, 2011 21 NHS NW London modelling


This means the NHS is required to deliver efficiency savings of at least 4% a year – something which has never been delivered before22. The total spend in the NW London health economy is £3.4 billion, which represents 24% of all NHS expenditure across London. Based on current services, by 2015 we estimate we could need an additional £1 billion of funding over and above that which is likely to be available, in order to keep pace with all these demands. This means services need to be redesigned to be more affordable. The diagram below shows the scale of the financial gap if we do not take action in NW London.

22 Where next for the NHS reforms? The case for integrated care, The King’s Fund, 2011


2. The NHS in NW London has also been changing

As the demands on the NHS have changed and available resources have become ever more limited, the NHS itself has been changing. This means more than simply improving individual services, it means better integrated working within the NHS and better partnership working with councils, schools, and the voluntary sector. The doctors, nurses, other clinicians, managers and staff of the NHS in NW London have been working hard to constantly improve healthcare delivery across hospital, primary care and in local communities. This has helped to ensure that critical services have started to be centralised where necessary to deliver high quality care.

At the same time the NHS has improved the way services are delivered in the community so care is delivered as close to where patients live as possible, and is integrated with local hospitals.

Below are a number of examples of where the NHS has been able to localise, centralise and integrate services to provide better care.

Examples of centralising specialist services in NW London:

Major Trauma:

People who suffer a serious injury or major trauma need high quality, specialist care to give them the best chances of survival and recovery. From 2010, NW London patients have received new world-class trauma care through the London trauma system. This is made up of four trauma networks. Each has a major trauma centre, including one at St Mary’s Hospital in Paddington, for treating the most seriously injured patients, linked in with a number of local trauma units for treating those people with less serious injury. During the first year the system has saved the lives of an estimated 58 people in London who would otherwise have been expected to die23. The network has prevented disability for many more.

Stroke Services:

The provision of stroke services across London, including NW London, has dramatically improved. This new approach is thought to have prevented an estimated 100 deaths per year in NW London24.

Only three years ago, stroke care was fragmented across the capital, being delivered in all of the 31 acute hospitals. Now a dedicated network of eight “hyper-acute” stroke units operate across London – in NW London at Northwick Park and Charing Cross Hospitals – to improve treatment for patients.

Each is staffed by stroke experts day and night to assess, diagnose and treat stroke patients within 30 minutes of arrival and to provide immediate care for the first 72 hours or until the patient has stabilised. Good care requires that we provide immediate access to a brain scan and clot-busting drugs, where appropriate, and thus these units are open 24/7. These eight units are supported by 24 stroke units across London to provide ongoing care once a patient is stabilised, including multi-therapy rehabilitation.

Now, four times as many patients are treated with clot-busting drugs, reducing disability, there is less variation in death rates around the capital and patients spend less time in hospital. The average journey time in London for a patient being taken to the new units is 14 minutes.

23 London Trauma Office 24 NHS press article: “Specialist stroke centres save lives across capital”


Examples of improved local care in NW London:

STARRS

The STARRS scheme (Short Term Assessment, Rehabilitation and Reablement Service) in Brent has improved the transition for patients between acute hospital services and community services, reducing the need for patients to go to hospital and leading to a much better, more independent quality of life. STARRS is an innovative new approach to provide rapid response, discharge support and rehabilitation, and access to community health beds. It includes a multi-disciplinary team of nurses, physiotherapists, occupational therapists, doctors, dieticians and healthcare support, as well as an administrative team who act as a single point of access for GPs and hospital staff so they can refer patients directly to the service.

Integrated Care Pilot

A major frustration of patients with long term conditions is that their care is not effectively coordinated across the boundaries of multiple different NHS organisations. As a consequence they often have to repeat information multiple times and deal with many different clinicians. To address this, an Integrated Care Pilot (“ICP”) has been set up focusing on the care of people aged over 75 or with diabetes. The ICP overcomes the boundaries between hospitals, community care services, social care and local authorities to allow faster access, streamlined for patients and a stronger focus on their long term needs. Through integrated care, providers work together as a team so that patients receive the right kind of treatment, in the right place at the right time. In addition patients are provided with more control over the care that they receive.

The pilot has already won a national award and is being seen as a model for how primary and community services can work better together to safely support people at home, reduce unnecessary hospital visits and provide a more seamless patient experience. The clinical teams within the ICP - with a complementary mixture of skills - have held over 50 integrated case conferences discussing over 400 patients. The GP practices involved have initially experienced a 3.8% reduction in non-elective admissions for diabetic and elderly patient groups, compared to just less than 1% for non-involved GP practices. This reduction is likely to increase as the pilot becomes fully operational25.

There is also ongoing work to improve local care:

Commissioning for quality

NHS NW London is underpinning its work on quality through the production of a series of quality standards. To bring these quality standards to life, we have with the input from our Clinical Commissioning Groups, described a series of patient stories that set out the ideal care that patients should receive when they use the NHS. The patient stories, although fictitious, cover all settings of care and the main types of illnesses that people experience. Underpinning each patient story are published standards, metric and guidelines from, for example, the Royal Colleges and National Institute for Clinical Excellent (NICE). The standards have been prioritised and we have chosen several to use in commissioning services for 2012/13. The full suite of stories and standards can be found on the NHS NW London website26.

25 North West London Integrated Care Pilot interim evaluation, 4th January 2012 26 www.northwestlondon.nhs.uk


Teaching and Research

NW London is a major international centre for teaching and research. At the heart of this sits our Academic Health Science Centre (AHSC). AHSCs are a new approach to healthcare in the UK, bringing a university and the NHS together and running them hand-in-hand to provide the best healthcare in the world. AHSCs help increase the speed at which new treatments can be moved from the laboratory bench to the patient’s bedside, providing faster access for patients to the latest, innovative treatments. Imperial College Healthcare NHS Trust and Imperial College London came together in October 2007 to create the UK's first AHSC. Working together with its healthcare partners, the AHSC has and will continue to bring significant benefits for patients, staff, students and North West London’s local population. It will also have wider benefits as the AHSC takes new discoveries and promotes their application in the NHS and across the world. It is top of the table for recruiting patients to clinical research studies, recruiting 69,260 patients in 2010/11 - more than any other NHS Trust in England. The AHSC builds on North West London’s position as one of the world’s foremost clusters for biomedical research and teaching. This enables us to provide patients with access to the latest clinical developments. The Academic Health Science Centre, is at the forefront of technology and research programmes. It has received £112m of funding for its Biomedical Research Centre (the largest amount given to any partnership). NW London research to help people living with complex heart and lung conditions was recently recognised with a grant of almost £20 million to two Biomedical Research Units (BRUs) run jointly by Royal Brompton & Harefield NHS Foundation Trust and Imperial College London. ASHCs support the position of NW London as a hub of medical education. There are over 4,00027 medical trainees in North London at any time enabling us to attract some of the best experienced doctors to highly prestigious teaching posts. The NHS in North West London is working hard to ensure that we maintain our position as world leading centre of teaching and research and to ensure that position translates into real benefits for patients.

27 POINT OF VIEW SURVEY 04-05, London Deanery


3. But more change is still needed…

3.1 … to prevent ill health in the first place

For the NHS, it is critical that now and in the future, people who live in NW London receive the highest quality of healthcare and are able to live healthy lives no matter where they live, how much money they have, or what their background is. But, like most areas of London, the North West of the capital is highly diverse, with very wealthy people living side-by-side with very poor households. And health varies just as much as wealth. In fact there is a strong link between poverty and health: evidence has demonstrated that the poorer you are, the more you are likely to suffer ill health. The result is that there is currently a difference of up to 17 years in life expectancy between different wards in NW London. For men, Queen’s Gate (in Kensington & Chelsea) has the highest life expectancy (88.3 years) and Harlesden (Brent) has the lowest (71.5 years). For women, Knightsbridge and Belgravia (Westminster) has the highest life expectancy (90.3 years) and Church Street (Westminster) and Feltham North (Hounslow) have the lowest (both 76.6 years)28. This can be caused by many things, including differences in living conditions, diet, levels of smoking and drinking, access to sport and leisure activities, social and support networks, as well as barriers to healthcare, including seemingly obvious things like language and literacy. A recent Strategic Review of Health Inequalities in England has highlighted the link between education, employment, and health29. Some ethnic groups tend to have poorer health outcomes than others. Work by the London Health Observatory suggests that Bangladeshi, Black African and Black Caribbean ethnic groups have significantly higher mortality rates than the overall population of the capital30. Some evidence suggests that Pakistani men are significantly more likely to suffer coronary heart disease or stroke than the general population. Poorer health among London’s black and minority ethnic groups can partly be explained by other associated factors, such as lower employment rates31. Smoking, and other forms of tobacco consumption, are the UK’s single greatest cause of preventable illness and early death, with around 107,000 people dying in 2007 from smoking-related diseases32. Clearly, more needs to be done to tackle these inequalities. Much can be done through successful promotion of public health information and campaigns that assist people to take personal responsibility for their own health. For example, the NHS and local councils can encourage people to give up smoking and avoid alcohol abuse.

28 Greater London Authority (London.gov.uk) 29 Fair Society Healthy Lives, Marmot Review, Executive Summary, Review of Health Inequalities in England, Post 2010 30 London Health Observatory, Ethnicity and mortality in London Rhiannon Walters, Justine Fitzpatrick and Ed Klodawski, March

2009 31 All statements in this paragraph based on data from Review of Evidence for the Mayor’s Health Inequalities Strategy, August

2009, GLA. 32 Peto, R et al, Mortality from smoking in developed countries 1995,2007 (2010)


So more needs to be done to promote health and stop the people of NW London getting ill. More proactive primary care and better integrated working needs to happen so that the whole system – from schools, to GPs, from community nurses to hospital doctors – works seamlessly to support everyone to lead healthier lives.

3.2 … to provide easy access to high quality GPs and their teams

People want to be able to see a doctor or a nurse in their GP practice easily, and quickly, whenever they have a health problem. Equally, when they have less urgent problems they want to be able to see their GP without having to take time off work. When they do see their GP, people want to feel that they are being treated with care and concern. Failing to provide such basic level of access to GP care simply results in more people resorting to using A&E services.

A&E services are not only more costly to deliver but also ‘episodic’ – they lack the continuity and historic knowledge that a GP practice can provide, resulting in poorer care for the patient. Despite many GP practices offering a good quality service, many patients still find it too hard to access good quality care.

Patient satisfaction with primary care is low in all eight NW London boroughs when compared with national levels:

• On average, 1 in 4 patients in each NW London GP practice are dissatisfied with access, and feel unable to see their doctor fairly quickly within the next 2 working days. The majority (79%) of GP practices in NW London have below national average satisfaction scores33. This could, in part, lead to the higher than average use of A&E in outer NW London in particular34.

• Similarly, 1 in 4 patients in NW London do not feel that they are being treated by their GP with care and concern.

• In terms of communication and access (such as communications by the doctor, level of empathy, satisfaction with out-of-hours service), five of the NW London boroughs rank in the bottom 10% of all parts of the country35.

The effectiveness with which services are being delivered by GP practices is also highly variable and often below national averages. The rate of A&E use is high across outer NW London (Brent, Ealing, Harrow, Hillingdon and Hounslow). In particular, emergency admissions are much higher in Ealing and Hounslow (595 and 495 per 100,000 population vs. a national average of 410 per 100,000)36,37

GPs should track the blood pressure of all patients identified with high blood pressure. Some practices in NW London track all patients with high blood pressure every nine months, whereas others they are only managing this for two out of every three of these patients. This kind of variation means we are not consistently delivering the kind of high quality primary care we should be.

33 GP Patient Survey, 2010/11 34 GP Patient Survey, 2010/11 35 GP Patient Survey, 2010/11 36 Emergency hospital admissions: acute conditions usually managed in primary care (ICD-10 codes H66.0 - H66.4, H66.9, I11.-,

I50.0, I50.1, I50.9, J02.0, J02.8, J02.9, J03.0, J03.8, J03.9, J04.0, J06.0, J06.8, J06.9, J31.0 - J31.2, N15.9, N39.0, N30.0) 37 DH A&E Activity Statistics 2008/09, Quality and Outcomes Framework (QOF) 2008-09


Quotes from the Health Care Commission and Diabetes UK on patients’ experience of inpatient care make particularly disturbing reading:

Because I have Type 2 diabetes, I was informed that I would need to be admitted the night before so that my diabetes could be monitored by specialist staff. During my stay I saw no-one from the diabetes care team.”

If the NHS wishes to save money, it perhaps should first look at diabetics who do not want to stay in hospital for yet another night, but who are unable to get out because their insulin is impounded, with nobody with sufficient authority to return diabetic control to the patient.”

…keep your wits about you as the ignorance of diabetes by a lot of staff is verging on criminal.”

“ “ “

3.3 … to support patients with long term conditions

In the future, many more people will be living with long term medical conditions. By this we mean health problems that are present for over a year or more, such as diabetes, heart disease, respiratory problems and asthma. Across the UK, patients with long term medical conditions make up 31% of the population but account for 52% of GP appointments and 65% of planned hospital appointments. These patients need very good, consistent and integrated hospital, primary and social care and when this is not delivered the impact on the lives of individual patients can be devastating. Shuttled constantly in and out of hospital, some are simply unable to lead normal lives.

Patients should be empowered and encouraged to help themselves so they don’t have to see a doctor and have more control over their lives. There are tools available to support this, such as NHS Direct. In NW London there are big differences in how well people with long term conditions are cared for, and big differences in their health as a result.


One of the complications of diabetes is reduced blood flow to the legs which, if not identified and treated at an early stage, can result in amputation. Patients who are cared for at practices with specialist clinics, supported by a diabetic nurse, are much less likely to need an amputation compared to those people looked after at practices without these specialist services38.

Unfortunately, there are not enough of these specialist services in NW London and as a result, amputation rates in some GP practice catchment areas are much higher than elsewhere39.

People with long term conditions also create a heavy burden for our hospitals – based on a Department of Health methodology, NW London estimates people living with such conditions currently account for 67% of all hospital bed days40.

The NHS has come up with solutions to these problems, including the NW London Integrated Care Pilot already described above. In Ipswich, a pilot project which has helped 107 patients to better manage their own conditions has seen a 75% reduction in GP visits and a 75% reduction in bed days in hospital over a six-month period. Staff are being trained to become ‘health coaches’ to their patients. Sutton Council has installed monitoring devices in patients’ homes so GPs can monitor their clients’ blood pressure, blood oxygenation and other indicators so they can take early action. A six-month pilot in the borough reduced admissions to hospital and saved around £322,00041.

3.4 … to enable older people to live more independently

People who are older can struggle, like those with long term conditions, to live independent lives. Most elderly people want to be able to live in their own homes, and not spend time in hospitals. They need support to do this from social care, the NHS and the local community working together in an effective way. When this works well it can prevent problems, for example patients who fall, and keep people healthier for longer by keeping them out of hospital. This is backed up by clinical findings. In hospital, older people are at risk of developing further conditions such as delirium, malnutrition, pressure ulcers, venous thromboembolism, hospital acquired infection, incontinence, functional decline, depression, falls and dehydration.

38 Matching the numerator with an appropriate denominator to demonstrate low amputation incidence associated with a London hospital multidisciplinary diabetic foot clinic, J Valabhji, et al, Diabetic Medicine, 2010

39 Total lower limb amputation rates per 1,000 adults with diabetes vary in NW London, Yorkshire & Humber Public Health Observatory.

40 http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_128890 41 http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_125042


“ A recent report made this point very clearly:

Hospitals are a dangerous place for older people. Around one in ten patients in UK hospitals, the majority of whom are elderly, experience an adverse event during their hospital stay ….Adverse events are traditionally defined as unintended injuries caused by medical management rather than the disease process, which are sufficiently serious to lead to prolonged hospitalisation, or temporary or permanent disability, or death…. Older patients are more susceptible to adverse events than their younger counterparts as they are more complex, with multiple co-morbidities, increased dependence and reduced physiological reserve 42.”

An analysis by Chelsea and Westminster showed that 30% of readmitted patients were over 70 years old43. Similarly, an analysis at Imperial College Healthcare Trust showed that 40% of readmitted patients were 65-84 years old44. It is incumbent on the NHS in NW London to help prevent elderly patients going to hospital in the first place, by improving the management of their conditions and when basic treatment is needed and when it is appropriate, moving care out of hospital altogether. Currently too many older people end up in hospital when, with appropriate out of hospital care, they could be treated in the community and looked after in their own home. Equally, at the end of people’s lives, more want to die at home rather than in hospital, and the NHS needs to do more to enable this. In NW London, only 18% of people are dying at home versus a national average of 23%45 and in contrast to the wishes of 54% of patients to die at home46. For those approaching end of life, there are proven ways to improve the end of life experience of patients and their families, for example following documented best practice such as the Liverpool Care Pathway47. We need to do more to implement these.

42 Identifying Risks to Older Patients – A Scoping Exercise - A Report for the Dunhill Medical Trust April 2009 43 Emergency Readmissions at Chelsea and Westminster Hospital 44 Readmissions Action Plan Imperial College Healthcare Trust 45 National Centre for Health Outcomes Development - Compendium indicators 2010-2011 46 http://www.londonhp.nhs.uk/services/end-of-life/case-for-change/ 47 The Liverpool Care Pathway helps doctors and nurses plan for what patients can expect in the final days and hours of life,

which also becomes a structured record of the actions and outcomes that develop.


4. Hospitals in particular need to change …

While the NHS will continue to focus on keeping people healthy and treating them, where possible, in the community or their own homes, there will always be the need to treat some patients in hospitals. In NW London, however, the NHS is struggling to deliver consistent, high quality hospital care:

• Patient experience is generally poor across NW London hospitals

• Many staff would not be comfortable sending their own relatives to hospitals in NW London

• There is marked variation in the quality of acute hospital services in NW London

4.1 … to improve patient and staff satisfaction

Patients are now regularly surveyed on their experience of hospital services and, in NW London, these results are mixed. Only the three specialist hospital trusts in NW London have scores substantially higher than the national average when it comes to overall patient experience48. Across the other five measures collected by the Care Quality Commission (CQC) non-specialist hospitals score about the same or lower than the national average. Staff are also regularly surveyed and, worryingly, in some NW London hospitals, a significant number of staff do not ‘agree’ or ‘agree strongly’ that they would recommend their hospital as a place to work or to be treated49. This means that not just patients, but also those closest to delivering frontline care themselves do not believe services delivered in NW London hospitals are up to standard.

4.2 … to make high quality more consistent

There are thousands of emergency admissions to NW London’s hospitals each year. Typically, these patients do not have the choice of where they are treated. They are also among the sickest patients that are cared for in hospital. The NHS believes these people should all receive consistently high quality services any day of the week, at any time.

48 CQC patient satisfaction survey 2010 49 National NHS Staff Survey 2010


In general, the clinical quality of hospitals in NW London compares well to the national average in terms of mortality rates. But there remain significant variations in mortality – for example, standardised mortality rates at Imperial are significantly lower than the other hospitals in NW London50. Fuller comparisons of hospital mortality are provided in the appendix. A pan-London study in 2011 established that there is a greater than 10% higher mortality rate in London for emergency admissions at the weekend, compared to weekdays, due to a lack of consultant cover and access to diagnostics at weekends51. Data for London shows that patients admitted at the weekend are more likely to die from an emergency admission compared to a weekday – around 130 lives could be saved across NW London every year if mortality rates for admissions at the weekend were the same as during the week in NW London trusts52. In other areas of care, there are far greater variations in quality – for example, when looking at readmissions to hospital after a number of procedures, the proportion of patients who need to be readmitted varies considerably from one hospital to another. For example, readmissions for cholecystectomy (the surgical removal of the gallbladder) vary substantially. This can be due to multiple reasons, but one reason is differences in the way in which patients are cared for which results in complications after surgery.

50 AES-Case-for-change-September-2011; Dr. Foster Ltd 51 Aylin, Yunus, Bottle, Majeed, Bell: Weekend mortality for emergency admissions. A large, multicentre study, NHS London:

London Health Programmes Adult emergency services – Case for change (2011) 52 High Quality Hospital Provision in London – an Analysis: Quotes 520 lives could be saved across London, North West London

estimated to account for 25% of these


4.3 … by providing 24/7 access to specialist emergency care

Clinical evidence compiled over a number of years now53 has highlighted that, in relation to emergency care services, early involvement of senior medical personnel in the assessment and subsequent management of many acutely ill patients improves outcomes i.e. patients suffer fewer complications and are less likely to die when they are cared for by senior, more experienced staff. A self-reported survey of London trusts, undertaken in March 2011, demonstrated there is considerable variation in the availability of senior experienced staff to care for patients between hospitals and between the service provided on weekdays compared to that at weekends. Findings included: • Senior doctor availability in acute medicine and emergency general surgery at the

weekends is more than halved at many sites compared to cover during the week;

• Patients admitted on a Saturday have a 16% greater chance of dying than if admitted on a weekday, with a corresponding figure of 11% on a Sunday.

• This is a group that has the least access to senior clinicians and diagnostics when they most need it.

The diagram below shows the significant reduction in review of emergency surgery admissions by senior doctors at weekends compared to weekdays.

53 National Confidential Enquiry into Patient Outcome and Death. (2007). Emergency admissions: A step in the right direction, NCEPOD, Royal College of Surgeons (2011) Emergency Surgery: standards for unscheduled surgical care. Guidance for providers, commissioners and service planners. The Royal College of Surgeons of England, Royal College of Physicians. (2007). Acute Medical Care: The right person, in the right setting – first time. Report of the acute medicine task force. Royal College of Physicians


This is not just a London challenge – the College of Emergency Medicine has said that consultant cover in emergency departments is inadequate nationally. The benefits of increased consultant presence includes improving care (how well patients recover, how quickly patients are seen) and how efficient the unit is. The College is actively targeting this issue and is now aiming to provide 10 whole time equivalent consultants as a minimum in every emergency department, nationally. But only one trust in NW London is currently providing this level of cover. This lack of staff means that patients are not being quickly seen by a consultant when they arrive in hospital. A survey in 201154 showed that in four NW London hospitals, emergency general surgery admissions were not always reviewed by a consultant within 12 hours (Chelsea and Westminster, Northwick Park, St. Mary’s and West Middlesex University Hospitals). The survey also found that four hospitals (Central Middlesex, Ealing, St. Mary’s and West Middlesex University Hospitals) did not free their consultants from other duties when providing emergency cover. Just as for emergency care, in maternity services the Royal College of Obstetricians and Gynaecologists (RCOG) has recommended that there should be a substantial increase in the presence of senior obstetricians in NHS hospitals. Babies can be born at any time of the day or night, any day of the week, and complications can occur at any time. Women and their families rightly expect there to be senior staff available to deal with any problems which may occur. Consequently, it is recommended that the largest maternity units (between 4,000 and 8,000 births per year) should provide round the clock senior doctor presence; while other units should provide 98 hours of cover a week55. Senior doctor presence in NW London is significantly below these levels, with current averages of between 48 and 66 hours of senior doctor presence in local maternity units per week. Implementing Royal College recommendations for obstetric presence on a labour ward is challenging not just within London, but nationally. In addition, there are shortages of midwives and neonatal nurses which leads to poorer quality care for women and babies. This is not a problem that can be solved by simply training and hiring more doctors, nurses and other clinicians. To provide safe and effective care, clinicians need experience of dealing with complications on a regular basis. They cannot get this experience if they are spread across lots of hospitals. Moving to higher rates of senior staff at all times of the week will mean reducing the number of units providing emergency care. At the same time, the introduction of the European Working Time Directive (EWTD) has quite rightly restricted the number of hours junior doctors can work to prevent them being over tired.

54 Survey of London Acute Trusts 2011 55 The Future Workforce in Obstetrics and Gynaecology (RCOG 2009)


Traditionally the NHS has relied on junior doctors to provide a lot of frontline medical care, particularly at evenings and weekends, so this is posing a real challenge. It is now much harder for smaller units to ensure that medical cover is available at all times of the day and night56. Since the application of the EWTD to junior doctors, there has been a 50% increase in the number of junior medical staff required to provide 24/7 care and many units have struggled to achieve this57. An example of where these challenges have been faced is Central Middlesex Hospital.

Central Middlesex Hospital A&E

Providing good hospital care, to a consistently high standard, across NW London, is not just about the quality of care delivered – it is also about the quality and availability of those delivering the care.

The A&E department at Central Middlesex Hospital has temporarily reduced the hours it is open because it does not have sufficient clinical staff, of the right level and expertise, available all the time. Departments such as this are finding staff recruitment challenging as the labour market is constrained and the roles are less attractive than those at larger centres.

There are also national shortages of some clinical staff groups, such as paediatricians, midwives, radiologists and pathologists (these latter two are important because of the work they do to support A&E, surgery and other services). National shortages due to the numbers of individuals currently entering training are expected to continue in the future. Though this is not simply a question of training and hiring more staff as even if there were more suitably trained staff in place, they would quickly begin to lose their skills as they would not be seeing sufficient volumes of patients.

These problems are not new; indeed they have been there for a long time. But as we have continued to improve our care provision, these areas have become increasingly noticeable and it has been demonstrated how care improves when we have the right supervising specialist staff available 24/7.

4.4 …and by providing access to specialised care

In some areas, quality of care is related to specialist teams who gain skills because of the increased numbers they treat. It has long been established from many clinical studies and reports that the more specialised doctors and other professional staff become, the better the results for patients.58

For example, specialist surgeons achieve better results for their patients than generalist surgeons performing the same operation in 9 out of 10 cases. Patients treated by a specialist surgeon are at lower risk of death, are likely to have fewer complications and are likely to benefit from shorter stays in hospital59. Specialists become proficient by dealing with large numbers of similar cases.

56 The King’s Fund Briefing 2011, Reconfiguring Hospital Services 57 The King’s Fund Briefing 2011, Reconfiguring Hospital Service 58 Hall B, Hsiao E, Majercik S, Hirbe M and Hamilton B, The Impact of Surgeon Specialization on Patient Mortality: Examination

of a Continuous Herfindahl-Hirschman Index; Annals of Surgery, 200 59 Chowdhury M, Dagash H and Pierro A, A systematic review of the impact of volume of surgery and specialization on patient

outcome; British Journal of Surgery, 2007


And by being located in specialist centres and working as part of a network of specialist staff, they can access the best equipment and develop their skills by working alongside other specialists.

There are some excellent specialist centres and networks already benefitting patients and carers in NW London. However, there are other areas of clinical practice which would also benefit by being centralised in a few centres of excellence, such as specialist laparoscopic or keyhole surgery60,61. Laparoscopic surgery is associated with faster recovery times and can improve patient outcomes, yet at Ealing Hospital only a third of surgeons providing emergency care are able to perform laparoscopic surgery.

NW London Emergency Surgeons62

With increasing specialisation and guidelines setting standards for the degree of experience staff need to get to be sufficiently qualified, it is becoming increasingly difficult for the NHS in NW London to sustain the specialist surgical teams needed and ensure they see the volume of cases to enable surgeons to maintain their specialist skills across all our current sites. There are a high number of sites with smaller staff teams. This results in patients not being assessed and treated by a specialist with the right experience. For example, in emergency surgery, the Royal College of Surgeons (RCS) has noted that a hospital delivering urgent surgery should have a population catchment area of around 450,000 – 500,000 to achieve the volume and case mix necessary to maintain the clinical skills of teams delivering emergency medical and surgical care, given the effect of sub-specialisation63.

60 NHS London, Adult emergency services: acute medicine and emergency general surgery, NHS London, 2011 61 Profile of health and services in South West London, Report of the Clinical Working Groups, July 2011 62 Trusts in NW London are working to address issues identified in this report and have made significant progress. For example

Chelsea and Westminster now have added surgical capacity to allow 24/7 consultant cover for providing laparoscopic surgery 63 RCS Delivering High Quality Surgical Services (2006)


With NW London’s population of 2 million it is increasingly hard to provide a broad range of services around the clock at nine sites to the standards we believe our population should expect. We have more A&E departments per head of population than other parts of the country and this makes it harder to ensure enough senior staff are available. In NW London the average catchment areas of our A&E sites are below the national average and all, with the exception of Northwick Park, are below the Royal College of Surgeons preferred level.

Other very specialist services – cardiology, oncology (cancer), vascular surgery and neurosurgery – need to be delivered in larger centres of excellence with specialist staff, equipment and facilities. This allows the workforce to train and maintain their expert skills and to utilise specialist facilities and equipment to deliver high quality outcomes.

Residents of NW London currently enjoy excellent access to acute services, with travel times between hospitals being relatively short in comparison to other areas of the UK. Our analysis suggests that we should be able to change where and how urgent care is delivered without significantly impacting how long it takes an ambulance to take a patient to hospital. We are certain that travel times will still be well within accepted limits.

Furthermore, medical evidence clearly indicates that for life-threatening conditions – for example a heart attack, stroke or major trauma – the clinical outcome is far more dependent on getting to the right specialist service than it is on small differences in travel times. Indeed NHS London has already implemented pathways of care that take patients with major trauma, acute heart attack or stroke to designated centres, even if that means going past another hospital. The clinical benefit, in terms of improved survival and reduced disability from the implementation of these pathways, has been proven. If high quality hospital care is to be delivered, there is a clear need to consolidate some services in North West London.


5. Providers face significant estates and financial challenges

5.1 NW London’s NHS hospital estate needs £150m investment at the same time as additional investment is needed for primary and community care facilities

The NHS is facing challenges not just in terms of the way it manages and delivers care in NW London, but also in terms of the facilities within which it delivers that care – NHS buildings in NW London are, generally, not in good shape. First, NW London spends more on hospital buildings than the NHS does in other parts of the country and, as a result, spends less in the community. The space per bed is approximately 50% larger than the rest of the country, and consequently there are higher fixed costs and they are more expensive to run and maintain than average.

This is not a good use of space in an expensive, densely populated area like London. It is not a good use of NHS resources and is part of the reason NW London currently spends 10% more per capita on hospital care than other parts of the country. Despite having three newly built hospitals (Central Middlesex, Chelsea and Westminster and West Middlesex), the physical condition of much of the NHS estate here is poor. Currently three quarters of hospitals in NW London require significant investment and refurbishment to meet modern standards, at an estimated cost of approximately £150m64. We need to prioritise where we invest to maximum effect as capital funding is a scarce resource. This is particularly important because centralising services will require investment.

64 ERIC Site-level data, HEFS, 2010/11 (http://www.hefs.ic.nhs.uk/DataFiles.asp)


In addition primary and community care requires further investment. Many of NW London’s GP practices do not fully meet statutory requirements and guidelines. For instance, GP practices in Ealing would require £6.5m investment to meet these standards – an average of £81,000 per practice65.

5.2 Our hospitals face extreme financial pressures

As well as their physical condition, many hospitals in NW London are facing acute financial challenges – three are currently in underlying financial deficit and this is likely to get worse. While there are a number of financially high performing hospitals including Chelsea and Westminster, Royal Brompton and Harefield, and the Royal Marsden, others in NW London struggle to operate within their means. Imperial College Healthcare Trust and NW London Hospitals Trust are projecting deficits for this financial year and several other trusts are facing challenges which are likely to lead to deterioration in their position in the future.

65 Ealing Facet Surveys 2008/9 summary findings, Ingleton Wood


There needs to be a hard look at the way services across this part of London are organised if high quality services are to be delivered in future in a financially sustainable way. This is not just because of funding constraints on the NHS – the boroughs in NW London spend more on healthcare overall than elsewhere in the country and spend more on acute hospitals per head of population than anywhere in the country, both on cost per case and in total spending.

Rather, the financial problems are caused by the previously noted problem of serving typically smaller populations and therefore having a cost per case that is much higher. This makes it relatively expensive to meet staffing guidelines which are often independent of the size of the hospital (for example, College of Emergency Medicine guidelines that 10 whole time equivalent consultants as a minimum in every emergency department independent of size). Added to this, some processes in NW London hospitals are simply not as efficient as they need to be. For example, planned surgery appointments are often cancelled on the day because emergencies in other parts of the hospital take priority. In 2010/11, many operations in NW London were cancelled on the day of the operation for non-clinical reasons such as this66. This is distressing for patients and carers and wasteful in terms of the resources needed to reschedule appointments. A detailed examination of the current level of productivity of our hospitals shows we have a big improvement opportunity. Doctor productivity (as measured by hospital clinical income per doctor) is close to 20% lower than average and it takes 20% more nurses to deliver our clinical activity than we might expect. But even if our hospitals can achieve these productivity gains, the way we are organised means they will still struggle to break even.

66 Department of Health



6. Rising to the challenge

In order to meet these challenges and improve the quality of care provided across NW London, we believe we need to ‘reconfigure’ our services and change the way they are currently provided across our hospitals, GP practices and other community care sites. This will mean we will need to review the current pattern of hospitals in NW London. We need to ensure that people in NW London have access to the right care in the right places. Higher quality, more effective treatments for patients need to be provided more consistently where they are needed, within higher quality, more up-to-date, safer places. Care needs to be provided in a more integrated way, in partnership with social services and local government, so that it is clear to patients who is managing their care and that they can seamlessly transition between care settings. More investment needs to be made in GP services and other local healthcare, so it is more consistent and of a higher standard, bringing better routine treatments closer to home and supporting more services outside hospitals, where they are needed. Alongside this, clinical teams need to be established so patients needing specialist treatment can be certain they will be seen by experienced specialist clinicians, who are familiar with, and who regularly treat, similar patients with their condition. This also implies more efficient use of NHS buildings and equipment and more targeted investment in both, as well as reduced management costs by planning care across a larger area and achieving savings on a larger scale.

Redesigning services, in the ways outlined above, will enable us to improve the quality of services and increase life expectancy within the resources available.

Our commitments to you once we have made these changes are that:

• You can be supported to take better care of yourself, lead a healthier lifestyle, understand where and when you can get treatment if you have a problem, understand different treatment options and better manage your own conditions with the support of healthcare professionals if you wish;

• When you have an urgent healthcare need, you can easily access a primary care clinician 24 hours a day, seven days a week by telephone, email and face-to-face consultations in local, easily accessible facilities;

• If you need to see a specialist or receive support from community or social care services, this will be organised in a timely way and GPs will be responsible for co-ordinating the delivery of your healthcare;

• If you need to be admitted to hospital, it will be to a properly maintained and up-to-date facility where you receive care delivered by highly trained specialists, available seven days a week, with the specific skills needed to treat you.

NW London has recently launched a programme to develop the options for service configuration together with local hospital, GP and community providers with the aim of identifying options for improving the configuration for public consultation, starting in June 2012.


In many ways, the case for making these urgent changes is compelling. In practice, there are understandable local loyalties to having services as close to home as possible and change can be difficult to achieve. It is imperative that we collectively work together to make changes that improve the standard of care for our local population.

But we need to make changes urgently. We can either keep a model of NHS care that will inexorably fall behind the rest of the country and the needs of our patients, or try to change things now and offer all members of our society the best care we can give them.

This is about the future, not the present. It is about saving lives, not money. By implementing these changes, we will save lives in NW London. The value of the NHS is not just about physical buildings, but about the collective skills and resources that need to be managed and properly planned, now, to offer the next generation even better care than we offer at present.

Letter: NHS change must be driven by clinical evidence67

There has been a wealth of clinical evidence for many years that specialist clinical services, such as stroke, trauma and heart surgery, should be concentrated in fewer centres. This would allow the latest equipment to be sited with a critical mass of expert clinicians who regularly manage these challenging clinical problems, and are backed by the most up-to-date research. The greater volumes of patients mean doctors are better at spotting problems and treating them quickly.

Survival and recovery rates would improve markedly with many lives saved. As techniques and technology have developed over recent years, specialty rather than proximity has become the key for patient safety. So increased patient safety and improved care must be the major drivers of any reconfiguration.

Patients may indeed have to travel further for some specialist care, but if it is significantly better care then we believe that centralisation is justified.

However, at the same time there is also strong evidence to support a large amount of more routine care, currently taking place in hospitals, being carried out closer to where patients live in the community with GPs playing a crucial role in the delivery of services.

Delivering this requires strong leadership and brave decision-making from doctors, managers and politicians. Simply condemning change as bad and defending the status quo as ideal is not serving the interests of patients.

Signed by all the Presidents of the following organisations at the time: Academy of Medical Royal Colleges, Royal College of Physicians, Royal College General Practitioners, NHS Confederation, Royal College of Obstetricians and Gynaecologists, Royal College of Paediatrics & Child Health, Royal College of Psychiatrists, Royal College of Anaesthetists, Royal College of Radiologists, Royal College of Ophthalmologists, Faculty of Public Health Medicine, Faculty of Pharmaceutical Medicine, Faculty of Occupational Health

67 Extract from a letter that appeared in The Guardian on the 28 April 2010, quoted in Safe and Sustainable: a new vision for children’s congenital heart services in England, Consultation document - 1 March 2011 to 1 July 2011


Appendix

Diagram 1

Diagram 2


Diagram 3

Diagram 4


Diagram 5

Diagram 6


Diagram 7

Diagram 8

Appendix E – Literature review of available relevant clinical evidence

Appendix E – Literature review of

available relevant clinical evidence


Edition: 1.0

12 February 2012

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E1. Literature Review of Clinical Evidence for Change and

Clinical Response to Consultation Responses

The changes in clinical services and the structural model in these proposals are a response to increasing evidence that the current delivery system is not optimal for care in the 21st century. The NHS structures were designed at a time when care was responding to infections and other acute short term reactive treatments. The health care system of the future needs to deliver integrated care for a growing and aging population coping with Long Term Conditions, whilst also providing the best modern care for severe conditions when they arise. This appendix reviews the clinical evidence that underpins the Case for Change. In particular, discussing evidence for recommended changes and considers clinically related concerns raised during consultation. The Clinical Board has considered a wide range of clinical evidence as part of defining clinical service models and clinical quality standards for NW London. NW London‟s report on the Quality and Safety Programme‟s audit of acute trusts is provided at Appendix E2. This shows variable achievement against these new clinical quality standards. Reconfiguration of services will better enable hospitals in NW London to meet clinical quality standards. This chapter covers:

The clinical evidence based underpinning our clinical recommendations, with a particular focus on:

o Variability in hospital services o The benefits of subspecialisation and centralisation o Interdependencies between services o “The weekend effect” and resulting benefit of consolidation of services

The clinical evidence in regard to the key clinical concerns raised during consultation,

namely: o Impact of reconfiguration on health outcomes of changes to Travel times and

Access o Impact of reconfiguration on health outcomes for Deprived groups o Safety of proposed Bed Reductions

This review did not find any evidence that suggested that the clinical elements of the recommendation should be amended. E.1 The clinical evidence base underpinning our recommendations Currently hospital services in NW London perform well - but not as well as they could. They have low mortality indices and outcomes can be amongst the best in the country. General Practitioners (GPs) similarly can provide excellent co-ordinated care from excellent premises and work well with integrated community services. However this is not consistent across the range of hospitals or out of hospital services. The current model of delivery does not offer the opportunity for optimal twenty-first century care in any setting. The current structure of the NHS was set out by the then Minister for Health, Enoch Powell, in the "Hospital Plan for England and Wales" of 1962. This plan developed "District General Hospitals" of 600-800 beds designed to serve populations of about 125,000. This basic model is still in place despite the fact that health needs and health treatments are now radically different. The

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prevalence of diabetes had been doubling every 20 years1, now is 5.5% of the adult population2 (and much higher in some groups). In 1960 the average length of stay for a surgical procedure was eleven days, now it is less than five days, with 80 % of surgery being day case or short stay.3 The first full hip replacement was in 1962, now there are over 76,000 each year4. In April 2010 the Presidents of the Medical Academy collectively called for the reconfiguration of specialist services to improve outcomes: "There has been a wealth of clinical evidence for many years that specialist clinical services such as stroke, trauma and heart surgery should be concentrated in fewer centres. This would allow the latest equipment to be cited with a critical mass of expert clinicians who regularly manage these challenging clinical problems, and are backed up the most up to date research. The greater volumes of patients mean that doctors are better at spotting problems and treating them quickly. Survival and recovery rates would improve markedly with many lives saved"5. More recently the Royal College of Surgeons pointed out: "It is often better to deliver complicated care in centralised centres of excellence"6. The Kings Fund similarly commented: "There is increasing recognition that services such as emergency surgery may be unsafe out of hours, and the provision of these services needs to be concentrated in fewer centres that are better able to provide senior medical cover"7. The Royal College of Physicians recent report states: "It is increasingly clear that we must radically review the organisation of hospital care if the health service is to meet the needs of patients"8. There is a very wide range of supporting evidence and this document can only describe some of this information. References point to greater granularity of information. A fuller set of references is available for those wishing to investigate this further9. E.1.1 Variability in Hospital Services Performance and outcome tables show a wide range of outcomes for the providers in NW London. Even in the crudest measures - mortality - this varies widely10.

1 T Barnett. Epidemiology, complications and cost of Diabetes Mellitus. The Insulin treatment of Diabetes, 1998 pg 6-9 2 Quality and Outcomes Framework (QoF), 2011 3 A Darzi. Saws and Scalpels to lasers and Robots - Advances in surgery: Clinical case for change; DoH, 2007 4 National Joint Register Annual Report, 2011 5 Letter from presidents of Academy of Medical Royal Colleges and others to The Guardian, April 2010 6 Royal College of Surgeons. Reshaping Surgical Services: Principles for Change, January 2013 7 C Ham, A Dixon, B Brooke. Transforming the Delivery of Health and Social Care. King's Fund, 2012 8 Royal College of Physicians. Hospitals on the Edge, 2012 9 2010 Annual Evidence Update on NHS Service reconfiguration. arms.evidence.nhs.uk/resources/hub/36894/attachment 10 From Acute Trust Quality Dashboard - Midlands & East quality observatory. http://www.emqo.eastmidlands.nhs.uk/welcome/quality-indicators/acute-trust-quality-dashboard/published-dashboards/ 2012

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Figure E.1.1: Summary of Standardised Hospital Mortality Indices across NW London

SHMI

Emergency and Elective

Age / Sex standardised mortality from

conditions amenable to healthcare

Age / Sex standardised in

hospital mortality in low

risk HRGs

Crude in Hospital perinatal

mortality per 1000 births

Q4 11/12 Q1 12/13 Q1 12/13 Q1 12/13

(Nat Ave 8.35)

Chelsea & Westminster 76.4 85 51.8 8.8

Ealing 91.3 99.8 78.4 9.86

Imperial 75.8 107.7 119.0 11.2

NWLHT 81.9 98.5 92.8 12.16

THH 88.8 114.3 68.8 0.94 WMUH 98.5 198.4 127.8 11.09

The Standardised Hospital Mortality Index (SHMI) reports deaths following hospital treatment. Based on all conditions, deaths are measured which take place in or out of hospital for 30 days following discharge. The standard mortality indices have a national average of 100. The SHMI is considered the most robust measure. These outcomes are monitored closely by NW London and the local CCGs and the reason for any deterioration is investigated so that actions can be taken. Following the publication of the Francis Report11 Sir Bruce Keogh is leading an investigation into hospitals that are outliers in hospital performance12, particularly with poor SHMI, these are seen to have considerable challenge. Two are in East England SHA and three are in North West SHA.

SHMI

Emergency and Elective

Age / Sex standardised mortality from

conditions amenable to healthcare

Age / Sex standardised in

hospital mortality in low

risk HRGs

Crude in Hospital perinatal

mortality per 1000 births

Q4 11/12 Q1 12/13 Q1 12/13 Q1 12/13

(Nat Ave 8.35)

Colchester 117.6 120.2 134.8 10.59

Tameside 118.3 143.5 109.5 6.81

Blackpool 124.7 99.3 78.4 1.37 Basildon & Thurrock 112.3 106.2 118 6.73

East Lancashire 113.4 131.1 87.6 9.24 Each of these measures has strengths and weaknesses and each trust‟s figures are influenced by population served, treatments given and service systems - the illustration is to demonstrate very noticeable variation. If service changes can move the mortality rates of all hospitals to those of the best we would save hundreds of lives annually in NW London.

11 http://www.midstaffspublicinquiry.com/ 12 http://commissioningboardintranet.ning.com/page/a-summary-of-professor-sir-bruce-keogh-s-hospital-outliers-invest

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The clinical services across the acute sites are currently mixed.

Figure E.1.2: Summary of clinical services across the current acute sites in NW London13

General surgery

General Medicine

Inpatient Paediatrics

Obstetrics A&E UCC

Chelsea & Westminster Y Y Y Y Y Y

Central Middlesex N Y N N Partial1 Y

Charing Cross Y Y N N Y Y

Ealing Y Y Y Y Y Y

Hammersmith N2 Y N3 Y Partial4 Y

Hillingdon Y Y Y Y Y Y

Northwick Park Y Y Y Y Y Y

St Marys Y Y Y Y Y5 Y

West Middlesex Y Y Y Y Y Y

The breadth of variation in care is shown, for example by:

The quarterly Acute Trust Quality Dashboards - produced by the Quality Observatory The monthly trust performance figures The new National Quality Dashboard.

Audits have recently been completed across all the acute providers in London against the range of acute services standards. These have shown that no hospital is achieving all of the standards, but conversely all of the standards are met in at least one provider. The full NW London audit is can be found in Appendix E2. The variation is also highlighted in the Care Quality Commission (CQC) survey of local staff14 and in training satisfaction surveys15. In some trusts half the respondents would not recommend their own hospital as a place to receive treatment.

13 Programme Information. Notes from Figure E.1.2: 1. CMH is currently closed over night 2. Surgical cover is provided by gynaecology, hepatobiliary surgery or transfer 3. neonatal unit at QCMH at this site covers the obstetric unit 4. A&E is not staffed by specialist Emergency Medicine specialists for most of the time 5. Major Trauma Centre 14 http://nhsstaffsurveys.com/cms/index.php?page=2011-results 15 General Medicine Council survey, 2012

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Figure E.1.3: Summary of key indicators from CQC staff survey and training satisfaction survey16

Staff recommend as a

place to receive treatment

Overall medical trainee global satisfaction score

Chelsea & Westminster 79.9% 79.7%

Ealing 50.2% 72.6%

Imperial 69.7% 78.5%

NWLHT 56.6% 79.0%

THH 55.8% 78.2%

WMUH 46.1% 76.2% Considerable centralisation of key highest risk services has already occurred in London, often despite some local clinical and political opposition. In NW London there has been centralisation of stroke services with Hyper-Acute Stroke Units (HASU) at Northwick Park Hospital and Charing Cross Hospital. Prior to this pan-London reconfiguration there was very variable access to co-ordinated care or thrombolysis. The service is now17:

Thrombolysing a greater proportion(14%) of its population than any other large city in Europe

Admitting more patients directly to stroke units than other cities Taking patients from home to HASU by LAS in an average of under 15 minutes Average patients stays in hospital are on average four days less than previously Reducing ongoing disability. 70% of patients are back home at 90 days (previously 58%), estimated to save £21.3 million over the next ten years Reducing 90 day mortality by 25% Saving 130 lives in NW London each year Resulting in London's mortality from stroke is now 20% lower than any other Strategic

Health Authority (SHA) in England. The development of four Major Trauma centres has also contributed to improvements of care. In the first year of the service (2010/11) there were 58 lives saved, and this is expected to rise to 100 lives saved annually when the service is fully functioning. Heart Attack centres are now in place in Hammersmith and Harefield Hospitals. Patients suffering from a STEMI (ST-elevation Myocardial Infarction) heart attack benefit from primary angioplasty18. The first studies showing the benefit of this treatment was published in 198619. The centres in London were designated in 2006. Recent research has confirmed that treatment in these centres reduces the death rate by 22%20.

16 Green is in much better than average (> 3 standard deviation from average), red is much worse than average (> 3 standards deviations lower than average), amber (if 2 standard deviations below average) 17 London Health Programmes - Review of London Stroke Services, 2012 18 EC Keely, JA Boura, CL Grines. "Primary angioplasty v. Intravenous therapy for acute myocardial infarction: a quantitative review of 23 randomised trials". The Lancet, 2003, 3611:13-20 19 W O'Neill, GC Timmis, PD Bourdillon et al. A prospective randomized clinical trial of intracoronary streptokinase versus coronary angioplasty for acute myocardial infarction. New England Journal of Medicine, 1986, 314: 812-818 20 S Sen et al. Why Does Primary Angioplasty Not Work in Registries? Quantifying the Susceptibility of Real-World Comparative Effectiveness Data to Allocation Bias‟ Circulation Cardiovascular Quality and Outcomes, 2012, 13 November

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The most recent centralisation has been in vascular surgery. There is strong evidence that complex vascular surgery is best performed by specialist surgeons in high volume hospitals21, as shown in Figure E.1.4. Figure E.1.4: In-hospital mortality for complex vascular surgery22

Similar strong evidence confirms that carotid endarterectomy and other complex vascular surgery is much safer at a hospital that performs these procedures regularly23, 24. Complex vascular surgery was centralised to St Mary's and Northwick Park in 2011. There is only limited published research, and none from the UK that could be sourced to study the variation in outcomes by Emergency Department (ED) size - but the co-dependency showing benefits from larger range of surgical speciality and surgical volume is evident. No benefit is seen in moderate trauma, such as fracture neck of femur, where organisational systems are more important than size. American studies showed that patients admitted with COPD (Chronic Obstructive Pulmonary Disease) through a large volume ED have a 50% reduction in early inpatient mortality25, with early inpatient mortality of 0.47% in patients admitted through large volume EDs compared to 1.13% in low volume EDs. Patients admitted through high volume EDs also have lower mortality from sepsis.26 and heart failure27. There is less evidence available regarding the clinical benefits of centralising other medical emergency services, but unless very sophisticated triage systems were in place this evidence suggests centralisation of emergency services, medicine and surgery will be beneficial. There is no consistent evidence of a relationship between outcomes and size of units in maternity and newborn care services28. Indeed for low risk second pregnancies home delivery is as safe as a

21 JB Dimick, JA Cowan, JC Stanley et al. Surgeon specialty and provider volumes are related to outcome of intake aortic aneurysm repair, Journal of Vascular Surgery, 2003, 38:739-744 22 Healthcare for London. Cardiovascular Service. Case for change 2010 after JB Dinnock et al 'Surgical speciality and provider volumes are related to outcome in intact aortic aneurysm repair. Journal of Vascular Surgery, 2003,38:739-744 23 TE Feasby, H Quan, WA Ghali. Hospitals and surgeon determinants of carotid endarterectomy outcomes. Archives of Neurology, 2002, 59:1877-1881 24 PJE Holt, JD Poloniecki, M Thompson. Demonstrating safety through in-hospital mortality analysis. Brit Jour of Surgery, 2008, 95:64-71 25 C Tsai, GL Delclos, CA Camargo. Emergency Department case volume and patient outcome in acute exacerbations of COPD. Academic Emergency Medicine, 2012, 19(6):656-663 26

ES Powell, RK Khare, DM Courtney, J Feinglass. Volume of emergency department admission for sepsis is related to inpatient mortality. Critical Care Medicine, 2010 38 (11) :2161-8 27

JS Ross, et al. Hospital volume and 30 day mortality for three common conditions. N Eng J Med. 2010;362;110-8 28 K Norton, M Longley, M Ponton. The best configuration of hospital services in Wales: Quality and safety, 2012

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maternity unit, but with lower risk of intervention (but 10% or more of women transfer to obstetric units)29. The Royal College of Obstetrics & Gynaecology recommend a consultant obstetrician is on the unit at all times30. Severe foetal distress is more common after midnight, requiring the highest skills to interpret and manage. This means that a large team of consultants is required, and in turn, is only achievable in larger units. This is both to be affordable, but as importantly, to ensure that individual obstetricians have sufficient exposure to complex care to enable their skills to be maintained. Similarly there is no consistent evidence regarding the quality outcomes and size of paediatric units. The standards set out by the Royal College of Paediatrics & Child Health recommend that units with fewer than 1800 children admitted each year should be closed, but all the units in NW London are much bigger than this. Paediatrics is particularly challenged by its workforce shortages. It has increasingly sub-specialised so that neonatologists and general paediatricians have separated meaning that two teams and rotas are required, with less overlap. Paediatrics has benefitted from a relatively large proportion of female doctors, with a higher than average desire to work less than full-time for at least some of their career31. The number of predicted trainees and consultants is considerably less than required to support the current number of units nationally - with an estimate that 25% of paediatric inpatient units will need to close nationally. Much work has been undertaken in the Paediatric Clinical Implementation Group (CIG) (see Chapter 7) to consider whether a reduction from the current six inpatient paediatric units to five is sustainable, without further reduction in the future. Analysis of our current workforce (some teams having considerably larger midgrade structures than others, and a Paediatric Ambulatory Unit at Hammersmith) suggest that with redistribution of current staffing numbers this will be achievable. E.1.2 The benefits of subspecialisation and centralisation Each hospital serves its own local population and has different services to neighbouring hospitals, but often the clinical teams in hospitals have developed in ways that reflect the interests of the clinicians more than the health needs of the local population. For example Ealing Hospital has a particular interest in cardiology and West Middlesex in gastroenterology. Despite the very large numbers of diabetics in Southall the diabetic team at Ealing is smaller than at West Middlesex. Smaller hospitals have a smaller workforce and have difficulty in providing uniform consultant skills, particularly in the emergency out of hours setting. Surgical specialties are particular problems for emergency care. Acute abdominal pain is a common presentation in A&E and requires a general surgeon's skills, preferably with laparoscopic skills to allow investigation and 'keyhole' treatment of conditions like appendicitis more effectively, with fewer complications and shorter lengths of stay. Subspecialties of urology, vascular and breast surgery are no longer considered suitable for inclusion in the general surgical on-call rota. Audit of the acute providers in London in 201132 showed very variable numbers of surgeons and even greater variability of access to laparoscopic skills.

29 P Brocklehurst et al. 'Perinatal and Maternal outcomes by planned place of birth for healthy women with low risk pregnancies: The Birthplace in England national prospective cohort study. British Medical Journal, 2011, 343:bmj.d7400 30 Safer childbirth. minimum standards for the organisation and delivery of care in labour. Royal College of Obstetrics & Gynaecology, 2007 31 Acute Health Care Services. Report of a working party. Academy of Royal Medical Colleges. 2007, p29 32 London Health Programmes. NHS London. Adult Emergency Services Audit, September 2011

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Figure E.1.5: Total number of emergency surgeons in NW London

Since this audit the access to laparoscopy at Ealing has improved substantially, but with small numbers of consultants available for rotas, routine availability out of hours (with the constraints of the European Working Time Directive) is limited in small units. The size of surgical team by itself is however not a guarantee of improved care. For some conditions the adherence to guidelines and protocols is a stronger determinant of outcome than volume of activity and this can be attained well in some small units33. Readmission rates for some common surgical procedures are high across NW London34. The potential benefit from specialisation is greater for life-threatening conditions like stroke and heart attack, but is also true for less severe conditions. In 1996 the NHS Centre of Reviews and Dissemination published a systematic review showing that similar association between volumes and outcomes was also present for gastric surgery, intestinal surgery, cholecystectomy and lower limb amputation35. Soljak reviewed a wider range of conditions that would benefit from such concentration of services36. For example, orthopaedic surgery on a hip has better outcomes when performed by a surgeon with that specialist interest who operates frequently37. There is also very strong evidence that hospitals that organise their care to enable rapid operation have much lower morbidity and mortality for patients who have fractured their hip38. Currently there is very variable delivery of a 48 hour standard across the provider units39 whilst the agreed London-wide standard is now to operate within 24 hours, as has been the standard in Scotland for some time. The CCGs in Hillingdon and Hounslow have identified this as a priority and have worked with their local hospital and this is evident in their much better access to rapid surgery.

33 The Royal College of Surgeons of England/DoH. The Higher Risk General Surgical Patient: towards improved care for a forgotten group. Available from http://www.rcseng.ac.uk/publications/docs/higher-risk-surgical-patient/ 2011 34 NWL Performance team from SUS data, April-Sept 2011 35 NHS Centre for reviews and dissemination: Hospital volume and health outcomes, cost and patient access. Effective Healthcare Bulletin, 1996, 2:8 36 M Soljak. Volume of procedures and outcome of treatment. British Medical Journal, 2002, 325:787-788 37 JA Browne, R Pietrobon, SA Olson, 2009, March, 66(3):809-14 38 NICE Hip fracture: the management of hip fracture in adults. NICE clinical guideline 124, 2011 39 Acute Trust Quality Dashboard. Autumn 2012. Midlands & East Quality Observatory, Data Q1 12/13

http://www.nice.org.uk/guidance/CG124

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Figure E.1.6: Percentage of hip fracture operations carried out within 48 hours40

% of hip fracture

operations carried out within 48 hours

Chelsea & Westminster 72.7%

Ealing 31.3%

Imperial 76.6%

NWLHT 51.2%

THH 83.3%

WMUH 100%

England (avg.) 77.9%

Figure E.1.7: Readmissions for cholecystectomies41, April to September 201142

The results from emergency surgery continue to be varied across the country, with a recent report from a voluntary audit into emergency laparotomy showing a twelve-fold difference in mortality between units43. Importantly this study again showed that mortality was less when consultant surgeon and consultant anaesthetist were present during the operation and this is least likely at night. E.1.3 Interdependencies between services There is often a presumption by the public that acute hospitals provide a similar range of high standard care and services. Currently this is far from the case with key acute services absent from acute sites (as shown in Figure E.1.2). The Shaping a healthier future Clinical Board felt strongly that in an urban area with short travel times the best care can be provided by ensuring that all hospitals with a full Accident and Emergency Department (also called 999 Emergency Departments) have a full complement of emergency services - general surgery, general medicine,

40 Acute Trust Quality Dashboard Q1 2012/13 41 Surgical removal of the gallbladder 42 NW London Performance team 43 DI Saunders, D Murray, AC Pichel, S Varley and CJ Peden. Variations in mortality after emergency laparotomy: the first report of the UK emergency laparotomy network. British Journal of Anaesthetics, 2012, 109(3):368-375

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obstetrics with neonatology, paediatrics, intensive care and diagnostics. These assertions are supported by the standards from the specialist colleges44, 45. The Acute Services Working Party of the Academy of Medical Royal Colleges recorded: "Hospitals accepting unselected medical patients must have on-site surgical opinion. Departure from this would only be tolerable in the most exceptional circumstances". This is currently not the case at Central Middlesex Hospital and surgical support at Hammersmith is not from general surgeons, but from specialist gynaecology and hepatobilary (liver) surgeons. As opposed to routine pregnancy and birth care, which can be safely delivered at home or in a standalone midwifery unit46, an obstetric unit (which deals with complex pregnancies which require medical intervention) needs to have co-located acute medicine, critical care, anaesthetics, emergency support services (imaging, transfusion, pathology) and neonatology47. These services also need very rapid access to acute surgical and interventional radiology support. It is possible to provide these in a formal network with rapid transfer of patient to another unit. Moving the surgical team as an alternative would mean that all sites would need to have surgical theatre and equipment provision, for occasional emergency work, as well as waste clinical skills during travel and leaving their base unsupported. If services are centralised then the risk of moving patients who deteriorate is avoided. The Clinical Board in NW London strongly supported the model of co-locating all the necessary emergency specialties on major hospital sites in view of the short distances between the current sites. Figure E.1.8: Clinical co-dependencies for an acute hospital and obstetric unit48

E.1.4. "The Weekend Effect" and resulting benefit of consolidation of services 44 Royal College of Surgeons of England. Delivering High Quality Surgical Services for the future, 2006 45 Royal College of Physicians. Isolated Medical Services, 2002 46 P Brocklehurst et al. Perinatal and Maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. British Medical Journal, 2011, 343:d7400 47 Critical Dependencies. London Health Programmes, 2013 48 London Health Programmes

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There is increasing evidence that patients admitted to hospital on Friday evening and at weekends do less well than patients admitted in the working week49, 50. Length of Stay is greater, complication rates higher and risk of death is increased, by on average 10%. Smaller studies have shown this affect some years earlier51, and literature is now clear, although small studies may be too small to detect differences in mortality 52. Following the large multicentre study, the same team from Dr Foster Intelligence were asked to review services in London and found similar results53. An excellent review of the literature was undertaken by Webb54 and interested readers can access many more references in that publication. The “Weekend Effect” is not consistently seen in intensive care, paediatric ICU or neonatology where senior clinicians manage the care much more consistently than in other hospital services. Conversely the effect was greatest in stroke and acute renal failure, where the increased mortality is nearer 20-30%. Importantly this extreme increase can be nullified and the effect removed with reorganisation of services55, 56, 57 and this has already been shown in the reorganisation of stroke services in London. The cause of the weekend effect is probably multi-factorial. It is evident that senior clinicians are less often on site at weekends. A recent audit of London sites showed consultant surgeons are on site for an average of four hours at weekends58. Whilst they are always available to junior staff for advice and willing to be called in there is often a reluctance to bother a senior clinician who will be responsible for the next reference.

49 P Aylin, A Yunus, A Bottle, A Majeed, D Bell. Weekend mortality for emergency admissions. A large multicentre study. Qual Saf HealthCare, 2010, 19(3):213-7 50 Freemantle et al (2012). Weekend Hospitalisation and additional risk of death an analysis of inpatient data. Journal of Society of Medicine, 2012, 1-11 51 C Bell, DA Redelmeier. 'Mortality among patients admitted to hospitals on weekends as compared with weekdays. NEJM, 2001, 345:663-668 52 L Schmulewitz, A Proudfoot, D Bell. The impact of weekends on outcome for emergency patients. Clinical Medicine, 2005, 5:621-625 53 Adult Emergency Services: Case for Change. London Health Programmes, 2011 54 M Webb. The weekend effect: a rapid review of the literature, Public Health Wales 55 KC Albright et al. Can Comprehensive Stroke Centres Erase the 'Weekend Effect'?. Cerebrovascular Discovery, 2009, 27:107-113 56 WL Palmer, A Bottle, C Davie, CA Vincent, P Aylin. Dying for the weekend: the association between day of hospital presentation and the quality and safety of stroke care. Arch Neurol. 2012. Jul 9:1-7. 57 JP Sheppard, J Mant, T Quinn, RJ McManus. Something for the Weekend?, JAMA Neurology, 70, 1:130 58 Adult Emergency Services. Hospital Services Audit. London Health Programmes. 2011

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Figure E.1.9: Average hours on site for consultants in London59

Factors proposed as explanations include staffing deficiencies at nights and at weekends, poor communication and handovers, and delays in diagnostic and therapeutic procedures. There may also be variation in populations admitted, with palliative patients being admitted at weekends when community care is also less well organised60. The NCEPOD report in 2005 highlighted that the most significant problem was lack of involvement of consultants61 and the report in 2007 showed that their input remained low in the first 24 hours of admission62. The Commissioning Standards that will be supported by the proposals in SaHF help address these issues. In the audit of emergency laparotomy it was evident that surgery at night was much less likely to have consultant presence, however the same study showed that these patients were most ill and more likely to die. Figure E.1.10: Variations in mortality after emergency laparotomy63

Time of day Number of procedures

Consultant anaesthetist present (%)

Consultant surgeon

present (%) 30 day mortality

08:00-17:59 1044 75.2 80.8 14.2

18:00-23:59 442 54.8 67.7 17.8

00:00-07:59 152 40.8 61.8 20.3

The proposals in the Shaping a healthier future seek to address each of these areas, with commissioning clinical standards, that incorporate more senior on site clinicians to deliver a consultant delivered NHS 64, access to diagnostics and improved care in the community through the out of hospital services.

59 Survey of London acute trusts (2011). London Health Programme Emergency Services Review 60 NCEPOD Report 2009: Caring to the end? 61 NCEPOD Report 2005: An acute problem? 62 NCEPOD Report 2007: Emergency admissions: a step in the right direction 63DI Saunders, D Murray, AC Pichel and CJ Peden. Variation in mortality after emergency laparotomy: The first report of the UK Emergency Laparotomy Network. British Journal of Anaesthetics. 2012, 109(3):368-375 64 The Benefits of Consultant Delivered Care. Academy of Medical Royal Colleges. 2012

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NHS planning guidance for 2013/1465 recognises that patients need access to services seven days a week to become an "every day health service" with the planning guidance supporting "routine NHS seven days a week". This will offer "a much more patient-focused service and also offers the opportunity to improve clinical outcomes and reduce costs"66.

The planning guidance suggests starting by focussing on diagnostics and urgent and emergency care. It emphasises that this is based on the premise that "primary and community services will also deliver a high quality responsive service both in and out of hours"67.

These proposals will help local commissioners to achieve these benefits to emergency care by concentrating services onto fewer sites so that access to senior clinicians will be available at weekends. The audit of emergency services showed that currently there is no routine A&E Consultant available in the smaller units at weekends. E.2 Specific Concerns raised during consultation During consultation many concerns were raised about the specific implications and fears about potential negative effects. Some of these were very specific, ("will I still be able to visit my neurologist in my Multiple Sclerosis clinic at Charing Cross?") and these were answered as they arose. However, three cross cutting themes of concern were noted. In part these are considered elsewhere in this DMBC (for example, the travel analysis in Chapter 12 shows that travel times in emergency are only slightly affected) but the Clinical Board asked for a review of literature around these three themes:

Impact of reconfiguration on health outcomes of changes to travel times and access (see also Chapter 12)

Impact of reconfiguration on health outcomes for deprived groups (see also Chapter 13) Safety of Proposed Bed Reductions

E.2.1 Impact of reconfiguration on health outcomes of changes to travel times and access Access is clearly an important issue. There is no benefit of having fantastic services if patients are unable to make advantage of them and conversely there is little benefit from accessing services that are likely to harm the patient. Alan Maynard points out: "For the last 20 years, the NHS has groped its way to centralising the provision of paediatric cardiac surgery and trauma centres. Neither policy is popular with the public, who often prefer more local and smaller facilities which are more successful at killing and maiming them.”68 Other factors are the quantity, skills and affordability if the workforce and system in which the patient is living. 65 Everyone counts: Planning for Patients 2013/14. available as http://www.commissioningboard.nhs.uk/files/2012/12/everyonecounts-planning.pdf 66 Everyone counts: Planning for Patients 2013,14, Section 1.14 67

Everyone counts: Planning for Patients 2013,14, Section 1.15 68http://www.healthpolicyinsight.com/?q=node/1433 Prof. Alan Maynard. Dir. of York Health Policy Group. University of York.

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Figure E.2.1: The determinates of high quality hospital care69 The challenge raised through consultation is that in attempting to improve quality (though some consulted question that as well) we have reduced access in a way that will have a detrimental effect on health outcomes. Firstly it is important to consider how access has been affected. Some access will improve, with:

More services will be provided at home o By community services, o Telemonitoring, improved access to self-help information o Improved and supported self care.

More services will be provided in GP surgeries and community hubs o By improved support to GP o Telemedicine, virtual health care teams, shared care records o Outreach clinics with specialist doctors and nurses coming into the community.

Many services will remain the same or better, with:

Most services will continue on local hospital sites o Outpatients (including where follow up to a more distant major hospital) o Diagnostic tests, e.g. X-rays and scans o Urgent Care (111 Emergency Service) - managing most noncomplex emergency

care

There will be some new services, with:

Increased rehabilitation service Increased dialysis

Some services will be more distant for some of the population, but often of a higher quality:

Emergency Departments (999 Emergency Service) Emergency medical, surgical and paediatric beds Obstetric unit

In addition to this there are a wide range of initiatives to reduce demand for these more distant services. This will be considered further in the section on bed reductions. Technology and „e‟ services are likely to be an important factor in improving access to services, particularly out of hospital services. However, eHealth technologies also have mixed evidence. A

69 M Longley. The best configuration of hospital services for Wales: a review of the evidence. Summary, 2012

Access

Cost

Workforce

Quality

Context e.g.

population health, other services, policy

Acceptable Balance for

Reconfigured Services

15

systematic review suggested that the benefits when rolled out were less than predicted70, or at least poorly evaluated. The Auditor General for Scotland did a further review71 and concluded that there were benefits regarding access, quality and efficiency. More specifically:

Telehealth o Allowed support for people at home and reduced need to travel o Mobile phones, internet services, digital TV, video-conferencing, self-monitoring

equipment Telecare

o Uses technology to support people to live independently o Fall monitors, motion detectors, alarms

eHealth o Allows a higher quality efficient service o IT systems, shared records, pathway and guideline tools

Most recently the Whole Systems Demonstrator Action Network (WSDAN) has reported72 showing that the use of technology by community staff caused very great increases in productivity, enabled more patients to manage at home and significantly reduced referrals and admissions. Whilst these actions reduce the numbers of people there will be some who have to travel further in the recommended reconfiguration. These are in two main groups:

1. People travelling to a more distant Major Hospital in an emergency 2. Visitors and carers to patients admitted at a more distant Major Hospital

E.2.1.1. Patient Travel Impact There is a limited evidence base to consider the impact of travel time to outcomes. The positive evidence showing no deterioration and improved outcomes in stroke, heart attack, aortic aneurysm and major trauma have not been reviewed here as these services have already benefitted from centralisation. Jones et al. reviewed access and outcomes for cancer73. This analysed data between 1994 and 2002 and showed that for breast and colorectal cancer a late diagnosis, and for prostatic carcinoma, mortality, was associated with increased travel time to the GP, but there was no association with travel time to hospital. Ravelli et al reviewed travel times from home to the hospital in the Netherlands74. This found that mortality and adverse neonatal outcomes were more likely if the car travel time to the hospital was over twenty minutes. Importantly the paper and the Royal College of Obstetrics & Gynaecology75 highlight that maternity care is very different in the Netherlands than in the UK. In their system most women at low risk have their babies delivered at home and only transferred to hospital if they are at high risk or if there are problems that become apparent in established labour. In contrast in the UK most women travel to hospitals in the early stage of labour. More recent reviews of neonatal and maternal death in London have not shown this association.

70 Black AD, Car J, Pagliari C, et al. The impact of eHealth on the quality and safety of health care: a systematic overview. PLoS Medicine, 2011, 8(1):e1000387 71 A Review of telehealth in Scotland (2011). Auditor General for Scotland. 72 National Mobile Health Worker Project. DoH, 2013 73 AP Jones, R Haynes, V Sauerzapf, SM Crawford, H Zhao, D Foreman. Travel times to healthcare and survival from cancers in Northern England. European Journal of Cancer, 2008, 44 74ACJ Ravelli et al. Travel time from home to hospital and adverse perinatal outcomes in women at term in the Netherlands. BJOG. 2011, 118:457-465 75 Nair, R. & Hawkins, E. Travel time from home to hospital and adverse perinatal outcomes in women at term in the Netherlands'. BJOG: An International Journal of Obstetrics & Gynaecology, 2011, 118: 887–888

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Infant death risk has been shown not to be affected by hospital accessibility76 following a review of all infant deaths in Cumbria from 1950-1993, where travel times are much greater than experienced in NW London. Nicholl however did show an increase in mortality in some emergencies77. A review of emergency ambulance patients (Category A excluding cardiac arrests) between 1997 and 2001 showed a 1% increased absolute risk of mortality for every 10km extra distance travelled. The association was greatest in patients with respiratory problems. Two further studies have shown similar increases in risk in asthma patients. A study in East Anglia78 showed that for patients between 1985 and 1995 there was an increased risk of 7% for each additional 10 minutes travelled. The same authors had previously shown79 a 10% relative risk of death for each 10km increase in distance in Norfolk between 1988 and 1992. Subsequent commentaries on these papers suggest that the key factor is differing utilisation of asthma preventative measures, access to primary care and delayed calling of ambulance during disease progression were the likely causative factor80, rather than the increased ambulance arrival or transfer times. No further studies have replicated these findings and Nicholl suggests that the time to initial treatment is the key factor81. He points out that studies looking at major trauma, road traffic accidents and ruptured aortic aneurysms don't show any increased risks by increased travel distances. Since these studies much work has progressed in training ambulance crews and the development of the paramedic role82. The scope of the interventions, including nebulisation of asthma treatments in ambulances has been developed83. It is considered that ambulances are no longer just "fast buses for the injured", but more akin to "Intensive Care Units on wheels"84, with ECG (ElectroCardioGram) and other monitoring and paramedics inserting drips and giving drugs. The areas of NW London furthest from major hospitals remained unchanged during the proposed consultation and it was not possible to find public health data suggesting increased asthma mortality in areas of NW London distant to A&Es compared to those closer to the current units, but this would require much greater analysis than is possible to exclude all possible confounding factors. Studies from the US have confirmed that greater distances from an Emergency Department reduces attendance85 and this has also been shown in audits of A&E attendances from practices within Ealing PCT, where practices closest to A&E have greater numbers of A&E attendees. The study did not assess the outcomes associated with this, but suggest that patients in more rural settings have differing coping strategies and use local primary care as a more convenient support service.

76 TJB Dummer, L Parker. Hospital accessibility and infant death risk. Archives of Disease in Childhood, 2004, 89:232-234 77 J Nichol, J West, S Goodacre, J Turner. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emergency Medicine Journal, 2007, 24(9):665-8 78 AP Jones, G Bentham and C Horwell. Health Service accessibility and deaths from asthma'. International Journal Epidemiology. 1999, 28(1):101-105 79 Jones AP, Bentham G. Health service accessibility and deaths from asthma in 401 local authority districts in England and Wales. 1988-92. Thorax 1997, 52:218–22 80 JE Garrett. Health Service accessibility and deaths from asthma. Editorial, Thorax. 1997, 52:205-206 81 J Nicholl. 2007 op cit 82 H Barratt, R Raine. Hospital Service reconfiguration: the battle for hearts and minds. British Medical Journal, 2012, 344:e953 83 P Spurgeon et al. Evaluating models of service delivery: reconfiguration principle. National Institute of Health Research Service Delivery and Organisation Programme, 2010 84 Prof Martin Gore. Conversation Clinical Board, January 2013 85 PL Hennerman et al. 'Geography and Travel Distance impact emergency department visits'. Journal of Emergency Medicine, 2011, 40:333-339

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Travelling long distances for regular visits and treatments places an increased stress on patients, but studies following centralisation of cancer services86 in Europe have been inconclusive in demonstrating a reduction in completion of treatment or outcomes. Attendance to Hepatitis C clinics following GP referrals in Scotland was not affected by the travel-time to the specialist clinic87. Most studies included within this review assessed impacts of travel distances in rural parts of Australia, Canada and New Zealand and were not directly applicable. Surveys in London have previously shown an acceptance of the need to travel for specialist and emergency care. Figure E.2.2: Survey results indicating willingness of London residents to travel for different types of treatment88

Currently there is a divergence in pattern between geographical access to emergency care, where patients tend to go to the closest unit (or are taken there by ambulance) and in conditions where patients have greater opportunity to exercise choice, e.g. in outpatients and planned care where there is a much greater use of specialist units in London, or more distant referrals near work or to clinicians with particular interests89. In summary the evidence supports the conclusion that distance to hospitals is a small factor in determining people's overall access to healthcare90. E.2.1.2. Visitor Travel Impact There has been a very slow increase in hospitals allowing greater flexibility in visiting hours for friends, carers and relatives91. The first government policy advocating greater flexibility of visiting

86 S Payne, N Jarrett, D Jeffs. 'The impact of cancer patient's experiences of treatment: a literature review. Europe Journal of Cancer Care, 2000, 4:197-203 87 T Astell-Burt, R Flowerdew, P Boyle, J Dillon. 'Is travel-time to a specialist centre a risk factor for non-referral, non-attendance and loss to follow-up among patients with Hep C infection? Social Science & Medicine, 2012, 75(1):240-247 88 Ipsos Mori survey for DH and NHS London, „Regional satisfaction with NHS Services‟, 2008 89 HES data from CCG spend analysis 90 J Posnett. 'Are bigger hospitals better'. in McKee and Healey. Hospitals in a Changing Europe. Open University Press

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was in 196292, but this was remarkably restrictive, "two afternoon visiting hours a week and on the remaining days a single visitor for twenty minutes in the afternoon, or thirty minutes in the evening"93. These policies developed following the Platt report94 which argued for open visiting on children's wards to improve the emotional state of child patients. Remarkably little research has been published to demonstrate the clinical outcome to patients of visiting95. Visitors to cardiac care and intensive care increase the bacterial counts in the environment96, but do not affect the rate of sepsis. However such visits also reduce the rate of respiratory infections, perhaps by relaxing the breathing of the patient. However, despite the lack of evidence on clinical outcomes there is strong evidence for the benefits of visiting73 (with some restrictions to allow rest and uninterrupted meals75) and that visiting provides support for patients and visitors, as well as allowing the invaluable sharing of information between staff and visitors that often complements the socio-clinical history from the patients. In the proposed centralisation of some emergency services and the further development of elective surgery centres there will be some patients who will be admitted to units further from their home and visitors, especially family members may therefore need to travel further. There is evidence that for elective care many patients choose this option now. Whilst a broad range of elective care is available at the Ealing Hospital site, the distribution of referrals and elective inpatient spells for residents from all parts of the borough is much more widely distributed than for emergency care. This suggests that when circumstances allow patients, their carers and visitors, are likely to opt for longer travel to get the treatment they choose. Of note however the National Patients Survey97 shows that closeness to home or work is the highest priority with 38% of those surveyed saying this was the most important factor, many times higher than other factors. More recent studies98 have indicated that 75% of people are supportive of the creation of specialist units, even if it meant travelling further, if it released money for local services. Similar studies have been completed in Wales99 Professor Longley100 concludes, "The findings of Picker Institute, Health Foundation and National Surveys are consistent with the increasing evidence base that, when given the facts, patients and carers will prioritise excellence and quality over convenience when it comes to their health care treatment, particularly for major treatment interventions and life threatening conditions"101. E.2.2 Impact of reconfiguration on health outcomes for deprived groups Hospitals have a highly valued "rescue" function for life threatening conditions, but their overall impact on public health is limited.102,103,104. 91 S Ismail, G Mulley. Visiting Times. British Medical Journal, 2007, 335:1316-1317 92 National Health Service. Visiting of Patients, 1962, HM 62:39 93 S Hastings. Visiting of Patients. British Medical Journal, 1963, 1148-1149 94 H Platt et al. Welfare of children in hospital: report of a committee of the central health services council, 1959 95 A Taylor. Exploring patient, visitor and staff views on open visiting. Nursing Times, 2008, 104:40, 30-33 96 Fumagalli et al. Reduced cardio-circulatory complications with unrestrictive visiting policy in an ICU. Circulation, 2006, 113:946-52 97 DoH National Patient Choice Survey, 2010 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_117096.pdf 98 YouGov study for RCN. reported on BBC, http://www.bbc.co.uk/news/uk-scotland-13175476 2011 99 Welsh NHS Confed Survey Results, 2011 100 K Norton, M Longley, M Ponton. The best configuration of hospital services: access, 2012, Pg 14 101 M Longley et al 'Stroke Rehab Services: the findings of a Citizens Jury, 2008, WIHSC 102 J Farrington-Douglas, R Brooks: The future hospital: the progressive case for change. IPPR, 2007 103 H Barton, M Grant. A health map for the local human habitat. The Journal for the Royal Society for the Promotion of Health, 2006, 126(6):252-253 ISSN 1466-4240 104 M Marmot. Social Determinates of Health Inequality. Lancet, 2005, 365:1099-1104

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There is a very large amount of evidence showing that patients suffering with socio-economic deprivation also have a higher burden of illness and also often have different mechanisms for gaining access to health care, with greater use of walk-in-centres, urgent care and A&Es and lower use of general practice. Higher costs of travelling to more distant services could reduce the likelihood of deprived populations accessing health care, particularly for the initial decision to consult, or to attend diagnostic tests where the perceived benefits may be low compared to the costs in terms of time effort and finance105. There is evidence that car ownership, distance to A&E106 or to general practice reduces the rate of attendance, particularly for women, the elderly or deprived. Studies in general practice have shown reduced rates of attendances for patients who live 3/4 of a mile from their surgery compared to those who live only 1/4 of a mile away107. Against this there is not clear evidence that distance is a critical factor for attendance to outpatients or attendance for planned surgery. There is evidence that distance affects psychiatry and alcohol outpatients, which are not provided by the acute trusts affected by the proposals in Shaping a healthier future108. Studies considering non-attendance comment that difficulty in transport, or distance, is sometimes given as a retrospective explanation109, but reminder phone calls and explanation of the reason to attend are equally effective for patients who have further to travel. In more rural areas travel may have a greater impact110, but this is not consistent111, 112. From a health improvement perspective identifying illness early and providing preventative care in a primary care setting are the most effective functions of the health system113. Once a need has been identified and a referral made with explanation, patients are likely to understand the benefits and attend any appointment. Despite this evidence the individual-borne costs are a factor in accessibility and Shaping a healthier future should seek to minimise this. But the key question is whether there is evidence that close proximity to a hospital improves health outcomes, especially for deprived populations? No UK evidence could be found to support this hypothesis. Any benefits from proximity in a population is likely to be more than counterbalanced by travelling further to a hospital operating with larger teams and greater volumes114, but through this limited review and through discussions with colleagues (led by the lead Programme Medical Director) it was not possible to find any support for this notion.

105 J Farrington-Douglas, R Brooks. The Future Hospital. 2007. Inst for Public Policy Research 106 SA Hull, IR Jones, K Moser. The attendance rate at A&E departments in East London: Journal of Health Services Research and Policy 1997, 2 (1):6-13 93 D Parkin. Distance as an influence on demand in general practice. Journal of Epidemiology and Community Health. 1979, 33, 96-99 107 D Parkin. Distance as an influence on demand in general practice. Journal of Epidemiology and Community Health 108AJ Mitchell, 'Why don't patients attend their appointments? Advances in Psychiatric Treatment (2007), 13: 423-434 109 PD Ritchie, M Jenkins. A telephone call reminder to improve outpatient attendance: a randomised controlled trial. Australian and New Zealand Journal of Medicine. 2000. 30 (5) 585-592 110 RM Haynes, CG Bentham. The effects of accessibility on GP consultations, out-patient attendances and in-patient admissions in Norfolk, England. Social Science and Medicine. 1982. 16 (5) 561-569 111 T Astell-Burt, R Flowerdew, P Boyle, J Dillon. 'Is travel-time to a specialist centre a risk factor for non-referral, non-attendance and loss to follow-up among patients with Hep C infection? Social Science & Medicine, 2012, 75(1):240-247 112 J Posnett, Are bigger hospitals better? 2002. Open University Press 113 J Farrington-Douglas, R Brooks. The future hospital, Jan 2007 p 25 114 PJ Roohan et al. Hospital Volume Differences and 5 year survival from Breast Cancer. American Journal of Public Health. 1998. 88 (3) 454-458

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Further analysis is beyond the scope of this review. However, if local populations are considered, the areas in Ealing with greatest deprivation115 are near Ealing Hospital in the Dormers Wells ward and in the Cleveland ward. Figure E.2.3: Deprivation Chart by LSOA and Ward for Ealing115

These two wards are co-incidentally the closest to a hospital (Ealing Hospital is within Dormers Wells ward) and the furthest (the deprived areas in Gurnell and Northolt Mandeville are mid way between Ealing and Northwick Park Hospital). Whilst there is a strong association between health and social and disability deprivation116 there is no suggestion that morbidity or mortality is reduced in wards in proximity to the hospital (if anything the reverse!). Figure E.2.4: Male life expectancy by ward in Ealing116

This is extremely crude analysis and formal evaluation would be complex to account for the multiple factors involved. E.2.3 Safety of proposed bed reductions 115 Ealing Health Profile 2013. from www.healthprofiles.info 116 Ealing JSNA 2012.

Cleveland

Dormers Wells

Ealing Hospital

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Hospital bed numbers have been reducing each year in response to the changes in health care provision. Whilst emergency admissions have been increasing this has been more than compensated by a reduction in average length of stay and the growth of day care117. Reductions in the number of hospital beds are possible by two simple themes:

Reducing admissions o Schemes to improve health o Schemes to improve self-care o Schemes to provide services in the community, including hospital at home o Schemes to improve discharge and so reduce readmission

Reducing length of hospital stay o Proactively managing the hospital processes to avoid delays o Supported early discharge o Increased use of day surgery and less invasive surgery

E.2.2.1 Reducing Admissions The King's Fund reviewed the effectiveness of a range of interventions aimed at reducing avoidable admissions. It is acknowledged that changing the trend from increasing emergency admissions is a challenge. Admissions have been increasing at an average of about 5% per year, but through a variety of initiatives this ranges from a reduction of 12.7% to an increase of 27.3%118. Purdy's findings are summarised in Figure E.2.5119. Figure E.2.5: Summary of findings on effectiveness of a range of interventions to reduce avoidable admissions Evidence of positive effect Evidence of little or no benefit Equivocal evidence Reducing admissions

GP continuity of care*

Hospital at home as an alternative*

assertive case management in mental health*

self management*

early senior review in A&E*

multidisciplinary interventions and telemonitoring in heart failure*

integration of primary and secondary care*

reducing readmissions

structured discharge planning*

personalised health care programmes*

pharmacy home-based medication reviews

intermediate care*

non-specific low-risk case management

early discharge to hospital at home in readmissions

nurse led interventions pre- and post- discharge for patients with COPD

increasing GP practice size

changing GP out of hours*

chronic care management in primary care*

telemedicine*

cost efficacy of GP in A&E*

access to social care in A&E

hospital based care management

rehabilitation programmes*

rapid response teams*

117 Institute for Innovation and Improvement. Length of stay. Reducing Length of Stay. (www.institute.nhs.uk) 118 S Gillam. Rising Hospital Admissions: Can the tide be stemmed?. British Medical Journal, 340:636 119 S Purdy. Avoiding Hospital Admissions. What does the research evidence say?. King's Fund, 2010. Items marked with an asterisk are reflected in schemes starting within NW London

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There is of course a difference between lack of evidence for a benefit and evidence of a lack of benefit. Management of Long Term Conditions is associated with improvements, for example provision of diabetes clinics is significantly associated with reduced admission rates120, but there wasn't similar evidence for GP asthma clinics - where compliance with national guidelines was a strong factor. A similar review by the Health Services Management Centre (HSMC) in Birmingham in particular reviewed the evidence in integrated care, as seen in Kaiser in the US and replicated in Torbay, where integrated care works with networks of GPs caring for populations of 25-40,000 are supported by health and social care teams using pooled budgets between health and social care121. CCGs working with Health & Well Being Boards are expected to have a greater emphasis on "the forgotten P in QIPP - prevention". The range of activities that have been shown to reduce admissions include smoking cessation programmes and flu immunisation campaigns. Weight loss and exercise programmes are longer term factors. It is estimated that 5% of all hospital admissions are attributable to smoking122. The 2007 ban of smoking in enclosed public spaces has been correlated to a 12.3% reduction in paediatric asthma hospital admissions123 in the first year, and a 2.4% reduction in the number of heart attacks requiring admission124. Ambulatory Care Sensitive (ACS) conditions are those for which hospital admissions could be prevented by interventions in primary care125 and often reflect poor co-ordinated care. The conditions can be grouped126 as:

Chronic conditions where effective care can prevent flare-ups Acute conditions where early intervention can prevent more serious progression and Preventable conditions where immunisation and other interventions can prevent illness

In most studies they include coding for 19 conditions within the ACS bundle. In 2009/10 they account for 15.6% of hospital admissions and are a much higher proportion of admissions in childhood and in old age. ACS admissions are very strongly associated with socio-economic deprivation with the rate of emergency admissions from the most deprived populations (24.5 admissions per 1000 population) being more than twice that from the least deprived (10.1 admissions per 1000 population). This emphasises the need to strengthen primary care services in deprived areas. Influenza and pneumonia account for the largest proportion of these admissions. Many could be prevented by improving uptake of influenza and pneumococcal immunisation127, 128. Influenza vaccination in patients with COPD varies by PCT from 77.5% to 84%129. The best performing PCT

120 S Saxena, L George, J Barber, J Fitzpatrick, A Majeed. 'Association of population and practice factors with potentially avoidable admission rates for chronic diseases in London: cross sectional analysis'. Journal of the Royal Society of Medicine, 99:81-8 121 Health Services Management Centre (2006) 'Reducing Unplanned Hospital Admissions: what does the literature tell us? (www.hsmc.bham.ac.uk/publications) 122 Statistics on Smoking. Information Centre. www.ic.nhs.uk, 2012 123 C. Millett et al. 'Hospital Admissions for Childhood Asthma After Smoke-free Legislation in England' Pediatrics 2013, 131:1–7 124 M Sims M, R Maxwell, L Bauld, A Gilmore 'Short term impact of smoke-free legislation in England: retrospective analysis of hospital admissions for myocardial infarction. British Medical Journal. 2010, 340:c2161 125 Y Tian, A Dixon, A Gao. 'Emergency hospital admissions for ACS conditions: identifying the potential for reductions.' Kings Fund, 2012 126 C Ham, C Imison, M Jennings. 'Lessons from evidence and experience', 2010, King's Fund 127 P Mallia, SL Johnston. 'Influenza infection and COPD. Int J COPD. 2007; 2(1):55-64 128 P Poole at al. 'Influenza vaccine for patients with COPD. Cochrane Database Syst Rev 2006; (1):CD002733 129 Information Centre Quality and Outcomes Framework Outcomes 2011/12.

http://pediatrics.aappublications.org/content/early/2013/01/15/peds.2012-2592.abstract

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nationally achieves 87% of their population. Hammersmith and Fulham achieved the fourth lowest rate nationally for this indicator, again suggesting benefits that could be gained. CCGs in North West London have very variable admission rates for these conditions, as shown in Figure E.2.6. Figure E.2.6: Admission rates for ACS conditions130

DSR for adult emergency

admissions for acute conditions that

should not usually require hospital

admission

DSR for adult Unplanned

hospitalisation for chronic ambulatory

care sensitive conditions

DSR for alcohol related liver

disease

Brent CCG 1165 1109 23.6 Central London CCG 1157 955 29.1 Ealing CCG 1351 1136 21.2 Hammersmith & Fulham CCG 1463 1190 29.7 Harrow CCG 964 757 13.8 Hillingdon CCG 1259 937 23.2 Hounslow CCG 1215 1101 35.6 West London CCG 1312 1012 10.0 National Average 1024 938 21.2 National Lowest 244 219 5.6 These results are standardised for age and sex but other demographic differences may contribute to the variation. The national lowest admission rates have been consistently in Crawley, a less deprived area than in North West London131. The variation indicates the opportunity of reducing unplanned admissions if community services are more effective and management of Long Term Conditions improved. The current rates in Harrow are 35% lower than the highest CCG, while Harrow CCG admission rates are below national average substantial improvement still looks likely. Attention in this area alone could produce a substantial reduction in bed requirements. Tian et al estimate that ASCs could be reduced by 8-18%98. Supporting evidence is shown from audits of admissions through A&Es and on inpatient wards. Using a structured on-line survey tool the admitting nurse is asked to consider, if other services were in place and functioning, whether hospital admission would be necessary. This can also be repeated following admission to support early discharge. These studies in the UK have shown that up to 25% of acute admissions could be avoided if the right level of care were provided in the community132. Short Audits in Ealing Hospital and Northwick Park Hospital using this structured survey tool suggested that 16% of admissions could be avoided if community services were available133. 'Virtual wards'134 and 'Hospital at Home'135 schemes have been shown to be successful. The Cochrane review showed that patient satisfaction was higher, mortality was lower and bowel and urinary complications were fewer. Readmission rates in NW London are also high. If multidisciplinary discharge planning was commenced earlier following admission these 'failed discharges' could reduce the need for beds.

130 CCG outcomes Framework 2011/12. From www.ic.nhs.uk. DSR is directly age and sex standardised per 100,000 131 Crawley Health Profile - from www.healthprofiles.info 132 MCAP. data from >19,500 reviews in the UK. Source: Finnamore 133 Finnamore survey summer 2012 134 e.g. Wandsworth CCG in C Ham et al. Avoiding Hospital Admissions. Kings Fund 2010 135 S Shepperd et al 'Admission avoidance hospital at home. Cochrane Database of systematic Reviews, 2008 issue 4

http://www.ic.nhs.uk/

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Readmissions rates across the country are increasing136, but have become an increasing area of Trust concentration. Audits at Imperial demonstrated that 7% of patients account for 25% of admissions137 and that concentrating co-ordinated care across the interface between primary and secondary care for this much smaller cohort could have substantial benefits. Figure E.3.7: Emergency readmissions in England between 200/01 and 2010/11138

The readmission rates in NW London are varied, with examples of best practice throughout. Figure E.2.8: Readmission rates in NW London139

Emergency readmission within 30 days following

non-elective admission

Emergency readmission within 30 days of elective

admission

Volume opportunity by reducing length of

stay

Q1 2012/13 Q1 2012/13 Q2 2012/13

Chelsea & Westminster 9.44% 6.90% 13.7%

Ealing 12.85% 7.75% 14.1%

Imperial 14.09% 6.69% 12.9%

NWLHT 13.51% 7.38% 12.5%

THH 13.70% 5.97% 12.9%

WMUH 11.76% 8.94% 13.6%

England (avg) 13.08% 6.65% 13.5%

136 DoH Jan 2013. http://www.dh.gov.uk/health/2013/01/data-emergency-readmissions/ 137 R Nouraei, A Hudovsky: An analysis of readmissions at Imperial. Dec 2011 138 www.indicators.ic.ac.uk/webview 139 Acute Trust Dashboards. Red is more than 3 standard deviations from average, green is more than 3 standard deviations less than average

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The Imperial internal audit110 highlighted many opportunities to improve care. A change in assessment of chest pain using an agreed panel of cardiac markers140 was predicted to avoid 900 short-stay chest pain admissions and over 150 readmissions for chest pain. A variety of other evidence based improvements in quality, such as improving palliative care support in the community, to allow more patients to die in their preferred place of death, often their own home, are underway and have also been shown to reduce demand for beds. Co-ordinate My Care (CMC) is being implemented in NW London. Where a patient has a CMC record, only 17% die in an acute hospital141 as opposed to 60% in areas that have not used this care tool.142 E.2.2.2 Reducing length of stay Whilst avoiding admission has the greatest benefit to the patient and the commissioner hospital finances benefit most from reducing the length of stay. Length of stay is one of the greatest variables between NHS Trusts. By reviewing and improving admission and discharge processes, trusts can improve the patient experience by reducing the number of days spent in hospital, and save bed days thus releasing capacity and saving money.143 The NHS Institute for Innovation and Improvement estimate that if all providers improved there would be a 13.5 % reduction in bed usage from this measure alone144 (see Figure xxxx, calculated on a 25% reduction in the length of time above the median length of stay for standardised patient). These estimates may be considered conservative. Audits of admissions can be assessed using a structured survey tool, MCAP. Using this audits across the UK suggest that up to 50% of length of stay beds could be avoided by providing the care in the community. The tool was used in a brief audit in NWLHT and Ealing Hospital showed that 61% of continuing care bed days could be provided in a setting other than an acute trust. For these patients it was found that:

Only 38% of patients had a discharge plan in the chart. This occurred 82% of the time when an Estimated Date of Discharge (EDD) had been established

Of the reasons for non-qualified days, 37% were due to consultant issues 7% of discharges were delayed because medication was not available for the patient at

the time of the planned discharge Further opportunities arise if surgical procedures are performed as day case. Some trusts are already excelling in some areas, for example Chelsea and Westminster are top ranked in country for arterial biopsy, but opportunities still exist, the same trust is ranked 131st for primary repair of inguinal hernia.

140 SW Goodacre et al, RATPAC: a randomised controlled trial of point-of-care markers in the emergency department 141 Co-ordinate My Care. London audit. 2012 142 National End of Life Care Intelligence Network, 2008-10 143 NHS Institute Clinical Productivity - acute trusts, Reducing Length of Stay 144 www.productivity. Q2 12/13 data

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Figure E.2.9: National ranking of Acute Trust for use of day case procedures145

National Rank (all

procedures) Volume

opportunity

Chelsea & Westminster 135 188

Ealing 98 79

Imperial 110 422

NWLHT 69 299

THH 11 87

WMUH 24 44

The hospitals Cost Improvement Plans have identified the opportunity to make their services more efficient and improve patient care by reducing length of stay. Approximately two-thirds of the predicted bed reduction in NW London is based on plans by the acute trusts to improve length of stay. In summary there is evidence that efforts to improve health and increase access to high quality care reduce hospital admissions. More effective hospital systems with integrated discharge planning can reduce hospital lengths of stay. Together these effects reduce the need for hospital beds.

145 London SHA performance Q2 2012/13 from http://www.productivity.nhs.uk/ShaDataDownload. See site for details of methodology

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E.3 Acute Trust Dashboards These are available from the East Midlands Quality Observatory146 and are updated quarterly. They bring data from various sources against the five domains of the NHS Outcomes Framework 1. Preventing people from dying prematurely 2. Enhancing quality of life for people with long term conditions 3. Helping people to recover from episodes of ill health or following injury 4. Ensuring that people have a positive experience of care 5. Treating and caring for people in a safe environment and protect them from avoidable harm They have added a sixth domain "organisational approach to quality" with a range of indicators that look at organisational behaviours.

Values in the grey area are within two standard deviations of the national average and variation may be caused by 'normal cause variation'. Values in the orange or light green are beyond two standard deviations (outside of 95% of the results) and should signal an alert; whist the variation could still be normal cause variation it is more likely to be 'special cause variation'. Values in the red or dark green are more than three standard variations (99.8%) from the national mean. Figures in the red should constitute an alarm and be investigated. Further detail and information about each measure is available on the web site

146 http://www.emqo.eastmidlands.nhs.uk/welcome/quality-indicators/acute-trust-quality-dashboard/published-dashboards/

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E.3.1 Chelsea & Westminster NHS Foundation Trust

29

30

E.3.2 Ealing Hospital NHS Trust

31

32

E.3.3 Imperial NHS Foundation Trust

33

34

E.3.4 North West London Hospitals NHS Trust

35

36

E.3.5 The Hillingdon Hospitals NHS Foundation Trust

37

38

E.3.6 West Middlesex University Hospital NHS Trust

39

2

Quality and safety programme: Audit of acute trusts Cluster report

NW London

FINAL DRAFT

3

Table of contents

1. Introduction ...................................................................................................................... 4

2. Development of clinical quality standards ........................................................................ 5

3. The audit process overview ........................................................................................... 10

4. Summary of adult emergency services audit findings for NW London hospitals .......... 12

5. Key findings in NW London for adult emergency services audit .................................... 29

6. Summary of NW London compliance with national standards ...................................... 33

7. Key findings in NW London for the national standards .................................................. 38

8. Activity summary for NW London sites: Adult emergency services ............................... 39

9. Activity summary for NW London sites: Paediatric emergency services and acute maternity services .............................................................................................................. 40

4

1. Introduction The NHS aspires to the highest standards of excellence and professionalism – in the provision of high quality care that is safe, effective and focused on patient experience.1 The public expect that the NHS will provide them with a consistently high quality service not dependent on location, time of day or day of the week; this expectation should underpin the way that all services are commissioned and delivered.

However, several recent reports from influential professional bodies, such as the Royal Colleges and NCEPOD (National Confidential Enquiry into Patient Outcomes and Death) have highlighted deficiencies of care in adult and paediatric acute emergency services. Significant evidence demonstrates a variation in outcomes for patients depending on the time and day of the week that they attend an emergency department, or are admitted to hospital as an emergency.

Additionally, London’s maternity services do not perform uniformly well with unacceptable inequalities in maternity outcomes in areas of mortality, morbidity and experience. This has been explicitly highlighted in several recent reports and reviews including the 2011 London maternal death review, Care Quality Commission (CQC) reports from individual Trusts and the London Local Supervisory Authority (LSA) annual report.

Emergency admissions account for roughly 31 per cent and births account for roughly six per cent of total hospital inpatient activity (including day cases).

These variations in emergency services outcomes have been associated with a lack of immediate access to senior medical personnel in the assessment and management of acutely ill patients, access to imaging and consultant reporting, and input from multidisciplinary teams particularly outside of traditional normal working hours, which accounts for roughly three quarters of the week. Inequalities in maternal outcomes have been linked with variation in midwifery staffing levels, consultant presence and obstetric anaesthetic cover, particularly outside of normal working hours.

The quality and safety of services as well as the variation in practice of emergency and maternity services across London should be addressed. The clinically-led development of minimum quality standards aim to ensure that patients admitted as an emergency or women who deliver a baby in an obstetric unit, or midwifery-led unit (co-located and non-co-located) should receive a consistent service seven days a week across all providers of these services. Compliance with these standards will help London provide a consistent high quality service in these areas.

The report provides the progress that the NW London cluster has made in meeting London Health Programmes’ standards already commissioned. The audit findings reported are an assessment of compliance with the adult and emergency standards (acute medicine and emergency general surgery) on the date of the site visits. Subsequent action plans and changes made have not been included and should be the consideration of commissioners. Additionally, where a site reported a robust plan in place to meet the standard it is the responsibility of the commissioner to confirm whether plans have been implemented and the standard has subsequently been met.

1 The NHS Constitution (2012)

5

2. Development of clinical quality standards The Quality and Safety Programme

The 2011 review of adult emergency services undertaken jointly by London Health Programmes and NHS London on behalf of London’s commissioners reviewed how providers in London compared with national standards and guidelines in the management of adult patients admitted to hospital with acute medical or emergency surgical conditions. The review of emergency pathways for adults led to the development and commissioning of clinical quality standards to improve acute medicine and emergency general surgery services. London acute hospitals were subsequently commissioned to deliver these standards from April 2012.2

The Quality and Safety Programme built on the review of acute medicine and emergency general surgery services in London. It was a clinically-led programme, supported by over 90 clinicians that formed multi-disciplinary expert panels, and involved service user and public groups. The programmes key components were:

Auditing of all acute London hospital sites against the agreed and commissioned acute medicine and emergency general surgery standards.

Exploring the service provision and outcomes of patients admitted to all adult and paediatric emergency services and maternity services not covered by the previous review.

Expanding the development of standards to all acute emergency services – adult and paediatric – and maternity services (obstetric led and midwifery led unit) to ensure they are of a consistently high quality and safe across all providers. London acute hospitals will be commissioned to deliver these standards from April 2013.

2.1 The need for change in London

The case for change was used as an evidence base for developing the standards. Within acute emergency and acute maternity services, there are significant variations which exist in service arrangements and patient outcomes between hospitals and within hospitals, between weekdays and weekends.

2.1.1 Adult emergency services

Data for London on adult emergency services (acute medicine and emergency general surgery) showed that a minimum of 500 lives in London could be saved every year if the mortality rate for patients admitted at the weekend was the same as for those admitted on a weekday.3

2 London Health Programmes (2011) Adult emergency services: commissioning standards

3 London Health Programmes (2011) Adult emergency services: case for change

6

Acute medicine and emergency general surgery

The 2011 review found that there was hugely variable and inadequate involvement of consultants in the assessment and subsequent management of acutely ill patients – particularly at the weekend, when average consultant cover was found to be half of what it was during the week. The review demonstrated that patients admitted to hospital as an acute medical emergency or for emergency general surgery at the weekend in London had a significantly increased risk of dying compared to those admitted on a weekday. Reduced service provision, including fewer consultants working at weekends, was associated with this higher mortality rate. Critical care

Whilst there is no difference between weekend and weekday mortality for critical care patients in London, data shows variation in other outcomes for patients. Variation exists in length of stay, discharges that occur out-of-hours, the provision of critical care response to deteriorating patients and bed availability. These factors significantly impact on the level of care patients receive and importantly affect patient experience.

Out-of-hours discharges from critical care units are less likely to involve consultant input and are associated with increased mortality. Currently, 39 per cent of patients in London are discharged between 18.00 and 08.00 with variation existing between sites.

While the majority of London units provide extended day consultant presence this varies greatly at the weekend and consultants are not always freed from other duties. The ability to respond to deteriorating patients and ensure timely input of critical care expertise is an important part of improving patient care and outcomes, but current provision is varied across London, with significant differences between weekdays and weekends.4

Emergency departments

London’s emergency departments see a large volume of cases of varying complexities, and despite changes in primary care services provision attendance over the past eight years attendance at London’s emergency departments has increased by over 60 per cent. Appropriate staffing is integral to an effective emergency department; however there is increasing difficulty in staffing emergency departments. Evidence suggests that consultant-delivered care brings benefits for patients receiving emergency care however significant variation exists in the numbers of hours that emergency medicine consultants are present in London’s emergency departments. Input from experienced, senior doctors twenty-four hours a day, seven days a week is required to ensure the delivery of high quality care and timely patient flow. However this practice is uncommon in London.5

There is significant variation in nursing management across emergency departments. Many departments have a high rate of nursing vacancies and inadequate skill mix, which can lead to poorer outcomes for patients. Where care has been found to be poor, the majority of care was delivered by nursing support staff with insufficient nurses to supervise them.

4 London Health Programmes (2012) Critical care: case for change

5 London Health Programmes (2012) Emergency departments: case for change

7

Evidence demonstrated that the safe delivery of care in an emergency department depends on timely access to diagnostics and investigations as clinical diagnosis alone cannot be relied on to make safe diagnoses in many cases. Early access to diagnostics can also prevent unnecessary admission to hospital, therefore providing better outcomes for patients. Fractured neck of femur pathway

The evidence is clear for patients who suffer a fractured neck of femur, the key early indicator of a patient’s outcome is the time to operation; operation delays have clear links to increased mortality rates. Avoidable delays are therefore unacceptable. However poor performance in time to operation is found across London. Twelve trusts in London undertake at least 30 per cent of operations two days after the patient’s admission. Additionally, patients admitted to hospital in London on a Friday or a Saturday are 18 per cent more likely to wait two days or longer for their operation compared to those admitted Sunday to Thursday. Lack of early pre-operative consultant input can delay patients being optimised for theatre, lack of consultant surgeon and anaesthetist involvement in operations can affect outcomes, and a lack of subsequent ongoing consultant input can delay post-operative recovery. There is considerable variation across London in the availability of consultants for fractured neck of femur patients with much less input found at the weekend.6

2.1.2 Paediatric emergency services

London has a higher mortality rate for paediatric emergency admissions when compared to the rest of the country and this is increasing when compared to mortality rates for other age groups in the capital. In addition, in-hospital mortality rates among children in London have been rising over the last five years, particularly for respiratory patients which accounts for almost two thirds of emergency medical admissions for children in London, this is in contrast to mortality rates for the same patient group among other regions.

There is significant variation in the provision of paediatric services between and within London hospitals. Hospitals need to ensure that the appropriate levels of trained staff are in place to ensure delivery of high-quality and safe care. However, there are significant workforce pressures on paediatric trained surgical, anaesthetic and nursing staff particularly out-of-hours, coupled with a variation in levels of training and an insufficient number of paediatric trained nurses with appropriate skills in London.

London’s paediatric emergency services are struggling to meet the Royal College of Paediatrics and Child Health (RCPCH) minimum standards for acute, general paediatric care7. There is variable access to senior personnel who undertake and influence clinical decision-making and models of care are such that children are often admitted unnecessarily when alternative management plans might be appropriate. Additionally, hospitals are not currently meeting Royal College of Surgeons, Royal College of Anaesthetists and NCEPOD recommendations which has resulted in variable surgical and anaesthetic staffing levels out-of-hours; too many children being treated by surgeons who specialise in operating on adults; and the appropriate skill mix and environment to safely anaesthetise and recover children not always being available.

6 London Health Programmes (2012) Fractured neck of femur: case for change

7 Royal College of Paediatrics and Child Health (2010), Facing the Future: Standards for Paediatric Services, RCPCH

8

2.1.3 Maternity services

London’s maternity services do not perform uniformly well with unacceptable inequalities in maternity outcomes in areas of mortality, morbidity and experience. As the demands on London’s maternity services are increasing, services face increasing challenges to provide safe, high quality care for the diverse needs of London’s pregnant women and their babies. Although these rising challenges can be seen nationally, the trend is most acute in the capital. The 2011 maternal death review found that the maternal death rate in London had doubled in the last five years and is twice the rate of the rest of the UK. Seventy percent of the direct maternal deaths and 58 per cent of the indirect maternal deaths were found to have avoidable factors, described as shortfalls in care that, if managed differently, may have saved lives. These avoidable factors included delays in recognising a woman’s high risk status, junior staff not being properly supervised or referring to an appropriate specialist leading to delays in, or inappropriate treatment. London’s maternity services struggle to meet national standards for safety, outcomes and women’s experiences; they are the least well performing nationally.8 Considerable evidence supports the need for consultant presence in order to reduce maternal mortality and poor outcomes yet few units in London met best practice recommendations for consultant labour ward presence. Additionally, it is widely acknowledged that experienced midwives have invaluable skills in recognising risk and referring appropriately, however less than one third of London’s maternity units meet midwifery staffing recommendations.

2.2 Standards for London that will ensure consistent high quality services

Clinical expert and patient panels developed evidence-based clinical quality standards for acute medicine and emergency general surgery services to address the variations found in service arrangements and patient outcomes. Data on adult emergency services showed that a minimum of 108 lives in NW London could be saved every year if the mortality rate for patients admitted at the weekend was the same as for those admitted on a weekday. London’s acute hospitals were subsequently commissioned to deliver these standards from April 2012.

The Quality and Safety Programme then drove the development and commissioning of clinical quality standards for further services not covered by the previous review. These standards will be commissioned from April 2013. Figure 1 shows the services in which standards were developed in acute emergency and maternity services.

8 London Health Programmes (2012) Maternity services: case for change

9

Figure 1: Clinical quality standards developed:

These standards represent the minimum quality of care that patients admitted as an emergency should expect to receive in every hospital in London that accepts patients – adult or paediatric – on an emergency basis.

The maternity services clinical quality standards similarly represent the minimum quality of care women who deliver a baby in an obstetric unit, or midwifery-led unit (co-located and non co-located) should expect to receive in every unit across London.

Compliance with standards would ensure that the assessment and subsequent care of patients admitted to these services would be consultant-delivered (when not in midwifery-led unit), seven days a week and consistent across all providers of these services.

Other services in London are now delivering consistent services across all days of the week including stroke, trauma and heart attack centres and the improvements in outcomes are clear. For example, London’s heart attack centres operate a consultant delivered service seven days per week and no observed difference is found in mortality rates in the week and at the weekend – demonstrating clearly where systems are in place to respond seven days a week, there is a direct effect on mortality rates.

Evidence is clear; if acute hospital sites in NW London are to provide consistent, clinically effective, safe and patient centered hospital care, across all acute emergency and maternity services, the cluster needs to ensure that consultants and their teams are available seven days a week, 24 hours a day.

• Acute medicine

• Emergency general surgery

• Emergency departments

• Critical care

• Fractured neck of femur

Adult emergency services

• Emergency departments

• Emergency inpatient medicine

• Emergency general surgery

Paediatric emergency

services

• Applicable to specific parts of the pathway requiring care from acute clinicians including midwives, obstetricians, anaesthetists and neonatologists. This includes labour and delivery (intra-partum care), antenatal referrals and admissions and immediate postnatal care.

Maternity services

10

2.3 Engagement on the case for change and standards

Extensive engagement has been undertaken to secure stakeholder buy-in to the Quality and Safety Programme, gain support of the case for change in each area and to inform the development of the clinical quality standards.

The development of the standards was clinically led, and supported by over 90 clinicians that formed multi-disciplinary expert panels, and involved service user and public groups.

Current and future commissioners were engaged in the programme and wider engagement with commissioners was undertaken throughout. Regular engagement occurred with acute trust Chairs, Chief Executives, Medical Directors, and Directors of Nursing and the London Clinical Senate. Other key stakeholders, including representative clinical bodies, Royal Colleges, and patient and public groups, have also been engaged through regular presentations and meetings.

Large stakeholder events were held for adult emergency services, paediatric emergency services and maternity services to seek feedback on the draft cases for change and clinical quality standards.

3. The audit process overview The audit process was developed by clinical expert and patient panels and quality assured by an independent academic review. Following two pilot audits, the full audit was undertaken between May and October 2012 to ascertain the current status of London hospital sites against their achievement of the adult emergency services clinical quality standards.

The audit consisted of two main stages:

Stage 1 Site self-assessment of compliance with supporting evidence.

Stage 2 A follow up site visit.

The audit was also an opportunity to survey sites on their current compliance against national standards in the clinical services areas not covered by the 2011 adult emergency services review. This was to understand the current baseline in London hospitals ahead of the development and commissioning of London clinical quality standards for these areas.

The Quality and Safety Programme audited the following nine acute hospital sites in NW London: Central Middlesex Hospital (NWLH-CMH) Charing Cross Hospital (ICH-CXH) Chelsea and Westminster Hospital (C&W) Ealing Hospital (EH) Hammersmith Hospital (ICH-HH) Northwick Park Hospital (NWLH-NPH) St Mary’s Hospital (ICH-SMH) The Hillingdon Hospital (THH) West Middlesex Hospital (WMUH)

11

Figure 2: Map of NW London

This cluster report details the findings and conclusions from the audit of adult and emergency services in NW London, and details compliance with national standards on services not covered by the by the 2011 adult emergency services review. Assessment of compliance with the acute medicine and emergency general surgery standards was based on findings at the time of the site visit. Any subsequent action plans and changes made to service delivery have not been included and should be the consideration of commissioners.

12

4. Summary of adult emergency services audit findings for NW London hospitals [DN: NW London sites have not yet agreed final sign off, therefore assessments made and ratings may change]

Table 1 summarises the overall assessment on compliance with each of the twenty-seven acute medicine and emergency general surgery standards that all hospitals in London were commissioned to meet from April 2012. Standards were classified as:

Red – not met; Amber – not met but the site had a credible plan in place that had Trust board level support, agreed funding and would be delivered in

2012/13 in order to achieve compliance with the standard; Green – met.

Table 1: Summary of compliance with the adult emergency standards at hospital sites in NW London

No.

Standard

NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH

NPH ICH SMH THH WMUH

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

1

All emergency admissions to be seen

and assessed by a relevant consultant

within 12 hours of the decision to admit or

within 14 hours of the time of arrival at the

hospital.

No

t m

et

No

t m

et

No

t m

et

Me

t

Me

t

Me

t

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

Me

t

No

t m

et

Me

t

No

t m

et

13

No.

Standard

NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH


Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

2

A clear multi-disciplinary assessment to be undertaken within 12 hours and a treatment or management plan to be in place within 24 hours (for complex needs patients see 23 and 24).

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

3

a) All patients admitted acutely to be continually assessed using a standardised early warning system (EWS).

No

t m

et

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

b) Consultant involvement is required for patients who reach trigger criteria. Consultant involvement for patients considered ‘high risk’ to be within one hour.

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

Me

t

Me

t

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

14

No.

Standard

NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH


Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

4 When on-take, a consultant and their team are to be completely freed from any other clinical duties or elective commitments.

No

t m

et

No

t m

et

No

t m

et

Me

t

Me

t

No

t m

et

Me

t

No

t m

et

Me

t

No

t m

et

No

t m

et

Me

t

Me

t

Me

t

No

t m

et

No

t m

et

5 In order to meet the demands for consultant delivered care, senior decision making and leadership on the acute medical/ surgical unit to cover extended day working, seven days a week

No

t m

et

No

t m

et

No

t m

et

Me

t

Me

t

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

Me

t

No

t m

et

Me

t

Me

t

No

t m

et

6 All patients on acute medical and surgical units to be seen and reviewed by a consultant during twice daily ward rounds, including all acutely ill patients directly transferred, or others who deteriorate.

No

t m

et

No

t m

et

No

t m

et

Me

t

Me

t

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

15

No.

Standard

NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH


Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

7 All hospitals admitting medical and surgical emergencies to have access to all key diagnostic services in a timely manner 24 hours a day, seven days a week to support clinical decision making: Critical – imaging and reporting within 1 hour Urgent – imaging and reporting within 12 hours

All non-urgent – imaging and reporting within 24 hours

No

t m

et

Me

t

Me

t

Me

t

Me

t

No

t m

et

No

t m

et

Me

t

No

t m

et

No

t m

et

Me

t

Me

t

No

t m

et

No

t m

et

No

t m

et

No

t m

et

16

No.

Standard

NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH


Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

8 All hospitals admitting medical and surgical emergencies to have access to interventional radiology 24 hours a day, seven days a week: Critical patients – 1 hour

Non-critical patients – 12 hours

No

t m

et

Me

t

Me

t

Me

t

Me

t

No

t m

et

No

t m

et

Me

t

No

t m

et

No

t m

et

Me

t

Me

t

No

t m

et

No

t m

et

No

t m

et

No

t m

et

17

No.

Standard

NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH


Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

9 Rotas to be constructed to maximise continuity of care for all patients in an acute medical and surgical environment. A single consultant is to retain responsibility for a single patient on the acute medical or surgical unit. Subsequent transfer or discharge must be based on clinical need.

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

No

t m

et

No

t m

et

No

t m

et

10 A unitary document to be in place, issued at the point of entry, which is used by all healthcare professionals and all specialties throughout the emergency pathway.

Me

t

No

t m

et

No

t m

et

Me

t

Me

t

No

t m

et

No

t m

et

Me

t

Me

t

Me

t

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

18

No.

Standard

NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH


Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

11 Patients admitted for unscheduled care to be nursed and managed in an acute medical or surgical unit, or critical care environment.

No

t m

et

Me

t

No

t m

et

Me

t

Me

t

Me

t

No

t m

et

No

t m

et

No

t m

et

No

t m

et

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

12 All admitted patients to have discharge planning and an estimated discharge date as part of their management plan as soon as possible and no later than 24 hours post-admission. A policy is to be in place to access social services seven days per week. Patients to be discharged to their named GP.

No

t m

et

No

t m

et

No

t m

et

Me

t

Me

t

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

Me

t

Me

t

19

No.

Standard

NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH


Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

13 All hospitals admitting emergency general surgery patients to have access to a fully staffed emergency theatre immediately available and a consultant on site within 30 minutes at any time of the day or night.

No

t m

et

Me

t

Me

t

No

t m

et

Me

t

No

t m

et

No

t m

et

20

No.

Standard

NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH


Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

14 All patients admitted as emergencies are discussed with the responsible consultant if immediate surgery is being considered. For each surgical patient, a consultant takes an active decision in delegating responsibility for an emergency surgical procedure to appropriately trained junior or speciality surgeons. This decision is recorded in the notes and available for audit.

No

t m

et

Me

t

Me

t

No

t m

et

Me

t

Me

t

Me

t

21

No.

Standard

NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH


Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

15 All patients considered as ’high risk’ to have their operation carried out under the direct supervision of a consultant surgeon and consultant anaesthetist; early referral for anaesthetic assessment is made to optimise peri-operative care. High risk is defined as where the risk of mortality is greater than 10%.

No

t m

et

Me

t

Me

t

No

t m

et

Me

t

Me

t

Me

t

22

No.

Standard

NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH


Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

16 All patients undergoing emergency surgery to be discussed with consultant anaesthetist. Where the severity assessment score is ASA3 and above, anaesthesia is to be provided by a consultant anaesthetist.

Me

t

Me

t

Me

t

No

t m

et

Me

t

Me

t

Me

t

23

No.

Standard

NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH


Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

17 a) The majority of emergency general surgery to be done on planned emergency lists on the day that the surgery was originally planned. The date, time and decision maker should be documented clearly in the patient’s notes and any delays to emergency surgery and the reasons why recorded.

No

t m

et

Me

t

Me

t

No

t m

et

Me

t

No

t m

et

Me

t

b) Any operations that are carried out at night are to meet NCEPOD classifications and be under the direct supervision of a consultant surgeon.

No

t m

et

Me

t

Me

t

No

t m

et

No

t m

et

Me

t

Me

t

24

No.

Standard

NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH


Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

18 All referrals to intensive care to be made from a consultant to a consultant.

No

t m

et

No

t m

et

No

t m

et

Me

t

Me

t

Me

t

Me

t

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

Me

t

Me

t

No

t m

et

No

t m

et

19 A structured process to be in place for the medical handover of patients twice a day. These arrangements to also be in place for the handover of patients at each change of responsible consultant/medical team. Changes in treatment plans are to be communicated to nursing and therapy staff as soon as possible if they are not involved in the handover discussions.

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

25

No.

Standard

NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH


Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

20 Consultant-led communication and information to be provided to patients.

Me

t

Me

t

No

t m

et

Me

t

No

t m

et

No

t m

et

No

t m

et

Me

t

No

t m

et

Me

t

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

Me

t

21 Patient experience data is captured, recorded and routinely analysed and acted on. Is a permanent item on board agenda and findings are disseminated.

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

Me

t

Me

t

Me

t

No

t m

et

No

t m

et

Me

t

Me

t

Me

t

Me

t

No

t m

et

No

t m

et

22 All acute medical and surgical units to have provision for ambulatory emergency care.

Me

t

Me

t

No

t m

et

Me

t

No

t m

et

Me

t

No

t m

et

Me

t

No

t m

et

No

t m

et

Me

t

Me

t

Me

t

No

t m

et

Me

t

Me

t

26

No.

Standard

NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH


Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

23 Prompt screening of all complex needs inpatients to take place by a multi-professional team which has access to pharmacy and therapy services, including physiotherapy and occupational therapy, seven days a week with an overnight rota for respiratory physiotherapy.

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

No

t m

et

24 Single call access for mental health referrals to be available 24 hours a day, seven days a week with a maximum response time of 30 minutes.

Me

t

No

t m

et

No

t m

et

Me

t

Me

t

Me

t

Me

t

No

t m

et

No

t m

et

No

t m

et

Me

t

Me

t

No

t m

et

No

t m

et

Me

t

Me

t

27

No.

Standard

NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH


Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

25 Hospitals admitting emergency patients to have access to comprehensive 24 hour endoscopy services that has a formal consultant rota 24 hours a day, 7 days a week

Me

t

Me

t

Me

t

Me

t

Me

t

No

t m

et

No

t m

et

Me

t

Me

t

Me

t

No

t m

et

No

t m

et

Me

t

Me

t

Me

t

Me

t

26 a) All hospitals dealing with complex acute medicine to have onsite access to levels 2 and 3 critical care (i.e. intensive care units with full ventilatory support).

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

b) All acute medical units to have access to a monitored and nursed facility.

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

28

No.

Standard

NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH


Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

Me

dic

ine

Surg

ery

27 Training to be delivered in a supportive environment with appropriate, graded consultant supervision

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

No

t m

et

No

t m

et

No

t m

et

Me

t

Me

t

Me

t

Me

t

Me

t

Me

t

29

5. Key findings in NW London for adult emergency services audit Key findings from the audits undertaken in NW London on compliance with the acute medicine and emergency general surgery standards are summarised below. All hospitals in London which provided these services were commissioned to meet these standards from April 2012.

5.1 Overall findings:

Although some progress had been made by some sites audited in NW London, no site met all of the adult emergency service standards for acute medicine and emergency general surgery. One site (Chelsea and Westminster Hospital) had made an excellent effort in order to achieve compliance with the standards and was meeting all but four standards across both acute medicine and emergency general surgery services.

There were two standards which all sites across NW London met, these were:

A structured process to be in place for the medical handover of patients twice a day. These arrangements to also be in place for the handover of patients at each change of responsible consultant/medical team. Changes in treatment plans are to be communicated to nursing and therapy staff as soon as possible if they are not involved in the handover discussions.

All hospitals dealing with complex acute medicine to have onsite access to levels 2 and 3 critical care (i.e. intensive care units with full ventilatory support) and all acute medical units to have access to a monitored and nursed facility.

There were two standards which all sites in NW London failed to meet however, one site (Chelsea and Westminster Hospital) had robust plans in place to achieve compliance with these standards during 2012/13:

A clear multi-disciplinary assessment to be undertaken within 12 hours and a treatment or management plan to be in place within 24 hours.

Prompt screening of all complex needs inpatients to take place by a multi-professional team which has access to pharmacy and therapy services, including physiotherapy and occupational therapy, seven days a week with an overnight rota for respiratory physiotherapy.

Future plans:

It was acknowledged by the majority of sites in NW London that significant difficulty was faced when planning for the implementation of the standards for acute medicine and emergency general surgery at a time of uncertainty, in the context of reconfiguration. However, there were a large number of improvements to be made in both acute medicine and emergency general services at most sites to ensure adequate involvement of consultants in the assessment and subsequent management of acutely ill patients – particularly at the weekend.

In all but two hospitals audited in NW London there was commitment shown from senior management to ensure that the standards would be met in the future. However, within the two hospitals there was little evidence to suggest that the Trust held a strong commitment to the value and implementation of the acute medicine and emergency general surgery standards in order to address the variation and inconsistencies across the provision of these services.

30

There was significant variation between the nine sites on the timescales in which all standards would be met. The audit team noted that some plans proposed by most sites were dependent on the Shaping a Healthier Future reconfiguration programme but did however note that implementation of the outcome of this may not take place until 2015. There were a small number of sites that had robust plans in place to achieve compliance with some standards within 2012/13. This was the case for Chelsea and Westminster Hospital for three standards. However, for the majority of sites in NW London there were no credible plans to meet standards that remained unmet.

5.2 The provision of consultant delivered care:

The standards mandate consistent consultant involvement in patient care through early assessment, involvement within one hour for high risk patients, twice daily ward rounds for all patients, continuity of care, extended day working seven days a week, and when on-take for acute emergency admissions consultants should be free of all other clinical duties. Recommendations from clinical evidence over a number of years has been resoundingly clear: early and consistent input by consultants improves patient outcomes.

Within acute medicine no site in NW London reviewed all acute medical admissions within the appropriate timescales consistently across seven days of the week. Only Ealing Hospital was able to demonstrate that consultant involvement was provided within one hour for high risk patients. Just Chelsea and Westminster Hospital ensured that all patients were reviewed by a consultant during twice daily ward rounds and along with West Middlesex Hospital, rotas were constructed to provide consultant extended day working seven days a week. However, all sites but West Middlesex Hospital were able to demonstrate that their acute medical patients received continuity of care due to the construction of their consultant rotas, and only Chelsea and Westminster, Northwick Park and the Hillingdon hospitals ensured that on-take consultants were free of all other clinical duties.

Within emergency general surgery, Chelsea and Westminster Hospital and the West Middlesex Hospital were the only sites to show that they ensured early review of all admitted patients within 12 hours, although only Ealing Hospital demonstrated review within one hour for all high risk patients. Just Chelsea and Westminster Hospital provided

all patients with consultant delivered twice daily wards and along with St Mary’s Hospital and the Hillingdon Hospital, rotas were constructed to provide consultant extended day working seven days a week. Chelsea and Westminster, Northwick Park and the HIllingdon hospitals provided sufficient evidence to demonstrate that their consultants were free from all other clinical and elective duties. However, although the provision of consultant delivered care needed improvement across the majority of sites; all but two hospitals had consultant rotas that provided continuity of care for their patients.

5.4 Access and provision of emergency theatres:

The standards stipulate immediate access to a fully staffed emergency theatre, and that the majority of surgery is carried out on the day it was originally planned. Additionally, all patients admitted as emergencies to be discussed with a consultant surgeon and consultant anesthetist. For each surgical patient, a consultant surgeon must take an active decision in delegating responsibility for an emergency surgical procedure to appropriately trained junior or specialty surgeon. High risk patients must be operated on with direct supervision from a consultant surgeon and consultant anesthetist. Any operations carried out at night need to meet NCEPOD classifications (national confidential enquiry into

31

patient outcomes and death), and must be carried out under the direct supervision of a consultant regardless of the complexity of the operation.

Only Chelsea and Westminster and Ealing hospitals met all of the standards for access and provision of emergency theatres. Northwick Park Hospital failed to meet any of the standards relating to emergency theatres, and along with Charing Cross, Hillingdon and West Middlesex hospitals were the sites that failed to provide immediate access to a fully staffed theatre due to limited capacity on their NCEPOD list to meet demand. The audit site visits confirmed that Charing Cross and Northwick Park hospitals did not require involvement from a consultant surgeon in the decision to operate for all patients, although a consultant surgeon would mostly attend if required at the request of junior staff. Additionally, the site visits confirmed that not all hospitals required surgery for high risk patients, and patients operated on at night to be carried out under the direct supervision of a consultant surgeon.

5.5 Multi-disciplinary care:

The standards require multi-disciplinary input within 12 hours of admission for all patients, and prompt screening for complex patients, including physiotherapy, occupational therapy and pharmacy provision. Multi-disciplinary input can speed up the discharge process.

None of the sites audited in NW London had the required multi-disciplinary provision seven days a week to meet these standards. Although Chelsea and Westminster Hospital was the only site that had a robust plan in place to achieve compliance with these standards in 2012/13. All sites failed to provide sufficient multidisciplinary care because of inadequate provision of therapy services and pharmacy provision at the weekend.

5.6 Diagnostics:

Timely access to imaging and reporting of all diagnostic services to enable appropriate treatment is required in order for hospitals to meet the standards. The standards set out that key diagnostic services should be available 24 hours a day, seven days a week with consultant rotas set up to support reporting within specified timeframes Charing Cross Chelsea and Westminster hospitals were the only two sites in NW London meeting this standard for both acute medicine and emergency general surgery admissions. In the remaining sites, weekend services, including access and reporting, were not consistent with those provided during the week. In most sites ultrasound was reported as problematic, particularly out-of-hours and at weekends.

5.7 Interventional radiology and endoscopy:

The standards require all hospitals admitting medical and surgical emergencies to have access to interventional radiology, and endoscopy services 24 hours a day seven days a week. Four out of the nine sites in NW London were able to demonstrate 24 hour seven day a week access to both interventional radiology and endoscopy. During the site visits, a particular problem was noted at the remaining five sites with ad-hoc arrangements, rather than formal arrangements.

5.8 Patient experience:

The standards aim to ensure that patient experience is at the forefront of care when admitting acute medical and emergency general surgery patients.

32

No sites (with the exception of Central Middlesex Hospital which does not provide an emergency general surgery service) in NW London provided consultant-led communication and information to patients in both acute medicine and emergency general

surgery. Ealing Hospital, St Mary’s Hospital and the Hillingdon Hospital were unable to demonstrate that they provided consultant-led communication and information to patients in both acute medicine and emergency general surgery. The remaining six sites met this standard in one service area, either acute medicine or emergency surgery.

Ealing Hospital, St Mary’s Hospital and the Hillingdon Hospital were able to demonstrate that in acute medicine and emergency general surgery services, patient experience data was captured, recorded, routinely analysed and acted upon. Ealing Hospital had an excellent system for the dissemination of patient feedback and actions to all levels of staff and patients. For most other sites further work was needed to fully embed the systems established.

33

6. Summary of NW London compliance with national standards The audit included a site self-assessment and audit team assessment against compliance with existing national standards in the clinical service areas within the Quality and Safety Programme not covered by the 2011 review of acute medicine and emergency general surgery.

The purpose of the assessment against national standards was to provide commissioners with an understanding of the baseline from which London clinical quality standards for these areas would be commissioned in April 2013.

Tables 2 – 6 summarises the overall assessment on compliance with existing national standards.

Table 2: summary of compliance with existing emergency department standards

No. Standard NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH

NPH

ICH SMH

THH WMUH

1

A trained and experienced doctor (ST4 and above) in emergency medicine to be present in the emergency department 24 hours a day.

Not met

Not met Not

met Not met Not met

2 24/7 access to plain x-rays and CT. Not met

Not met Not

met Not met Not met

3 Timely support from inpatient teams and efficient procedures for admission to hospital.

Not met Met Not

met Not met Met

4 A clinical decision unit/ observation area in the emergency department.

Met Met Met Not met Met

34

Table 3: summary of compliance with existing critical care standards

No. Standard NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH

NPH

ICH SMH

THH WMUH

1

Medical staff trained in critical care must be available onsite 24 hours a day, with access to an appropriately trained consultant at all times.

Met Met Met Met Unable to assess

Met Unable to assess

Not met

2

Nurse: patient ratio.

1:1 nursing ratios for level 3 patients and 1:2 ratios for level 2 patients.

Met Met Met Met Unable to assess

Met Met Met

3 Non-clinical transfers out of and into a unit. 0 0 16 0 5 2 0 0

4

Proportion of discharges during out of hours (i.e. between 22.01 and 06.59).

7% 7.3% 11% 6% 13% 14% 16 in 6 months 10%

35

Table 4: summary of compliance with existing fractured neck of femur pathway standards

No. Standard NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH

NPH

ICH SMH

THH WMUH

1 Hip fracture patients should be operated on within 24/ 36/ 48 hours of admission

Not met Not

met Not met Not

met Not met

Not met Not met

2

All patients presenting with a fragility fracture should be managed on an orthopaedic ward with routine access to acute orthogeriatric medical support from the time of admission.

Met Not met Met Met Met

Unable to assess

Met

3 Is all hip fracture surgery undertaken on planned trauma lists?

Not met Not

met Met Met Met Unable to assess

Met

4

Offer patients mobilisation at least once a day (seven days a week) and ensure regular physiotherapy and input from occupational therapists.

Met Met Met Met Met Unable to assess

Met

36

Table 5: summary of compliance with existing maternity services standards

No. Standard NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH

NPH

ICH SMH

THH WMUH

1 Service has staffing levels for obstetric presence on the labour ward in line with Safer Childbirth recommendations.

Not met

Not met Not

met Not met

Not met Not met

2 Obstetric unit provides a ratio of one midwife to 28 births.

Not met

Not met Not

met Not met

Not met Not met

3 Women are provided with 1:1 care during active labour.

Met Met Not met

Not met

Not met Met

4 Clinical labour ward co-ordinators are supernumerary to midwives providing 1:1 care.

Met Not met Met Not

met Met Not met

37

Table 6: summary of compliance with existing paediatric standards

No. Standard NWLH

CMH

ICH

CXH C&W EH

ICH

HH

NWLH

NPH

ICH SMH

THH WMUH

1

All paediatric emergency admissions to be seen by a consultant paediatrician (or equivalent staff, speciality and associate specialist grade doctor who is trained and assessed as competent in acute paediatric care) within the first 24 hours.

Met Met Met Met Met

2

All emergency admissions to be seen and assessed by the responsible consultant within 12 hours of admission or within 14 hours of the time of arrival at the hospital.

Additionally, where children with surgical problems are admitted to a non-specialist surgical unit, they should be jointly managed and reviewed by both surgical and paediatric senior teams within 12 hours of admission

Not met

Not met Not

met Not met Not met

3 One paediatric trained nurse to be present in the emergency department at all times. Met Not

met Met Met Not met

4

Access to a paediatrician with child protection experience and skills (of at least Level 3 safeguarding competencies) to provide immediate advice and subsequent assessment, if necessary, for children and young people under 18 years of age where there are child protection concerns.

Met Met Met Met Met

38

7. Key findings in NW London for the national standards This section provides the key findings from the evidence reviews undertaken for NW London on compliance with the national standards.

Overall finding:

Emergency departments:

Critical care:

Fractured neck of femur:

Maternity services:

Paediatric emergency services:

Next steps: The Quality and Safety Programme has developed further clinical quality standards based on existing national standards included in the baseline audit. The standards have been developed and agreed by clinical expert panels, and patient and service user groups. The clinical quality standards for these areas are more ambitious than the national standards which have been used as a baseline.

39

8. Activity summary for NW London sites: Adult emergency services

West Middlesex:• Adult emergency department attendances:77,882• Total adult emergency admissions: 7,951• Emergency general surgery admissions: 1,264• Emergency acute medicine admissions: 8,952• Fractured neck of femur admissions: 249• Critical care emergency admissions:1,175

Hillingdon Hospital:• Adult emergency department attendances: 79,030• Total adult emergency admissions: 9,199• Emergency general surgery admissions: 1,155• Emergency acute medicine admissions: 9,211• Fractured neck of femur admissions: 221• Critical care emergency admissions: 403

Northwick Park Hospital:• Adult emergency department attendances:• Total adult emergency admissions: 9,406• Emergency general surgery admissions: 1,896• Emergency acute medicine admissions: 13,855• Fractured neck of femur admissions: 291• Critical care emergency admissions:801

Chelsea and Westminster Hospital:• Adult emergency department attendances:65,736• Total adult emergency admissions: 7,156• Emergency general surgery admissions: 1,152• Emergency acute medicine admissions: 8,651• Fractured neck of femur admissions: 200• Critical care emergency admissions:302

Hammersmith Hospital:• Adult emergency department attendances: • Total adult emergency admissions: 7,688• Emergency general surgery admissions: 656• Emergency acute medicine admissions: 8,038• Fractured neck of femur admissions: 97• Critical care emergency admissions:2,246

Hillingdon

Ealing

West Middlesex

Northwick Park

Central Middlesex

Hammersmith

St Mary’s

Chelsea and Westminster

Charing Cross

Brent

Ealing

Harrow

Hounslow

Hillingdon

H&F K&C

Westminster

Charing Cross Hospital:• Adult emergency department attendances:• Total adult emergency admissions: 7,210• Emergency general surgery admissions: 635• Emergency acute medicine admissions: 9,403• Fractured neck of femur admissions: 98• Critical care emergency admissions: 3,083

St Mary’s Hospital:• Adult emergency department attendances:• Total adult emergency admissions: 7,817• Emergency general surgery admissions: 1,389• Emergency acute medicine admissions: 9123• Fractured neck of femur admissions: 171• Critical care emergency admissions:2,105

Ealing Hospital:• Adult emergency department attendances:69,772• Total adult emergency admissions: 8,024• Emergency general surgery admissions: 1,052• Emergency acute medicine admissions:7,510• Fractured neck of femur admissions:153 • Critical care emergency admissions:353

Central Middlesex Hospital:• Adult emergency department attendances:• Total adult emergency admissions: 3,764• Emergency general surgery admissions: 109• Emergency acute medicine admissions: 4,973• Fractured neck of femur admissions: 109• Critical care emergency admissions:207

40

9. Activity summary for NW London sites: Paediatric emergency services and acute maternity services

West Middlesex:• Paediatric emergency department attendances:• Total paediatric emergency admissions:• Paediatric emergency general surgery admissions:• Paediatric emergency acute medical admissions:• Number of births:

Hillingdon Hospital:• Paediatric emergency department attendances: 26,895• Total paediatric emergency admissions:• Paediatric emergency general surgery admissions:• Paediatric emergency acute medical admissions:• Number of births: 4,030

Northwick Park Hospital:• Paediatric emergency department attendances :• Total paediatric emergency admissions:• Paediatric emergency general surgery admissions:• Paediatric emergency acute medical admissions:• Number of births:5,152

Chelsea and Westminster Hospital:• Paediatric emergency department attendances :• Total paediatric emergency admissions:• Paediatric emergency general surgery admissions:• Paediatric emergency acute medical admissions:• Number of births:

Hammersmith Hospital:• Paediatric emergency department attendances :• Total paediatric emergency admissions:• Paediatric emergency general surgery admissions:• Paediatric emergency acute medical admissions:• Number of births: 5,195

Hillingdon

Ealing

West Middlesex

Northwick Park

Central Middlesex

Hammersmith

St Mary’s

Chelsea and Westminster

Charing Cross

Brent

Ealing

Harrow

Hounslow

Hillingdon

H&F K&C

Westminster

Charing Cross Hospital:• Paediatric emergency department attendances :• Total paediatric emergency admissions:• Paediatric emergency general surgery admissions:• Paediatric emergency acute medical admissions:• Number of births:

St Mary’s Hospital:• Paediatric emergency department attendances :• Total paediatric emergency admissions:• Paediatric emergency general surgery admissions:• Paediatric emergency acute medical admissions:• Number of births:4,588

Ealing Hospital:• Paediatric emergency department attendances:69,722• Total paediatric emergency admissions:• Paediatric emergency general surgery admissions:• Paediatric emergency acute medical admissions:• Number of births:3,045

Central Middlesex Hospital:• Paediatric emergency department attendances :• Total paediatric emergency admissions:• Paediatric emergency general surgery admissions:• Paediatric emergency acute medical admissions:• Number of births:

41

Appendix F – Ipsos MORI consultation analysis report

Appendix F – Ipsos MORI consultation

analysis report


Edition: 1.0

12 February 2012

‘Shaping a healthier future’ consultation for NHS North West London Final Report 28 November 2012

Legal notice

© 2012 Ipsos MORI – all rights reserved. The contents of this report constitute the sole and exclusive property of Ipsos MORI. Ipsos MORI retains all right, title and interest, including without limitation copyright, in or to any Ipsos MORI trademarks, technologies, methodologies, products, analyses, software and know-how included or arising out of this report or used in connection with the preparation of this report. No license under any copyright is hereby granted or implied.

Contents

Executive summary .......................................................................4

1. Overview of the consultation process....................................12

1.1 Background: the case for change ................................................. 12

1.2 Structure of the document............................................................. 14

1.3 Structure of the consultation ......................................................... 14

1.5 Responses to the public consultation............................................ 16

1.6 Interpreting the consultation responses ........................................ 20

1.7 Further technical details................................................................ 21

2. The case for change ................................................................22

3. Care inside and outside of hospital ........................................26

3.1 The importance of different elements of care................................ 26

3.2 The standards for care outside hospital ........................................ 29

3.3 The standards for care in hospital................................................. 30

3.4 Delivering services locally............................................................. 31

3.5 Bringing healthcare services together........................................... 33

3.7 Improving the range of services delivered outside hospital........... 38

4. Urgent care ...............................................................................41

4.1 Provision in acute hospitals........................................................... 41

4.2 Urgent care centres ...................................................................... 42

5. Elective hospitals using high quality buildings.....................45

6. Major hospitals.........................................................................48

7. Paediatric care..........................................................................51

8. Maternity care...........................................................................53

9. Criteria for choosing which hospitals are major hospitals ...55

9.1 Way of choosing which possibilities to recommend ...................... 55

9.2 The importance of each criterion................................................... 56

10. Options for the location of hospitals ....................................60

10.1 The location of major hospitals in North West London.................. 60

10.2 Central Middlesex Hospital as an elective and local hospital........ 77

10.3 Hillingdon Hospital as a major hospital ......................................... 82

10.4 Northwick Park Hospital as a major hospital................................. 85

10.5 Hammersmith Hospital as a specialist hospital ............................. 88

11. Hyper-acute stroke unit .........................................................92

12. The Western Eye Hospital .....................................................95

13. Further comments..................................................................98

14. Stakeholder responses........................................................100

14.1 Overall comments on ‘Shaping a healthier future’.......................... 100

14.2 The case for change ...................................................................... 103

14.3 Principles of care............................................................................ 105

14.4 Out of hospital care ........................................................................ 106

14.5 Care in hospitals ............................................................................ 110

14.6 Urgent Care Centres ...................................................................... 111

14.7 Major hospitals and criteria for choosing........................................ 114

14.8 Paediatric and maternity units in major hospital ............................. 115

14.9 Location of major hospitals – Options A, B and C .......................... 116

14.10 Central Middlesex Hospital........................................................... 123

14.11 Hillingdon, Northwick Park and Hammersmith Hospitals.............. 125

14.12 Moving the hyper-acute stroke unit and Western Eye Hospital to St

Mary's..................................................................................................... 126

14.3 Public transport and journey times ................................................. 127

14.14 Implementation of the ‘Shaping a healthier future’ proposals....... 130

14.15 Comments on the consultation process ....................................... 138

15. Roadshows, meetings and focus groups...........................142

16. Petitions and campaign responses ....................................170

17. Late responses.....................................................................178

18. Appendices...........................................................................180

Appendix A: Organisational responses ...................................181

Appendix B: Demographic information....................................184

Appendix C: Petitions and campaigns .....................................187

Appendix D: West London Citizens form .................................187

Shaping a healthier future - Final Report 28.11.12

4

This work was carried out in accordance with the requirements of the international quality standard for Market Research, ISO 20252:2006.

© 2012 Ipsos MORI.

Executive summary

The consultation process

The ‘Shaping a healthier future’ consultation on NHS North West London’s vision for

changing and improving health services ran from 2 July 2012 to 8 October 2012.

During the consultation period, the ‘Shaping a healthier future’ team attended or arranged

over 200 events which included two roadshows in each of the eight North West London

boroughs as well as an additional roadshow in the neighbouring boroughs of Camden,

Richmond and Wandsworth; public meetings and debates; GP events and other events for

staff.

In addition to these meetings, there were a number of other channels through which

members of the public and organisations could make their views known:

� Online response form – a questionnaire on the proposals which could be

accessed through the ‘Shaping a healthier future’ website and which was

hosted by Ipsos MORI. Closed questions were asked to gauge levels of support

for the proposals among those responding to the consultation. Open-ended

questions were included to give respondents the opportunity to express their

opinions in their own words.

� Paper response form – a questionnaire on the proposals, mirroring the

questions asked in the online response form, available in 10 languages.

� Written comments – letters, emails and postcards sent to the ‘Shaping a

healthier future’ email or postal address by members of the public and

stakeholders. A number of petitions were also submitted by email and post.

All responses dated and received within the consultation dates were treated as valid

responses. In addition, to make allowance for any potential delays within the post or

misdirection of emails, paper responses, letters and emails were accepted up until 15

October 2012. Responses received between 15 October and 2 November have been

considered, but are analysed separately, in Chapter 17 of this report.

A total of 17,022 responses were received within the consultation period. The number of

responses received from different channels is shown in Table 1.


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© 2012 Ipsos MORI.

Table 1 – Responses to the public consultation

Method Total Paper response forms 5,045 Online response forms 11,725 Written comments (letters and emails) 148 Voicemails 12 Stakeholder responses 74 Petitions 18 TOTAL

17,022

The number of people responding to this consultation is higher than we have seen for some

other NHS consultations we have analysed.

Key findings from the response forms1

� The majority of respondents (64%) who responded to this question2 agree that there

are convincing reasons to change the way healthcare is delivered in North West

London.

� There are high levels of support for the standards agreed for care both outside (67%)

and in (76%) hospital. The balance of opinion in favour of the following proposals is

also positive:

� Continuing provision of urgent care centres and outpatient appointments at acute

hospitals (83% agree, 13% disagree)

� All major hospitals having consultant-led maternity units (75% support, 5%

oppose)

� Use of hospital buildings with spare space as elective hospitals (68% support,

21% oppose)

� All major hospitals having inpatient paediatric units (54% support, 28% oppose)

� Delivering some hospital services locally (43% agree, 25% disagree)

� Plans for urgent care centres (41% agree, 24% disagree)

� However attitudes towards the following proposals are more negative than positive,

with higher levels of opposition than support:

� Delivering different forms of care in different settings (36% support, 56% oppose)

� Plans to improve the range of services delivered outside hospital (44% support,

48% oppose) 1 It is important to remember that the results contained in this report are not representative of the population – they only refer to the people and organisations that responded to the consultation. 2 Please note that all percentages in this report are based on the number of respondents answering each question


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© 2012 Ipsos MORI.

� Bringing more healthcare services together on fewer sites (30% support, 38%

oppose)

� The majority (61%) agree with the recommendation that there should be five major

hospitals in North West London. There is also majority (60%) support for the way in

which North West London should chose between the various possibilities to decide

which option to recommend.

� Option A received the highest level of support of all three options for organising

hospital services, with a majority of respondents supporting this option. Levels of

support have been influenced by campaign responses submitted by Chelsea and

Westminster Hospital (strongly supporting this option) and West London Citizens

(strongly opposing it). If we include these responses in our analysis, support stands at

83% of respondents answering this question. If they are excluded, support stands at

63%.

� A majority of respondents oppose Option B, with 64% in opposition while 21%

support it. Option C is the second most preferred option, with 31% supporting it, while

59% oppose it.

� While many do not express a view either way, the balance of opinion in favour of the

following proposals is positive:

� Central Middlesex Hospital as an elective and local hospital (30% support, 19%

oppose)

� Hillingdon Hospital as a major hospital (33% support, 9% oppose)

� Northwick Park Hospital as a major hospital (33% support, 10% oppose)

� Hammersmith Hospital as a specialist hospital with a maternity unit (40% support,

17% oppose)

� Relocating the Western Eye Hospital to the major hospital at St Mary’s (27%

support, 22% oppose).

� While a significant proportion of respondents do not express a view on the proposal, the

balance of opinion on moving the hyper-acute stroke unit from Charing Cross to St

Mary’s is slightly more negative than positive (23% agree, 29% disagree).

Main themes raised in the response forms

The response forms included a number of open-ended questions which enabled respondents

to comment on the proposals in their own words. Accessing services was a key theme

which was raised throughout. Respondents commented on journey times, accessing services

using public transport and the impact of the proposals on ambulance journeys.


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© 2012 Ipsos MORI.

Some respondents expressed opposition to some or any services closing. The proposed

closure of Ealing Hospital A&E received particular attention. Where people live, and the

hospital closest to them, is an important determinant of their views.

Quality of services emerged as another key theme, with concerns raised about the capacity

of both major hospitals and out of hospital services (for instance GPs) to deal with

anticipated increases in demand.

Some respondents criticised the consultation process itself, for instance the evidence

provided in the consultation document or the response form itself.

These themes were echoed in the roadshows, hospital site events, GP events and focus

groups held by NHS North West London during the consultation period. In this strand of the

consultation, the need to inform the public about the proposed changes, and how to access

services, was frequently raised.

Petitions

A total of 18 petitions were received both opposing and supporting the proposals. 12 of the

petitions opposed the closure of A&E and other departments in hospitals, five were in

support of Option A while one supported West Middlesex’s status as a major hospital.

Petition Number of

signatures

Patients opposed to the proposed closure of the A&E departments at

Ealing Hospital, from Eastmead Surgery

76

Petition opposed to the closure of services at Charing Cross and

Hammersmith hospitals and the closure of the hyper-acute stroke unit

at Charing Cross, from Hammersmith and Fulham Council

492

Petition opposing the downgrading of hospitals in North West London 19

Email postcard petition registering support for Option A from

Hounslow Council

47

Email petition supporting West Middlesex’s status as a major hospital

in NW London from London Borough of Hounslow

643


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© 2012 Ipsos MORI.

Petition opposing the downgrading of services and the closure of the

A&E Department at Central Middlesex Hospital from Harlesdon

Methodist Church

43

Email petition supporting Chelsea and Westminster Hospital being

one of five major hospitals and Option A

6,611

Email petition registering support for Option A from West Middlesex

Hospital patients

151

‘Save Hammersmith Hospital’ petition calling for A&E and other

clinical services to be retained at Hammersmith Hospital, from

Hammersmith and Fulham Council

2,613

‘Save Charing Cross Hospital’ petition calling for A&E and other

clinical services to be retained at Charing Cross Hospital, from

Hammersmith and Fulham Council

9,388

‘Save Hammersmith & Charing Cross Hospitals’ petition, calling for

the Secretary State for Health to stop the closure of hospital services

in West London, from Hammersmith and Fulham Council

15,263

Chelsea and Westminster Hospital ‘Safe in Our Hands’ campaign.

Postcard and online postcards in support of Option A, calling for

Chelsea and Westminster Hospital to be a major hospital with a full

A&E

11,263

(9,927 of these

also submitted in

the online form)

Petition calling for the A&E department of Hammersmith Hospital to

be retained, from residents of Hetley Road, W12

58

Petition registering support for Option A, from residents of the Heath

Court Sheltered Scheme

92

Petition calling for Ealing, Central Middlesex, Charing Cross and

Hammersmith Hospitals to retain their status and keep all existing

services, from Ealing Council

25,193


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© 2012 Ipsos MORI.

‘NHS Under the Knife’ campaign calling for the A&E department of

Central Middlesex Hospital to remain open and for no cuts to or

privatisation of services

1,932

Petition calling for Secretary of State for Health to stop the closure of

Hospital Services in west London, in particular the A&E Departments

of Hammersmith and Charing Cross Hospitals

1,332

Petition calling for the protection of A&E departments in Hammersmith

and Charing Cross Hospitals and opposing the closure of the stroke

unit at Charing Cross

2,044

Stakeholder responses

74 stakeholders submitted a response to the consultation. These responses followed their

own format and very few covered every question asked about in the consultation. Our

analysis of these responses has been qualitative in nature, drawing out the key themes and

issues stakeholders have commented on.

All of the stakeholders who expressed a view on this supported the need for change. A

number of stakeholders expressed overall support for the ‘Shaping a healthier future’

proposals. Several others expressed strong opposition, notably Ealing and Hammersmith

and Fulham Councils who both provided detailed criticisms on the way in which the

consultation proposals had been decided upon.

Most stakeholders commenting on the issue expressed support for the out of hospital

proposals, although some called for more detailed plans about timing and implementation.

The point was made that primary and community services need to be improved before there

is any reduction in acute provision.

There were calls for consistent standards across Urgent Care Centres and more detail on the

proposals. The need to build public understanding and awareness of UCCs was also

mentioned.

The proposal to have five major hospitals in North West London and the criteria for deciding

upon these was supported by a number of stakeholders, while some criticised it.


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© 2012 Ipsos MORI.

A number of stakeholders , including local authorities, LINks, Clinical Commissioning Groups

and MPs, put on record their support for Option A. Options B and C received fewer

comments and only a couple of stakeholders expressed explicit support for either. A couple

of stakeholders expressed opposition to the proposed closure of services without specifically

mentioning any of the options. Among those not supporting any of the options, no

alternatives to the status quo were put forward,

Several stakeholders expressed support for Central Middlesex Hospital being an elective and

local hospital, while others opposed this because of the impact of the A&E department being

closed. There was support for Hillingdon and Northwick Park being major hospitals, although

a couple raised concerns about capacity at the latter. The proposal for Hammersmith

Hospital to be a specialist hospital was also supported.

Reaction to moving the hyper-acute stroke unit to St Mary’s was mixed, with some

stakeholders supporting this while others felt it should stay were it is or would be better

located elsewhere. Some stakeholders commented on the need to improve facilities at St

Mary’s before either the hyper-acute stroke unit or Western Eye Hospital are moved there.

A number of detailed comments were made about public transport and journey times, with

particular concerns raised about vulnerable groups and follow-up appointments. The need for

detailed travel plans and improvements to public transport were highlighted. Some called for

more detailed analysis.

A wide range of comments were made about the delivery and implementation of the

consultation proposals. A number of stakeholders commented on the potential difficulties and

risks in handling the transition. In addition, concerns were raised about timescales, the

capacity of both acute and out of hospital services to meet demand and the financial position

of hospital trusts. More detailed impact assessments were called for (including equalities

analysis), and more information on the workforce strategy was requested. The importance of

public information was also stressed by some stakeholders, and the need for effective

integration was also highlighted.

While a couple of stakeholders made favourable comments about the consultation itself,

others criticised the consultation process and materials.


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© 2012 Ipsos MORI.

Concluding comments

A consistent picture emerges from the different strands of the consultation. Overall, there is

support for many of the proposals outlined in the consultation document, and a widespread

acceptance of the case for change. There is majority support for the proposal that there

should be five major hospitals in North West London and Option A. It is also worth nothing

that there has been clear and vocal opposition to the proposed closure of A&E and other

services in some areas, particularly Ealing and Hammersmith and Fulham.

All the different strands of the consultation highlight some clear concerns about the

proposals:

• Their impact on accessing services – in particular journey times and public transport

accessibility

• The capacity and ability of both hospital and out of hospital services to meet demand

and support the changes in how health services are delivered

• The need for information on what these changes will mean for people in practice, as

well as when and how they should access particular services

Potential changes to services, particularly where closures are involved, understandably

cause apprehension among those who may be affected. Whatever decisions NHS North

West London takes as a result of this consultation, it has two key challenges. The first of

these is to explain any proposed changes in a way that addresses these concerns and the

second is to explain clearly what the changes will mean for people in practice.


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© 2012 Ipsos MORI.

1. Overview of the consultation process

1.1 Background: the case for change

The NHS in North West London (NHS NW London) faces the challenge of meeting the needs

of a growing and changing population, while making the best use of NHS resources,

buildings and facilities.

NHS NW London has therefore developed a vision for how health services can be changed

and improved. This vision, ‘Shaping a healthier future’, is being taken forward by eight clinical

commissioning groups (CCGs), made up of GPs representing NW London’s eight primary

care trusts (PCTs).

There are three main principles which inform the new vision of care:

• Localising: By localising routine medical services, patients should have better

access to healthcare closer to home and an improved experience.

• Centralising: There is evidence to suggest that patients have better and safer

outcomes if specialist services are centralised.

• Integration: Where possible, care should be integrated between primary, secondary

and social care to give patients a co-ordinated service.

A number of proposals have been made to deliver health services in the future:

• People are to be supported to take better care of themselves, lead a healthier

lifestyle, understand where and when they can get treatment if they have a problem,

understand different treatment options and better manage their own conditions with

the support of healthcare professionals if they prefer.

• People will be able to easily see a GP or community care provider 24 hours a day,

seven days a week by phone, email, or face-to-face in local, convenient facilities.

• People will be able to see a specialist or receive support from community or social

care services if necessary (this will be organised quickly and GPs will be responsible

for co-ordinating healthcare).

• If people need to go into hospital, it will be a properly maintained and up-to-date

hospital where they receive care from highly trained specialists, available seven days

a week, who have the specific skills needed to treat them.


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© 2012 Ipsos MORI.

NHS NW London has proposed that all nine current acute hospitals in North West London

(Charing Cross Hospital, Chelsea and Westminster Hospital, Central Middlesex Hospital,

Ealing Hospital, Hammersmith Hospital, Hillingdon Hospital, Northwick Park Hospital, St

Mary’s Hospital and West Middlesex Hospital) should continue to provide local hospital

services, including an urgent care centre and outpatient and diagnostic services.

It has been recommended that five of these hospitals are designated major hospitals,

providing a full A&E service, emergency surgery, maternity and inpatient paediatric services.

NHS NW London is recommending that two of the five proposed major hospitals are

Northwick Park Hospital and Hillingdon Hospital, while Central Middlesex Hospital is a local

and elective hospital and Hammersmith Hospital is a specialist hospital with a maternity unit.

To ensure that services at the remaining three major hospitals are distributed appropriately

across NW London, the programme has proposed:

• Chelsea and Westminster Hospital, St Mary’s Hospital and West Middlesex Hospitals

as major hospitals, with Charing Cross Hospital and Ealing Hospitals as local

hospitals (Option A, the preferred option).

• Charing Cross Hospital, St Mary’s Hospital and West Middlesex Hospital as major

hospitals, with Chelsea and Westminster Hospital and Ealing Hospital as local

hospitals (Option B).

• Chelsea and Westminster Hospital, Ealing Hospital and St Mary’s Hospital as major

hospitals, while Charing Cross Hospital is a local hospital and West Middlesex

Hospital is a local and elective hospital (Option C).

While Option A is the preferred option, no decisions have been made by NHS NW London

and participants are able to propose alternatives to the three options. A consultation has

been held to give both individuals and organisations the opportunity to put forward their

views and comments on the proposals.

Following the consultation, the Joint Committee of Primary Care Trusts (JCPCT), which

consists of NW London PCTs, Camden PCT, Richmond PCT and Wandsworth PCT, will be

making the final decision on the proposals in early 2013.


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© 2012 Ipsos MORI.

1.2 Structure of the document

This report sets out the main findings from the public consultation. This first chapter gives

details on the background to the consultation, how it was set up and run, and who

responded, as well as some points on how to interpret the data.

The following chapters discuss Ipsos MORI’s analysis of responses. The report follows the

order of the consultation response form and covers:

• The case for change

• Care inside and outside of hospital

• Urgent care

• Elective hospitals using high quality buildings

• Major hospitals

• Paediatric care

• Maternity care

• Criteria for choosing which hospitals are major hospitals

• Options for the location of hospitals

• Hyper-acute stroke unit at Charing Cross

• The Western Eye Hospital

1.3 Structure of the consultation

Over half a million summary leaflets setting out the ‘Shaping a healthier future’ proposals

were distributed. These leaflets were sent to all GP surgeries, libraries, hospital sites, town

halls, local LINks offices and pharmacies. A dedicated website was created

(www.healthiernorthwestlondon.nhs.uk), which received over 18,500 visits during the

consultation period. Advertisements were placed in 13 local papers across North West

London and neighbouring boroughs. Over 70,000 full consultation documents and response

forms were sent out.

During the consultation period, the ‘Shaping a healthier future’ team attended or arranged

over 200 events which included two roadshows in each of the eight North West London

boroughs as well as an additional roadshow in the neighbouring boroughs of Camden,

Richmond and Wandsworth; public meetings and debates; GP events and other events for

staff.


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© 2012 Ipsos MORI.

In addition to these meetings, there were a number of other channels through which

members of the public and organisations could make their views known:

� Online response form – a questionnaire on the proposals which could be

accessed through the ‘Shaping a healthier future’ website and which was

hosted by Ipsos MORI. Closed questions were asked to gauge levels of support

for the proposals among those responding to the consultation. Demographic

information was also collected to allow for sub-group analysis where possible.

Open-ended questions were included to give respondents the opportunity to

express their opinions in their own words.

� Paper response form – a questionnaire on the proposals, mirroring the

questions asked in the online response form, available in 10 languages.3

� Written comments – letters, emails and postcards sent to the ‘Shaping a

healthier future’ email or postal address. A number of petitions were also

submitted by email and post.

Prior to launching the response form, Ipsos MORI conducted a series of cognitive interviews.

These interviews were designed to test whether respondents understood the response form

and provide the answers they wished, and whether they were able to access and use the

online version. Feedback from this testing was fed back into the design of the response form.

On the back of this testing changes were made to the online form, and a series of FAQs

were added to the consultation website.

The ‘Shaping a healthier future’ consultation ran from 2 July 2012 to 8 October 2012. All

responses dated and received within the consultation dates were treated as valid responses.

In addition, to make allowance for any potential delays within the post or misdirection of

emails, paper responses, letters and emails were accepted up until 15 October 2012.

3 English, Arabic, Bengali, Hindi, Polish, Punjabi, Somali, Swahili, Tamil and Urdu


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© 2012 Ipsos MORI.

1.5 Responses to the public consultation

The consultation sought to reach a wide-ranging audience and responses came from both

the general public and various stakeholders. A total of 17,022 responses were received

within the consultation period. The number of responses received from different channels is

shown in Table 1.

Table 1 – responses to the public consultation

Method Total Paper response forms 5,045 Online response forms 11,725 Written comments (letters and emails) 148 Voicemails 12 Stakeholder responses 74 Petitions 18 TOTAL

17,022

Included among these responses, a number of responses in languages other than English

were received, as detailed in the table below.

Table 2 – responses in languages other than English

Language Total Arabic 12

Bengali 74

Hindi 47

Polish 17

Punjabi 68

Somali 40

Swahili 48

Tamil 109

Urdu 6

TOTAL 421 Throughout the report, key themes are broken down by audience where appropriate and

possible. The total number of responses by audience group is shown in Table 3. Please note

that demographic data are self-reported and that, in the majority of cases, no demographic

information was included in response forms. While not representative, we have a good

spread of responses by age, ethnicity and disability.


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© 2012 Ipsos MORI.

In Appendix B, the profile of consultation responses by age, gender and ethnicity is

compared with the profile of the eight North West London boroughs. These profiles are

similar in terms of ethnicity but consultation respondents are more likely to be older and

female than the population of North West London as a whole.

Table 3 – Responses by audience group (where data is provided)

Audience Total Response type Individual 4,728 Organisation 76

Employment within the NHS Currently working in the NHS 880 Used to work in the NHS 315 Currently work in the independent health sector 75 Used to work in the independent health sector 78 Never worked in either the NHS or independent health sector 3,181

Age Under 16 23 16-24 155 25-34 540 35-44 960 45-54 891 55-64 827 65+ 1,156

Ethnicity White 2,724 Mixed 132 Asian or Asian British 888 Black or Black British 220 Chinese 42 Other 236

Disability Yes 593 No 3,678

ALL ONLINE AND PAPER RESPONSES 16,770

Where respondents have provided their postcode, they have been allocated to a local

authority. In instances where postal districts cross local authority boundaries, respondents

were assigned to the local authority where that particular postal district is most predominant.


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© 2012 Ipsos MORI.

As the table below illustrates, the great majority of respondents who could be allocated to a

local authority come from one of the eight North West London boroughs (Brent, Ealing,

Hammersmith and Fulham, Harrow, Hillingdon, Hounslow and Kensington and Chelsea and

Westminster). A number of responses also came from people in Camden, Richmond and

Wandsworth. These responses have been highlighted separately because of the potential

impact of the programme on residents of these areas.

Table 4 – Responses by local authority

Barnet 20 Kingston Upon Thames 5

Brent 60 Lambeth 15

Bromley 3 Lewisham 2

Camden 27 Luton 1

Chiltern 1 Merton 14

Crawley 1 Redbridge 1

Croydon 3 Reigate and Banstead 3

Dacorum 1 Richmond Upon Thames 226

Ealing 1,713 Runnymede 4

East Hertfordshire 1 South Oxfordshire 1

Elmbridge 7 Southwark 9

Enfield 3 Spelthorne 25

Epsom and Ewell 1 Surrey Heath 2

Hackney 2 Sutton 4

Hammersmith and Fulham 290 Tower Hamlets 1

Haringey 5 Wandsworth 83

Harrow 72 Waverley 2

Hillingdon 111 Wealden 3

Horsham 1 Westminster 67

Hounslow 888 Woking 3

Islington 8 Worthing 1

Kensington and Chelsea 219 TOTAL 3,909 Total North West London boroughs Total Camden/ Richmond/ Wandsworth* Other ‘bordering areas’ Total ‘other areas’

3,420 336 48 112


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© 2012 Ipsos MORI.

Open written responses – general public and stakeholders

Some respondents chose not to use the response form but sent in bespoke written

comments via letter, postcard and email. A total of 148 were from individuals. It is not known

to what extent these respondents had read or consulted the consultation document. The

themes emerging from these letters can be found at Chapter 13 of this report.

A number of responses were also received from stakeholders such as local authorities,

health providers and commissioners, LINks, and professional bodies. The qualitative analysis

of these responses can be found at Chapter 14 of this report.

Petitions

Campaign responses and petitions (some with a large volume of signatories) were generally

in support of particular hospitals. These tended to either be in support of a specific option for

hospitals set out in the consultation document, or called for specific services (for instance

A&E) to be preserved for a particular hospital or hospitals.

While the number of signatories to each is known, very little else is known about these

individuals. It is not known how much those signing the petition would have known about the

proposals or whether they would have read the consultation document. Chapter 16 contains

details of these responses.

Campaigns – general

It is likely that local campaigns have increased awareness and encouraged a greater number

of responses via all methods of response, not just petitions.

A number of campaigns provided recommended responses to both open and closed

questions. In our analysis of responses to open-ended questions, we have been able to

identify these campaign responses.

Campaigns – Chelsea and Westminster Hospital and West London Citizens

We are aware of two campaigns which explicitly participated in the online and paper

response channels.


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© 2012 Ipsos MORI.

Chelsea and Westminster Hospital distributed postcards and hosted an online form on their

website. Both asked people to tick a box supporting Option A (under which Chelsea and

Westminster would be a major hospital) and requesting consent for Chelsea and

Westminster Hospital to complete the online response form on their behalf. Chapter 16 sets

out details of how many postcards we received and the numbers of people listed in a

spreadsheet who had completed Chelsea and Westminster’s online form.

Chelsea and Westminster Hospital have confirmed that it completed 9,927 responses in the

consultation online response form on behalf of people who had submitted postcards. All of

these responses selected ‘strongly support’ at Option A but answered no other questions on

the form.

West London Citizens produced a document recommending specific responses to many of

the questions in the consultation response form. This document is reproduced at Appendix

D. It advises strongly opposing Options A and B and strongly supporting Option C. Boxes

containing 529 responses, together with this document, were delivered to Ipsos MORI.

In our analysis of online and paper responses, we have reported levels of support for Options

A, B and C with and without these two campaigns included. The Chelsea and Westminster

Hospital campaign has had a significant impact on levels of support for Option A, while the

West London Citizens campaign has increased levels of support for Option C. However

neither campaign has changed the overall balance of opinion for each of the options asked

about in the consultation.

The one question where responses from the West London Citizens campaign have made a

difference to the overall finding is the question on plans to improve the range of services

delivered outside hospital. The balance of opinion overall is more negative than positive.

Almost all of the responses from this campaign opposed this recommendation. If these

responses are excluded from the total, opinion shifts to becoming marginally positive.

1.6 Interpreting the consultation responses

While a consultation exercise is a very valuable way to gather opinions about a wide-ranging

topic, there are a number of issues to bear in mind when interpreting the responses. While

the consultation was open to everyone, the respondents were self-selecting, and certain

types of people may have been more likely to contribute than others. This means that the

responses are not representative of the population as a whole.


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© 2012 Ipsos MORI.

Typically with consultations, there can be a tendency for responses to come from those more

likely to consider themselves affected and more motivated to express their views. In previous

consultations, we have found that responses also tend to be more biased towards those

people who believe they will be negatively impacted upon by the implementation of

proposals. As we have discussed above, responses are also likely to be influenced by local

campaigns. It is certainly the case that a greater number of responses have been received

from areas where local hospitals are perceived as being under threat.

While every attempt has been made to classify each respondent into the correct category for

reporting purposes, it is not always clear from the response the specific category to which

they belong. The information is self-reported and is often incomplete.

The consultation included a number of open-ended questions which are exploratory in nature

and allow respondents to feed back their views in their own words. Not all respondents chose

to answer all questions, as they often had views on certain aspects of the consultation, and

made their views on these clear, but left other questions blank. Therefore, there were many

blank responses to certain questions. A wide range of points were made in response to the

questions which were answered.

Responses from the open questions and written comments were coded to categorise and

group together similar responses and identify the key themes. Ipsos MORI used qualitative

analysis software (Ascribe) to build up a thematic framework (called a 'codeframe') from the

first responses. The codeframe was then used to identify common themes and key issues,

and continued to be added to and refined throughout the consultation as more responses

were received and new issues were raised. A number of responses to open-ended questions

used the same or very similar wording. Where this could be identified as originating from a

campaign, these were coded as campaign responses.

Some of these figures are reported in this document, although they must be treated with

caution. While some figures may seem small given the scale of the overall consultation, all

those reported on have been highlighted due to their importance relative to other themes,

and despite small figures can reflect important themes. A number of verbatim comments are

included to illustrate and highlight key issues that were raised.

1.7 Further technical details

A separate annex will be produced which will set out further technical details on the

consultation.


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2. The case for change

The majority of the 4,951 respondents who answered this question agree that there are

convincing reasons to change the way the NHS delivers healthcare in North West London.

Almost two thirds agree, including a fifth of respondents who strongly agree with the case for

change (64% agree; 20% strongly). A significant minority disagrees, however. Three in ten

disagree, which includes one in eight respondents who strongly disagree (29% disagree;

16% strongly), giving a net agreement level of +35 percentage points.

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Q1. Do you agree or disagree that there are convincing reasons to change the way we deliver healthcare in NW London?

Reasons to change the way healthcare is delivered

20%

45%

5%

13%

16%

2% Strongly agree(975)

Tend to agree(2,209)

No views either way(236)

Tend to disagree(645)

Strongly disagree(810)

Not sure/don’t know(76)

% n

Agree 64 3,184

Disagree 29 1,455

Base: All answering question (4,951) Source: Ipsos MORI

Although views differ to some extent according to respondents’ location, the level of

agreement with the general case for change is above 50% in all areas. Agreement is highest

in Kensington and Chelsea (78%). Both Ealing and Hammersmith and Fulham respondents

record higher levels of disagreement with the case for change (37% and 38% respectively).

Considering respondents’ nearest hospital for urgent care, those likely to attend Chelsea and

Westminster and St Mary’s are more likely to agree that there is a convincing case for

change (76% and 80% respectively). Those likely to visit Central Middlesex and Charing

Cross hospitals (47% and 46% respectively), Hammersmith Hospital (41%) and Ealing

Hospital (34%) are more likely to disagree.


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Respondents who have current or past experience of working in the NHS (66%) or in the

independent healthcare sector (73%) are more likely to agree with the case for change than

those who do not have this experience (62%).

Respondent age appears to have little bearing on attitudes to change. Only one group is

significantly more likely to disagree; one in three (35%) of those aged 55-64 disagree. Views

are also consistent between respondents who say they have a disability and those who do

not.

Views do differ by ethnicity, however. A higher proportion of black and minority ethnic (BME)

respondents agree compared with white respondents (68% vs 62%) and, conversely, white

respondents are more likely to disagree that there are convincing reasons to change (31% vs

27% of BME respondents).

People who look after a child with healthcare needs are much more likely to agree with the

case for change, and less likely to disagree (73% agree and 23% disagree) when compared

with the average, and specifically with those who care for an adult, or have no caring

responsibilities within the family.

Open-ended responses

Respondents were asked ‘What comments if any do you have on any of the issues raised in

sections 1, 2 or 3 of this consultation document?’ This section of the consultation document

is primarily concerned with setting out the challenges faced by the NHS and the case for

change.

A total of 2,413 respondents provided a written comment in response to this question. The

majority of comments concerned access to and quality of care. Two fifths made comments

about access to care, variously mentioning concerns about the loss of A&E and specialised

services, increased travel times, and the demands being placed on GPs and other services,

as well as causative factors such as population growth and complexity of needs.

I accept that thinly spread clinical resources may lead to lack of experience for

doctors/ nurses and a consequent deterioration in service standards. I also accept

that, sadly, financial challenges are forcing NHS NWL to rationalise rather than invest

more in the existing estate/ clinical resources.


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We cannot drive change based on a financial model alone. Consideration of the local

population's wishes, distances travelled by them in order to reach a healthcare

provider and the healthcare provider themselves need to be looked into carefully

before making drastic changes (such as the ones mentioned in SaHF).

The proposed radical changes in health provision are being pushed through for the

wrong reasons, with great fear of the wrong outcomes. The degree to which it is

financial cuts driven, the short timetable, the huge scale of change without adequate

investment and without convincing assessment are due to government political

choice. It is based on its unsupported desire for greater privatisation of the NHS and

a disastrous response to the economic recession. I cannot support the

downgrading/closure of hospitals when there is such uncertainty over the

GP/community based health provision being a suitable alternative for local services

that would be lost from hospitals.

Just over a quarter of respondents answering this question referred to quality of care in some

way. These comments cover a range of issues such as the need for investment and training

and for quality of care to improve. A mixture of positive and negative comments on the

impact of the proposals on quality of care were made.

I am thoroughly convinced by the argument that it is beneficial to concentrate

specialist doctors at fewer hospitals, thereby enabling them to have more experience

of treating serious illnesses. I am sure it will be better for patients to have more

treatment options in the wider community, particularly having access to urgent care

24/7, thereby relieving A&E departments of less serious conditions, so that they can

concentrate on real emergencies..

We need to limit the number of major hospitals to improve the quality of delivery of

inpatient services to ensure this is consultant led at all times with appropriate

supporting services.

Cutting inpatient capacity in a large metropolitan region with a growing population is

foolish. As a doctor who has worked in most of the region's hospitals I cannot think of

a time when bed usage is at full capacity. Reducing beds further will reduce the

quality of care provided as it will cause delays in getting patients through Accident

and Emergency. Northwick Park already struggles to cope with the number of

ambulances arriving - this situation will worsen with the ongoing downgrading of

Ealing and Central Middlesex.


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A number of respondents made comments provided by campaigns, with one in six making

the point that there are difficulties around accessing GPs in Ealing/Southall.

Around one in six made comments supportive of the case for change. These were a mixture

of the general and specific (e.g. supporting the case for fewer hospitals).

There was a wide range of comments covering cost/value for money, buildings/facilities,

specific hospitals, as well as the consultation process itself.

Please note that a number of stakeholders also commented on the case for change. Analysis

of all stakeholder submissions, together with quotations to illustrate points made, can be

found in Chapter 14.


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3. Care inside and outside of hospital

3.1 The importance of different elements of care

Respondents were asked to say how important each of six separate aims are for the NHS in

North West London in terms of what it should strive to provide to the public, by rating their

importance on a scale where 10 means ‘absolutely vital’ and 0 means ‘not important at all’.

This data has been analysed in two ways; calculating a mean value for each criterion (i.e. an

average score across all respondents answering the question). In addition, the top three

scores (10, 9 and 8) have been combined to determine the percentage of people rating the

criteria as ‘important’, and similarly the bottom three scores (0,1 and 2) are used to

determine the percentage of people rating the criteria as ‘not important’. Both sets of data are

shown on the chart below for each criterion and provide a rank order of importance.

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*%

1%

1%

1%

2%

1%

87%

86%

82%

80%

52%

52%

Not important Important

Q3. Please say how important you think it is that we should aim to make sure that you and everyone else in NW London will have each of the following, rating their importance on a scale where 10 means ‘absolutely vital’ and 0 means ’not important at all’.

Principles of delivering healthcare

Base: All answering question Source: Ipsos MORI

The support you need to take better care of yourself (4,636)

A better understanding of where, when and how you can be treated (4,615)

The tools and support you need to better manage your own medical conditions (4,599)

Fast and well-co-ordinated access to specialists, community and social care providers (this access will be managed by GPs) (4,599)

Easy access to primary care providers, such as GPs, 24 hours a day, seven days a week; by phone, email or in person – when

you need to be seen urgently (4,610)

Properly maintained and up-to-date hospital facilities with highly trained specialists available all the time (4,616)

Mean

9.60

9.22

8.75

8.58

8.19

8.13

The resulting rank order of importance is the same regardless of the analytic approach used.

Furthermore, few respondents select scale points below number seven, and there is a

consistent level of ‘don’t know’ responses across each of the six aims (9%-10%).


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© 2012 Ipsos MORI.

Rank ordering places ‘properly maintained and up-to-date hospital facilities with highly

trained specialists available all the time’, as the most important aim of the six listed. The

vast majority (87%) of respondents indicate this as important (by giving it a score between 8

and 10), most of whom (74%) consider this to be ‘absolutely vital’ by awarding a score of

‘10’.

Respondent groups who are more likely than average to say this aim is ‘important’ include

those aged 65+ (89%); black and minority ethnic respondents (90%); those caring for a child

because of health needs (90%) and those who have/are working in the independent health

sector (92%). Location also has some bearing on perceived importance; respondents from

Westminster (97%), Kensington and Chelsea (95%), Richmond (95%) and Hounslow (93%)

all consider this aim more important than the average.

A similarly high proportion (86%) consider ‘easy access to primary care providers - such

as GPs 24 hours a day seven days a week by phone/email/in person – when you need

to be seen urgently’ important. However, fewer consider this absolutely vital than the

previous aim, with just under half (46%) awarding this a maximum score of 10.


those aged 35-44 (88%); black and minority ethnic respondents (89%); those caring for a

child because of health needs (90%). Location also has some bearing on perceived

importance; respondents from Kensington and Chelsea (95%) Richmond (92%) and

Hounslow (91%) all consider this aim more important than average.

The third most important aim among those asked about is ‘fast and well coordinated

access to specialists, community and social care providers (access to be managed by

GPs)’. Four in five (82%) rate this as important, including two in five (39%) who see it as

‘absolutely vital’.


those aged 65+ (86%); women (84%); people who do not have a disability (83%) and those

who visited hospital more than a year ago (85%). Those who have/are working in the

independent health sector are also more likely to say this is important (88%). In addition,

location has some bearing on perceived importance; respondents from Kensington and

Chelsea (93%), Richmond (92%) and Hounslow (89%) all consider this aim more important

than the norm.


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© 2012 Ipsos MORI.

In fourth place is the aim to make sure everyone has ‘a better understanding of where,

when and how you can be treated’. Again four out of five (80%) rate this as important,

including almost two in five (37%) who see it as ‘absolutely vital’.

There are few differences between respondent groups in respect of this aim. Although there

are no differences by age in terms of overall ‘importance’, it is notable that a higher

proportion of those aged 16-34 see this aim as ‘absolutely vital’ (43% compared with 37%

overall). People who have a disability (83%) and those caring for a child because of health

needs (86%) also think this aim is more important than average. In terms of area, only those

from Kensington and Chelsea (85%) consider this aim more important than respondents in

general.

Below the top four aims there is a notable drop, with the remaining two both achieving an

overall ‘important’ rating from half (52%) of respondents. The aim of providing ‘the support

you need to take better care of yourself’ achieves a fractionally higher mean score (8.20)

and has just over a third (36%) of respondents indicating this is ‘absolutely vital’.

Respondent groups who are more likely than average to say this aim is ‘important’ are in

many ways a contrast of those groups who find other aims more important. For instance, in

terms of age, those aged 16-24 (63%) see this as more important than other age groups

followed by those aged 25-34 and 55-64 (both 57% important). Men (56%), people from a

white background (59%), those who do not have a disability (55%) and do not have caring

responsibilities (55%) are also more likely than average to view this aim as important.

Perhaps not surprisingly, current and former health care workers are more likely to say this is

important (65% NHS and 62% independent sector). Respondents in Kensington and Chelsea

(85%), Hounslow (77%), Richmond (75%), Hammersmith and Fulham (66%) and Hillingdon

(61%) are more likely than average to see this aim as important. It is notable that both Ealing

and Hillingdon record significantly higher levels of ‘don’t know’ responses (18% and 20%

respectively).

Of the six aims, providing ‘the tools and support you need to better manage your own

medical conditions’ achieves the lowest mean score (8.14). This still, of course, indicates

relatively high importance and reflects the fact that half (52%) of respondents see it as such.


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© 2012 Ipsos MORI.

Reflecting the patterns for the previous aim, respondent groups who are more likely than

average to say this aim is ‘important’ are in many ways a contrast to those groups who find

the top four aims more important. In terms of age, those aged 25-34 and over 55 see this as

more important than other age groups (56% and 58% respectively). People from a white

background (60%) those who do not have a disability (55%) and do not have caring

responsibilities (56%) also rate this higher than the norm. Again, current and former health

care workers are more likely to say this is important (64% NHS and 70% independent

sector).

Respondents in Kensington and Chelsea (87%), Richmond (80%), Hounslow (76%), ,

Hammersmith and Fulham (67%) and Hillingdon (61%) are more likely than average to see

this aim as important. Again both Ealing and Hillingdon record significantly higher levels of

‘don’t know’ responses (18% and 21% respectively).

3.2 The standards for care outside hospital

Two thirds of the 4,598 respondents answering this question support the standards that have

been agreed for care outside hospital, including one in five who strongly support them (67%

and 19% respectively). Just one in eight people (12%) oppose these standards of care,

giving a net support level of +54 percentage points.

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Q4a. How far do you support or oppose the standards that have been agreed for care outside hospital?

Standards for care outside hospital

19%

47%

9%

8%

5%

12% Strongly support(882)

Tend to support(2,176)


Tend to oppose(345)

Strongly oppose(225)



% n

Support 67 3,058

Oppose 12 570


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© 2012 Ipsos MORI.

Among the North West London boroughs, levels of support are higher than average in

Kensington and Chelsea (76%), while opposition is above average in Hammersmith and

Fulham (18%); Hounslow (16%); Ealing (14%). Similarly, there is greater opposition from

respondents who would visit particular hospitals for urgent care; Hammersmith (23%);

Charing Cross (22%); West Middlesex (16%).

People who currently or have previously worked in the independent healthcare sector are

more likely to support these standards (75%), while a greater proportion of non-healthcare

workers are more likely to oppose (14%).

There is some difference of opinion by age, with respondents aged 65+ more likely to

support (71%), and those aged 45-54 and 55-64 more likely to oppose (15% and 16%

respectively). Black and minority ethnic respondents are also more likely to oppose the

standards than white respondents (16% vs 11%).

3.3 The standards for care in hospital

Three quarters of the 4,540 respondents answering this question support the standards that

have been agreed for care in hospital, including one in four who strongly support them (76%

and 26% respectively). Just 6% oppose these standards of care, giving a net support score

of +69 percentage points.

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Q4b. How far do you support or oppose the standards that have been agreed for care in hospital?

Standards for care in hospital

26%

50%

6%

3%3%

12% Strongly support(1,166)



Tend to oppose(158)




% n

Support 76 3,429

Oppose 6 286


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© 2012 Ipsos MORI.

There is greater opposition to these standards from respondents who would visit particular

hospitals for urgent care; in this case Central Middlesex (18%); Hammersmith (16%);

Charing Cross (14%). Again, and in contrast, levels of support are higher than average in

Kensington and Chelsea (88%).

Among different types of respondent, again, those aged 65+ are more supportive than other

age groups (80%).Black and minority ethnic respondents (80%) are also more supportive.

There is no difference of opinion according to experience of working in the health care

sector, although people with a disability and those with caring responsibilities for children are

both more supportive than average (79% and 82% respectively).

3.4 Delivering services locally

Two in five of the 4,595 respondents answering this question agree that some services which

are currently delivered in hospital could be delivered more locally, including one in six who

strongly agree (43% agree; 16% strongly). A significant minority (25%) disagrees however,

giving a net agreement of +18 percentage points. It is also notable that three in ten (31%)

express no view either way – which suggests that some respondents answering this question

may not have been clear about what this proposal might mean for them.


Q5. Do you agree or disagree that some services which are currently delivered in hospital could be delivered more locally?

Delivering some hospital services locally

16%

26%

31%

10%

15%

2%Strongly agree

(750)

Tend to agree(1,205)No views either way

(1,403)





% n

Agree 43 1,955

Disagree 25 1,148


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© 2012 Ipsos MORI.

People who currently work in the NHS or have done previously are more likely to express an

opinion being both more likely to agree and disagree with this statement than average (53%

agree and 29% disagree).

Respondents aged 35-44 are more sceptical, and are less likely to agree that some services

currently delivered in hospital could be delivered more locally (40% agree and 26%

disagree). However, those aged 55-64 are both more likely to agree with this statement and

to disagree than average (46% agree and 28% disagree). This relationship is also evident

among respondents belonging to white ethnic groups (50% agree and 28% disagree – both

above average scores). It is also notable that around half of black and minority ethnic (BME)

respondents express no views either way – more than twice the figure for white respondents

(47% vs 20% respectively) which impacts on the overall level of agreement (50% white

versus 32% BME).

Location appears to have some influence over respondent attitudes in this respect. Although,

on balance, respondents in most areas agree with this proposition, and in many areas the

level of agreement is above average, there are also areas where disagreement is higher,

notably Ealing (30%); Hammersmith and Fulham (34%) and Hounslow (33%). Conversely

levels of agreement are higher than average in Kensington and Chelsea (76%), Richmond

(67%), and, as with levels of disagreement, both Hammersmith and Fulham (58%) and

Hounslow (57%).


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3.5 Bringing healthcare services together

On balance more of the 4,628 respondents answering this question oppose than support the

idea of bringing more healthcare services together on fewer sites (38% vs 30% respectively,

a net oppose score of -7 percentage points). Notably, one in four (26%) respondents strongly

oppose this.


Q6. How far do you support or oppose the idea of bringing more healthcare services together on fewer sites?

Bringing more healthcare services together on fewer sites

9%

21%

31%

12%

26%

2%


Strongly support(436)

Tend to support(960)

No views either way(1,412)

Tend to oppose(547)

Strongly oppose(1,190)


% n

Support 30 1,396

Oppose 38 1,737

People who currently work or have previously worked in the healthcare sector are more likely

to agree with this proposal (43% NHS and 42% independent sector) than those who have

not. In contrast, those who have never worked in the healthcare sector are more likely to

disagree than average (39%).

Location is an important factor. Respondents based in Kensington and Chelsea are

supportive on balance (net support score of +38 percentage points), in contrast to Ealing (net

support of -27 percentage points) and Hounslow (net support of -16 percentage points)

where levels of opposition are higher than average. Levels of opposition are also higher than

average in Hammersmith and Fulham (49%) and Richmond (48%). This suggests that this

proposal might be associated with the perceived loss of services by respondents in certain

areas.


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On balance all age groups oppose this idea, with the exception of 16-24 year olds where

opinion is very much divided (35% agree vs 35% disagree). Around half of black and minority

ethnic (BME) respondents express no views either way – more than twice the figure for white

respondents (48% vs 20% respectively) and this impacts on the overall level of agreement

(36% white vs 21% BME).


Respondents were given the opportunity to comment on the issues asked about in the first

five sections of this chapter: ‘What comments if any do you have on any of the issues raised

in sections 4, 5, 6, 7 or 8 of this consultation document?’

A total of 2,108 respondents provided a written comment in response to this question.

Access to care was the most common theme, mentioned by two fifths. Comments about the

time and distance patients and ambulances would have to travel were made most often.

General concerns about the loss of A&E services and the availability of GPs were also

raised.

I live in Wembley. I don't have a car and rely on public transport. Central Middx

Hospital is a lifeline to us, and I have used its A&E dept on a number of occasions.

Northwick Park is nowhere near where I live and would take four times as long to get

to. Think about the old, infirm and those who rely on public transport. From your map,

it looks as if all these hospitals are close to each other, but that is misleading --

especially when you put the travel links in. We would much rather see you

INCREASE services in our area rather than cut them. Thank you.

A number of respondents made comments suggested by campaigns which challenged the

relevance of the examples given on page 21 of the consultation document. One in eight

commented that they were not sure that what worked for stroke and trauma patients would

work for all other aspects of care, while one in ten questioned the evidence for integrated

care pilots, both mentioned by one in ten. A further one in ten queried who would be

accountable if alternatives fail to materialise.

I am not sure that what works for stroke and trauma patients works for all other

aspects of care. There is no sign yet of Integrated Care Pilots in my area despite a

high prevalence diabetes and coronary diseases.


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Who will manage and maintain the 111 number that is mentioned in this document

and how will they be accountable if they do not meet their targets or offer inaccurate

advice? What will happen if the NHS fails to deliver on your proposals? What will be

the fallback position if you have already closed your A&E services at some hospitals?

Around one in five responding to this question made comments about quality of care. Some

stressed the importance of quality of care, others argued that the quality of care needs to

improve, with specific mentions of GP services. Some respondents raised concerns about

the impact of proposals on quality of care, while others thought they would improve it.

If this could actually take place as suggested it would be a great improvement on

things as they are at present.

UCCs cannot replace A&Es, their reception staff are not triage nurses and are not

competent to decide clinical need. Please keep the A&Es.

Around one in ten mentioned centralised services, with a mix of comments for and against

this. Care outside hospital attracted fewer specific comments, which were again a mixture of

positive and negative.

3.6 Care in different settings On balance more of the 4,563 respondents answering this question oppose than support the

proposals to deliver different forms of care in different settings (56% vs 36% respectively,

giving a net support score of -20 percentage points). Of note, one in five (22%) respondents

strongly oppose this.


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© 2012 Ipsos MORI.


Q8. We have described the proposals to deliver different forms of care in different settings. How far do you support or oppose these proposals?

Proposals to deliver different forms of care in different settings

10%

26%

6%33%

22%

2%





Tend to oppose(1,522)


Not sure/ don’t know

(98)

% n

Support 36 1,636

Oppose 56 2,537

2%


to agree with this proposal (49% NHS and 42% independent sector) than those who have

not. Furthermore, those who have never worked in the healthcare sector are more likely to

disagree than the average (59%).

People who do not have a disability and those who do not have caring responsibilities for a

family member are more likely to support this proposal (both 39% support). By contrast,

those who say they have a disability (67%) or care for an adult (62%) or child (72%) with

health needs are more likely to oppose it.

There are no significant differences of opinion by age at the overall level though respondents

aged 45-54 and 55-64 are much more likely to strongly oppose this proposal (27% and 28%

respectively). In terms of ethnicity, white respondents are much more likely to support the

proposal (43%), and black and minority ethnic respondents to oppose (68%).

Location is an important factor and it is especially notable that only respondents based in

Ealing and Hillingdon are on balance opposed to this idea. In Ealing four in five respondents

are opposed (80%; 35% strongly) while in Hillingdon over half are opposed (57%; 26%

strongly). In Hounslow, Kensington and Chelsea and Richmond, respondents are mostly

supportive and above average. This suggests that respondents in particular areas may feel

that this proposal will result in their losing or having greater difficulty accessing some

services.


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© 2012 Ipsos MORI.

510 of the 523 West London Citizens campaign responses who answered this question

opposed this proposal. If we exclude all of these 523 responses from our analysis, the

balance of opinion is still more negative than positive towards this proposal, although net

support is closer to zero at -10 percentage points.


Respondents were given the opportunity to comment in their own words on these proposals

with the question ‘What further comments, if any, do you have on any of the issues raised in

sections 9 or 10 of this consultation document? (For example, do you have any concerns

about arranging care in this way, or about the way we propose to classify hospitals? Can you

suggest a better way of delivering care?)’


One in three respondents commented on access to care, with a wide range of specific

concerns raised. Most of these again were about the accessibility of A&E services, and the

increased distance some patients would have to travel for services (together with concerns

about the time and cost of travel, poor public transport links, ambulance availability and

response times).

Removing A&E from some local hospitals will mean that emergency cases will have

further to travel. Whilst the Ambulance staff have an important part to play at the

scene of say an accident, they still then have to get that person to hospital within a

certain time frame - removing A&E from 'local' hospitals increases the time/distance

that needs to be covered on what are already very congested roads in the area.

One in eight respondents answering this question mentioned a variety of quality of care

issues, for instance raising fears over potential dilution of services and inadequately trained

staff.

A huge presumption of patient capability. A huge presumption of quality amongst

GPs. Holding a thousand GPs to account will be impossible. Holding a handful of

hospitals to account is not. If you are the patient (a bit old/confused) stuck with a less

than energetic/competent GP, good luck.

I feel hospitals providing different services will improve health care rather than all

hospitals providing all services but of a poor standard.


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Comparatively few people made direct reference to the various types of setting described in

Section 10 (p.34); one in twelve said something about care networks and local hospitals, and

very few referred to plans for major, specialist or elective hospitals.

Around two fifths of the responses to this question were answers suggested by campaigns.

One in five made comments about the proposals not having enough local detail. Around one

in ten commented on each of the following: the need for detail on workforce plans; doubts

about whether the network of GPs is sufficient; the need for assessment in local areas; local

hospitals should be called polyclinics.

There is not enough local detail. I would like information about workforce plans, skill

mix, needs assessment for local areas and how this affects delivery plans. I am not

sure that a network of GPs will work as planned: they may be competitors in terms of

provision and in our area there is a high proportion of single-manned GPs and GPs

approaching retirement. I am concerned about problems in recruiting and retaining

staff.

3.7 Improving the range of services delivered outside hospital

Opinion is fairly evenly divided among the 4,598 respondents answering this question on the

NHS plans to improve the range of services delivered outside hospital. Marginally more are

opposed (44% support vs 48% oppose), giving a net oppose score of -4 percentage points.


Q10. How far do you support or oppose our plans to improve the range of services we deliver outside hospital?

Plans to improve the range of services delivered outside hospital

19%

25%

6%

33%

16%

2%








% n

Support 44 2,033

Oppose 48 2,212


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© 2012 Ipsos MORI.


to support this proposal (NHS and independent sector both 56%) than those who have not.

Furthermore, those who have never worked in the healthcare sector are more likely to

express opposition than the average (51% versus 49% overall).

People who do not have a disability and those who do not have caring responsibilities for a

family member are more likely to support this proposal (47% and 49% support respectively).

Those who say they have a disability (55%) or care for an adult (54%) or child (72%) with

health needs are more likely to oppose it.

Younger age groups between 16 and 34 are much more likely to support – and ‘strongly’

support this proposal; 16-24 year olds 52% support; 27% strongly and 25-34 year olds 50%

support and 23% strongly. In addition, support is also above average among 25-34 year olds

(52%) and those aged 65+ (47%). White respondents are more likely to support the proposal

(53%), and black and minority ethnic respondents to oppose (62%).

Again, in terms of location, only respondents based in Ealing and Hillingdon are overall

opposed to this idea. In Ealing three quarters are opposed (74%; 25% strongly) while in

Hillingdon over half are opposed (52%; 25% strongly). In Hammersmith and Fulham,

Hounslow, Kensington and Chelsea and Richmond, the balance of opinion is positive. This

may suggest that opposition to what would appear to be an uncontentious proposal – to

improve services – stems from concerns that services would not be so well delivered outside

hospital in these areas specifically. Opposition may also be influenced by concerns about

loss of services in some areas.

499 of the 519 West London Citizens campaign responses answering this question oppose

this proposal. If we exclude all of these 519 responses from our analysis, the balance of

opinion shifts, with a net support score of +7 percentage points.


Respondents were given the opportunity to comment in their own words on these proposals

with the question ‘What further comments, if any, do you have on any of the issues raised in

section 11 of this consultation document? (For example, what comments do you have on our

plans to improve the range of services we deliver outside hospital?)’



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© 2012 Ipsos MORI.

Overall, comments about access to care were the most prevalent, with just over a quarter of

respondents saying something about this. Many focused on access to local care and GP

services while others felt GPs and community based staff are not sufficiently knowledgeable

to carry out some functions (which are best delivered by hospitals). Around one in ten

respondents mentioned financing (with a mixture of positive and negative comments) and a

similar proportion raised quality of care issues.

I do not want a GP to stitch wounds or take x-rays any more than I want a doctor to

take blood. I want a GP to diagnose a condition and refer me to the relevant

consultant. Expecting a GP to perform so many different functions is unreasonable

and could lead to a diminishment of diagnostic ability due to over-stretching their

responsibilities.

Comparatively few people made direct reference to the out of hospital care pathways

described in Section 11 (p.32) of the consultation document. One in fourteen said something

about co-ordinated care or care plans, with most expressing concern about GP workloads

and ability to cooperate to deliver a joined up service.

A number of respondents made comments suggested by campaigns. A fifth of respondents

answering this question said that there is no evidence that the proposals will be deliverable in

Ealing/Southall. A further one in eight queried where the £120 million budget for the

delivering the proposals will come from.

Where is the £120 million? At the moment it's just a plan for a budget, taken from

savings. Where will the 130 beds in the community be? Health Centres are already

at near capacity, you can't get a GP appointment easily, so where is all this

'community service'? Who will have access to your medical records?


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© 2012 Ipsos MORI.

4. Urgent care

4.1 Provision in acute hospitals

As the chart below shows, a large majority of the 4,648 respondents answering this question

agree that local hospital services such as urgent care centres and outpatient appointments

should continue to be provided at the nine acute hospitals in North West London. 83% agree,

compared with 13% who disagree, giving a net agree score of +70 percentage points. More

respondents ‘strongly’ agree than ‘tend to’ agree (45% and 38% respectively). Very few

respondents have no view on the matter (3%) and more respondents ‘strongly’ disagree

(10%) than those who ‘tend to’ agree (3%).


Q12. Do you agree or disagree that local hospital services such as urgent care centres (those open 24 hours a day, seven days a week) and outpatient appointments should continue to be provided at the nine acute hospitals in North West London that currently do so?

Continuing provision of urgent care centres and outpatient appointments at acute hospitals in NW London

45%

38%

3%3%

11%1% Strongly agree

(2,091)






Base: All answering question (4,648)

Source: Ipsos MORI

% n

Agree 83 3,855

Disagree 13 622

Perhaps as expected with such a high level of support overall, there is little variation among

those who agree according to age, gender and ethnicity. There is also no significant

difference between those with and without a disability.

Levels of agreement are higher among respondents who have never worked in the health

sector (85%) compared with current/past NHS employees (77%).


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Levels of agreement are higher than average among residents in Hounslow, Kensington and

Chelsea and Richmond (87%, 91% and 92% respectively). Residents of Ealing and

Hillingdon are more likely than overall to disagree (21% and 23% respectively). Respondents

who would attend West Middlesex and Chelsea and Westminster Hospitals for urgent care

are also more likely to agree (89% in both cases).

4.2 Urgent care centres

Support for the plans for urgent care centres is less strong than for the proposal to continue

urgent care and outpatient provision as laid out in section 12 of the consultation document.

However, the balance of opinion remains positive. The following chart shows that two in four

of the 4,543 respondents answering this question agree (41%) and one in four disagree

(24%), giving a net agree score of +17 percentage points. Of note, one in three (33%) have

no views either way.


Q13. How far do you agree or disagree with our plans for urgent care centres?

Plans for urgent care centres

21%

20%

33%

7%

17%

3%Strongly agree

(942)

Tend to agree(927)No views either way

(1,479)




Base: All answering question (4521)

Source: Ipsos MORI

% n

Agree 41 1,869

Disagree 24 1,068

There is some variation across sub-groups, with those aged 16-24, 55-64 and 65+ more

likely to agree (53%, 46% and 45% respectively). Respondents from white ethnic groups are

more likely than those from BME groups to agree (50% compared to 30%), and those without

a disability show higher levels of support than those with a disability (44% compared to 36%).


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Current and former health sector workers in the NHS (53%) or the independent health sector

(49%) this time show higher levels of support than those who have never worked in the

health sector (38%), who are also more likely to have no views either way.

Levels of agreement are higher in several of the North West London boroughs, in particular

Kensington and Chelsea (79%), but also Hounslow (62%) and Hammersmith and Fulham

(52%). In all three areas, respondents are less likely to say ‘no views either way’ in response

to this question. More residents in Hammersmith and Fulham disagree than in other areas

(38% compared to 23% overall).

Respondents who would attend Hammersmith, Charing Cross, Ealing and Central Middlesex

hospitals for urgent care are most likely to disagree with the proposal (36%, 46%, 27% and

40% respectively). Significantly more of those who would attend St Mary’s and Chelsea and

Westminster hospitals for urgent care agree (80% and 75% respectively) than those who

would attend another hospital for urgent care.


Respondents were asked to comment in their own words on the proposals discussed in this

chapter with the question, ‘What further comments, if any, do you have on any of the issues

raised in section 12 of this consultation document? (For example, if you disagree with our

proposals, what would you do differently?)’


Overall, comments about access to care were the most prevalent, with about a third of

respondents saying something about this. The primary concerns here are about loss of

and/or access to A&E and specialised services, with the associated need to travel further

afield for care.

Urgent Care Centres will provide a quicker service and will lessen pressure on A&E

depts.


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© 2012 Ipsos MORI.

An urgent care centre is not the same as an A&E department. Every person has the

right to quick access to a specialist emergency unit. GPs are not the same as an A&E

specialist, undergoing very different training and having different real-world

experience, and nursing care for these specialties is also very different. If people are

in a life-threatening situation, they need fast access to a specialist A&E unit rather

than a GP surgery. If it is the case that people attend A&E with GP-treatable

conditions, then the answer is in more and better access to GPs, not to close the A&E

department.

Over a quarter of respondents referred to the proposals for Urgent Care Centres in their

response. Key concerns focused on the ability/skills/experience of staff to deal with issues

presenting at UCCs, the potential for public confusion about where to go for treatment and

therefore the need to inform and educate, and concerns about the quality of care that would

be received in a UCC compared to A&E.

Urgent Care Centres (together with a working and effective telephone system) are a

great help. It would be helpful to separate and publicise UCCs from A&Es – to relieve

the load in the latter.

Fragmentation of service and poor coordination of care treatments and domiciliary

service account for inordinate suffering and distress - until technology and

administrative and financial processes are in place to improve coordination I fear that

more centres will rest in greater confusion, costs and worse outcomes for staff and

patients.

A significant proportion of responses were campaign generated. One in five answering this

question commented that there is too great a difference in service provision in the different

locations across North West London. One in eight said that patients will not get a consistent

message about what might be available and a similar proportion simply expressed fears that

the proposed transition will continue.


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5. Elective hospitals using high quality

buildings

The consultation document proposes that any high quality buildings that have spare space

should be used to house elective hospitals. Two hospitals are named specifically as having

been built especially to deliver high-quality elective care: West Middlesex Hospital and

Central Middlesex Hospital.


Q15. How far do you support or oppose our recommendation that we should use our high quality hospital buildings with spare space as elective hospitals?

Use of hospital buildings with spare space as elective hospitals

17%

51%

9%

6%

15%

2%





Tend to oppose(262)



% n

Support 68 3,108

Oppose 21 967

Respondents were asked how far they supported or opposed the recommendations that high

quality hospital buildings with spare space should be used as elective hospitals. This

question generated 4,596 responses, with a majority (68%) in support. One in five (21%) are

opposed to the recommendation, including 16% who are strongly opposed. This give a net

support score of +47 percentage points.

Support for the proposal does not show much variation by respondent age or gender.

Respondents from BME backgrounds are significantly more likely to support the proposal

than white people (73% versus 65%, respectively). Respondents are also significantly more

likely to support the proposals if they have a disability (a net support score of +53 percentage

points compared to +47 overall).


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© 2012 Ipsos MORI.

Support for the proposals is significantly higher in Kensington and Chelsea (76%) compared

to Ealing (64%), Hammersmith and Fulham (56%) and Hounslow (61%). Conversely,

opposition is significantly higher in Hillingdon (29% compared with 23% overall), but lowest in

Kensington and Chelsea (11%).

Respondents who would be most likely to use Chelsea and Westminster, Ealing, Hillingdon,

St. Mary’s and West Middlesex hospitals for urgent care are all more likely to support the

proposals than those who would use Charing Cross or Central Middlesex.

There are no significant differences between respondents who work or had worked in the

NHS compared with other respondents. Those aged over 65 are slightly more likely to

support the proposals than respondents as a whole, with 72% in support.


Respondents were asked for further comments on proposals to use hospitals with spare

space as elective hospitals with the question ‘What further comments, if any, do you have on

any of the issues raised in section 13 of this consultation document?’


The largest proportion of responses overall was received from people using comments

generated by campaigns. One in seven queried why the local NHS will be incapable of

running elective and emergency services under one roof. One in eight commented that co-

locating elective and emergency centres makes it more likely that there will be an overspill

from one to the other, and a similar proportion made the point that this is a management

problem only.

Why can’t you run elective and emergency services under one roof in the changes

you plan? It has happened already for generations. Surely this is a purely

management issue.

There were also a number of campaign generated responses, mentioned by around one in

ten of those responding to this question, which argued that it makes sense for West

Middlesex Hospital not to have an A&E/emergency service and that West Middlesex Hospital

has the capacity to accommodate elective hospital beds.


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Just over a quarter of respondents made comments about access to care. Some feel that the

proposal makes the best use of current buildings/facilities/resources, while others argue that

there will still be a lack of space/ beds or see this as an attempt to downgrade some

hospitals.

With all the challenges outlined in this document, spare space in the hospitals in NW

London has to be utilised.

It makes perfect sense to utilise to the full all the available space – particularly high

quality. I definitely agree that it is a good thing that elective surgery is not disrupted by

emergencies – as far as is possible. It is very distressing to have these delayed or

postponed. I have seen a relative suffer in this way.

It's a reasonable proposal, but there's too little detail on where that space should

come from. Certainly this would be a good use of space that is simply unused, but it

should not come at the expense of other existing services.

Quality of care issues were mentioned by a fifth of respondents overall, with a number of

respondents commenting that elective and acute/emergency care should not be separated.

Another contingent expressed concerns about the consultation process, saying there is a

lack of sufficient detail, clarity or evidence for the [preferred] proposals and that they would

prefer the status quo or alternatives.


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6. Major hospitals

The consultation document proposes that there should be five major hospitals in North West

London where a full range of services are available. Each major hospital would also provide

local hospital services, including an urgent care centre.

Respondents were asked how far they supported the recommendation that there should be

five major hospitals in North West London. This question generated 4,786 responses, and on

balance respondents are in favour of the recommendation. Three in five (61%) are in

support and one in three opposed, giving a net support score of +27 percentage points.

However, of note, most (26%) of those who oppose the idea, strongly oppose it.


Q17. How far do you support or oppose the recommendation that there should be five major hospitals in North West London?

Having five major hospitals in North West London

20%

41%4%

7%

26%

1%





Tend to oppose(333)



% n

Support 61 2,912

Oppose 33 1,598

509 of the respondents in support of this proposal were part of the West London Citizens

campaign. If we remove these responses from the total, levels of support fall slightly to 56%.

Support for the proposal does not show much variation by respondent age or gender,

although over 65s are slightly more likely to support it (64%) and 45-64 year olds more likely

to oppose it. There are no differences on the basis of whether or not respondents are current

or past NHS employees.


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© 2012 Ipsos MORI.

Respondents from BME backgrounds are significantly more likely to support the proposal

than white people (65% versus 58%). Additionally, support for the proposal is not more likely

if the respondent has a disability.

Support for the proposals is significantly higher in the Kensington and Chelsea area (77%),

and significantly lower in Ealing (56%), Hammersmith and Fulham (43%), and Hounslow

(55%). Conversely, opposition is highest among residents of Hammersmith and Fulham

(46%).

Respondents most likely to go to Chelsea and Westminster for urgent care are more likely to

strongly support the proposals (52%) than those who cite other hospitals as their main urgent

care hospital.


Respondents were asked if they had any further comments on this element of the

consultation with the question ‘What further comments, if any, do you have on any of the

issues raised in section 14 of this consultation document? (For example, if you oppose the

recommendations, how many major hospitals do you think there should be in North West

London? Why do you think that?)’


As with many of the other open questions, the largest proportion of responses focused on

access to care, mentioned by just under half of those providing an answer. Around one in ten

made comments around increasing demand for services, for instance because of a growing

and ageing population. Just under one in ten argued that the area needs more than five

major hospitals, and a similar proportion said all hospitals should be major/retain all their

services. Comments also reflected concerns about the loss of specific services in some

hospitals; notably maternity, paediatrics and A&E.

There should be adequate healthcare provision to cover the AGEING and

INCREASING population of NW London. In the long term these proposals will fall

short of need. I recommend the current number of hospitals.

Quality of care issues were mentioned by a fifth of respondents responding to this question.

Views were varied, with some supporting the proposal and other opposing it on the basis of

its perceived ability to enhance or diminish the quality of medical care by re-organising

services around five major hospitals.


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© 2012 Ipsos MORI.

It appears that although there will be less hospitals, there will be an increase in

surgeons, which I feel is a better use of money.

I am concerned that the new hierarchy of hospitals will reduce medical standards at

"secondary" hospitals and "centres". Also that changes that reduce expenditure will

be carried through, but money not found to complete the whole plan.

From reading the consultation document it seems that 5 major hospitals is the best

number to tackle the problems faced by the NHS in NW London, but also to provide

the right amount of services. All hospitals with maternity services should definitely

have inpatient paediatric units.

One in five respondents made comments about the consultation process, and most of these

were critical about different aspects ranging from lack of evidence, to the criteria themselves

as well as questionnaire design among others.

Three in ten answers were responses suggested by different campaigns. The most prevalent

of these were that hospitals are located where people need them and all hospitals should

remain open, each mentioned by one in six. One in ten asked why South West London has

one paediatric unit with smaller assessment units at other sites with an A&E (which is

different to the model proposed in North West London).


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7. Paediatric care

Under the proposals in the consultation document, all five major hospitals may have an

inpatient paediatric unit, in addition to consultant-led maternity units. Respondents were

asked to indicate the extent to which they support or oppose this recommendation.

Of the 4,572 respondents answering this question, just over half support the proposal (54%),

and most of these ‘strongly support’ it (33% of all respondents answering the question,

compared with 21% who ‘tend to support’ it). Three in ten respondents oppose the

recommendation (28%), giving a net support score of +27 percentage points.


Q18. How far do you support or oppose the recommendation that all major hospitals should have inpatient paediatric (children’s) units?

All major hospitals having inpatient paediatric units

33%

21%8%

26%

1%10%

Base: All answering questio (4,572) Source: Ipsos MORI

Strongly support(1,511)




Strongly oppose(65)


% n

Support 54 2,464

Oppose 28 1,262

Levels of support vary across key demographic groups, with those aged 16-24 more likely to

support the recommendation (65%) than overall (54%). This is also the case for respondents

aged 25-34 (65%) and 35-44 (59%). Support is higher among white ethnic groups than BME

(62% compared with 43%). Respondents with a disability are more likely to oppose the

proposal than those without a disability (40% compared to 23%).

More of those respondents currently or formerly working for the NHS or the independent

health sector support the proposal (68% and 69% respectively) than those who have never

worked in the health sector (50%).


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© 2012 Ipsos MORI.

Opposition to this proposal is significantly higher among residents of Ealing (45%). Levels of

support are highest in Richmond (91%), Kensington and Chelsea (85%), Hounslow (82%)

and Hammersmith and Fulham (71%).

Respondents more likely to attend Chelsea and Westminster and West Middlesex Hospitals

for urgent care are most likely to support the proposal (87% of respondents for both

compared to 54% overall). Meanwhile, opposition is significantly greater among those who

would attend Ealing Hospital for urgent care (55% compared with 28%).


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8. Maternity care

This chapter considers the proposal in the consultation document that all major hospitals will

have a consultant-led maternity unit.

Respondents were asked how far they support or oppose the recommendation that all major

hospitals in North West London should have consultant-led maternity units, with an extra

consultant-led maternity unit at Queen Charlotte’s and Chelsea Hospital if Hammersmith

Hospital is not a major hospital.

The following chart shows that this question was answered by 4,564 respondents, and a

large majority support the proposal (75%). However, this view is not strongly held, and

respondents are more likely to ‘tend to support’ than ‘strongly support’ this proposal (47%

and 28% respectively). One in twenty of the respondents answering this question oppose

the proposal (5%), giving a net support score of +70 percentage points.


Q19. How far do you support or oppose the recommendation that all major hospitals in North West London should have consultant-led maternity units, with an extra consultant-led maternity unit at Queen Charlotte's and Chelsea Hospital if Hammersmith Hospital is not a major hospital?

All major hospitals having consultant-led maternity units

28%

47%

9%

2%2%

11%





Tend to oppose(112)



% n

Support 75 3,421

Oppose 5 224

Support for the proposal is higher among women (77%) than men (72%), and higher among

those from BME groups (82%) compared with those from white backgrounds (73%). Those

aged 25-34 are more likely to support the proposal than overall (81% vs 75%). There is no

significant difference in support between respondents with a disability and those without a

disability.


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© 2012 Ipsos MORI.

There is no significant difference in overall support between current/past workers of the NHS

or independent health sector and those who have never worked in the health sector.

Across the eight North West London boroughs, support is significantly higher among those

living in Kensington and Chelsea than overall (85%). Higher levels of support are also seen

among those living in Richmond (87%) and Wandsworth (92%).

Support for the proposal is also significantly higher than overall among those most likely to

receive urgent care at Chelsea and Westminster Hospital (83%) and West Middlesex

Hospital (81%).


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9. Criteria for choosing which hospitals

are major hospitals

9.1 Way of choosing which possibilities to recommend

Among the 4,541 respondents answering the question, three in five (60%) agree that the way

NHS North West London decided which hospitals to recommend as major hospitals (as set

out in sections 15 and 16 of the consultation document) was the right way to choose between

the various possibilities and decide which options to recommend. Nevertheless, over a

quarter (28%) disagree, including one in five (20%) who disagree strongly, giving a net agree

score of +32 percentage points.


Q21. Please consider the way we decided which hospitals to recommend as major hospitals, as set out in sections 15 and 16. Do you agree or disagree that this is the right way to choose between the various possibilities in order to decide which options to recommend?

Basis of decision of which hospitals to recommend as major hospitals

16%

44%8%

8%

20%

3%


Strongly agree(743)






% n

Agree 60 2,744

Disagree 28 1,289

Respondents from Ealing and Hammersmith and Fulham express highest levels of

disagreement (38% and 43% respectively). The most positive views are from respondents

based in Kensington and Chelsea (75%). Respondents in other boroughs are broadly in line

with the average.


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When considering the hospital respondents would be most likely to visit for urgent care,

some groups are more likely to disagree than agree with this process; those most likely to

visit Central Middlesex Hospital (31% agree vs 50% disagree), Charing Cross Hospital (29%

vs 58%) and Hammersmith (40% vs 46%). All other groups are positive on balance, and

there is strong agreement from those who would most likely visit Chelsea and Westminster

Hospital (75% agree vs 13% disagree) or St Mary’s Hospital (71% vs 15%).

Respondent demographic characteristics have some, but relatively little impact on the level

of agreement or disagreement with the process used by NHS North West London to choose

the potential major hospitals. Those aged over 65+ (64%), respondents with a disability

(65%) and BME respondents (67%) are slightly more likely to agree with the process. No

demographic group is critical on balance.

9.2 The importance of each criterion

Respondents were asked to say how important each of fourteen separate criteria (measures)

should be in choosing which hospitals should be major hospitals, by rating their importance

on a scale where 10 means ‘absolutely vital’ and 0 means ‘not important at all’. This data has

been analysed in two ways; calculating a mean value for each criteria (i.e. an average score

across all respondents answering the question). In addition, the top three scores (10, 9 and

8) have been combined to determine the percentage of people rating the criteria as

‘important’, and similarly the bottom three scores (0,1 and 2) are used to determine the

percentage of people rating the criteria as ‘not important’. Both sets of data are shown on the

chart below for each criterion and provide a rank order of importance.

The chart shows the most important criterion for respondents in the decision making process

is ‘clinical quality’; the vast majority (88%) cite this as ‘important’ and similarly the mean

score is highest at 9.42 suggesting most people have given it a score of nine or ten.

Furthermore, although there are some small differences in the scores given by different sub

groups, ‘clinical quality’ is consistently the most important criterion.


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Criteria for choosing which

hospitals should be major hospitalsQ22. Please say how important you think each of these criteria (measures) should be in choosing which hospitals should be major hospitals, rating their importance on a scale where 10 means ’absolutely vital’ and 0 means ‘not important at all’


Mean

9.42

8.94

8.31

8.48

7.59

7.25

7.15

6.93

6.48

6.68

6.59

6.27

6.29

6.01

Clinical quality (4,516)

Patient experience (4,488)

Workforce (4,152)

Distance/Time to access (4,512)

Patient Choice (4,484)

Developing research/ education (4,438)

Expected time to deliver (4,426)

Viable trusts/sites (4,442)

Disruption (4,405)

Capital cost to system (4,458)

Transition costs (4,432)

Fitting in with other strategies (4,413)

Surplus for acute sector (4,370)

Net present value (4,367)

The second most important criterion is ‘patient experience’, with four in five (81%) rating

this highly and just one per cent saying it is not important. Again there are no notable sub

group differences as all groups are in general agreement on the importance of this criterion.

The third most important criterion is the ‘workforce’; the consultation document (at page 53)

links this to the options that would provide the best workplace for staff. Here, three quarters

(74%) of respondents consider this aspect important and 2% say it is not important. Again

there are no notable sub group differences. It is worth mentioning that a comparison of

means places this in fourth place - behind distance and time to access services (below).


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When ranked according to the percentage of respondents identifying each criterion as

‘important’, the ‘distance and time to access services’ is in fourth place (57%), but is

ranked third according to the mean score calculation. This item focuses specifically on

minimising the average or total time it takes people to get to hospital by ambulance, car (at

off peak and peak times) and public transport and there are some groups where this seems

to be particularly important.

Just a third (35%) of those who support Option C see ‘distance and time to access services’

as important. Similarly, just one in three (33%) respondents based in Ealing rate this criteria

as ‘important’, although almost half (45%) rate this a ‘7’ on the response scale.

‘Distance and time to access services’ is also seen as more important to respondents of

white ethnic origin compared with black and minority ethnic respondents (66% vs 45%). It is

also of less importance to people in the middle age bands (ages 35-54: 58% important) than

to either younger groups (16-34: 66%) or older people (55+: 60%).

Patient choice is the fifth most important criterion, rated as ‘important’ by just under half of

respondents (46%). Organisations responding to the consultation tend to see this as more

important than individuals (58% vs 46%). Similarly, people who do or have worked in the

NHS tend to rate this as more important than those who have never worked in the health

sector (54% vs 43%).

The remaining criteria are considered important on balance, and with no more than 5% of

respondents identifying each factor as ‘not important’. The least important criterion is ‘net

present value’ a term used to describe the overall financial benefit that would be accrued

over the next 20 years (consultation document page 53).


Respondents were given the opportunity to comment in their own words on the criteria used

to decide upon which hospitals should be major hospitals, with the question ‘What further

comments, if any, do you have on any of the issues raised in sections 15 or 16 of this

consultation document? (For example, please tell us if you think there are any criteria that we

have missed and which should also be taken into account in choosing which hospitals should

be major hospitals).



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The largest proportion of responses, just under half in total, were comments generated by

different campaigns. The most prevalent campaign response was the argument that access

to public/private transport is essential. Just over one in five comments mentioned the

variability of primary care in the area, and noted that where GP/community/walk-in provision

is low, people need to be able to access care via hospitals. Just over one in seven argued

that there needs to be a good cultural match between staff and patients. Another commonly

recurring campaign comment is that public opinion on closures should be on the list.

Variability of primary care - communities with not enough GPs and walk in clinics rely

more on hospitals. Access to public transport is vital - people living in poor and

vulnerable communities and with higher number of the elderly are less likely to have

access to a car, and rely heavily on buses. Hospital staff should reflect ethnic,

cultural and linguistic diversity of the population it serves - even asking for a drink of

water is difficult if you can't make yourself understood. These criteria are all more

important in long-term planning than speed of delivery of change or the short-term

finances of individual trusts which could be reorganised if necessary. It is particularly

important that you add in some or all of these criteria if you agree.

Almost two in five respondents who answered this question made a comment relating

specifically to the assessment criteria outlined in section 16 (p.52) of the consultation

document. These covered a broad spectrum of comments, but (reflecting the criteria

themselves) emphasised again concerns about travelling to access care, quality of care,

capacity and ability to meet local needs, workforce issues, patient experience and costs. One

in fourteen commented that the needs of the public and patients should be listened.

There is no criterion of general public acceptability, no requirement for majority

support from clinicians and local healthcare providers, No mention of support from

Health and Wellbeing Boards, no mention of impact on Public Health.

More generally, one in five respondents said something about the consultation. A wide range

of points were made about the evaluation criteria and the arguments in the consultation

document, and these tended to be more negative than positive.


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10. Options for the location of hospitals

10.1 The location of major hospitals in North West London

The three proposed options (Options A, B and C respectively) were outlined in the response

form and consultation document. These options are shown in the table below.

Option A Option B Option C

St Mary’s Major hospital Major hospital Major hospital

Hammersmith Specialist hospital Specialist hospital Specialist hospital

Charing Cross Local hospital Major hospital Local hospital

Chelsea and Westminster Major hospital Local hospital Major hospital

West Middlesex Major hospital Major hospital Local hospital and elective hospital

Ealing Local hospital Local hospital Major hospital

Central Middlesex Local hospital and elective hospital

Local hospital and elective hospital

Local hospital and elective hospital

Northwick Park Major hospital Major hospital Major hospital

Hillingdon Major hospital Major hospital Major hospital

Those who responded to the consultation via a response form were asked to rate their level

of support or opposition towards each of these three core options.


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Option A

Option A is the preferred option, with over four in five of the 16,463 respondents answering

this question supporting it and almost all in strong support (83% support overall; including

81% strongly). One in seven respondents (14%) oppose Option A, giving a net support score

of +69 percentage points.


Q24a. Please say how far you support or oppose each of the three proposed options for the location of major hospitals in North West London.

Option A

81%

2%0%

1% 13%2%




Tend to oppose(180)



Major hospitals - Chelsea and Westminster Hospital, Hillingdon Hospital, Northwick Park Hospital, St Mary’s Hospital and West Middlesex Hospital. Elective and local hospital – Central Middlesex Hospital. Local hospitals – Charing Cross Hospital, Ealing Hospital. Specialist hospital (with maternity unit) – Hammersmith Hospital.

% n

Support 83 13,697

Oppose 14 2,309*NB – a further 80

respondents said that they had ‘No views either way’. These represent less than 1% of responses and have

not been charted

When the campaign data is excluded from the analysis, Option A remains the preferred

proposal. Excluding the Chelsea and Westminster Hospital campaign, the figures for Option

A are 58% support and 35% oppose. Excluding both the Chelsea and Westminster Hospital

campaign and the West London Citizens campaign, the figures are 63% support and 30%

oppose.


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Option A (excluding campaign responses)

57%

6%1%3%

26%

6%

Base: All answering question minus campaign responses (6,007) Source: Ipsos MORI



Tend to oppose(180)



Major hospitals - Chelsea and Westminster Hospital, Hillingdon Hospital, Northwick Park Hospital, St Mary’s Hospital and West Middlesex Hospital. Elective and local hospital – Central Middlesex Hospital. Local hospitals – Charing Cross Hospital, Ealing Hospital. Specialist hospital (with maternity unit) – Hammersmith Hospital.

% n

Support 63 3,770

Oppose 30 1,780



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Option B

Option B is the least preferred option of the three, with just one in five of the 4,718

respondents answering this question supportive (21%). Almost two thirds of respondents

oppose Option B (64%) including over half who strongly oppose it (54%), giving a net support

score of -43 percentage points.


Q25a .Please say how far you support or oppose each of the three proposed options for the location of major hospitals in North West London.

Option B

11%

10%

6%

10%54%

9%




No views either way

(297)

Tend to oppose(453)Strongly oppose

(2,564)


Major hospitals - Charing Cross Hospital, Hillingdon Hospital, Northwick Park Hospital, St Mary’s Hospital and West Middlesex Hospital. Elective and local hospital – Central Middlesex Hospital. Local hospitals – Chelsea and Westminster Hospital, Ealing Hospital. Specialist hospital (with maternity unit) – Hammersmith Hospital.

% n

Support 21 972

Oppose 64 3,017

If we exclude West London Citizens campaign responses (which strongly oppose this option)

from the total, levels of opposition fall to 59%, while support increases slightly to 23%. (NB -

Respondents within the Chelsea and Westminster campaign did not answer this question.)


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Option C

Option C is the second most preferred option. Three in ten of the 6,297 respondents

answering this question are supportive (31%), including a quarter of all respondents who

strongly support it (26%). Six in ten respondents oppose Option C (59%), however, including

over half of respondents who strongly oppose it (53%). This gives a net support score of -28

percentage points.



Option C

26%

4%

4%6%

54%

7%





Tend to oppose(402)



Major hospitals - Chelsea and Westminster Hospital, Ealing Hospital (with the stroke unit at West Middlesex Hospital moved to Ealing Hospital), Hillingdon Hospital, Northwick Park Hospital and St Mary’s Hospital. Elective and local Hospital – Central Middlesex Hospital and West Middlesex Hospital. Local hospitals – Charing Cross Hospital. Specialist hospital (with maternity unit) – Hammersmith Hospital.

% n

Support 31 1,925

Oppose 59 3,716

If we exclude West London Citizens campaign responses (which strongly support this option)

from the total, levels of support fall to 24% while opposition rises to 64%.

A comparison of the overall response to Options A, B, C therefore indicates that Option A is

the preferred option (81%). Option B gleans the lowest levels of support, while Option C is

supported by around one third of respondents answering the question relating to this option.

The analysis that follows considers the factors underlying respondents’ support for Options

A, B and C respectively.


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Impact of respondents’ location on preference

As might be expected, responses differ markedly by respondents’ location. The weight of

opposition to Option A comes from within the borough of Ealing (75% oppose; 70% strongly).

Opinion is evenly balanced in Hammersmith and Fulham, although Option A would mean the

loss of services at local hospitals. In the remaining North West London boroughs, the

balance of opinion is strongly positive in favour of Option A. Option A is also favoured by

those based in other locations, as the table below illustrates. This table highlights with grey

shading the option most preferred among respondents responding to each question.

Support/Opposition to Options A, B and C by respondent location

Location Support/ Oppose

Option A %

Option B %

Option C %

Support 49 23 24 Brent (A: 57*, B: 56*, C: 54*)

Oppose 46 63 61

Support 11 6 57 Ealing (A: 1,626, B: 1,580, C: 1,613) Oppose 74 77 27

Support 45 26 14 Hammersmith and Fulham (A: 283, B: 274, C: 273) Oppose 43 59 67

Support 58 17 16 Harrow (A: 71*, B: 64*, C: 64*) Oppose 27 39 44

Support 42 13 38 Hillingdon (A: 106, B: 97*, B: 97*) Oppose 38 58 36

Support 86 49 5 Hounslow (A: 866, B: 734 C: 819) Oppose 10 31 89

Support 93 8 27 Kensington and Chelsea (A: 216, B: 208, C: 208) Oppose 5 86 57

Support 84 14 21 Westminster (A: 64*, B: 57*, C: 57*) Oppose 8 69 54

Support 92 35 13 Out of NWL: Camden/ Richmond/ Wandsworth (A: 332, B: 293, C: 309) Oppose 7 48 81

Support 79 31 34 Out of NWL: Bordering areas (A: 48* B: 45*, C: 44*) Oppose 19 53 43

Support 82 23 13 Out of NWL: Other areas (A: 111, B: 106, C: 110) Oppose 11 65 68

Note: * indicates small base size and where caution is due in interpreting this data


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Substantially more respondents answering a question on each oppose Options B and C than

support them. However, again local preferences are evident. In Hounslow, around half (49%)

of respondents support Option B, and 31% oppose – though Option A remains the strongest

preference here. Opposition to Option B is very strong in Ealing (70% ‘strongly’ oppose) and

in Kensington and Chelsea (69% ‘strongly’ oppose).

Option C emerges as the preferred option among those answering this question only in the

borough of Ealing. Here over half support the proposal (57% support; 52% strongly) though a

substantial minority opposes it (27%).

Impact of respondents’ choice of hospital most likely to attend for urgent care

There are clear preferences among the three options, depending on the hospital respondents

would most likely attend for urgent care. The table below presents the data for each hospital

and highlights with grey shading the option most preferred among respondents responding to

each question. As is clear from this analysis, respondents are again mostly in favour of

Option A. The exceptions here are respondents who would most likely use Ealing Hospital

for urgent care who prefer Option C; in line with the views of respondents from Ealing.

Respondents who would most likely use Charing Cross Hospital favour Option B.


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Support/Opposition to Options A, B and C by hospital respondent would most likely visit for urgent care Hospital most likely visit for urgent care

Support/ Oppose

Option A %

Option B %

Option C %

Support 45 18 33 Central Middlesex (A: 91*, B: 89*, C: 90*) Oppose 45 57 49

Support 23 47 11 Charing Cross (A: 252, B: 254, C: 241) Oppose 66 35 73

Support 91 7 29 Chelsea and Westminster (A: 458, B: 433, C: 431) Oppose 7 87 57

Support 5 3 65 Ealing (A: 1,837, B: 1,786, C: 1,812) Oppose 80 82 20

Support 37 29 22 Hammersmith (A: 110, B: 109, C: 108) Oppose 55 50 57

Support 56 22 24 Hillingdon (A: 86*, B:76*, C: 79*) Oppose 28 51 46

Support 57 23 20 Northwick Park (A: 108, B: 97*, C: 98*) Oppose 28 43 44

Support 80 24 21 St Mary’s (A: 94*, B: 88*, C: 90*) Oppose 12 58 56

Support 93 51 5 West Middlesex (A: 1,092, B: 901, C: 1,023) Oppose 5 30 91

Note: * indicates small base size and where caution is due in interpreting this data

Impact of respondent demographics on preference

Respondent age has a nominal effect on the preferred option. Option A is clearly preferred

by respondents aged 16-44 answering this question. Older groups have more mixed views,

though there is no more than three percentage points between those who support and

oppose in the three age groups (ages 45 to 65+). For Options B and C, respondent age

appears to have little impact on preference among those answering each question, with each

age group in broad opposition and reflecting the overall position.

Only twenty two young people aged under 16 responded to the questions on Option A and C

and 21 to the question on Option B. These respondents were opposed to Options A and B

and in favour of Option C. Again grey shading highlights the option most preferred among

respondents responding to each question.


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Support/Opposition to Options A, B and C by respondent age group Age group Support/

Oppose Option A

% Option B

% Option C

% Support 54 20 41 16-24 (A: 155, B: 150,

C:152) Oppose 41 65 50

Support 55 24 33 25-34 (A: 530, B: 503, C: 513) Oppose 37 60 54




Support 44 23 40 65+ (A: 1,103, B: 979, C: 1,025) Oppose 47 62 47

Views do differ according to ethnicity, although, as we discuss in more detail below, location

appears to be a key factor here. It is therefore worth noting that a significant proportion of

BME respondents come from Ealing. While over half of respondents from a white

background answering the question support Option A (53% support; 38% oppose), just over

one third of black and minority ethnic respondents do (36% support; 57% oppose). This

pattern is reversed for Option C where over half of respondents from a black and minority

ethnic background answering the question support Option C (54% support; 36% oppose),

and about three in ten white respondents do (29% support; 57% oppose). The views of both

groups are more in alignment for Option B (60% white and 68% BME support Option B).

If we look at patterns of support by borough and ethnicity, we see that among BME

respondents living in Ealing, 80% strongly oppose Option A. In Hounslow, the only other

borough where base sizes are large enough to analyse responses by ethnicity, only 7% of

BME respondents strongly oppose Option A, while 82% strongly support it. Meanwhile, 67%

of BME respondents from Ealing strongly support Option C, compared to 5% of BME

respondents living in Hounslow. Almost seven in ten (69%) of BME from Hounslow strongly

oppose Option C. The widely diverging views among BME respondents in Ealing and

Hounslow suggests that location is a more important factor than ethnicity.

Respondents who consider themselves disabled who answered each question are more

likely to favour Option C (46%) over Options A (33%) or B (19%). There may also a link with


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location as a significant proportion of disabled respondents come from Ealing. For example,

64% of disabled respondents from Ealing strongly oppose Option A, compared to 12% of

disabled respondents from Hounslow, the only other borough where base sizes are large

enough to analyse responses by disability. Support for Option C among disabled

respondents is much higher in Ealing (45% strongly support) compared to Hounslow (5%

strongly support). As with ethnicity, this suggests that location is a more important factor than

disability.

Respondents who are providing support to a family member because of a health need are

more likely to favour Option C. Among those who care for an adult (aged over 16) Option

C is preferred (support 40%; 45% oppose) compared with Option A (support 37%; 52%

oppose) and Option B (18% support; 63% oppose). The same relationship applies to those

who care for a child with health needs, although opinion among these is more polarised.

Option C is preferred (56% support; 33% oppose) over Options A (30% support; 63%) and

Option B (13% support; 76% oppose). Again, this may be influenced by geography as a

significant proportion of carers come from Ealing. For example, 65% of carers in Ealing

strongly oppose Option A, compared to 7% of carers in Hounslow. Support for Option C is

higher among carers from Ealing (48% strongly support) than Hounslow (3% strongly

support. As with ethnicity and disability, this suggests that location is a more important factor

than caring responsibilities.

Respondents’ experience of working in the health sector also differentiates between

preferences for the three options. Among current/past NHS workers Option A is also

preferred (60% support; 29% oppose) among those answering the question; compared with

Option B (23% support; 59% oppose) and Option C (25% support; 58% oppose).

Among current/past independent health sector workers Option A is preferred (56%

support; 38% oppose); compared with Option B (21% support; 68% oppose) and Option C

(30% support; 58% oppose).

Among respondents with no employment experience in the health sector on balance,

Option C is preferred (41% support; 47% oppose); but this is based on slightly fewer people

opposing it than Option A (41% support; 51% oppose). In contrast, opposition to Option B is

strong (20% support; 65% oppose).


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Reasons given for supporting or opposing different options

Reasons for response to Option A

A total of 3,289 respondents provided comments on their reasons for their response to

Option A. Among these 1,610 support Option A and 1,295 are opposed.

Among the 1,610 respondents supporting Option A, around one in five made favourable

remarks about West Middlesex Hospital and the case for retaining it as a major hospital.

Comments were made about West Middlesex Hospital’s reputation for good quality care, its

location and good transport links.

Because West Middlesex has the facilities to expand and it would be a terrible waste

of public money and a blow to NHS standards if its high performing and high quality

A&E, maternity and children's services were lost.

Around one in ten respondents supporting Option A also made favourable comments about

Chelsea and Westminster hospital, for instance highlighting its good reputation.

Chelsea and Westminster is a fantastic site for a hospital, it has room to expand with

new departments, it receives constantly high reports from patients on how good their

experience was, it is a major teaching and research hospital, it is a regional burns

centre treating bombing victims, eg after 7/7 bombings, it regularly wins major

healthcare awards, it has a great and efficient managerial team, and it works hard to

make treatment as bearable an experience as possible. Many people describe how it

hardly feels like being in hospital. Chelsea and Westminster needs to become a

major hospital.

Around a quarter of responses from respondents supporting Option A used wording

suggested by campaigns in favour of West Middlesex and Chelsea and Westminster

Hospitals. The most frequent comments in favour of West Middlesex Hospital were that

Option A offers the greatest benefits and the fewest negative effects on patients and staff,

that it makes use of the modern well-situated hospital, and offers the best financial security

for the NHS. Comments in favour of Chelsea and Westminster argued it is one of the best

performing organisations in the country, both in terms of its clinical quality and financial

sustainability.


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I believe Option A will provide the greatest benefits with fewer negative effects on

both patients and staff. Both West Middlesex and Chelsea and Westminster have

modern, well situated hospitals and this option would also provide the best financial

security for the NHS.

We strongly support this option because Chelsea and Westminster Hospital NHS

Foundation Trust is one of the best performing organisations in the country both in

terms of clinical quality and financial sustainability. Removing the A&E would

effectively close most services on the current site including our excellent specialist

services in paediatrics, burns, HIV, and high risk maternity as well as most elective

and outpatient services currently provided to the local population.

Turning to more general comments, access to care and quality of care emerge as the two

key themes. Around one in ten of those supporting Option A say this is because the

geographical spread/location is good, and a similar proportion mention quality of care issues.

Among those supporting Option A, around one in ten mention that this option is the most cost

effective (in terms of Net Present Value, transition costs, stability etc), and a similar

proportion make comments about its advantages in terms of delivery.

Good value for money. Least disruptions. No need to develop brand new services.

Among the 1,295 respondents who gave a reason for opposing Option A, around half made

comments suggested by campaigns, mostly in favour of retaining Ealing Hospital as a major

hospital. A further one in seven cited reasons relating to Ealing Hospital and just under one

in ten mentioned Charing Cross Hospital. Access to care was the most commonly raised

general issue, mentioned by two fifths, with comments about the loss of A&E services and

transport issues.

This proposal will leave the central areas of North West London without a major

hospital. It would be more sensible to keep Ealing hospital as a major acute and have

West Middlesex as an elective hospital.

Although this is the easiest and most financially beneficial option, it does not make

use of many of the features at hospitals such as Ealing, and has more inpatient cases

needing to move.


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Among those who responded to this question who express support for Option B, favourable

comments were made concerning West Middlesex. By contrast, however, their support was

directed towards Charing Cross Hospital as the other major hospital rather than Chelsea and

Westminster which is a key element of Option A.

Among those who support Option C, the weight of comments provided at this question (many

of them campaign responses) were in favour of retaining Ealing Hospital as a major site.

Reasons for response to Option B


Option B. Among these, 317 support Option A and 1,096 are opposed.

Among the 317 respondents giving a reason for supporting Option B, a third mention Charing

Cross Hospital. These comments were mostly positive about the site, with many in favour of

this as a major hospital due to good accessibility and transport links and good quality care.

One in five also made favourable remarks about West Middlesex Hospital and the case for

retaining this as a major hospital, again pointing to its good quality care, its location and good

transport links. One in seven made comments about Chelsea and Westminster Hospital, with

some mentioning poor accessibility and transport links. However a number of the comments

on Chelsea and Westminster Hospital were positive.

WMUH is a new hospital with excellent facilities, professional staff, low infection

rates, and is close to my home.

Charing Cross should be a Major Hospital as it has better transport links than

Chelsea and Westminster Hospital

Again access to care emerges as a key reason for supporting this option, mentioned by a

third of those providing a response. Around one in ten say the geographical spread/location

is good. However there are also negative comments made about accessing care by

respondents supporting Option B.

Major hospitals well spread across North West London, good use of existing buildings

and expertise. Less waste of tax payers money rebuilding certain units.

Don’t want longer travelling times in an emergency, and public transport links to the

proposed major hospitals is poor.


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Turning to the reasons given by those opposing Option B, around two-fifths of the 1,096

responses were comments suggested by campaigns, with a quarter of responses in favour of

Ealing Hospital. A further one in twelve made comments about quality of care and service in

Ealing Hospital. Just under a fifth gave reasons relating to Chelsea and Westminster for

opposing this option.

Strongly oppose relegation of Ealing Hospital to local hospital status, due to its

proximity to a vulnerable, low-income, population with high birth-rate, and high rates

of strokes, and very limited easy access to transport to West Mid.

As with those supporting this option, access to care is a key issue raised, cited by just over a

quarter. One in ten argue against the loss of any hospital services.

All hospitals should keep their A&E departments.

Reasons for response to Option C


Option C. Among these, 991 support Option C and 1,120 oppose it.

Among the 991 respondents supporting Option C, three in five were campaign-generated

responses. Half made comments in favour of Ealing being a major hospital, while a third

argue that because of the diverse/disadvantaged population in Ealing/Southall, Ealing

Hospital should be a major hospital.

Ealing Hospital serves a wide diversity of people especially those from deprived

areas of Southall. The birth rate in the borough of Ealing is soaring - see the increase

in demand for school places mainly from immigrant families. Services cannot be lost

from Ealing Hospital

This will deliver an excellent major hospital located within our community, easily

accessed by bus from a wide area including Ealing, West Ealing, Hanwell and

Southall. Applying the criteria listed in answer to Q23, specifically in relation to the

large diverse and disadvantaged population of Southall, Ealing Hospital should

definitely be designated a major hospital.

As well as the campaign responses, one in five supporters of Option C spoke in favour of

Ealing Hospital and its specific services being retained.


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Access to care is again a key theme, mentioned by a fifth of those supporting Option C. The

diversity of the local population and services being locally accessible both received a number

of mentions.

Seems better distributed and accessible for the general public.

Among those opposing Option C, a fifth mention West Middlesex Hospital, with comments

made about its good reputation and the need for it to retain its services. One in six of the

comments were suggested by a campaign, with arguments that this option does not make

good use of the facilities and services at West Middlesex and offers poor value for money to

the NHS

Ealing Hospital needs significant refurbishment whilst WMUH is a new Fit for purpose

PFI. WMUH has room to expand if required. High quality A&E performance figures.

Excellent training record at WMUH as opposed to Ealing.

Around one in eight opposing Option C give reasons relating to Ealing Hospital saying it is

old and therefore costly to renovate and that it has a reputation as a hospital with poor

facilities.

Ealing Hospital does not have the estates resource or experience/expertise to be a

Major Hospital. It does have very good transport links and needs to retain a

prominent role in local healthcare provision.

Access to care issues are mentioned by around a third, with concerns about the loss of A&E

services and transport difficulties. A number mention their opposition to any services being

lost.

I do not want any of the proposals to be actioned – i.e. A&E closures etc.


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Respondents were also asked ‘Are there any other options we should consider when making

our decisions?’

A total of 1,225 respondents provided a written comment in response to this question. The

range of suggestions made very much reflect the issues raised in response to the more

specific questions. As with a number of other questions, the largest proportion of responses

focused on access to care, mentioned by three in ten. Some argued against any changes at

all, and there are particular concerns over the loss of A&E services. The impact the changes

will have for some on journey times and cost of travel to access was also raised.

You should consider keeping the A&Es at least until such time as you have working,

viable alternatives in place, up and running and meeting all the needs of the local

community. You should also consider waiting until next year when, under the health

reforms, GPs are put in charge of decision making and can make informed decisions

for their local communities.

Public need to be able to physically access these sites by improving public transport

routes which would cost money, having Ealing as major would not need this thus

saving money.

I think that the whole of these proposals are a disgrace. Having seen what is

happening within the NHS the whole of these proposals are fatally flawed and should

be abolished now. Its appalling to even think of closing A and E's and some of these

hospitals and expect patients to travel miles more to access services. It will mean

more patients dying. It will mean more time for Ambulance crews to reach and take

patients to A and E's. I do not believe for one moment that this will help patients. It will

cause more deaths cause more upset for patients and families trying to access

services. With the population of London expanding hugely and the health of people

getting worse these proposals should be scrapped.

One in five people also mention quality of care issues here. One in ten say they would like to

see all the hospitals and current services improved.

You should at least maintain, if not improve, the existing services, rather than

endangering lives and health by a closure and stuff-cutting programme. The

Government needs to fund the NHS, and there are ways in which it could find more

money.


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Over one in six of those responding to this question provided a comment suggested by a

campaign: ‘Keeping and improve what we already have and have invested in for 65

years/rather than wasting money on silly projects.’

Try keeping what we already have, and have invested in for nearly 64 years. You use

a version of the tired and inaccurate mantra 'the status quo is not an option' to try to

justify change which is finance-led rather than led by the wishes of local people, GPs

and elected politicians. One option would be for someone to have the guts to say that

the health of the public is worth more than the health of bankers, and support

hospitals in their attempts to provide good, value-for-money services. It's a

management issue, not Armageddon, and could be dealt with by competent officials.

Around one in seven mentioned specific hospitals, although no single hospital attracted more

than 4% of comments.


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10.2 Central Middlesex Hospital as an elective and local hospital

At the overall level, three in ten of the 4,489 respondents answering this question support the

proposal for Central Middlesex Hospital to be an elective and local hospital (30% support;

15% strongly). Around two in ten oppose it (19%; 15% strongly), giving a net support score of

+11 percentage points. However, the largest proportion of respondents expresses no views

either way (45%).


Q27a. All the options above include the recommendation that Central Middlesex Hospital should be an elective and local hospital. How far do you support or oppose the recommendation that Central Middlesex Hospital should be an elective and local hospital?

Central Middlesex Hospital as an elective and local hospital

15%

15%

45%

4%

15%

6%





Tend to oppose(171)



% n

Support 30 1,348

Oppose 19 836

Impact of respondents’ location on preference

Among respondents from North West London, in several of the boroughs a significant

proportion have no views either way, most notably Ealing (54%) and Hillingdon (43%). There

is clear support from several other boroughs and those based in other locations as the table

below illustrates.

Grey shading highlights the majority view.


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Support/Opposition to proposal for Central Middlesex Hospital to be an elective and

local hospital

Location Support/ Oppose %

Support 49 Brent (51*)

Oppose 20

Support 15 Ealing (1,597)

Oppose 27

Support 35 Hammersmith and Fulham (276) Oppose 24

Support 52 Harrow (66*)

Oppose 23

Support 29 Hillingdon (97)

Oppose 24

Support 38 Hounslow (803)

Oppose 16

Support 59 Kensington and Chelsea (209) Oppose 4

Support 47 Westminster (59*)

Oppose 11

Support 54 Out of NWL: Camden/ Richmond/ Wandsworth (310) Oppose 7

Support 57 Out of NWL: Bordering areas (46) Oppose 16

Support 58 Out of NWL: Other areas (109) Oppose 7

Note: Base figures are shown in brackets. * indicates small base size and where caution is due in interpreting this data. Where no cell is shaded, this indicates majority stating ‘No views either way/ Don’t know’



opinion becomes more polarised among those answering this question., Those people who

would most likely visit Central Middlesex hospital tend to oppose this proposal (53% oppose;

42% strongly). That said, almost a third of respondents most likely to visit Central Middlesex

for care support the proposal (31% support; 17% strongly), suggesting that, even here,

opinions are divided.


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Those who would be most likely to visit Ealing hospital for urgent care tend not to express an

opinion either way (64%). Among the rest, respondents tend to support the proposal on

balance ranging from a notable 61% support vs 5% oppose among those most likely to use

Chelsea and Westminster hospital, to a more evenly split 31% support vs 26% oppose

among those most likely to visit Charing Cross Hospital.

Grey shading highlights the majority view.

Support/Opposition to proposal for Central Middlesex Hospital to be an elective and

local hospital

Hospital most likely visit for urgent care Support/ Oppose %

Support 31 Central Middlesex (89*)

Oppose 53

Support 31 Charing Cross (246)

Oppose 28

Support 61 Chelsea and Westminster (430) Oppose 5

Support 9 Ealing (1,618)

Oppose 24

Support 35 Hammersmith (96)

Oppose 25

Support 36 Hillingdon (80*)

Oppose 21

Support 53 Northwick Park (99)

Oppose 20

Support 55 St Mary’s (94)

Oppose 9

Support 40 West Middlesex (915)

Oppose 12

Note: Base figures are shown in brackets. * indicates small base size and where caution is due in interpreting this data. Where no cell is shaded, this indicates majority stating ‘No views either way/ Don’t know’


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Impact of respondent demographics on support for Central Middlesex Hospital to be

an elective and local hospital

Respondents’ age has a nominal effect on the preferred option. On balance all age groups

answering this question support the proposal, but the level of support declines to some

extent with age. Broadly speaking about four in ten respondents aged 16-34 support the

proposal, while fewer - around three in ten - of those aged 35 and over support it . The

reverse is also true, with opposition to the proposals higher among respondents aged over

45. As noted previously, however, most respondents in each age category are ambivalent

about this proposal, and there is little difference between each age group in this respect.

Views are fairly consistent between respondents’ of different ethnicity, with both white and

black and minority ethnic (BME) respondents supporting this option on balance. Most people

are ambivalent, although this is more notable among the BME respondents (57% express no

view either way vs 39% white respondents).

Respondents who consider themselves disabled are more likely to support than oppose

this option (24% vs 19%) although again the majority are ambivalent (52%).

There is some difference of opinion between respondents who are caring for family

members. Among those caring for an adult (aged over 16), opinion is very much divided,

with around a quarter in support and the same proportion of this group are opposed to

Central Middlesex Hospital becoming an elective and local hospital (24% and 23%

respectively). The rest are ambivalent (48%). Among those caring for a child under 16,

two in ten are supportive, while one in eleven oppose the idea (19% and 13% respectively).

Among these groups of respondents answering this question, a large majority is ambivalent

(65%).

Respondents’ experience of working in the health sector affects the strength of opinion

towards this proposal. Among current/past NHS workers most support the proposal (45%

support; 18% oppose). The same is true of those who have experience of working in the

independent health sector workers (43% support; 18% oppose). Among respondents with

no employment experience in the health sector, opinion is somewhat divided (24%

support; 19% oppose), with the majority unable to express an opinion or saying they ‘don’t

know’ (50% no view; 6% don’t know).


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Respondents were then asked ‘Why is this your answer?’ A total of 1,261 respondents

provided a response to this question.

407 respondents answering this question support the proposal. The most common reason

given, by one in five of this group, is that it is a good idea/makes practical sense. A further

one in seven mention Central Middlesex Hospital’s location and general accessibility.

Another one in seven comment that it is already an established elective care centre or has

had services removed. One in six responses were campaign generated stating that the

respondent supported this proposal given the analysis provided in the consultation

document.

Central Middlesex is not well served by public transport and isn't in a great location. It

makes sense to downgrade it.

Central Middlesex has been built with excellent theatre facilities and outpatient

diagnostics. It is in the wrong location and does not have the bed capacity to support

being a major acute hospital.

Turning to the answers given by those opposing this proposal, the most common responses

are generated by campaigns. Two fifths argue that Central Middlesex needs help not closure

and that it has been badly managed previously.

Central Middlesex Hospital has been badly managed and as a result is in the state its

in. It needs improvement and better management - not closure.

Other respondents answering this question commented more generally on their preference to

retain Central Middlesex as a major hospital, and for it to continue to offer an A&E service.

We should either cut our losses and close Central Middlesex totally or we should use

the building to its capacity. It would be a great shame if we could not recoup

something from all the money that was spend on it in the last few years.


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10.3 Hillingdon Hospital as a major hospital

At the overall level, one in three of the 4,432 respondents answering this question support

the proposal for Hillingdon Hospital to be a major hospital (33% support; 19% strongly). Just

9% oppose it (6% strongly), giving a net support score of +24 percentage points. Of note, the

largest proportion of respondents express no views either way (45%).


Q28a. All the options above include the recommendation that Hillingdon Hospital should be a major hospital. How far do you support or oppose the recommendation that Hillingdon Hospital should be a major hospital?

Hillingdon Hospital as a major hospital

19%

14%

45%

3%

6%

14%




No views either way

(1,980)

Tend to oppose(142)



% n

Support 33 1,460

Oppose 9 393

Impact of respondents’ location on support for Hillingdon Hospital as a major hospital

As might be expected, responses differ by respondents’ location, although in all areas and

boroughs the balance of opinion among those answering this question is in support of this

proposal.

In Hillingdon, half of respondents support the proposal for Hillingdon Hospital to be a major

hospital and most of these do so strongly (51%; 39% strongly). Looking at the data for other

individual boroughs, the highest levels of support are recorded in Kensington and Chelsea

(60%). Support for this proposal is much weaker in Ealing, although this is due to almost

three quarters of respondents not expressing a view or saying ‘don’t know/not sure’ (54%

and 20% respectively). In the remaining boroughs of Harrow and Hammersmith and Fulham,

opinion is about four-to-one in favour of the proposal.


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When considering the hospital respondents would be most likely to visit for urgent care, there

are sharper differences of opinion among those answering this question. As we might expect,

those people who would most likely visit Hillingdon Hospital strongly support this proposal

(69% support; 60% strongly). Just four per cent oppose it. It should be noted, however, that

comparatively few respondents overall (n=81) say that Hillingdon Hospital is where they

would go.

The vast majority of those who would visit Ealing Hospital for urgent care tend not to express

an opinion either way or ‘don’t know’ (64% and 18% respectively). Similarly half of those

most likely to visit Hammersmith Hospital are ambivalent or don’t know (36% and 16%) and

those expressing an opinion are divided on the issue (26% support vs 22% oppose).

Among the rest, respondents tend to support the proposal on balance ranging from a notable

61% support vs 4% oppose among those likely to use Chelsea and Westminster Hospital, to

30% support vs 15% oppose among those likely to visit Charing Cross Hospital.

Impact of respondent demographics on support for Hillingdon Hospital as a major

hospital

Respondent age has no notable effect on support or opposition to this proposal among

those answering this question. On balance all age groups support the proposal, and no more

than one in ten opposes it. Those aged between 16 and 34 tend to express more strongly

positive views than others (16-24: 27% and 25-34: 22% strongly support), while respondents

aged 35-44 and 65+ are most likely to be ambivalent (49% and 45% respectively).


black and minority ethnic (BME) respondents supporting this option on balance. Ambivalence

is more notable among the BME respondents (57% express no view either way vs 38% white

respondents).


this option (25% vs 11%) although again a majority is ambivalent (53%).


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There is some difference of opinion between respondents answering this question who are

caring for family members, although on balance the proposal is supported. Among those

caring for an adult (aged over 16), 29% support the proposal and just 9% oppose, with the

majority ambivalent or indicating ‘don’t know’ (46% and 16% respectively). Among those

caring for a child under 16, two in ten (19%) are supportive while 7% oppose. Three

quarters express no opinion or say they ‘don’t know” (63% and 11%).


towards this proposal among those answering this question, although on balance all support

it. Among current/past NHS workers almost half support the proposal (47% support; 8%

oppose). The same is true of those who have experience of working in the independent

health sector workers (46% support; 11% oppose). Respondents with no employment

experience in the health sector, also tend to support this proposal in the ratio of 3:1 (29%

support; 9% oppose), though the majority is unable to express an opinion or say ‘don’t know’

(49% no view; 13% don’t know).



provided comments on this. Among these, 500 were from those in support of this proposal

and 160 were from those opposed to it. The remaining comments are from people who have

no views either way on this proposal or are unsure about it.

The primary reasons given for supporting Hillingdon Hospital as a major hospital are related

to its location. Among the 500 respondents supporting the proposal who answered this

question, three in ten say that the location is accessible. One in eight people specifically

mention its proximity to Heathrow Airport and major roads (e.g. M25). In addition, comments

note that it serves a diverse population across a wide geographic area. One in five also

argue it offers good quality care. One in ten made a response suggested by a campaign: ‘We

support this proposal given the analysis.’

It's location, it's current outcomes and the ability to deal with the clinical work from

Heathrow airport mean this hospital needs to be a major centre. I strongly support

this option.

I'm overall neutral about Hillingdon. Geographically it is an essential choice for a

major hospital. On the other hand it has (or had until recently) an awful reputation

with patients.


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Among the 190 respondents who oppose this proposal and provided a comment, the most

common reason given is that Hillingdon Hospital is in an inconvenient location. One in seven

respondents argue that Hillingdon Hospital does not deliver good quality care, and the same

proportion comment that the proposal is impractical or does not make sense.

Where is the evidence that this small hospital can mop up all the patients from Ealing

and Greenford without harm being caused

10.4 Northwick Park Hospital as a major hospital

At the overall level, one in three of the 4,424 respondents answering this question support

the proposal for Northwick Park Hospital to be a major hospital (33% support; 19% strongly).

One in ten oppose it (6% strongly), giving a net support score of +23 percentage points. Of

note, the largest proportion of respondents express no views either way (44%).


Q29a. All the options above include the recommendation that Northwick Park Hospital should be a major hospital. How far do you support or oppose the recommendation that Northwick Park Hospital should be a major hospital?

Northwick Park Hospital as a major hospital

19%

14%

44%

4%

6%

13%





Tend to oppose(162)



% n

Support 33 1,458

Oppose 10 444

Impact of respondents’ location on support for Northwick Park as a major hospital


boroughs the balance of opinion is in support of this proposal.


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Although caution needs to be applied to this finding because the base size (n=66) is low, in

Harrow, the vast majority of those answering this question support this proposal and two

thirds strongly support it (83% and 67% respectively). Six people here (nine per cent of

respondents) oppose it.

Looking at the data for the other individual boroughs in North West London, the highest

levels of support are recorded in Kensington and Chelsea (60%). Support for this proposal is

much weaker in Ealing, although this is due to almost three quarters of respondents not

expressing a view or saying ‘don’t know’ (52% and 20% respectively). In Hillingdon and

Hammersmith and Fulham, around four in ten respondents support this proposal and a

comparatively small minority in each location is opposed.



differences of opinion are more evident. As we might expect, those people who would most

likely visit Northwick Park hospital strongly support this proposal (84% support; 68%

strongly). Just 5% oppose it. It should be noted, however, that comparatively few

respondents overall (n=103) say that Northwick Park hospital is where they would go.

The vast majority of those who would visit Ealing hospital for urgent care tend not to express

an opinion either way or ‘don’t know’ (62% and 18% respectively).

Among the rest, respondents tend to support the proposal on balance ranging from a notable

62% support vs 5% oppose among those likely to use Chelsea and Westminster, to 28%

support vs 22% oppose among those likely to visit Hammersmith Hospital.

Impact of respondent demographics on support for Northwick Park as a major

hospital On balance all age groups support the proposal, with no more than one in eight

opposing it. Those aged between 16 and 24 are generally more positive (45% support; 22%

strongly) than the older age groups where views are very much in line with the overall

picture.

Views are fairly consistent between respondents’ of different ethnicity answering this

question, with both white and black and minority ethnic (BME) respondents supporting this

option on balance. Many are ambivalent, although again this is more notable among BME

respondents (56% express no view either way vs 37% white respondents).


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this option (24% vs 12%) although again a majority is ambivalent (53%).

There is some difference of opinion between respondents who are caring for family members

although on balance the proposal is supported. Among those caring for an adult (aged

over 16), almost three in ten (28%) support the proposal and 12% oppose, with the majority

ambivalent or indicating ‘don’t know’ (45% and 14% respectively). Among those caring for

a child under 16, two in ten (19%) are supportive while 7% oppose. Among these

respondents over half express no opinion or ‘don’t know’ (63% and 11%).


towards this proposal among those answering the question, although on balance all support

it. Among current/past NHS workers almost half support the proposal (48% support; 8%

oppose). The same is true of those who have experience of working in the independent

health sector (47% support; 10% oppose). Respondents with no employment experience

in the health sector, also tend to support this proposal (28% support; 11% oppose), though

the majority is unable to express an opinion or say ‘don’t know’ (48% no view; 13% don’t

know).



provided comments on their reasons for their response. Among these, 450 were from those

in support of this proposal and 190 from those opposed to it, with the remaining comments

provided by people with no views either way or who are unsure about it.

Among the 450 agreeing with the recommendation that Northwick Park Hospital should be a

major hospital, its accessible location is the most commonly given reason, mentioned by just

under three in ten of those providing a comment. Mentions were also made of it serving a

diverse population across a wide geographic area. One in ten made favourable comments

about Northwick Park’s quality of care and a further one in ten simply argued that it should

remain as a major hospital. One in ten provided a response suggested by a campaign: ‘We

support this proposal given the analysis.’

Good facilities and more likely have opportunity to expand. Additionally the Northwick

Park is the biggest in the area and already equipped and have specialised wards, for

example big Maternity, paed, GUM clinics, etc.


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Turning to the 190 respondents who oppose this recommendation and provided a comment,

its inaccessible location is the most commonly given reason for opposing, mentioned by two

fifths. One in eight say they oppose the recommendation because it is impractical/does not

make sense.

Very hard to reach unless you drive. Transport from West London to N Pk difficult to

reach.

10.5 Hammersmith Hospital as a specialist hospital

At the overall level, two in five of the 4,428 respondents answering this question support the

proposal for Hammersmith Hospital to be a specialist hospital with a maternity unit (40%

support; 17% strongly). Almost one in five opposes it (17% oppose; 13% strongly), giving a

net support score of +23 percentage points. A significant minority expresses no views either

way (39%).

Version 1 | Public © Ipsos MORI

Q30a. All the options above include the recommendation that Hammersmith Hospital should be a specialist hospital. There would continue to be a maternity unit at Hammersmith. How far do you support or oppose the recommendation that Hammersmith Hospital should be a specialist hospital with a maternity unit?

Hammersmith Hospital as a specialist hospital

17%

23%

39%

3%

13%

4%




No views either way

(1,721)

Tend to oppose(151)



% n

Support 40 1,774

Oppose 17 747


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Impact of respondents’ location on support for Hammersmith Hospital to be a

specialist hospital with a maternity unit


boroughs, except Ealing, the balance of opinion is in support of this proposal.

In Hammersmith and Fulham, over half support this proposal though more ‘tend to’ support it

than do so ‘strongly’ (36% and 19% respectively). Furthermore, a quarter of respondents

here oppose this proposal (23%; 17% strongly). One in six (16%) express no views either

way.

Looking at the data for the other individual boroughs, the highest levels of support among

those answering this question are recorded in Kensington and Chelsea (69%), Richmond

(65%) and Hounslow (61%). Support for this proposal is much weaker in Ealing, although

this is due to over half of respondents not expressing a view or saying ‘don’t know/not sure’

(51% and 3% respectively). In Hillingdon, levels of opposition are higher than average at

25%.



differences of opinion are more evident among those answering this question. Among those

people who would most likely visit Hammersmith Hospital for urgent care, views are quite

mixed, with support for the proposal in the ratio of 2:1 (i.e. 54% vs 24%). It should be noted,

however, that comparatively few respondents overall (n=96) say that Hammersmith Hospital

is where they would go.

There is a great deal of support for this proposal among those most likely to visit Chelsea

and Westminster (70%), St Mary’s (66%) and West Middlesex (64%); each of which records

between nine and ten per cent opposition.

On balance, those who would be most likely to visit Ealing Hospital for urgent care oppose

this proposal (13% support vs 23% oppose). Almost two thirds tend not to express an opinion

either way or ‘don’t know’ however, (62% and 2% respectively); a characteristic of the

responses received from this location.


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Impact of respondent demographics on support for Hammersmith Hospital to be a

specialist hospital with a maternity unit

On balance all age groups support the proposal. Those aged between 16 and 24 are

generally most positive (48% support vs the average of 40%), but strong support is quite

consistent regardless of age (between 15-19%). By contrast, respondents aged between 45

and 64 are more likely to oppose this proposal (20% oppose vs the average of 17%).


black and minority ethnic (BME) respondents supporting this option on balance. Many are

ambivalent, although again this is more notable among BME respondents (53% express no

view either way vs 29% white respondents).

Respondents who consider themselves disabled who answered this question are more

likely to support than oppose this option (31% vs 15%) although the largest proportion is

ambivalent (50%).

Respondents who are caring for family members on balance support the proposal, although

most tend to not express an opinion either way. Among those caring for an adult (aged

over 16), almost two in five support the proposal and one in five opposes it (37% support;

19% oppose), with the majority ambivalent or indicating “Don’t know” (41% and 3%

respectively). Among those caring for a child under 16, a quarter is supportive while half

as many oppose (25% and 14% respectively) though most express no opinion or ‘don’t know’

(59% and 2%).


towards this proposal, although on balance all support it. Among current/past NHS workers

almost half support the proposal (53% support; 18% oppose). The same is true of those who

have experience of working in the independent health sector workers (54% support; 13%

oppose). Respondents with no employment experience in the health sector, also tend to

support this proposal (37% support; 17% oppose), though many are unable to express an

opinion or say ‘don’t know’ (42% no view; 4% don’t know).



provided comments on their reasons for their response. Among these, 495 were from those

in support of this recommendation and 475 from those opposed to it, while the remainder

were provided by people with no strong view either way.


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Among the 495 respondents agreeing with this recommendation who provided a comment,

one in five noted that Hammersmith is already established as a specialist hospital. A similar

proportion make positive comments about Hammersmith and its services and one in eight

make comments about Hammersmith’s good reputation. One in eight comment specifically

that Hammersmith Hospital should have a maternity unit. Another one in eight argue that the

recommendation makes sense and one in ten say that its location is accessible.

Hammersmith already deal with a lot of specialist areas Cancer being a major part

this should continue for patients all ready under their care and being recognised as a

specialist hospital would improve the service.

Turning to the 475 respondents who oppose this proposal and provided a comment, the

question of how safe Hammersmith Hospital would be without an A&E, a response

suggested by a campaign, was the mostly commonly made point, put forward by just over

two fifths.

One in seven argue that Hammersmith Hospital needs an A&E department, and a further

one in ten comment that this is important to have this if a maternity unit is located here.

I have concerns as to why the maternity unit can be allowed to continue on the

Hammersmith site where there will be no A&E - one rule for Imperial and one rule for

other trusts in NWL???

We need both A&E and maternity services at Hammersmith Hospital - indeed at all

the hospitals. There is currently not enough maternity provision in the community, and

people are being turned away.


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11. Hyper-acute stroke unit

The consultation document proposes that the hyper-acute stroke unit (HASU) is moved from

Charing Cross Hospital to St Mary’s Hospital under Option A and Option C, where Charing

Cross Hospital is not a major hospital. This chapter considers responses to this proposal.

Respondents were asked whether they agree or disagree that the HASU, which was

designated to Charing Cross Hospital following the stroke and major trauma consultation,

should move to be with the major trauma unit at St Mary’s Hospital.

The following chart shows that of the 4,483 respondents who answered this question, just

under a quarter agree (23%) compared with three in ten who disagree (29%). Just over four

in ten (42%) have no view either way. The balance of opinion is more negative than positive,

with a net agreement score of -5 percentage points


Q32a. Do you agree or disagree that the hyper-acute stroke unit, which was designated to Charing Cross following the stroke and major trauma consultation, should move to be with the major trauma unit at St Mary's?

Locating the hyper-acute stroke unit at St Mary’s

8%

15%

42%

8%

21%

6%

Strongly agree(369)

Tend to agree(669)






Source: Ipsos MORI

% n

Agree 23 1,038

Disagree 29 1,285

Respondents most likely to go to Charing Cross Hospital for urgent care are more likely to

disagree with the proposal (68%) than those who would receive urgent care at any other

hospital. Those who are most likely to receive urgent care at St Mary’s and Chelsea and

Westminster are most likely to agree with this proposal (73% and 59% respectively).


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Respondents who are current/past workers in the NHS or the independent health sector are

more likely to agree (34% and 39% respectively) than those who have never worked in the

health sector (19%). Respondents in the latter group are most likely to have no views either

way (46%).

Across the eight North West London boroughs, those living in Kensington and Chelsea are

most likely to agree (60%) with the proposal. Those living in Hammersmith and Fulham are

most likely to both agree (36%) and disagree (49%) with the proposal, as far fewer than

average have ‘no views either way’ (11%). Levels of agreement are also higher in Richmond

(32%).

Across other key sub-groups, those aged 16-24 are more likely than other age groups to

agree (34%), whilst those aged 45-54 are most likely to disagree (34%). Three in five

respondents from BME backgrounds have no views either way (58%) compared to one in

three of those from White backgrounds (34%). Fewer respondents with a disability agree with

the proposals than overall (16% compared to 23% overall), and 29% of those with a disability

disagree (compared to 29% overall).



provided comments on reasons for their response. 397 of these responses agreed with the

proposal, while 692 disagreed with it.

The mostly commonly given reason for supporting the proposal, mentioned by three in ten, is

that it makes good sense and/or good clinical sense. A similar proportion provided a

comment suggested by a campaign: ‘We agree as long as the unit is co-located with

neurosurgery.’

One in seven of the comments made by those supporting the proposal relate to St Mary’s,

with comments about its accessibility and the quality of its services.

St Mary's being a major hospital it makes more sense to have it there alongside major

trauma, especially with the a&e department and because of its central location in

London

Among the 692 respondents who oppose this proposal who provided a comment, over a third

of these were suggested by a campaign – it was only moved to Charing Cross two years ago

and now it is being suggested that it should be removed again.


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Only 2 years ago it was thought a good idea to put it there, now we are told it should

be moved again. Who actually makes these decisions ? If wrong decisions keep

being made has anyone been SACKED ?

One in seven made comments about travel times/accessibility and a further one in seven

argued that no change is required. A quarter of respondents made comments relating to

Charing Cross, some stating that the HASU unit should not be moved, while others comment

on its good transport links and reputation.

Charing Cross Hospital is easily accessible from most parts of London - even during

rush hour traffic - St Mary's in Paddington IS NOT! For a service where time is a

major issue as to whether there is a positive outcome or not - ease and speed of

access to a designated hospital - such as Charing Cross - is vital

Charing Cross has a very large Neurology and Neurosurgery service which is well

supported by good intensive care facilities. This provides good back up to the HASU

service. Unless all of this was moved to the St Mary's site then I cannot see how the

HASU would function as well. The site at St Mary's is unlikely to be large enough to

take many more large specialist services.

Around one in seven mentioned St Mary’s, with comments about it being difficult to access

being raised most often.


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12. The Western Eye Hospital

The consultation document proposes that services provided at the Western Eye Hospital are

moved to St Mary’s Hospital under all options. This chapter considers responses on this

proposal.

Respondents were asked whether they agree or disagree that Western Eye Hospital should

be relocated with the major hospital at St Mary’s.

The chart below shows that of the 4,475 respondents who answered this question, just over

a quarter agree (27%) compared to one in five who disagree (22%). The overall balance of

opinion is just positive with a net support score of +5 percentage points. Of note, however,

almost half (46%) have no views either way.


Q33a. Do you agree or disagree that the Western Eye Hospital should be relocated with the major hospital at St Mary's?

Relocating Western Eye Hospital to St Mary’s

13%

13%

46%

6%

16%

6%

Strongly agree(588)

Tend to agree(602)






Source: Ipsos MORI

% n

Agree 27 1,190

Disagree 22 963

Respondents most likely to go to St Mary’s Hospital for urgent care are more likely to agree

with the proposal (64%) than those who would receive urgent care at any other hospital.

Those who are most likely to receive urgent care at Charing Cross Hospital are most likely to

disagree with this proposal (36%).


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Current/past workers in the NHS or the independent health sector are again more likely to

agree with the proposal (38% and 40% respectively) than those who have never worked in

the health sector (23%). Respondents in the latter group are most likely to have no views

either way (49%).

Across the eight North West London boroughs, those living in Kensington and Chelsea are

most likely to agree (66%), whilst those living in Ealing and Hillingdon are most likely to

disagree (both 28%). Respondents from Hammersmith and Fulham are more likely to both

agree (45%) and disagree (25%) with the proposal, with the proportion having no views

either way being lower than average at 23%.

Among other groups of the population, those aged 45-54 are more likely to disagree (25%)

than overall (22%). Just over half of respondents from BME backgrounds have no views

either way (59%) compared to two in five of those from White backgrounds (39%). Again,

fewer respondents with a disability agree with the proposals than overall (19% compared to

27% overall).



provided a written comment in response to this question including 402 who agree with the

proposal and 471 who disagree.

Among those agreeing with this proposal who responded to this question, three in ten argue

it makes good practical sense to do this. One in five make comments relating to the quality of

care, with one in eight arguing that the move would improve this.

A number of comments were suggested by campaigns. Just over one in six wrote ‘We do

agree with this proposal as this would provide higher quality care to patients as set out in the

consultation document.’ A further one in ten comments from a campaign focus on the

financial arguments in favour of this proposal. Other campaign generated responses made

arguments relating to buildings and facilities, for instance that this proposal gave the

opportunity to dispose of an outdated building which occupies a prime site.

The convincing argument for this is the financial saving. Taking that as accurate, the

case for it is reasonable. I observe, however, that Imperial's record in financial

matters is abysmal and it would be as well to have external audit of their figures (and

subsequent delivery of the savings) before endorsing the move (which must involve

major service disruption).


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The building are old and costly to maintain. Its part of St Marys and rationlisation of

services and sell of prime real estate in Marylebone Road would generate some

much needed money to support these changes.

Among those disagreeing with this proposal who responded to this question, a third made

comments criticising the consultation process. One in six put forward arguments that no

change is required. A similar proportion criticised the consultation document, for instance for

being confusing or providing insufficient evidence.

No evidence for moving it - was this a "nice to have" option to fit the plans instead of

thinking what was actually necessary for the patients?

A third of respondents made a comment suggested by a campaign: ‘You have no evidence

based case for moving it other than Imperial ‘would like to move these services’.’

About one in six respondents oppose the idea because they think it is generally impractical,

while a similar proportion raise issues relating to quality of care, for instance highlighting the

current good level of care offered by the Western Eye Hospital.

Again no rationale is given as to why this should move other than a wishy-washy

management speak of "inefficiencies". Ophthalmic care is very specialised and is

therefore best provided from a specialised group. There is no obvious reason to

change what is working well.


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13. Further comments

Respondents were given the opportunity to raise any other issues not already covered in

their response with the question ‘Is there anything else you want to say about the

consultation or the issues it covers?’


The written responses to this question very much reflected and re-iterated many of the

issues raised in the other open question responses throughout the consultation response

form. As elsewhere, the largest proportion of respondents focused on topics relating to

access to care, mentioned by just over one in three. The most common issues raised were

concerns about the loss of A&Es and specialised services, negative impact on travel times

and accessibility via public transport, and the overall importance of services that cater to

local population groups and patient needs. In addition, 9% raised quality of care issues and

8% referred to costs and value for money.

The consultation process was mentioned by around one in three respondents answering this

question. The views expressed were almost entirely negative and ranged from a perceived

lack of evidence in the consultation document to criticisms about the response form design,

concerns about the evaluation criteria and the absence of the status quo as an option.

The consultation is very confusing and complicated. It makes it too difficult to give

views and it is very long.

This consultation is ill conceived, ill thought out, does not contain sufficient

information, vague costings, does not spell out the hidden consequences of the

options proposed. It is misleading and biased and MUST be scrapped.

This is not a real consultation because you have not included options where all

hospitals retain A&Es.

Three in ten respondents provided answers suggested by campaigns. The most commonly

occurring of these were ‘The questions lead me into answers I disagree with. It's a flawed

consultation’ and ‘I am concerned that the criteria known to be of concern to people in my

area doesn't appear to have been considered in the initial review’, both mentioned by around

one in ten.


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One in ten respondents discussed a specific hospital in their response, typically focusing on

their preference for it to remain as a major hospital. Ealing Hospital, mentioned by 6%,

received the most comments.

Letters and emails from members of the public

158 members of the public responded to the consultation by letter or email. This section of

the report summarises the key issues and themes which emerged. When reading this

section, it should be borne in mind that this analysis refers to a small number of responses.

Two thirds of these responses mentioned a specific hospital, with around one in five

commenting upon Charing Cross and Chelsea and Westminster. Around one in six

mentioned West Middlesex and one in eight Ealing. Hammersmith and Central Middlesex

received just under one in ten mentions. Comments centred on calling for hospital services to

be retained or positive mentions of the hospital.

Just over half of these responses raised issues relating to access to care. Travel

times/difficulties were mentioned by just over one in five. One in eight expressed concerns

about A&E or other specialised services being lost. One in ten expressed opposition to any

services being closed. Issues relating to quality of care were mentioned by just under three in

ten. One in ten commented that this would worsen under the proposals.

Just under half of these responses made comments relating to the consultation itself. While

7% said that a convincing case had been made, most of the other comments were negative,

with one in six criticising the arguments made in support of the proposals in some respect.

Two fifths commented specifically on the options for the location of major hospitals. Just

under one in ten said they opposed all the options. Option A received the most mentions,

with 19% making comments in support of it, while 6% supported Option B and 3% Option C.


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14. Stakeholder responses

A total of 74 stakeholders submitted written responses to the consultation by post or email. A

list of the stakeholders responding to the consultation can be found at Appendix A. This

chapter examines these submissions, broadly following the same order as the response

form.

Responses ranged from one page letters to long and detailed submissions, some with

supporting documents. Stakeholders used their own format and very few covered every

question asked about in the consultation. Some stakeholders made general points about the

proposals, while others made more specific comments about individual aspects. All

stakeholder responses can be viewed at www.healthiernorthwestlondon.nhs.uk.

Our analysis of these responses has been qualitative in nature, drawing out the key themes

and issues stakeholders have commented on. We have not inferred support or opposition for

any element of the proposals unless this has been explicitly stated.

All of the stakeholder responses have been read and considered by NHS NW London. In

addition, through various forms of engagement, NHS NW London has been able to hear first

hand the different views and concerns of stakeholders.

14.1 Overall comments on ‘Shaping a healthier future’

Some stakeholders commented on the proposals overall. A number of these comments are

positive:

We consider that the criteria used to develop the proposals are fundamentally sound

based on clinical evidence which we have been presented with by NHS North West

London. On this basis we are able to support the direction of travel underlying the

consultation paper.

Westminster City Council, Adult Services and Health Policy and Scrutiny Committee

We consider that the criteria used to develop the proposals are fundamentally sound.

We are able to support the direction of travel underlying the consultation paper.

Royal Borough of Kensington and Chelsea Health, Environmental Health and Adult

Social Care Scrutiny Committee


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The Governors were impressed by the thoroughness and care with which the

proposals in the document were prepared, and the clarity with which they were

explained. The elected Governors broadly approve the proposals, noting that it will

take some years before they can be fully achieved in practice.

Governors of the Chelsea & Westminster Hospital NHS Foundation Trust

NHS Central London CCG supports the rationale behind Shaping a Healthier Future.

NHS Central London Clinical Commissioning Group

The solutions you propose to meet the challenges for NW London are very similar to

the ones we are intending to consult the public in South West London on, and so we

fully understand and endorse both the approach you have taken and the options you

are proposing. All of the options you propose will improve the quality and

sustainability of NHS services for the population of NW London.

St George’s Healthcare NHS Trust

The AHSC [Academic Health Science Centre] continues to strongly support the

principles of reconfiguration as articulated in the SaHF document and shown by the

Trust’s active participation to date.

Imperial College Academic Health Science Centre

The RCP cannot comment on specific service locations or distribution, but the

principles and approach adopted in ‘Shaping a healthier future’ resonate with the

analysis the RCP has published in its review [‘Hospitals on the edge? The time for

action’]….Consequently the RCP strongly supports the direction for service re-design

as proposed as in the best interests of public and patient services.

Royal College of Physicians

Some stakeholders strongly criticised the proposals:

I urge you to reconsider the current plans which I believe to be fundamentally flawed

and will lead to severe adverse results for my constituents and patients.

Onkar Sahota, London Assembly Member for Ealing and Hillingdon


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We are alarmed by the proposals which will serve no other function than to accelerate

the privatisation of our health services. The proposals will not only fail to improve the

health care system but it will fragment the NHS by making it only available to those

who have the means to access it.

Southall Black Sisters

Members unanimously reject the changes as a crude and expensive attempt to

downgrade NHS services.

Unite (West London branch)

There is also firm evidence that patient safety could be at risk under the consultation

proposals, which rely heavily on assumptions about the ability of out of hospital care

to pick up the slack… We therefore do not accept any of the three options specified in

the consultation document and would urge NHS NWL to reconsider its proposals in

order to come up with a solution more suited to the health needs of the local

population.

Labour Group at Kensington and Chelsea Council

Hammersmith and Fulham Council and Ealing Council provided detailed submissions and

each local authority had commissioned a report from Tim Rideout to examine the ‘Shaping a

healthier future’ proposals. Both councils rejected the proposals outright:

The Council considers that there are several key flaws in the proposals. Broadly,

these can be categorised as fundamental problems with the consultation process and

methodology, failure to take account of current relative clinical outcomes, and a lack

of due regard for the impact on the people who live and work in Hammersmith &

Fulham. The proposals are consequently seen as unsafe from the Council’s

perspective.

Hammersmith & Fulham Council and its Health, Housing & Adult Social Care Scrutiny

Committee (joint response)

The variety and volume of issues identified through the review process with the SAHF

proposals make support for the total package of proposals in their current form

completely untenable.

Ealing Council


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A couple of other stakeholders commented on the data and modelling underpinning the

proposals:

The accuracy of data and the base-assumptions that underpin NHS NWL’s financial

modelling behind “The Case for Change” are not significantly robust nor detailed

enough to give us the confidence that the proposals in SaHF are rational, deliverable

and that alternative solutions had been fully explored.

Hillingdon LINk

Concerns about the lack of data and evidence provided to back up a number of the

proposals in the report making it difficult to draw on our conclusions on your

proposals. Whilst access to the pre consultation business case was available via your

website, this is a very inaccessible document and therefore unhelpful source of

further information.

Richmond Upon Thames LINk

Several stakeholders argued that the proposals lack support among both patients and GPs in

Ealing:

It is clear that there is a lack of support from local stakeholders and in particular the

frontline primary care physicians whose patients actually use the hospitals (the main

example here is Ealing Hospital).

Ealing Hospital Medical Staff Committee

14.2 The case for change

All of the stakeholders commenting on this support the need for change, with a number

making the point that doing nothing is not an option:

We support the drive to improve the quality, safety and sustainability of emergency

care in NW London. The need to address current variations in services and poor

outcomes for patients is urgent. The case has been clearly made.

North West London Joint Health Overview and Scrutiny Committee

The Board agreed with SaHF premise that to leave healthcare in north west London

as it is would be untenable.



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The case for change is strong…no change presents a serious risk to patient safety.

As such, we realise that a reconfiguration of this scale is necessary in order to meet

these emerging challenges.


We believe that the case for change that has been developed by clinicians from

across North West London is based on the best available clinical evidence and when

introduced will provide improved clinical outcomes for our patients.

NHS West London Clinical Commissioning Group

The Brent Health Partnerships Overview and Scrutiny Committee believes a strong

clinical case for change has been made by NHS North West London and that health

services need to be reconfigured to secure better outcomes for patients. This will

mean that difficult decisions will need to be taken, but to “do nothing” is not an option

and it is in everyone’s interests to ensure that services in London have a sustainable

future.

Brent Health Partnerships Overview and Scrutiny Committee

We strongly support the case for change set out in the consultation document. We

agree that in North West London, as in a number of other areas of the country,

services are spread too thinly to ensure safe, sustainable, high quality care. Our own

modelling, in common with that of the project team, demonstrates that only by

reducing the number of inpatient units will we be able to improve outcomes for the

sickest patients.

Royal College of Paediatrics and Child Health

Because of the importance of these standards [Commissioning Standards, published

in 2012 by London Healthcare Programmes] for emergency surgical care, the College

of Surgeons has been represented on the North West London reconfiguration Board

to ensure that the principals of best practice in emergency surgical care will be

strengthened and improved by the chosen or preferred options for change…..At the

present time, it is clear that the surgical standards cannot be met with any

consistency across North West London.

Royal College of Surgeons


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The need for change is supported by some of the opponents of the proposals overall:

The Council recognises that NHS North-West London have attempted to make a

strong case for the need for change, and that difficult decisions have to be made. It

accepts that “do nothing” is not an option and it is in everyone’s interests to ensure

that there is a sustainable and effective health economy in North West London.

Ealing Council

However a couple of stakeholders argue that the case for change is financially driven:

The present proposals are driven mainly by financial imperatives rather than a

comprehensive review of what needs to happen to improve health in North West

London.


14.3 Principles of care

Relatively few stakeholders commented on this element of the consultation but those that did

expressed their support for some or all of the principles of care proposed.

The principles and objectives - to prevent ill health in the first place; to provide easy

access to high quality GPs and their teams; and to support patients with long term

conditions and to enable older people to live more independently - are appropriate.



The Council fully understands the case for change from both a service quality and

financial perspectives, and fully supports the direction of travel which will enable

people to receive health and care support in their own homes and in community

settings, avoiding the need for hospital admission unless this is absolutely necessary.

Richmond Borough Council

We strongly support the principle of care provision using integrated care pathways

within the clinical network model, and that outcome measures must drive service

improvement.

Royal College of Paediatrics and Child Health


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The RCM does accept, in general, that hospital care in North West London should be

based on the principles of localising routine services, centralising specialist care and

integrating primary and secondary care.

Royal College of Midwives

14.4 Out of hospital care

The proposals relating to out of hospital care generated a range of comments, some of them

detailed. A number of stakeholders highlighted the importance of these proposals and/or

expressed their support for them:

Our Trust strongly supports the proposals relating to Out of Hospital Care that are

contained within the consultation document….If, as is proposed, resources will be

redirected and realigned, we agree that a sufficient scale in the organisation of

primary and community health provision will be achieved to secure good health

outcomes for patients in the setting of their choice in or closer to home within the

available resource limits. This will reduce the current level of demand for hospital bed

days.

Central London Community Healthcare Trust

The out of hospital strategy will be the foundation to ensuring changes in acute

services succeed.

Harrow Council Health and Social Care Scrutiny Sub-Committee

A number of stakeholders made the point that primary and community services need to be

improved before there is any reduction in acute provision:

We welcome the move to improved Out of Hospital services and see these as the

essential building block, which must be in place and effective before any reduction of

current hospital services…we continue to have a major concern that the out of

hospital plans are less well developed than the A&E reorganisation.

Kensington & Chelsea LINk

We particularly fear the consequences of early closure of hospital services to meet

financial targets, before corresponding community services have been established.

The Community Voice


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We support the vision outlined in the consultation but advise caution in

implementation of hospital service reconfiguration until robust out of hospital services

are in place.

Harrow LINk

Related to this, some stakeholders called for more detailed plans about timing and

implementation:

It is essential that the proposed improved Out of Hospital services need to be place

before any major reconfiguration of hospital services can take place. Therefore we

would like to see a clear implementation plan to ensure that patient care is not

compromised by any early changes in the acute hospital provision.


No timetable is given for when the community settings, where much of this work is to

be carried out, will be established. There is no indication that local government, which

will continue to be responsible for social care and is shortly to take on public health,

has been consulted over exactly how these proposals will work. Overall, while the

intentions are laudable, the consultation document offers an unconvincing case for

how they are to be met.


Whilst the H&F LINk very much welcomes this initiative, the timeframes for

implementation seem very challenging and there is an absence of detail in the

strategy. Indicators of success and safeguards to protect patient safety during the

transition are required.

Hammersmith and Fulham LINk

The described vision for out of hospital care must be in place before the

reconfiguration of hospital services begins. In addition, to ensure that the vision is

delivered in practice, the NHS Commissioning Board must put in place robust

contract levers so that GPs deliver the quality standards and vision for primary care

set out in the consultation document.

London Borough of Hounslow Health and Adult Care Scrutiny Panel


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We recommend NHS NWL provides far more detail on the implementation of the Out

of Hospital service. CCGs need to set out detailed implementation plans for their Out

of Hospital Strategies.



A couple of stakeholders queried the timescales proposed:

We think that the timescales are not long enough to enable sufficient investment to go

into community services to ensure that these services work well, are able to meet the

demand, and are able to reduce demand on A&E services.

User Panel, NHS Central London Clinical Commissioning Group

There are concerns over the readiness and capacity of out of hospital services, the

realism of timescales for change and the likelihood of cost transfer from the NHS to

others.


A couple of stakeholders argued that Out of Hospital (OOH) strategies need to be fully

implemented before any hospital reconfiguration:

It is stated that the developments planned for Out of Hospital care will take the

pressure off local hospitals but the proposals to reconfigure hospital services are due

to begin implementation before the Out of Hospital developments have been fully

implemented. The two programmes of development should be decoupled. The Out of

Hospital strategies should be fully implemented and evaluated before any final

decision is made on hospital reconfiguration, let alone before reconfiguration actually

starts.



A number of stakeholders raise concerns about the investment required to implement the

plans:

We have significant concerns that the Out of Hospital Care Strategy won’t receive the

required investment needed to ensure that it is successfully delivered as money will

continue to flow into acute services as demand can’t be properly controlled.



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Successful implementation of the ‘Out of Hospital’ strategy will also require ‘pump

priming’ funding.


Turning to specific services, the need to improve GP services is raised by several

stakeholders:

A number of Westminster residents and the Council agree that there is a need to

improve access for residents at GPs and other local services so patients can be seen

more quickly and at a time that is convenient to them.


Several stakeholders highlight the importance of integrating out of hospital and social care:

Social care is central to the success of the out of hospital strategy and therefore it

must be ensured that social care colleagues are engaged throughout the process.


The SaHF proposals heavily rely on the delivery of the ambitious OOH [Out of

Hospital] strategies of each of the 8 CCGs in the NHS NWL region. The delivery of

OOH strategies in turn is heavily dependent upon the need to integrate health and

social care services across all 8 of the London Boroughs in NWL. This is particularly

important in the London context as patients usually do not recognise borough

boundaries and access both health and social care services across boundaries.

Hillingdon LINk

Sustainable reform will require effective partnerships with local authorities - as the

distinction between ‘health’ and ‘social’ care becomes increasingly blurred. Barriers to

good joint working should not be erected.



Finally one stakeholder made the point that the plans pose unacceptable risks in

Hammersmith and Fulham:

From the perspective of Hammersmith and Fulham the combination of poor historic

investment and a hugely ambitious scale of primary care development alongside

inadequate risk management strategy poses unacceptable risks.

Hammersmith NETWORK 2


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14.5 Care in hospitals

This element of the consultation attracted much less comment. Only a couple of stakeholders

commented on the standards as such, expressing their support. Hillingdon LINk commented

that they are too vague and aspirational.

On the issue of delivering more hospital services locally, there were only a handful of

comments on this. The importance of finding the right staff was raised:

Any care delivered at a local level must be supported by the appropriate numbers of

staff and right skills mix.


Turning to the principle of specialisation of services, a couple of stakeholders expressed

support for this:

The College supports the principle of consolidation of specialist expertise with a focus

on a limited number of hospitals which provide the full range of specialist emergency

care.

The College of Emergency Medicine

We support the idea of centralising specialist services and understand that from a

clinical point of view this is necessary to deliver high quality care which results in

better outcomes for patients.


But a few stakeholders raised concerns, with one saying the clinical case is not proven,

another that it removes choice for patients while one queried the impact on people with

multiple health needs:

Centralising the treatment of some specific types of conditions to a select number of

hospitals (such as the London Hyper-acute Stroke Centres) makes clinical sense and

yields measurable improvements in clinical outcomes. However, this in itself is not

sufficient evidence that centralising all A&E activity onto fewer but bigger hospitals

will also yield the same clinical outcomes or the quality of care experienced by

patients. There is a counter argument (not addressed by SaHF) that once A&E

departments get to a certain size, they essentially become “un-manageable” in a safe

manner.

Hillingdon LINk


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Where services are to be specialised there is a removal of choice for the patient,

therefore it is important that these services are monitored to ensure that they are run

in a sensitive manner, are accessible, and that all staff are trained in accordance with

a robust equality delivery strategy.


We are concerned that the care for people with multiple health needs (often referred

to as ‘co-morbidities’) are not adversely affected by the increased specialisation of

hospital care. We recommend that NHS NWL clearly outlines how people with

multiple health needs are affected by the changes.



The proposals to deliver different forms of care in different settings and use hospitals with

spare space as elective comments received only a handful of comments, all of them in

support.

14.6 Urgent Care Centres

Proposals relating to Urgent Care Centres (UCCs) attracted some detailed comments from

stakeholders.

Several stakeholders made the point that standards need to be agreed upon and applied

uniformly across UCCs:

We consider that it is unhelpful that standardisation in the treatment of injuries does

not exist across urgent care centres, especially given that patients using central

London hospitals will not be familiar with local sites. At one urgent care centre, burns

may be treated, yet at another, the facility may not accept burns patients. It is

essential that the cluster works with all Acute providers in London to define what

constitutes ‘urgent care’ and standardise the clinical services that should be available.


The Panel are keen to see an agreed definition of urgent care developed and a

definitive list of conditions that can be treated in UCCs. We believe that this is a

priority; particularly in light of the need make sure that the public understand how and

where they go to access care.



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As a related point, several stakeholders requested more details on the proposals:

The way the proposed network of A&Es and UCCs will work together, the flows of

patients across the system and the staffing needs are not clear to all our members.


There is insufficient detail at present about the exact services provide by Urgent Care

Centres and Local Hospitals. The leaflets on these arrived very late in the

consultation process and it is unclear how standardised the services will be.


Theme A, describing delivery of 9 Urgent care centres open 24/7 with only 30-35

extra staff, appears unrealistic. More details of the proposed working of the Urgent

care centres would be required before this could be supported.


The impact of the proposals on patient transfers was noted:

We note that the separation of some UCCs from A&E departments will increase the

need to transfer seriously ill patients who present to stand-alone UCCs on to a major

hospital. We have been told that new arrangements for transfers are being specified

and will operate smoothly from inception. Patients need to be transferred quickly and

at the clinically correct time and they and their carers should have arrangements

explained clearly to them.


Several stakeholders expressed their opposition or raised concerns about UCCs being

decoupled from A&Es, particularly in Ealing:

There is no evidence that Urgent Care Centres, without a co-site Type 1 A&E

Department, could cope with the range of pathology that presents to Ealing Hospital.


We wish to place on record that a non co-localised UCC cannot be safely delivered

on the Ealing site and fulfil the needs of the population.

Ealing Hospital A & E Team


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As Ealing Hospital had co-located Urgent Care and Accident and Emergency

services, it meant that patients, once diagnosed with a serious condition requiring

emergency treatment, could be escalated to Accident and Emergency rapidly. Under

the preferred option this would not be the case, with patients having to wait an

additional period of time for an ambulance to take them to West Middlesex University

Hospital…..The [Health and Adult Social Services Standing Scrutiny] Panel shares

the concerns expressed that this is an issue in Ealing, and feels it is another strong

argument against downgrading hospital sites.

Ealing Council

Brent LINk has yet to be convinced that UCC can function without at least some type

of A&E.

Brent LINk

We are particularly concerned that if the stand-alone UCC at Ealing Hospital (SaHF

Option A and B) is not readily accepted by the residents of Ealing, then excessive

patient flows to Hillingdon Hospital’s A&E/UCC unit will become unmanageable and

unsustainable. This would adversely affect the quality of care provided at Hillingdon

Hospital.

Hillingdon LINk

A number of stakeholders commented that there is a lack of public awareness about UCCs

which needs to be tackled:

It is apparent that the general public is not clear what an Urgent Care Centre is and

that this will need further explanation and communication. This suggests there is real

potential for confusion amongst the public and a danger, as a result, of even reduced

speed of access to the right care and treatment arising from the separation of A&E

and UCC facilities.


We need to build greater awareness of these facilities so that the public have a

clearer understanding of the appropriate setting to attend in their particular

circumstances and to increase their confidence in such services as more appropriate

to attending an A&E department with relatively minor conditions.

Central London Community Healthcare Trust


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14.7 Major hospitals and criteria for choosing

The proposal to have five major hospitals in North West London and the criteria for choosing

them was criticised by some stakeholders with links to Ealing Hammersmith or Charing

Cross Hospitals. Hammersmith & Fulham Council and its Health, Housing & Adult Social

Care Scrutiny Committee endorsed the conclusion in the Rideout Report that there is not the

empirical evidence to support the case:

The methodology used to identify and choose between the various reconfiguration

options is open to challenge as it contains a number of fundamental flaws.



It was also argued that the impact of the proposals upon Ealing have not been properly

tested:

As clinicians we have grave concerns that NHS NW London have not properly tested

out the impact of the loss of acute service provision from the Ealing site and that their

pathways do not take account of complexity of the population who will be most

affected by this.


Several stakeholders argued against having to choose from the three options presented:

Given my close association with both Charing Cross and Chelsea & Westminster, I

am appalled that the consultation gives no consideration to allowing both to continue

as major hospitals. The premise of the option structure is that one or the other must

be downgraded.

Greg Hands, MP for Chelsea & Fulham

One stakeholder, Hammersmith and Fulham LINk, questioned why St. Mary’s Hospital was

removed from the consultation options given its proximity to other ‘major’ London hospitals.

Several stakeholders raised concerns about the risk registers for the three options:

The [Health and Adult Social Services Standing Scrutiny] Panel is concerned as a

result of its own analysis and evidence submitted to the JHOSC [Joint Health

Overview Scrutiny Committee] that a risk register for delivering the programme has

not been compiled for any of the three possible options.

Ealing Council


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A couple of stakeholders expressed their support for the process of deciding upon major

hospitals:

We are supportive of the process and criteria used to designate major hospitals.


We accept that a clear, logical process of evaluation was used to arrive at the three

options presented for consultation.


14.8 Paediatric and maternity units in major hospital

Very few stakeholders commented on the specific proposal that all major hospitals should

have inpatient paediatric units. Those that did, including the Royal College of Paediatrics and

Child Health, supported it.

The proposal for all major hospitals to have consultant-led maternity units, together with a

unit at Queen Charlotte’s and Chelsea Hospital if Hammersmith Hospital is not a major

hospital, was also supported by most of the relatively small numbers of stakeholders

commenting on it.

The Royal College of Midwives supported the proposals but criticised the absence of any

freestanding midwife-led units in the proposals or discussions on how to facilitate home

births:

The loss of consultant obstetric services at Ealing will have a negative impact on

tackling health inequalities in the borough; this could be mitigated – at least for

women at low medical risk - if the obstetric service were replaced by a FMU…. we are

extremely disappointed that Shaping a healthier future does not include any

proposals for the establishment of freestanding midwife-led units (FMUs).

The Royal College of Midwives

This proposal also attracted some concerns and criticisms. Ealing Hospital Medical Staff

Committee questioned where the ‘extra births’ were going to go to and how maternity

services are going to cope. Ealing Council raised “the clear risk of loss of valued and high

quality maternity services should SAHF proposals be taken forward.”

Hillingdon LINk argued that the targets to increase the number of home births are highly

ambitious and questioned whether “large maternity units” meet the needs of expectant

mothers.


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14.9 Location of major hospitals – Options A, B and C

The following stakeholders expressed their support for Option A:4

Chelsea and Westminster Hospital NHS Foundation Trust

Governors of the Chelsea & Westminster Hospital NHS Foundation Trust

Harrow LINk

Hillingdon Council's External Services Scrutiny Committee

Hillingdon Hospitals NHS Foundation Trust

Hounslow Clinical Commissioning group

Imperial College Healthcare NHS Trust

Jane Ellison, MP for Battersea, Balham and Wandsworth


London Borough of Richmond upon Thames’ Health, Housing and Adult Services Overview

and Scrutiny Committee

NHS Central London Clinical Commissioning Group

NHS West London Clinical Commissioning Group


Royal Borough of Kensington and Chelsea Health, Environmental Health and Adult Social

Care Scrutiny Committee

Ruislip Residents Association

Sir Malcolm Rifkind, MP for Kensington


The Community Voice

The Royal Marsden NHS Foundation Trust

User Panel, NHS Central London Clinical Commissioning Group

West London Mental Health NHS Trust

West Middlesex University Hospital NHS Trust

Westminster and City of London Liberal Democrats


Westminster LINk

4 Please see Chapter 17 on late responses for details of other stakeholders expressing support for

Option A


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Stakeholders giving reasons for supporting Option A argued that it makes the best use of

NHS resources and/or has the potential to improve quality of care in North West London:

We formally support the recommended option (option A) which, provided it is

effectively implemented and backed by the requisite investment, has the potential to

improve the quality of care, make good use of buildings and resources, and support

research and education.

Hillingdon Hospitals NHS Foundation Trust

The West Middlesex University Trust supports Option A because it delivers the best

use of estate, best value for money and minimises the level of disruption which such

large scale change will generate.


Option A, the clinically recommended and preferred option, provides the best option

for residents and the million visitors and commuters who come into Westminster daily.

We have been assured that the option provides the safest, easiest and most cost

effective result for the population of North West London.


The Trust Board firmly believes that Option A is the best solution for the population of

North West London in terms of the provision of health services within the available

resources to ensure that we have a sustainable healthcare system for the future.

Chelsea and Westminster Hospital NHS Foundation Trust

We support Option A…this provides an excellent opportunity to further integrate

mental health and primary care as well as creating opportunities for new inpatient

provision to replace older and outdated building stock that is no longer fit or

appropriate for modern mental health services.



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Two MPs supported Option A because it retains services at Chelsea and Westminster

Hospital:

A number of my constituents have written to me with their concerns about the

possibility of Chelsea & Westminster Hospital being redesignated a 'local hospital',

and after consultation with the hospital I am convinced that such a move, which

would involve the loss of the hospital's A&E and Maternity Unit, would make the

hospital non-viable and under severe threat of closure.

Sir Malcolm Rifkind MP for Kensington

Given its proximity to Battersea, Chelsea and Westminster is used by many of my

constituents. As well as the loss of specialist expertise and knowledge that would

follow the downgrading of Chelsea and Westminster, it is likely that already stretched

maternity services at St George's in Tooting would come under increased pressure.

Similarly, I understand that option C could see greater pressure put on Kingston

Hospital, which is used by many some residents living in the western part of

Wandsworth. For these reasons, I support option A.

Jane Ellison, MP for Battersea, Balham and Wandsworth

A couple of stakeholders stated a preference for Option A but with specific provisos:

Prefers option A with the caveat that more needs to be done to accurately establish

the best provision and distribution of hyper-acute stroke units to provide more even

geographical access.

Richmond Clinical Commissioning Group

The Champions of Older Peoples Network….indicate their preference is for Option A

– with a proviso that the Central Middlesex Hospital continues to have an A&E

department.

Brent Age UK


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Richmond Council’s strong support for an option that retains West Middlesex as one

of the major hospitals. There has been some discussion locally about the future

location of hyper acute stroke units, and with this some debate about whether option

A or B would be preferable. The consultation document makes a clear case for

option A but at the time of writing, we do not have more detailed information about

impact on journey times etc for Richmond residents. Assuming there is no adverse

impact for Richmond residents, the Council will support option A.

Richmond Borough Council

Turning to those stakeholders who criticised Option A, the closure of Ealing Hospital’s A&E

was given as a reason for this:

Despite the preferred option A in SHF, the right model for Ealing, given its population,

must be co-localised services with an A&E to ensure the safest care in this situation.


Several stakeholders argued against the closure of Ealing Hospital’s A&E without explicitly

mentioning Options A or B:

The closure will be catastrophic and irreversible; it will have a profoundly detrimental

and life threatening impact on our users and more generally it will have a negative

and disproportionate impact on the poor and vulnerable in Southall.

Southall Black Sisters

Others criticised the proposed transfer of services from Charing Cross Hospital (with one

also mentioning Hammersmith Hospital):

Along with A&E, [Charing Cross] hospital would lose paediatric, maternity and

general surgery in the first instance, as has happened across London in recent years.

Other services follow as it becomes more difficult to recruit and retain staff, leading to

the closure as ‘unviable’ of the remaining hospital services.



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Option A fails to reflect the impact on Chelsea & Westminster should the A&E at

Charing Cross close, even if capital costs are incurred by expanding the current site.

That site is severely constrained, placing a limit on what can be added. …I fear that

the influx from Fulham, Hammersmith, and beyond, would create detrimental

pressure on the service provided at Chelsea & Westminster under Option A.

..Charing Cross Hospital is a world-class research and teaching facility. It is one of

the few hospitals to have a sufficient number of beds under the consultation criteria

and hosts regionally important services such as the hyper acute stroke unit. Given its

size and quality, it seems extraordinary for it to be downgraded to become a minor

local hospital, unrecognisable from the facility that exists today.


It is highly inappropriate to seek to transfer services away from Charing Cross and

Hammersmith Hospitals…..the impact on Hammersmith & Fulham and Ealing is

significantly greater than for any of the other boroughs. For both boroughs, it is

essential that before any decisions are made, the impact of these changes is tested

on a needs based population basis, rather than being primarily driven by the need to

ensure NHS Trust organisational sustainability.



Option B

Option B attracted much less specific comment from stakeholders than Option A. Two

stakeholders expressed explicit support for it, Hammersmith NETWORK 2 and London

Borough of Richmond upon Thames’ Health, Housing and Adult Services Overview and

Scrutiny Committee. The latter argued “this will provide the best outcome for residents of the

borough.”

A number of stakeholders opposed or raised concerns about Option B because of the impact

of Chelsea and Westminster Hospital losing services:

Option B would threaten the viability of Chelsea and Westminster Hospital.



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The transfer of inpatient paediatrics and maternity to Charing Cross… could only be

achieved with significant investment and appears extremely disruptive to patients and

the public as well as not making good use of public money.


Option B....would give rise to more adverse impacts for equality groups than the other

two options.


We are opposed to the proposal (option B) to move obstetric services from Chelsea

and Westminster Hospital to Charing Cross Hospital. Aside from the cost of moving

obstetric services from Chelsea and Westminster, we are also concerned that it will

take time for the new unit at Charing Cross Hospital to build up demand for services

and activity.

Royal College of Midwives

The CF Trust has a particular concern as to the possible impact on cystic fibrosis

services at the Royal Brompton Hospital in the event that Option B were selected with

the result that the Chelsea & Westminster Hospital would lose “major hospital” status.

Cystic Fibrosis Trust

Members of the panel know from information shared by health colleagues and a

visit undertaken by the Hounslow representatives on the JHOSC [Joint Health

Overview Scrutiny Committee] that Chelsea and Westminster has a recognized

reputation for the delivery of high quality, outstanding services. The panel would not

want to see access to these services put at risk as a result of the reconfiguration

proposals.


Option B would have a major impact on patient flows into St George’s and we would

not support it for this reason.


This option would mean significant activity shifts to St Thomas’ Hospital and…the site

does not have the spare capacity to absorb the extra activity.

Guy's and St Thomas' NHS Foundation Trust


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Option B would involve the loss of accident and emergency and maternity services,

and of non-elective surgery at the Chelsea and Westminster Hospital. All of these

services are used by a significant proportion of Wandsworth residents….The

displacement of activity to St George's Hospital would impose further pressure at St

George’s Hospital a time when it will be expected to accommodate increased

demands arising from the reconfiguration of services under the Better Services,

Better Value proposals.

Wandsworth Council Adult Care and Health Overview and Scrutiny Committee

Option C

Option C also attracted fewer comments than Option A. Ealing Clinical Commissioning

Group’s poll of GPs found that a majority supported Option C.

Westminster City Council, Adult Services and Health Policy and Scrutiny Committee argued

that Option C is better than Option B. St George’s Healthcare NHS Trust, on the other hand,

stated a preference for Option C over Option B:

Whilst Option C would not lead to significant flows to St George’s from NW London,

there would be an impact on Kingston Hospital. Under the Better Services Better

Value options, Kingston is proposed as a major hospital and would therefore, as St

George’s, see increased patient flow if changes are implemented here. It is for

Kingston Hospital to make their own response to this consultation, but from a SW

London health economy perspective, a smaller impact from changes in NW London

would be preferable.


Several stakeholders argued that Option C would have a negative impact:

The transfer of acute services from the West Middlesex…would have a detrimental

impact on access to healthcare for the Richmond population and could overwhelm

trusts in the SWL [South West London] sector.


Option C would result in thousands of disenfranchised Richmond residents with no

easy access to services.

London Borough of Richmond upon Thames’ Health, Housing and Adult Services

Overview and Scrutiny Committee


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Option C would result in a substantial shift of patients away from the West Middlesex

Hospital to Kingston Hospital. As Kingston Hospital is likely also to be facing

additional demands arising from the reconfiguration of services under ‘Better

Services, Better Value,’ there may be questions as to whether it would have the

capacity to cope with this additional influx of patients. The Overview and Scrutiny

Committee therefore cautions against the adoption of this option.

Wandsworth Council Adult Care and Health Overview and Scrutiny Committee

Specific comments on hospitals and alternative suggestions

Several stakeholders expressed support for West Middlesex Hospital remaining a major

hospital:

The panel does not have a view on which option it supports, but we do strongly

support the designation of West Middlesex as a major Hospital for our residents.


I write in support of West Middlesex staying open as a major hospital. This would be

vital to keep the busy A&E which serves my constituents so well, and West Middlesex

Hospital’s award winning maternity service.

Seema Malhotra, MP for Feltham & Heston

Camden Council, Housing and Adult Social Care stated that it support the proposal for the

retention of St Mary’s as a major acute hospital, while Imperial College Academic Health

Science Centre said it supported the designation of Charing Cross as a local hospital.

It is worth noting that among those not supporting any of the options, no alternatives to the

status quo were put forward,

14.10 Central Middlesex Hospital

Several stakeholders expressed support for Central Middlesex Hospital being an elective and

local hospital:

Central Middlesex is not currently providing the services that would be delivered at a

major hospital site and it therefore makes sense for it to continue to operate as a local

hospital.



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We have considered the future role for CMH [Central Middlesex Hospital] and while a

number of staff and local people would like to retain all traditional DGH [District

General Health] services they recognise that the commissioning of the Brent Urgent

Care Centre (that is able to treat the vast majority of patients who use it and will

remain open 24/7) has enabled the Trust to improve a number of hospital delivered

services.

North West London Hospitals NHS Trust

The provision of elective services at Central Middlesex Hospital is of direct relevance

to a section of our membership and the proposals are recognised as a pragmatic

compromise. Providing elective services at the hospitals without A&E departments is

seen as protection of those services.

The Community Voice

Several stakeholders expressed opposition to this:

At the Brent LINk 24 September SAHF public debate, members of the public

unanimously opposed the proposal to close Central Middlesex A&E …Central

Middlesex Hospital has recently undergone a major rebuild…Brent LINk feels that this

has resulted in a service being offered and then taken away.

Brent LINk

I am so bitterly disappointed that this consultation does not give Brent's residents the

chance to save the A&E at Central Middlesex Hospital, especially as it seems like

only yesterday that the hospital was rebuilt at a cost of £80 million….The decision to

close the A&E has been taken anyway without any reference to the needs or views of

local residents. This is an appalling decision.

Sarah Teather, MP for Brent Central

Concerns about the long-term future of this hospital were expressed, with one stakeholder

making the point that the concerns of Brent residents need to be addressed:

The closure of hospital A&Es raises questions about the future of hospitals in the

longer term e.g. Central Middlesex Hospital and possibly Ealing Hospital. There is

real concern that services will diminish incrementally at hospitals downgraded to local

hospital status, as fewer and fewer services stay clinically viable.



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On balance [the Committee] does not object to the Shaping a Healthier Future

proposal that it becomes a local hospital and elective centre…would oppose any

measures to close the hospital..the real work explaining the changes should begin

now.


14.11 Hillingdon, Northwick Park and Hammersmith Hospitals

A couple of stakeholders expressed support for Hillingdon being a major hospital and a

number of stakeholders also supported Northwick Park being a major hospital.

A couple of stakeholders highlighted capacity issues for Northwick Park:

We therefore believe that the hospital (with support from local CCGs) is generally well

placed to support increased demand although new inpatient capacity is likely to be

required until local out of hospital strategies are fully implemented.


We remain concerned about the capacity and infrastructure at Northwick Park

Hospital to take on the growth in demand in its services and the additional patient

flow.


The proposal for Hammersmith Hospital to be a specialist hospital was supported by the

handful of stakeholders who mentioned this. However, as noted above, Hammersmith &

Fulham Council and its Health, Housing & Adult Social Care Scrutiny Committee criticised

moving any services away from Hammersmith Hospital.

A couple of stakeholders, including the Royal College of Midwives, expressed support for

Hammersmith Hospital having a maternity unit.


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14.12 Moving the hyper-acute stroke unit and Western Eye Hospital to St Mary's

A number of stakeholders commented that improvements in facilities and/or capital

expenditure are required before either of these units are moved to St Mary’s:

There must be absolute guarantees that capital is available so that major estate and

infrastructure issues at St Mary’s are addressed in time to accommodate the extra

service and capacity requirements to provide specialist health services in the 21st

century. Decanting Western Eye Hospital and Hyper Acute Stroke Services into the

site requires major investment in the current infrastructure, accessibility and facilities.


We seek….reassurance that specialist services currently at Charing Cross will remain

at Charing Cross until high quality facilities are available at St Mary’s and that if the

Western Eye Hospital moves to St Mary’s it will move into a quality facility.



While a couple of stakeholders expressed support for this proposal, several others

questioned whether the hyper-acute stroke unit (HASU) should move to St Mary’s. West

Middlesex University Hospital NHS Trust made the point that this would make it very close to

the HASU at University College London and at a significant distance from areas like Ealing

and Hounslow. London Borough of Hounslow Health and Adult Care Scrutiny Panel argued

that the HASU could be located at West Middlesex Hospital:

If West Middlesex Hospital is designated a major hospital, then there is a case for

locating the HASU there. We know that there is flexible capacity in the hospital’s

specialist stroke unit which could accommodate this. This would strengthen services

for our residents and provide overall better coverage for the population in NW

London.



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North West London Cardiovascular and stroke network argued that the unit should stay

where it is because it needs to be in the same location as the tertiary neuroscience centre:

It is the networks view that to cleave the HASU from the tertiary neuroscience centre

– neurosurgery and interventional neuroradiology - would be to the absolute

detriment of stroke patients compared to the current arrangement at CXH [Charing

Cross Hospital] and also severely limit the capacity for the HASU to innovate and

embrace new stroke acute care technologies.

North West London Cardiovascular and stroke network

Moving the Western Eye Hospital attracted very few comments. Those stakeholders that did

mention this asked for reassurance that services would remain at their current levels and

quality:

Residents of Westminster deem the standards at the hospital to be extremely high

and want assurances that services and quality will not change when ophthalmic

services are moved.


We would expect the full range of services currently available at the Western Eye

Hospital to continue to be provided including emergency beds protected for

ophthalmic use. Will these beds continue to be available following relocation?


14.13 Public transport and journey times

The impact of the proposals on accessing services is a key theme emerging from

stakeholder responses:

The key issue is public transport. Links to many hospitals are poor and complex and

the time to improve links is too slow. Patients requiring immediate, urgent care don't

have transport issues but visitors and patients who need follow-up appointments have

a great deal of difficulty.

Paddington Green Health Centre Practice Patient Participation Group


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Several stakeholders made the point that vulnerable groups are more likely to be impacted:

The proposed changes would lead to increased journey times to major hospitals for

more than 174,000 people from key equality groups such as older people and

pregnant women. These adverse effects would disproportionately affect people in

deprived parts of the borough.


Under the NWL NHS preferred ‘Option A,’ a significant number of local residents will

have to travel to St Mary’s to access an ‘A&E’ department. The LINk has received a

number of concerns from our members about the accessibility of transport options

and proposed transport times to St Mary’s especially for disabled people.


Follow-up appointments were identified as a specific issue by some stakeholders:

We know from evidence received from the JHOSC [Joint Health Overview Scrutiny

Committee] that some patients have been deterred from attending follow-up

appointments because of costs they would incur as a result of hospital transport not

being available. We see this as a risk to patient care. Patients must not be deterred

from attending follow-up appointments because of expensive travel costs. We

strongly believe that there needs to be a review of hospital transport criteria to ensure

consistency in what hospitals provide so that vulnerable patients who have no other

means to get to appointments receive the transport support they need.


Some stakeholders, such as Ealing Passenger Transport Users' Group, made detailed

submissions about public transport. This organisation, along with others such as Harrow

Council Health and Social Care Scrutiny Sub-Committee, made the point that Northwick Park

station is not step-free.

A couple of stakeholders commented that more detailed analysis required and/or queried the

accuracy of the analysis already undertaken:

Concerns that travel times analysis does not accurately reflect the reality of travelling

across the borough; neither does it account for the impact of planned regeneration

developments in coming years. As a consequence there are significant concerns that

this will result in delayed access to health services including emergency services.

Ealing Council


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There is insufficient analysis of the impact of the proposals on travel at a borough

level, especially for the poorest and most vulnerable communities. Plans to reduce

any negative impact on access to re-located services by some local populations are

not yet identified.


Access by public transport in the view of the Board needs to be reconsidered to

ensure patient flows are not different to those modelled. If the modelling is incorrect

some hospitals potentially could become overwhelmed and families or carers may

have difficulty visiting patients in hospital.


Whilst total numbers of trips to each hospital have been clearly modelled, data on

absolute and percentage increase in trips to hospital sites such as West Middlesex

are not available. Rationalising provision across the sector would inevitably lead to

significantly more trips from patients and staff. It is essential for the Council to have

this information if we are to understand the transport impact of the programme on the

borough.


The need to have detailed travel plans and improvements to public transport were both

highlighted. It was argued that hospitals need to update travel plans in conjunction with

Transport for London and relevant local authorities. Provision of car parking was also raised.

As a matter of priority, much improved public transport will be required for patients to

access reconfigured hospital services.

Brent North Constituency Labour Party

The impact of the proposals on ambulance journey times was discussed by some

stakeholders, and several called for an increase in resources:

We note slightly longer Blue Light ambulance journey times to transport emergency

cases to 5 instead of 9 sites. We consider it essential that London Ambulance Service

gets the additional crews and vehicles it needs.



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The need to develop clear transfer pathways was also raised:

With the consolidation of the Emergency departments, the run time and number of

ambulance transfers will increase. The College would suggest further detailed

modelling and involvement of the London ambulance service for impact assessment

is crucial. Clear pathways and standards for transfers from urgent care centres must

be agreed.


We wish to declare our support for developing clinically necessary transfer pathways

including mechanisms for safe, expedited transfer between sites.

North West London Critical Care Network

14.14 Implementation of the ‘Shaping a healthier future’ proposals

Stakeholder submissions included a number of comments about the delivery and

implementation of the consultation proposals. These fall into eight broad categories:

• Concerns about timescales

• Handling the transition

• Capacity issues

• Impact assessments

• Financial concerns

• Workforce issues

• The importance of integration

• Public information

We will consider each of these in turn.

Concerns about timescales

Several stakeholders commented that the timescales are ambitious:

These changes will take time to deliver so the pace of change required by SaHF is an

important consideration. Given the scale of change required across eight clinical

commissioning groups, we are concerned that the implementation date of March

2016 may be too optimistic.



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The scale of change envisaged in SaHF in the timeframe suggested is very ambitious

and the Board hoped this would be reviewed prior to any reconfiguration.


2 to 3 years for delivery of enhanced community health services is overly optimistic.

Brent North Constituency Labour Party

Handling the transition

A number of stakeholders made comments about the potential difficulties and risks in

handling the transition:

The greatest challenge for critical care during service reconfiguration is to maintain

and develop adequate infrastructure at expanding sites, while maintaining critical

mass and sustainability of resource� and skill�intensive critical care at contracting

sites…..There are significant phasing risks with all options. The biggest risk areas we

perceive are the management of acute/emergency medicine and emergency surgery

patients.

North West London Critical Care Network

We would want to see at the earliest opportunity how commissioners intend to ensure

the necessary investments in community services are to be made and the transition

risks managed, whilst ensuring service continuity in the transition period.


Some stakeholders argued that implementation would have to be closely monitored and that

a staged or flexible approach might be most appropriate:

Extensive reform can be risky, and teething problems with new health services could

have fatal consequences. We recommend that a staged approach is undertaken to

implementing new care pathways. Results must be evaluated with learning fed into

any subsequent roll-out.




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The need to make short term efficiencies may lead to reduced services or capacity

which might later then be needed to meet transferred demand from elsewhere. The

Committee would urge NHS NW London to consider the flexibility and transitional

funding should such issues arise.

Hillingdon Council's External Services Scrutiny Committee

The panel is extremely surprised that a programme of this scale does not identify

headline risks and mitigating actions in relation to implementing and delivering the

proposals at the outset.


Capacity issues

A number of stakeholders are seeking reassurance that hospitals will have capacity to meet

any increased demand or raise concerns that these issues have not been addressed

properly:

We would like external assurance that Chelsea and Westminster and St Mary’s have

the capacity to meet increased demand from A&E closures at other hospitals.



No clear or adequate contingency arrangements for the projected 1000 bed reduction

across the North West Sector (and its effective impact on Hammersmith and Fulham)

placed in the public domain.

Hammersmith NETWORK 2

There is a major risk that NHS services in North West London that are expected to

cope with increases in demand would not be ready before hospitals are downgraded,

and concerns that “major” hospitals across North West London will not be able to

cope with the additional pressures on demand and capacity that will result from the

changes.

Ealing Council


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A couple of stakeholders argued that this capacity does not exist:

The proposals assume that the various parts of the NHS in NW London have (or will

have) the capability and capacity to implement the proposals, but there is currently

insufficient capacity and capability in primary and community services to support the

proposed changes, which include the removal of 1,000 adult beds from the acute

sector.



There is very good evidence that major hospitals in the sector already cannot meet

current demand.


Impact assessments

A number of stakeholders call for more detailed impact assessment:

The scale of change proposed, and in particular the significant and potentially

adverse impact on the people of Hammersmith & Fulham, has not been adequately

explained or addressed.



Given the radical nature of the change, this would be almost reckless to carry it out in

one process, without any proper assessment of the impact of so many closures on

the surviving A&E units.


A couple call for more detailed equality impact analysis:

We are concerned that the detailed equality impact analysis will not be published until

after the SaHF consultation ends. This is extremely surprising considering the large

diversity of the population in the NW London region and where inequality in health is

already a widely recognised issue, (which remains unaddressed).

Hillingdon LINk


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The panel recognise the work that has been done to date to establish the equalities

implications of the proposals. The panel feels that this is too high level and lacks

detail.


Financial concerns

A number of stakeholders raised concerns about the financial position of hospital trusts:

The programme therefore will not answer the serious challenges posed by the current

financial situations faced by acute trusts in the sector, not least NW London Hospitals

Trust’s rather precarious financial position and long-term viability. We would also

seek further clarification around how any monies harnessed from estate

reconfigurations will be distributed back into the NHS.


The precarious financial status of some NHS Trusts calls into question the

sustainability of services and their ability to provide care at the levels envisaged. Lack

of finance for major hospitals to address deficient estate and to co-locate core

services, means none of the acute reconfiguration options are financially viable.


We seek …reassurance that all NHS and Foundation Trusts in NWL post-

implementation of the proposals are financially robust.



More detail was requested:

We need far greater clarity than we have had to date about the capital provision and,

possibly more crucially, the long-term revenue funding to support these services in

Westminster.

Karen Buck, MP for Westminster


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Workforce issues

A couple of stakeholders called for more detailed plans on the workforce strategy or

reassurance that this is feasible:

There is a clear issue in relation to workforce strategy which needs further detailed

consideration, since out-of-hospital services need to be built up before surplus staff

are released from the acute sector for re-deployment.


See clear plans to deliver the necessary workforce and estate configurations to

facilitate the out of hospital care expectations that underpin many of the delivery

assumptions behind the options.


Moving services and human resources to an out of hospital setting will involve

retraining large numbers of staff to work in a different environment requiring a

different skillset, greater independence and responsibility. We have not seen any

studies on the feasibility of this, and seek assurances that existing staff are willing to

make this transition.


A couple of stakeholders argued that the changes will make it harder to attract and maintain

staff at affected sites:

The very clear facts are that once the decision is made, the individual sites affected

will find it much harder to attract and maintain staff, safety is likely to be compromised

much sooner than they anticipated and there is very likely to be a crisis of healthcare

access and capacity which will lead to a dramatic effect on patient healthcare

outcomes.


The need to engage staff was raised:

The proposals have the best chance of succeeding at the implementation stage if the

workforce is included in discussions and all staff have been fully involved and

engaged in the plans for change.



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The importance of integration

Several stakeholders highlighted the importance of integration:

We feel the case for change would be stronger, be better understood and have a

greater chance of success if it could be located in a clear and agreed strategy on

integrated health and social care for North West London.


To minimise the impact on continuity of patient care, particularly for those patients

living in one borough with GP registration in another, we would strongly advocate the

importance of having consistent systems for discharge planning and integrated care

pathways across borough and cluster boundaries.

Camden Council, Housing and Adult Social Care

Want to ensure that the continuity of mental health services and our close links with

acute providers are not disrupted within the transitional phase(s) following your final

decision on reconfiguration.


The increased likelihood of patients travelling across local authority boundaries will

make it paramount that robust social service protocols exist across NWL and social

care departments have in-reach capacity (partnership working) in other LA areas. If

these challenges are not met the patient experience, length of stay projections and

therefore the financial modelling will be impacted.

Hillingdon LINk

Public information

A number of stakeholders made the point that it is crucial that the public is informed about

how to access health services:

There is a major need for educating the public about how best to use the reformed

health services …We consider that the education point is especially important in

Westminster, where hospitals both within and outside of the cluster area operate

different models of urgent care centres.



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There is an urgent need for a Public Information Campaign to acquaint people with

the changes and their meaning. For example the difference between A & E depts.

and Urgent Care Centre.

Westminster and City of London Liberal Democrats

As has already been noted, this is seen to be particularly important in relation to Urgent Care

Centres and A&E:

Local people need to know what they will be able to get at each centre e.g. facilities,

diagnostics and where they will go for each particular condition e.g. cancer,

paediatrics, mental health and maternity.


A key challenge will be to ensure Westminster residents are cognisant of which

services to use for different care and treatment needs. We therefore feel that it is vital

that a Public Information Campaign is undertaken, to acquaint people with the

changes and their meaning; for example to explain to people of the difference

between A & E depts. and Urgent Care Centres.

Westminster LINk

Communications to residents regarding the rationale for changes in acute services

and the out of hospital transformation is crucially important. The appropriate use of

primary care and Urgent Care Centres (UCC) is highlighted as one area which could

benefit from concentrated effort in communicating key messages to the general

public, especially the most vulnerable in the community who may use these services

the most.


As part of getting the public to buy in to using out of hospital care, knowledge and

understanding about when it is appropriate to use A&E services needs to be

developed. Local communication campaigns developed by CCGs should have the

input of local authorities and should also be supported at a sector and national level.



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Some raised concerns about reaching vulnerable groups:

How will ‘hard to reach’ and more ‘vulnerable’ groups be supported to understand the

new ‘111’ phone line, urgent care services and thus prevent the exacerbation of

health inequalities?


Other issues

A number of other issues were raised by stakeholders:

• The need to understand impact of the proposals on carers, a point raised by a couple

of stakeholders. Carers UK Hounslow observed that carers are only mentioned twice

in the consultation document. Ealing Council and Hillingdon LINk both argued that the

proposals could negatively impact carers.

• Understanding the impact of the proposals on the support provided to specialist

hospitals by nearby acute hospitals

• Provision of maternity services

• Ensuring effective mental health services

• The need for careful coordination with South West London ‘Better Services Better

Value’ programme

• The implications of the proposals on education and research need to be addressed

14.15 Comments on the consultation process

A number of stakeholders made positive comments about the consultation process and/or

documentation:

We are pleased that the consultation has been led by clinicians who are directly

responsible for delivering frontline healthcare in North West London. We have seen

no evidence to suggest that there are a significant number of local clinicians that have

serious concerns about the proposals and thus do not support the proposed changes,

although we noted evidence presented to the JHOSC [Joint Health Overview Scrutiny

Committee] that ~10% of GPs in Ealing attended a meeting to oppose the changes

recommended in the proposals put forward in the consultation.



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The team who developed the supporting consultation documentation should be

congratulated as it is very well set out, easy to read and understand.


Our experience of the consultation process delivered by NHS NWL has been a

positive one.



However the consultation process was criticised by some stakeholders:

Profound flaws in the approach to public consultation during the development of the

proposals and a flawed method of enabling members of the public to submit their

views, despite the crucial role of the community in enabling any changes to be

successfully delivered.

Ealing Council

It has been claimed that GPs in general are on side with this plan although, so far as

we are aware, they have not been consulted.…Equally, there is little sign that NHS

staff have been consulted in a meaningful way and many are taking part in

campaigns to save this or that hospital or A&E department. The general public has

had little opportunity to have a say in the process…. We see the consultation process

as deeply flawed.


Periphery boroughs have not been engaged adequately. The fact that Richmond

residents have received little information about the consultation, the roadshow in the

LBRuT was held 3 weeks before the end of the formal (14 week) consultation period

and the presentation by NHS NW London to the Health, Housing and Adult Services

Overview and Scrutiny Committee shortly before the consultation closes highlights

this point.

London Borough of Richmond upon Thames’ Health, Housing and Adult Services

Overview and Scrutiny Committee


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The consultation materials were also subject to criticism from some stakeholders:

The opaqueness of much of the consultation material, and the impression it creates

of a foregone conclusion, makes the genuineness of this engagement process

questionable.


There has been a lack of information in accessible formats and the questionnaire is

wordy and obscure and does not encourage an open thoughtful response.


The LINk continues to express concern over the consultation process. The lack of

clear information, the length and format of the questionnaire, the delay in the

production of accessible formats and the communications strategy have all caused

confusion.


One stakeholder commented that the consultation materials failed to help people to

understand the implications of the changes for them and their families:

In relation to the consultation process we believe that there has been a clear process

based on communication and explanation…..We believe that the consultation has

been taken forward according to a clear communication plan. We feel that the

website and different written material did get across the main arguments but fell short

of actively helping people get to grips with the likely implications for them, their

families and communities.


Some stakeholders queried the timing of the consultation:

We have throughout questioned the wisdom of conducting a consultation over the

summer months at the same time as the Olympics, the Paralympics and the holiday

season. We would suggest the consultation has as a result failed to allow local

populations sufficient time to digest and engage with the plans and their likely

consequences.



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We appreciate the various means that have been employed to reach out to residents

within each borough, for example roadshows, attendance at public meetings, inserts

into local newspapers, summary documents in key community venues, as well as

online access to the consultation. These are especially important given the complex

messages that the programme is aiming to achieve public understanding of. However

we also note that consulting over the summer period on changes as substantial as

these is never ideal especially given the uniquely busy summer London has

experienced in 2012.



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15. Roadshows, meetings and focus

groups

As part of the consultation process, NHS NW London provided members of the public,

clinical and other staff with the opportunity to participate in a wide variety of events. These

events aimed to provide further information on the proposals and respond to people’s

questions and concerns, as well as giving attendees the opportunity to give their feedback to

key representatives of the ‘Shaping a healthier future’ (SAHF) programme. These sessions

were managed and facilitated by the independent engagement organisation, Office for Public

Management (OPM).

This chapter of the report summarises the key themes coming out of these consultation

strands:

• Roadshows across the eight North West London boroughs and three neighbouring

boroughs

• Hospital site events (mainly involving hospital staff)

• GP events held in Ealing

• Focus groups across the eight North West London boroughs and three neighbouring

boroughs

This analysis is qualitative in nature. A broad range of views were expressed during these

events across a range of issues, echoing points made in other strands of the consultation.

Roadshows

Two rounds of roadshow events were held over the consultation period in each of the eight

North West London boroughs, as well as the three neighbouring boroughs. The primary

objective of these events was to engage directly with the public and give them the means to

take part in the consultation process.

Everyone who visited a roadshow event was given a consultation document. Hard copies of

the consultation response form were also available at the event, as were laptops logged onto

the consultation website. Most people preferred to take a response form to complete at

home, although some used the online facilities to provide feedback.

Visual display boards were used to summarise versions of the key points, with SAHF

representatives on hand to provide commentary on the boards or answer questions.


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Clinicians were also present throughout the day at each event and there was typically one or

more question and answer (Q&A) sessions held during the day. Q&A sessions were

generally scheduled to be one hour in length, though on several occasions these were

extended to allow all attendees the opportunity to present their questions to the panel. In

addition, several members of the public and representatives of organisations made

statements and/or provided their feedback separately to SAHF representatives which were

also recorded.

Details of roadshows Round 1 Round 2

Borough Date Number of attendees Date Number of

attendees

Total attendees

1 Brent 31 July 35 29 Sept 35 70

2 Ealing 21 July 80 11 Sept 63 143

3 Hammersmith & Fulham

28 July 200 19 Sept 55 255

4 Harrow 26 July 30 25 August 40 70

5 Hillingdon 14 July 40 5 Sept 47 87

6 Hounslow 17 July 11 18 August 20 31

7 Kensington & Chelsea

30 July 15 15 Sept 60 75

8 Westminster 24 July 12 06

October

23 35

9 Camden - - 1 Sept 11 11

10 Richmond - - 22 Sept 17 17

11 Wandsworth - - 8 Sept 15 15

The following offers a very top line overview of the major themes raised by visitors to the

roadshow events. OPM has provided NHS NW London with a comprehensive account of the

specific questions and statements made by visitors at each session taking place.

Top line analysis of the feedback shows a great deal of consistency in the comments and

questions raised by visitors to the roadshow events. In addition, a wide range of detailed

comments and questions were put to the panel and SAHF representatives. While many of

these are specific in nature, a thematic analysis shows that the types of comments made

largely centre on the potential impact on the local hospital of the proposed changes. The

following summary therefore presents the data as follows:


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• Universal themes

• Themes raised in Brent/Ealing/Hammersmith where the proposed closure of local

A&E departments is a major concern

• Themes raised in the other North West London boroughs where the local hospital is

either proposed to be retained as a major hospital, or this has been proposed in at

least two of the three options

• Neighbouring areas

Universal themes

The universal themes mentioned at all, or nearly all, events include:

• Concerns that out of hospital services (i.e. primary and community care services)

currently have insufficient capacity or capability to deal with the anticipated increases

in demand. There is also concern about whether it is viable for these services to be

able to sufficiently support the proposed changes

• Specific needs of the deprived/vulnerable local population and the specific role A&E

is seen to play for these people

• Queries about whether there would still be patient choice

• Accessibility/validity of the consultation process. This covers a wide range of

comments on the consultation document and response form, publicity about the

roadshow events, and the decision making process

• Perception that the move to rearrange services is financially driven, rather than by

quality and patient care

• Whether the proposed reconfiguration is based on a tried-and-tested model or is

experimental for NW London

• Concerns about the timescales for change

• Perception of a politicised process

Themes arising in areas where proposed closure of the local A&E is a major issue

Events held in Brent, Ealing and Hammersmith were very much dominated by comments on

the proposed closure of A&E departments. As well as general opposition, a range of

comments and questions were raised relating to:


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• Travel times to and accessibility of alternative A&E services

• Capacity of the alternative site(s) to deal with the additional demand

• Ability to dealing with medical emergencies at the current site if there is no A&E

• The Urgent Care Centre model; effectiveness, standards of care; private provision

• Performance monitoring to assess impact and success of changes once in place

• Need for communication and education of the public; to understand changes e.g. the

different types of hospital; support decision-making regarding which service to

access; accessing available support; e.g. transport options

• The ability of the hospital to attract, train and retain staff once the A&E has closed

• Longer term aim to close the hospital

In Brent people were also interested to know whether changes to other hospitals and

services used by North West London residents e.g. UCH, Moorfields Eye Hospital, mental

health and learning disability services would be affected, and whether there are anticipated

changes to services in neighbouring boroughs. One person from Brent LINk attended the

second roadshow and provided a detailed statement for inclusion in the report.

In Ealing the majority of attendees were well acquainted with the consultation with a strong

view about the proposals and preferred option. A small number of protestors were present

outside the venue for some of the day during the first event and were handing out leaflets

entitled ‘Stop the plans to cut and wreck our hospitals’. They were invited to attend the

Question Times. The local MP and several local councillors also attended for some of the

day, as did a local LINk member.

In addition to those noted above, attendees in Ealing raised a number of other issues:

• Concerns about the proposals pitting hospitals against each other

• Whether a ‘do nothing’ option is viable

• What the plans are for the reduced Ealing Hospital site

In Hammersmith approximately 200 people attended the first roadshow event and a further

55 attended a second. Key issues raised included:


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• Opposition to the closure of Hammersmith Hospital A&E department

• Travel times to/difficulties accessing other A&E departments

• Capacity at other hospitals expected to take up demand

• Dealing with medical emergencies under the new proposals

• Staff resources/ retention/training

In addition, a total of 26 people supplied questions concerning the consultation at a meeting

at Hammersmith Town Hall on 24 September. These were generally concerning the

proposals to close Charing Cross A&E, and in opposition to this option.

Themes arising in areas where the hospital will or is proposed to remain a major

hospital

People attending events in Harrow, Hillingdon, Hounslow, Kensington and Chelsea and

Westminster were generally more open to discussing the proposals and in exploring and

understanding the potential impact of the proposals on wider service provision. Comments

and questions were raised relating to:

• General interest in what is being proposed and how this is being presented to the

public

• General feedback that the roadshow provided some reassurance in the context of

various rumours about hospital closures and reduction in primary and community

services

• The broader role of GPs; in commissioning, referrals, CCG responsibilities

• Impact of the proposals on specific sites and services

o London Ambulance Service

o Ealing & Northwick Park merger

o Closure of Ealing A&E; specifically on Northwick Park and Hillingdon Hospitals

o Closure of Charing Cross A&E

o Closure of St Mary’s A&E

o Closure of West Middlesex Hospital A&E

o Impact on Mount Vernon Hospital

• Impact on social care provision and mental health services


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Neighbouring areas

A comparatively small number of people attended the roadshows that took place in the three

boroughs neighbouring the North West London consultation area; Camden, Richmond,

Wandsworth. While comments relating directly to this consultation largely reflected the

universal themes above, the primary focus for these participants was their local services.

Consequently, in Wandsworth, people wanted to know whether similar proposals were being

discussed for South West London and in Camden conversations focused on services in the

North Central London area. In Richmond, questions were asked about living near the border

of NHS NW London and the impact on residents of potential changes to services at Charing

Cross and West Middlesex Hospitals.

Hospital site events

A total of 12 events were held on the nine hospital sites between 5 July and 25 September

2012. The format of each event was typically a presentation of the core options by one of the

SAHF clinicians followed by a Q&A session facilitated by a representative from OPM. Each

session typically lasted an hour. Most sessions were run specifically with staff, though on

some occasions members of the public were also able to attend. In addition, an open day

was held at Hillingdon Hospital, with SAHF personnel available to discuss proposals. More

detail of each session is provided in the table below.

Key Hospital site Date Format Participants

1 Central Middlesex 19 September 3x 1 hour sessions 27 staff

2 Charing Cross 17 July 1 x 1 hour session 53 staff

5 July 3 x 1 hour sessions 126 staff

4 September 1 x 1 hour session Not stated 3 Chelsea &

Westminster 14 September 2 x 1 hour sessions 32 staff

4 Ealing 6 September 2 x 1 hour sessions Around 70

participants

5 Hammersmith 19 July 1 x 1 hour session 59 participants

14 August 2 x 1 hour sessions 100 staff

6 Hillingdon 24 September

Open day stand 2-

5pm

25+ visitors; mix

staff/public

7 Mount Vernon 14 August 1 x 1 hour session 17 participants

8 Northwick Park 25 September 2 x 1 hour sessions 30 participants

9 West Middlesex 25 July 2 x 1 hour sessions 68 participants


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The following sections offer a very topline summary of the topics covered by questions and

comments elicited from staff and members of the public at each hospital site. A more

complete summary of the feedback from each session has been produced by OPM. Several

key concerns, similar to those raised in the roadshows, recurred in many of the meetings:

• Ability to sufficiently improve primary care and community-based services

• Standards/running of Urgent Care Centres

• The distance/time/access to alternative hospitals

• Capacity of alternative hospitals

• Timescales

• Proposals being financially driven

1. Central Middlesex Hospital

The event on 19 September comprised three separate sessions, including a presentation

and Q&A. Key issues raised at the event included:

• General opposition to the closure of the A&E department at Central Middlesex;

perception that this will lead to hospital closure

• Importance of/concerns about ability to sufficiently improve primary care and

community-based services

• Concerns about standards/running of Urgent Care Centres

• Concerns about the distance/time/access to alternative hospitals

• Concerns about resource planning/recruitment/retention/training opportunities

• Criticisms of the consultation process regarding public engagement and complexity of

issues/lack of understanding/reaction to proposals

• Questions concerning the expected impact of proposals on the merger with Ealing

• Criticism of the merger between Central Middlesex and Northwick Park


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2. Charing Cross

A total of 53 staff attended a one hour meeting which was held between on 17 July 2012.

Key issues raised here included:

• General opposition to closure of the A&E at Charing Cross Hospital

• Significant concerns about potential for staff redundancies; future closure

• Some agreement with the case for change and in the particular case for reduction in

A&E provision




• Concerns about local population needs

• Concerns that proposals are financially driven

• Concerns that proposals haven’t been subject to adequate modelling/planning



• Importance of communicating any changes to the public and staff; particularly

regarding the Urgent Care Centre

• Potential impact on medical research at Charing Cross

Some specific suggestions were also made regarding reconfiguration of services:

• Move Western Eye hospital to Charing Cross given its current proximity to Moorfields

• Create a model hospital for West London on the Charing Cross site

• Join Charing Cross Hospital with Chelsea & Westminster Hospital

3. Chelsea & Westminster

Three events took place in Chelsea & Westminster Hospital. The first staff event on 5 July

comprised some three separate Q&A sessions, with a total of 126 attendees and panel from

SAHF. On 4 September an event for Foundation Trust members of Chelsea and

Westminster Hospital was held involving a presentation and Q&A. The event on 14

September comprised two separate sessions, involving a presentation and Q&A. The report

produced by OPM states that “Overall, staff in all three of the sessions appeared to accept

the need to change healthcare and recognised the problems of the current system. They felt

that Chelsea & Westminster has gone through an intensive re-organisation and the current

proposals fit well with this. Staff appeared to agree with the vision, with some reservations”.


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Key issues raised at the events in Chelsea & Westminster included:

• Support for Option A



• Concerns about capacity at Chelsea & Westminster to cope with extra demand for

services

• Concerns about capacity at other hospitals

• Concerns over the potential future loss of maternity services at Chelsea &

Westminster


• Concerns about competition arising with Central Middlesex Hospital for elective

surgery cases


• Comments about the political context

• Suggestions to improve public engagement/locally campaign for Option A as part of

the consultation process

• Concerns about the proposals pitting hospitals against each other


• Need to engage with London Ambulance Service

4. Ealing

The Ealing Hospital event on 6 September involved two separate Q&A sessions, with around

70 attendees and a panel from SAHF. Key issues raised at the event in Ealing included:

• General opposition to the closure of A&E at Ealing Hospital



• Concerns about A&E capacity/rates elsewhere


• Concerns about disadvantaged and vulnerable groups; notably Southall population

• Concerns about the timeframe for change





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5. Hammersmith

A total of 59 staff attended the event on the 19 July. The event was a Q&A panel session.

Key issues raised at the event in Hammersmith included:

• General opposition to the closure of A&E at Hammersmith

• Specific concerns about access to specialist treatment in the absence of A&E

• Concerns about the timeframe for change



• Concerns about staff morale

• Viability of the status quo an option

• Concerns about loss of A&E at Central Middlesex Hospital which is equipped to deal

with industrial accidents from local site and/or major incident at Wembley

6. Hillingdon

Two events took place in Hillingdon Hospital. The first staff event on 24 August comprised

some three separate Q&A sessions, with a total of 100 attendees and panel from SAHF.

In addition, a consultation stand was attended by OPM representatives on 24 September

between 2 and 5pm. In total 25 people visited the stand; approximately 15-20 consultation

documents were taken, other visitors (staff and members of the public) already had them and

were encouraged to return the response form.

Key issues raised at these events included:



• Concerns about capacity at Hillingdon to cope with extra demand for services


• Comments about the political context

• Need to improve public education so people understand the changes after they have

happened

• Querying what assumptions were being made about patient choice

• Concerns about the future possibility of general closure resulting from closure of the

A&E



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• Concerns about timescales/speed of change

• Concerns about impact of concurrent changes in social care provision

• Concerns about loss of A&E at Central Middlesex Hospital which is equipped to deal

with industrial accidents from local site and/or major incident at Wembley

• Criticisms of the consultation process; regarding public engagement and complexity

of issues/lack of understanding/ reaction to proposals. Also the non-inclusion of other

local hospitals and lack of explanation for their omission was mentioned.

7. Mount Vernon

Seventeen people attended a Q&A event at Mount Vernon Hospital on 14 August. Key

issues raised at this event included:



• Whether Hillingdon will expand to cope with extra demand for emergency care;

whether financing is in place


• Querying whether there would still be patient choice


• Concern about the proposed metrics/monitoring to assess impact/success

• Consultation process; specific query concerning whether other areas from which

Mount Vernon gets some elective referrals (e.g. Buckinghamshire, Hertfordshire) are

being engaged


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8. Northwick Park

The Northwick Park Hospital event took place on 25 September. Two separate Q&A

sessions were held, with a third session abandoned shortly after the Q&A started due to a

fire alarm. There were a total of 30 attendees for the first two sessions. Key issues raised at

Northwick Park included:



• Concerns about timescales/speed of change

• Concerns about impact of concurrent changes in social care provision

• Concerns about whether the proposed elective care model will work


• Concern about the proposed metrics/monitoring to assess impact/success


of issues/lack of understanding/reaction to proposals. Also whether clinicians are

being consulted

• Question: why is Charing Cross not proposed as a major hospital?

• Question: will the Western Eye Hospital close?

9. West Middlesex

The West Middlesex Hospital event took place on 25 July. Two separate Q&A sessions were

held involving a total of 68 attendees. Key issues raised at West Middlesex included:

• Concern about potential closure of West Middlesex A&E

• Concerns about capacity at West Middlesex to cope with extra demand for services



• Concerns about disadvantaged and vulnerable groups; notably transient populations

and asylum seekers


• Queries about the likelihood of any of the options going ahead or nothing happening


of issues/lack of understanding/reaction to proposals

• Extensive discussion/suggestions to widen public engagement locally

• Concerns about the proposals pitting hospitals against each other.


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GP events

GPs discussed the issues in regular meetings but three events were specifically set up by

NHS North West London and facilitated for Ealing GPs by OPM. These events were

attended by approximately 75 GPs, a consultant and a Director of Public Health. It is not

known whether some GPs attended more than one event.

GP Events Date Number of

participants

Ealing #1 15 August 25

Ealing #2 5 September 28

Ealing #3 26 September 25

These sessions took the form of Q&A sessions with a panel of representatives from NHS NW

London. The following section offers a very topline summary of the findings from these

events. A more complete summary of the feedback from each session has been produced by

OPM.

The issues raised in each of these meetings were broadly consistent. These covered:

• Opposition to closure of A&E at Ealing Hospital



• Concerns about A&E capacity elsewhere

• Concerns over the loss of maternity and paediatric services at Ealing Hospital

• Concerns about ability of Ealing Hospital to recruit/retain/train doctors/consultants


• Concerns about disadvantaged and vulnerable groups; notably the population in

Southall

• Suggestions to slow the process and introduce an Option 4 of reducing from 9

hospitals to 6


issues/lack of understanding/ reaction to proposals


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Focus groups

Two rounds of focus groups were held over the consultation period. The primary objective of

these discussion groups was to obtain independent, qualitative feedback on people’s views

of the ‘Shaping a healthier future’ (SAHF) programme. The groups were managed and

facilitated by the Office for Public Management (OPM).

Group participants were recruited from across North West London and other areas most

likely to be affected by the proposals (Camden, Richmond and Wandsworth). Recruitment of

participants for each group was undertaken by a specialist agency to a defined specification.

Participants were selected to provide a mix of demographic characteristics in each group (i.e.

gender, age and ethnicity), but with more emphasis given to recruiting certain types of people

with particular needs. These were:

• People who would need to get to hospital by public transport or taxi, as opposed to

via their own transport

• People who frequently use primary care services and who have used acute services

in the past 12 months

• People with a black or minority ethnic background, since it is known that certain BME

groups tend to have poorer health outcomes

• People who are unemployed, not working, in education, retired or permanently sick,

and benefits claimants

• People with no qualifications since education can affect how well one can navigate

the health system

• People with long term conditions and/or multiple health problems

• New mothers

Except where stated, therefore, each group was very demographically mixed and

participants represented a range of ethnic backgrounds and had experience of a variety of

care settings.


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The groups were held in accessible community locations in the relevant borough. Each

discussion was facilitated using a topic guide to maintain focus on the core issues and

ensure consistency across all sessions. Where the group size was particularly large,

participants were divided into two smaller sub groups. Each session typically lasted 2.5

hours, with a 15 minute refreshment break and was video recorded after relevant consent

and confidentiality permissions were obtained. A small incentive was paid to each participant

in recognition of their contribution.

The following section offers a topline overview of the findings from each group taken directly

from a more complete summary of the feedback from each focus group produced by OPM.

Some of the key themes which emerged are:

• An acceptance of the case for change among many participants

• Concerns about the resourcing and/or quality of GP/primary care services

• Some concerns about the impact of closure of A&E departments

• The need for information about what the changes will mean for people personally and

how and when to access particular health services (e.g. Urgent Care Centres)

Focus groups: Round 1

Round 1 comprised one focus group in each of the eight core boroughs in NW London.

Sessions took place between 15 to 29 June 2012, as follows:

Borough Date

Number of

participants

1 Brent Wednesday 20 June 12

2 Ealing Thursday 21 June 12

3 Hammersmith & Fulham Friday 15 June 15

4 Harrow Wednesday 20 June &

Friday 29 June

17

5 Hillingdon Tuesday 26 June 10

6 Hounslow Thursday 21 June 13

7 Kensington & Chelsea Wednesday 27 June 9

8 Westminster Wednesday 27 June 14


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1. Brent

The group was attended by 12 Brent residents.

Overall the case for change and the rationale behind the vision were well understood, the

reasoning underpinning the proposals was clear and participants agreed that proposed

changes seem a sensible way to address the challenges identified.

Participants broadly agreed that trade-offs arising under the proposals e.g. travelling further

to access better or more specialist care are acceptable, although a small number of people

were concerned when they thought about how the changes might affect them personally and

their use of services. They felt more information and discussion was needed to understand

how it will work in practice, the effect on patient journeys and how problems could be solved.

The group’s main concern was whether what is outlined on paper, will work in practice.

Participants were particularly concerned about the ability of primary care services to cope

under the new model; the group believe there is insufficient resource for primary or

community based care as it stands and are concerned that primary care will not be able to

cope with the increased volume of patients and deliver the best health outcomes and care

needed in order to keep patients out of hospital settings.

People were also concerned about the care pathway in an emergency following the closure

of four A&E departments (e.g. not being left by paramedics at an overloaded A&E).

2. Ealing

The group was attended by 12 Ealing residents.

There was broad agreement and acceptance of the proposed changes and most seemed to

make sense to participants. There were very few spontaneous concerns – these were

around the number of local A&E and urgent care services. There was some discussion about

Ealing Hospital and how this would change going forward. Younger, pre-families and low

health service users (some men) found it hard to envisage how the changes may affect them

in the future.


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3. Hammersmith and Fulham

The group was attended by 15 Hammersmith and Fulham residents.

Overall the case for change and the vision and patient stories were understood and well

received. People felt that the descriptions of different types of hospital needed more detail –

it was unclear exactly how the changes will affect people personally and what it will mean for

them if their local hospital loses its A&E. There were no significant concerns or challenges.

The main groups of patients that people were concerned about in the future were older

people and children/maternity care.

4. Harrow

Two groups were convened in Harrow as part of the first round, as there was a low turn-out

for the first of these. A total of 17 people participated in these two sessions.


received. People understood the broad picture about the potential changes and welcomed

the core aspects of localising and integrating care. There was concern about the recent

reduction in opening hours of a valuable walk-in clinic. The main group of patients that

people were concerned about in the future are older people and those who do not speak

English.

5. Hillingdon

The group was attended by 10 Hillingdon residents.

Overall participants agreed with the challenges outlined in the case for change – the

challenges around staffing and GP access were particularly well understood. Participants

broadly agreed that the proposed changes are sensible but many were concerned that the

problems they experience now in both primary (GPs who do not have the time or patient

information to adequately address problems) and secondary care settings (overcrowded and

poorly staffed hospitals with poor quality or dangerous level of care in some instances) would

not be solved by the proposals.

Participants agreed that the trade-offs they were asked to consider concerning travelling

further to access better or more specialist care were acceptable, but only if the planned

changes could be shown to result in better health outcomes, more care in community

settings, improved specialist delivery. They felt that it will be a “big job” to make it work in

practice and some were pessimistic about the plans being achievable.


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The group emphasised the centrality of information and education to the success of the

proposed model and highlighted the need for much more information for patients and the

public. The group also highlighted the importance of working with patients and the public to

help them understand the resource implications of their choices and the effect on the system

as a whole.

The group was keen that more care is delivered in community settings and in particular

advocated the use of community or local hospital services, community nurses and extended

GP practice services so basic tests and services can be delivered out of hospital settings

(e.g. blood tests, very minor surgery, X-Ray, mother and baby services).

6. Hounslow

This group was attended by 13 Hounslow residents.

Overall the case for change, the vision and patient stories were accepted. Participants

understood the model and the types of hospital, except the description of the local hospital.

A much clearer explanation of the difference between an A&E Department and an Urgent

Care Centre was needed. There was a general concern about GPs and their capacity to

deliver the vision of localisation, particularly as GP access was one of the current challenges.

Participants like the design of more local care, particularly home care for older people and

children.

7. Kensington & Chelsea

The group was attended by 9 residents of Kensington & Chelsea.


received. People felt that the description about the model (types of hospitals) was adequate.

They had some concerns about the reduction in the number of A&E departments in the area,

but were reassured by continuing provision of 24 hour and urgent care in all hospitals and

were particularly supportive of the idea of elective hospitals.

The only significant concern about the model was the extra travel time and expense for

people visiting relatives in major hospitals and how the new changes would be funded. There

was also an underlying issue about the quality of staff across all service levels, which was

seen as fundamental to the model delivering improved care. The main groups of patients that

people were concerned about in the future were older people, new parents, and people with

long term conditions and mental health issues.


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8. Westminster

The group was attended by 14 Westminster residents.

Overall the vision was considered common sense and participants supported the emphasis

on localising, centralising and integrating services. The patient scenarios showed to the

group were felt to illustrate what should be happening now. Not all elements of the case for

change were accepted by all. For example, some were simply not prepared to consider

either of the “pairs” of hospitals diminishing A&E services for local people. Participants called

for more clarity about the difference between a local Urgent Care Centre and an A&E. There

was a lot of dissatisfaction with local health services in this area, with GP access being a key

issue. Some participants view A&E as the one place people feel they can get same day

access to competent help. Participants were unconvinced that GPs would have the capability

or the capacity to offer better local services.

Focus groups: round 2

Residents from each of the eight boroughs participated in a second wave of focus groups,

including specific sessions with new mothers, disabled people and young people. In addition,

sessions were run with residents of Camden, Richmond and Wandsworth, three of the

boroughs neighbouring NW London whose residents could be most affected by the

proposals.

Borough Date

Number of

participants

9 Brent Wednesday 26 September 18

10 Brent

(Stonebridge Park; new mothers)

Friday 5 October 9

11 Ealing Thursday 27 September 18 12 Ealing (Southall; young people) Thursday 4 October 12 13 Hammersmith Friday 5 October 20 14 Hammersmith (disabled people) Monday 8 October 15 Harrow Friday 28 September 15 16 Hillingdon Wednesday 3 October 20 17 Hounslow Wednesday 26 September 20 18 Kensington & Chelsea Wednesday 26 September 16 19 Westminster Tuesday 2 October 21 20 Camden Thursday 27 September 14 21 Richmond Friday 21 September 18 22 Wandsworth Friday 21 September 15


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9. Brent

This focus group was attended by 18 people. Half of the group were Somalis, several others

were non-white and one person was a refugee from Bosnia. The group spanned a wide

range of ages. While some of the group had lived in Brent for many years others were new

arrivals.

The group recognised that the NHS is under pressure and that change is needed. They liked

the ‘Shaping a healthier future’ vision, but did have some concerns about whether there

would be the capacity and appetite in primary care to deliver what would be required to make

the vision work. The group liked the idea of major hospitals being able to deliver better

quality care and were willing to travel further to receive this care, however they felt that this

could affect some groups more than others so support will need to be out in place for them.

Overall the group was in favour of Option A. They felt this option was preferable to Options B

and C in terms of the care it could deliver and the money it could save.

10. New mothers (Stonebridge Park, LB Brent)

Nine new mothers attended this focus group. Participants were all female, aged between 22

and 39 years, and had at least one child aged 2 or under. Participants were either not

working or unemployed and were from a wide range of ethnicities. Several of the participants

were also users of urgent and unscheduled emergency care and one had a long term health

condition.

While some participants were very engaged in the issue and could reflect on what the impact

of the changes may mean for them, this was not the case for all. Participants were, however,

in agreement that change in the NHS is needed; they variously reported experiences of not

being able to get GP appointments when needed, a child’s scheduled operations being

‘bumped’ by an emergency, of being told to go to another hospital after waiting several hours

at A&E.


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Participants were broadly happy with the proposed changes, and were on the whole

supportive of:

• Reducing 9 major hospitals to 5 on the basis that they could see that Urgent Care

Centres were the most appropriate setting for them and their children to attend

• Option A; particularly for a couple who had bad experiences when they used

maternity services at Central Middlesex

• The system of 8 different healthcare settings. While seen as potentially more

complicated, it was generally thought this could bring benefits in terms of waiting

times and receiving the best care, if under the new system, they knew when to

access what setting.

• They felt strongly that the new system would only work if they had better information

about where they should go and what was available.

11. Ealing

Eighteen local residents attended the group and participants were from a wide range of ages,

from 21 to 76 years, and ethnicities including a high proportion of Indian and other BME

groups, some of which were recent immigrants to the UK. There were a number of

participants living with long-term conditions including high blood pressure, diabetes, physical

disabilities, as well as informal carers for others with such conditions. Many participants were

users of unscheduled care and regular users of primary care. Socio-economic backgrounds

were also diverse with unemployed participants, students as well as some retired or still in

work.

Participants were generally in agreement with the case for change. They were mainly

dissatisfied with the current waiting times in the health system. They complained of long

waits to see a GP in primary care and specialists in secondary care. There were examples

given of long waits for outpatient appointments that were exacerbated by additional waiting

times for particular scans, blood tests and other hospital investigations.

Participants accepted the vision, models of care and proposals for improvement. They

expressed the need for more communication to the general public on the models of care

already in use, e.g. Urgent Care Centres, specialist centres for certain conditions. Publicising

new patient experiences may reassure those that are more sceptical.


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Many participants accepted the criteria for change to five major hospitals, understanding how

the demand for care would be managed better. They saw all options as practical;

nevertheless, most participants admitted geographical bias in wanting their current local

hospital, Ealing, to be one of the major hospitals (Option C). The negatives pointed out in

both Options B and C were not accepted. The belief was that money would continue to be

found to overcome poor estate and to balance the deficits.

12. Ealing (young people, Southall)

Twelve young people aged 16-18 attended the group. Two thirds of the group were from

BME backgrounds and two of the group were Irish. Four of the group were not in education

or employment, three were employed part time (working in the restaurant and leisure

industries) and five of the group were full time students.

The group were not sure whether the facts presented in the case for change were accurate

and did not feel they personally had a good enough overview or understanding of the local

population to say whether there is a case for change.

Members of the group expressed their approval for the grouping of hospitals by location (so

one is a major and one a local) – they felt this was a sensible approach.

Many of the group were uncertain as to how they could make the decision between Option A,

B or C. When prompted to choose most of the group said they preferred Option C because it

gives Ealing a major hospital; some of the group highlighted that Ealing Hospital would need

investment and improvement if it was to become a major. One member of the group felt

strongly that Option A was the best option.

Some of the group felt that with no major hospital in the borough of Ealing, the spill-over into

Hillingdon or West Middlesex would be considerable and mean longer waiting times at these

A&E departments.

Participants stressed that whatever is decided, the messages about the changes need to be

communicated well and communicated widely. They highlighted the particular need to

communicate the changes to older people.


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13. Hammersmith

Twenty people attended the group, including six men and women from the local Somali

population.

Overall the proposed changes were considered beneficial to the area. Most agreed that

change is needed and proposals including the elective/emergency split; improvement of

coordination of care; specialisation/centralisation; and improved access to primary care; were

felt by many to be a good way forward.

Objections to the proposals arose primarily from cynicism of change in the public sector ever

bringing improvement. Specific and strong objections were also heard concerning the ability

of GPs to cope with the level of responsibility they are being asked to take on in coordinating

care.

Some participants had heard about the changes and following the discussion felt that the

way they had been informed about them by campaign groups had led them to believe that

they were full hospital closures.

14. Hammersmith (disabled people)

This group was held with physically disabled respondents. There were respondents with MS,

mobility problems, hearing and visual impairments and other long term life limiting conditions.

A good range of ages and a good gender split were present.

The key points raised were the need for improved transport services and particularly

improved active signposting to existing transport (and other relevant) services.

Also of importance to this group was the localising or ‘home-basing’ of routine services such

as rehabilitation; physiotherapy; treatments and services that currently require one day

hospital stays such as treatments for MS and dialysis.

In addition participants believed that GPs will lack time, knowledge and enthusiasm to be at

the centre of patient care. It was not felt this policy change would work or improve quality or

access to care.

No one option stood out as a favoured option, but at the same time the group were not in

strong opposition to any. Discussion instead was mostly around the larger problems in the

NHS (laid out above) which the group did not feel these changes would address.


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15. Harrow

The group was attended by 15 Harrow residents.

Overall, many expressed frustrations with both the access to and quality of services both at

GP and hospital level, with heavy and almost complete reliance on Northwick Park as the

main hospital and A&E in the near vicinity. The introduction of healthcare centres in Pinner

and Harrow in recent years were said to have improved access to GPs and a broader range

of support services, rehabilitation and therapies. However these have been dramatically

reduced recently and this was seen as a retrograde step.

There was consensus that change in the NHS is needed. However, participants said they are

keen to know that changes introduced will bring about improvements both in terms of access

and quality of care.

As all three options retain Northwick Park as a major hospital, the core proposals were not

seen as contentious and some participants even refused to favour any option on the basis

that Harrow residents are least affected. Option A received strongest support overall, as

most supported the idea of Chelsea and Westminster and West Middlesex as major hospitals

in view of their superior sites and more modern facilities. Others were concerned about the

potential “increase in pressure” on Northwick Park’s A&E, which is perceived as “very busy

and over stretched”, due to other recent A&E closures at Edgware and Mount Vernon

Hospitals. There were also concerns about the potential loss of beds from Central Middlesex

which would again create heavier use of services at Northwick Park. No strong views were

expressed about preferences for Ealing or West Middlesex Hospitals although there was

some comment on the poor state of repair of Ealing Hospital.


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16. Hillingdon

20 local residents attended the focus group, representing a wide range of age groups and

ethnic backgrounds. Key points from the group were as follows:

• There was acceptance that the world is changing and that the NHS needs to change

to better serve today’s population in the way they want to be served.

• Concerns were raised about existing services, particularly long waiting times to see

disinterested and time-pressed GPs.

• Overall there was a cautiously positive response to the changes proposed.

Centralisation was well understood and accepted (except for anything which may be

an emergency). Localisation was very welcomed and idea of health centres was well

received.

• All options retain Hillingdon as a major hospital which participants were happy with.

There was appreciation that Option A offers best value for money. Some favour

Option C because it adds Ealing Hospital as a nearby major hospital.

17. Hounslow

This group was attended by 20 Hounslow residents.

Participants were generally dissatisfied with the accessibility and quality of primary care in

the borough. They mentioned difficulties in seeing their GP as often and for the length of time

wished. Secondary and community care were less mentioned. There was consensus that

change in the NHS is needed and support for the general principle for services to offer

sufficient time with healthcare providers which is seen as particularly important for health.

The group was largely comfortable with the vision and the proposed changes. The changes

to hospitals proposed in Option A (and B) were felt, by the majority, to make little difference

to the care they receive. There were minor reservations about the increased pressure on

West Middlesex by increased traffic from Ealing but felt that out of the two hospitals, Ealing

was the most appropriate to downgrade. Option C was least favoured. The major criteria

people used to assess how the changes would affect them were journey time and waiting

time.


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18. Kensington & Chelsea

This group was attended by 16 Kensington and Chelsea residents.

Participants generally regarded themselves as comparatively unaffected by the proposed

changes, with most using St Mary’s as their nearest hospital. Many also use Hammersmith

Hospital, but felt that the lack of an A&E at Hammersmith was not a major issue because of

its proximity to St Mary’s.

Overall most were receptive to the case for change, the vision and the options. Option A was

seen as most viable particularly in terms of the proposed use of existing buildings and

therefore offering value for money.

19. Westminster

Twenty one local residents attended the group. Participants were from a range of age groups

and ethnic groups. There were a number of participants living with long term conditions

including diabetes and there were several informal carers in the group. Many of these were

users of unscheduled care and regular users of primary care.

Participants noted that in Central West London patients were very well served by health

services when they compared themselves to people living in other parts of the country or

even North West London. Access to primary care was the main frustration: limited access to

GPs, inconsistent service; and lack of time taken or listening by GPs. Secondary care

(primarily St. Mary’s) was considered good (or very good) once access was gained.

Participants preferred Option A with St Mary’s becoming a Major and with the Western Eye

hospital relocating to this site. They found it more difficult to comment and reflect on Options

B and C as they would not be affected.

They wanted more information about how achievable the proposals and reassurance that if

the proposals were put into action that they wouldn’t be ‘scrapped’ by a new Government.


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20. Camden

This group was attended by 14 Camden residents.

As Camden residents the group see themselves as relatively unaffected by the proposed

changes in the NW London area and few real concerns were raised. Most consider

themselves well served by a good choice of excellent local hospitals served by good

transport links. Across the group a minority had used St Mary’s or Hammersmith on an

occasional basis but the majority of the hospitals in the consultation were unknown and seen

as geographically distant from Camden.

There was, however, overall agreement and appreciation of the need for the NHS to change

the way it currently provides services across the primary and acute sectors and all supported

the proposed model as a sensible approach. Frustrations with access to services at primary

care level mean that most are keen to consider a service that appears to address this

concern and increase access to services locally.

Option A was regarded as the best approach overall and received strong support.

21. Richmond

This group was attended by 18 Richmond residents.

Overall the case for change, vision and models of care were understood and accepted. All

but one participant agreed that all of the options were practical though Option A was

preferred because it offers the least disruption. The 24/7 Urgent Care Centres, with

ambulance back up for transferring patients if necessary, were seen as essential.

Participants stated that acceptance of these options was conditional upon the health system

offering quicker community access (more drop in facilities) and improved quality of care,

before the number of major hospitals was reduced. Participants were also reassured by the

timetable, as this would allow them to experience these improvements before hospital

services change.

There was general agreement among the group that attitudes of some staff working within

the NHS could be improved via training and monitoring.


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22. Wandsworth

15 participants attended the focus group in Wandsworth. A good spread of local residents

were represented across different ethnic and age groups and having a range of experiences

of local health services and a wide variety of long term health conditions.

Overall most were receptive both to the idea that changes were required in the way services

are currently provided, the overall structure of the model and the options suggested, with A

seen as the preferred option. There were high levels of sympathy expressed about the

pressures on the NHS and many appreciate the level of service it currently provides given

the huge challenges and demands placed on the system and what is regarded as ‘abuse’ by

some patients.

Wandsworth residents generally regarded themselves as relatively unaffected by the

proposed changes in the NW London area. with many using St George’s at Tooting as their

main hospital for A&E access, although many also use Chelsea and Westminster Hospital in

preference because it was (for some) nearer, had shorter waiting times and is a better

hospital in terms of quality of buildings and facilities. There was concern about a knock-on

effect on St George’s in terms of capacity, were Chelsea & Westminster’s A&E to close.

Most other hospitals referenced were largely unknown and as such few concerns were

raised about the proposed changes.


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16. Petitions and campaign responses

A total of 18 petitions and campaign responses were received. 12 of the petitions opposed

the closure of A&E and other departments in hospitals, five were in support of Option A while

one supported West Middlesex’s status as a major hospital.

The following table lists each of these, indicating what each was supporting and listing the

number of signatories. Ipsos MORI counted the number of signatories to all the petitions. If

there was a discrepancy between the number of signatories counted and provided with the

petition, we have used the figure from counting the petitions.

Petition/campaign on behalf/in support of Number of

signatories

A Patients opposed to the proposed closure of the A&E

departments at Ealing Hospital, from Eastmead Surgery

76

B Petition opposed to the closure of services at Charing Cross

and Hammersmith hospitals and the closure of the hyper-

acute stroke unit at Charing Cross, from Hammersmith and

Fulham Council

492

C Petition opposing the downgrading of hospitals in North West

London

19

D Email postcard petition registering support for Option A from

Hounslow Council

47

E Email petition supporting West Middlesex’s status as a major

hospital in NW London from London Borough of Hounslow

643

F Petition opposing the downgrading of services and the

closure of the A&E Department at Central Middlesex Hospital

from Harlesdon Methodist Church

43

G Email petition supporting Chelsea and Westminster Hospital

being one of five major hospitals and Option A

6,611

H Email petition registering support for Option A from West

Middlesex Hospital patients

151


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I & J ‘Save Hammersmith Hospital’ petition calling for A&E and

other clinical services to be retained at Hammersmith

Hospital, from Hammersmith and Fulham Council

Number of signatories to online petition: 1,483

Number of signatories to paper petition: 1,130

2,613

K & L ‘Save Charing Cross Hospital’ petition calling for A&E and

other clinical services to be retained at Charing Cross

Hospital, from Hammersmith and Fulham Council

Number of signatories to online petition: 6,084

Number of signatories to paper petition: 3,304

9,388

M ‘Save Hammersmith & Charing Cross Hospitals’ petition,

calling for the Secretary State for Health to stop the closure

of hospital services in West London, from Hammersmith and

Fulham Council

15,263

N & S Chelsea and Westminster Hospital ‘Safe in Our Hands’

campaign. Postcard and online postcards in support of

Option A, calling for Chelsea and Westminster Hospital to be

a major hospital with a full A&E

11,263

(9,927 of these

responses were

also submitted

in the online

form)

O Petition calling for the A&E department of Hammersmith

Hospital to be retained, from residents of Hetley Road, W12

58

P Petition registering support for Option A, from residents of the

Heath Court Sheltered Scheme

92

Q Petition calling for Ealing, Central Middlesex, Charing Cross

and Hammersmith Hospitals to retain their status and keep

all existing services, from Ealing Council

25,193

R ‘NHS Under the Knife’ campaign calling for the A&E

department of Central Middlesex Hospital to remain open

and for no cuts to or privatisation of services

1,932


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S Please see Petition N

T Petition calling for Secretary of State for Health to stop the

closure of Hospital Services in west London, in particular the

A&E Departments of Hammersmith and Charing Cross

Hospitals

1,332

U Petition calling for the protection of A&E departments in

Hammersmith and Charing Cross Hospitals and opposing the

closure of the stroke unit at Charing Cross

2,044

As can be seen, these petitions and campaigns have focused on supporting specific units or

hospitals (or a relevant option). In addition to forming responses in their own right, it is likely

that these campaigns have influenced responses via other methods by raising awareness

and encouraging people to respond to the consultation. However, it is difficult to quantify their

impact. We cannot identify the extent to which individuals may have signed one or more

petition, but, given the levels of engagement from the wider community, we believe that this

is likely to have been the case. We appreciate, however, that there are subtle differences

between the various campaigns, and so individuals who express their support for multiple

campaigns are not being ‘double-counted’.

Petitions T and U also allowed signatories to post their own comments or respond to specific

questions about the proposals. All of these comments have been read by Ipsos MORI and

the general themes identified.

Comments provided by signatories to Petition T

Respondents to Petition T were able to provide a comment to support their signature: 634 did

so. Of those signatories who provided a comment one in three express concerns about the

loss of A&E and/or specialised services, while a further one in five say that they believe no

services should close.

Closing hospitals is a false economy and endangers our lives. At times of

economic difficulty we need to preserve the public services which distinguish us

from states who have scant care for their citizens. In this country we CAN afford to


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offer our citizens proper health provision.

A&E's all over London, from experience are already very, very badly congested

and desperate. How will closing more A&E Departments make the situation better?

Around one in five people who provided a comment through Petition T express concerns that

lives could be lost as a result of the planned changes to services in NW London, while a

further one in six state that the plans could results in greater travel times (particularly for

patients trying to access A&E) and therefore risk worse outcomes for patients.

With no local A&E people will die unnecessarily. Traffic can get easily gridlocked

around here. The time tests you have carried out stating it will only add two

minutes to 999 calls to other A&E departments is highly flawed and based upon

normal traffic conditions. This is a money saving proposal and not based upon the

needs of people whose taxes fund the NHS.

Related to concerns over travel, around one in six people who commented say that care

should be provided locally/should serve the local community

Having lived in West London, I find it particularly disturbing that you are closing

these two A&E departments. With an ageing and infirm population, then travelling

further across London puts lives in danger. If we can afford to keep bailing out

banks, we can certainly maintain existing A&E services, unless the economy is

worth more than human life? Your choice.

In particular, one in ten who provided a comment say that Charing Cross should not lose its

A&E service, while a further one in ten commented on the excellent service they feel Charing

Cross hospital provides.


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I have used the A&E at Charing Cross, as well as the main hospital departments

and have always had excellent service. It will be a tragedy if either the A&E or the

hospital services are lost and patients have to travel further, possibly fatally. The

same applies to the Hammersmith hospital.

This closure must not go ahead. Charing Cross is an outstanding hospital, recently

renovated at great cost. I have been treated successfully by at least 5 different

departments since coming to live here, and am currently receiving treatment from

two departments. It is unthinkable that a leading hospital of this stature and value

to a large surrounding area should even be considered at risk.

Comments provided by signatories to Petition U

People who signed Petition U were also able to provide a comment to support their

signature: 758 signatories provided a comment. Of these, one third say they have concerns

about loss of A&E/specialised services, while a further one in five feel that no hospitals in

NW London should close or lose services.

A&Es are essential. Don't close them down. Instead ensure the biggest/rich

companies pay their taxes and ensure the banks pay their dues and treat money

correctly!

I think it is absolutely necessary to keep these A + E depts open. Why is the NHS

been targeted when the real problem of cutting back on Management salaries

needs to be addressed and NOT our NHS services and departments. I had to use

the A+E several times.

I am horrified to hear of these plans which seem to have appeared with no warning

or consultation with the residents who will inevitably be affected. It is unthinkable

that a borough of this size should be left with no accident and emergency provision.


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One in five of those signatories to petition U who also provided a comment offer the opinion

that lives could be lost as a result of the proposals. In particular, one in seven say that the

distance/time to travel to A&E will increase.

Closing any emergency care service will cost lives. This closure a death sentence

to anyone who has an accident or serious illness. Having to use another A&E such

as an already stretched Chelsea and Westminster, will have a knock on effect on

the people.

Health bosses have admitted it could take up to 53 minutes longer to get to a

hospital. It doesn’t take a doctor to predict that in the case of an emergency, the

best part of an hour could mean the difference between life and death.

A notable proportion of people offering comments in this petition specifically mention services

at Charing Cross hospital. One in six say that Charing Cross shouldn’t lose A&E, while a

further one in ten mention previous positive experiences of Charing Cross hospital.

A friend was admitted to Charing Cross A&E as an emergency just one week ago,

and is now receiving very good care in the specialist stroke unit. The

consequences of a longer journey and delay in her reaching hospital do not bear

thinking about.

I recently (in the past week) received excellent care from Charing Cross' A&E unit.

This is a fully functioning service, the loss of which would mean many people could

potentially lose life saving care. Please rethink your decision.

Charing Cross hospital provides a vital service of A&E together with walk in centre

which is essential as GPs are not available at weekends.


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Chelsea and Westminster Hospital ‘Safe in our Hands’ campaign

The totals for the paper postcards broke down as follows:

Response Total

Boxes supporting Option A and consenting to vote being submitted to the public consultation by Chelsea and Westminster Hospital both ticked

8,291

Box supporting Option A ticked but box consenting to vote being submitted to the public consultation by Chelsea and Westminster Hospital not ticked

911

Box consenting to vote being submitted to the public consultation ticked, Option A box not ticked

234

Both ‘yes’ and ‘no’ boxes consenting to vote being submitted to the public consultation by Chelsea and Westminster and box (15 of these also ticked Option A)

18

Only ‘no’ box ticked 13

No boxes at all ticked 354

TOTAL 9,821

The totals for the online postcards (as set out in a spreadsheet supplied to us by Chelsea

and Westminster Hospital) broke down as follows:

Response Total

Boxes supporting Option A and consenting to vote being submitted to the public consultation by Chelsea and Westminster Hospital both ticked

1,359

Box supporting Option A ticked but box consenting to vote being submitted to the public consultation by Chelsea and Westminster Hospital not ticked

24

Box consenting to vote being submitted to the public consultation ticked, Option A box not ticked

56

‘No’ box ticked, Option A box not ticked 3

TOTAL 1,442


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Chelsea and Westminster Hospital have confirmed to us that they inputted 9,927 responses

into the online response form. All of these responses selected ‘strongly support’ at Option A

but answered no other questions on the form. This figure does not exactly tally with our

analysis of the postcards above. For the purposes of analysing responses to the online and

paper forms, we have used the figure of 9,927.

West London Citizens campaign

West London Citizens produced a document recommending specific responses to many of

the questions in the consultation response form. This document is reproduced at Appendix

D. It advises strongly opposing Options A and B and strongly supporting Option C. Boxes

containing 529 responses completed using the paper response form, together with this

document, were delivered to Ipsos MORI. It appears that some or all of a number of the

response forms have been filled in by the same person (because of similarities of

handwriting), although it is impossible to verify this. It may be that some respondents asked

someone else to fill in the form on their behalf.

We have included responses to the West London Citizens campaign and the Chelsea and

Westminster Hospital ‘Safe in our Hands’ campaign in our analysis of the quantitative data.

By contrast, we analysed responses to other petitions separately. This is because the two

mentioned campaigns exactly replicated the wording of questions within the official

consultation response form.


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17. Late responses

The consultation period ran from 2 July 2012 to 8 October 2012. To make allowance for any

potential delays within the post or misdirection of emails, paper responses, letters and emails

were accepted up until 15 October 2012. A number of responses were received after this

date but before 2 November 2012. As at 2 of November the following late responses were

received:

• 55 paper questionnaires

• 18 letters

• 5 emails

• A template letter produced by the Save our Hospitals campaign and filled in by a

member of the public opposing Charing Cross Hospital becoming a local hospital and

complaining about the consultation process

• Five stakeholder submissions:

o A letter from Hammersmith and Fulham Clinical Commissioning Group

accepting the case for change and the general principles of care outlined. The

governing body concluded that Option A is preferred, although some

members expressed a preference for Option B. Reassurances were sought on

specific points such as the extent and pace of acute bed reductions.

o A letter from Brent Clinical Commissioning Group accepting the case for

change and the general principles of care outlined. This also stated that

Option A is the preferred option and asked for reassurances on points such as

further development of the out of hospital proposals.

o A letter from Harrow Clinical Commissioning Group accepting the case for

change and supporting Option A. Clarification was sought on the pace of

acute bed reductions and the investment required to deliver improvements in

primary care.

o A letter from Hillingdon Clinical Commissioning Group accepting the case

for change and the general principles of care outlined. It has concluded that

Option A is the preferred option. Assurance was sought on the further

development of the out of hospital proposals and more detailed modelling of

the implications of bed-base changes was requested.


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o A letter from Kingston Hospital NHS Trust confirming that it could develop

cost effective solutions to accommodate the additional activity in relation to

Options A and C. Option C was described as more challenging and it would

need to do further analysis of the implications of this option. Concerns were

raised about the impact of Option B

o A letter from London Ambulance Service NHS Trust supporting the options

presented in the consultation document predicated on additional investment in

the London Ambulance Service to provide the increased staffing required.

• 256 additional signatures to Petition C, opposing the downgrading of hospitals in

North West London

• 251 additional signatures to Petition E, supporting West Middlesex’s status as a

major hospital in NW London from West Middlesex

The paper questionnaires arrived too late for inclusion with the rest of the responses. Given

the small number received, they would not have shifted results for any given question by

greater than ± 2%. All emails and letters received after the closure of the consultation were

read. These did not present any different viewpoints from that correspondence received prior

to the deadline (see chapter 13), and so have not been analysed separately.


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18. Appendices


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Appendix A: Organisational responses

Responses by letter and email (not via the response form)

The organisations, groups and stakeholders that submitted responses by letter and email are

listed below. Some of these have submitted more than one response. A total of 74 responses

were received by 15 October 2012.

Brent Age UK Brent Health Partnerships Overview and Scrutiny Committee Brent LINk Brent North Constituency Labour Party Camden Council, Housing and Adult Social Care Carers UK Hounslow Central London Community Healthcare Trust Chelsea and Westminster Hospital NHS Foundation Trust Cystic Fibrosis Trust Ealing Clinical Commissioning Group Ealing Council Ealing Hospital A & E Team Ealing Hospital Medical Staff Committee Ealing Hospital NHS Trust Ealing Passenger Transport Users' Group Governors of the Chelsea & Westminster Hospital NHS Foundation Trust Greg Hands, MP for Chelsea & Fulham Guy's and St Thomas' NHS Foundation Trust Hammersmith & Fulham Council and its Health, Housing & Adult Social Care Scrutiny Committee (joint response) Hammersmith and Fulham LINk Hammersmith NETWORK 2 Harrow Council Health and Social Care Scrutiny Sub-Committee Harrow LINk Hillingdon Council's External Services Scrutiny Committee Hillingdon Hospitals NHS Foundation Trust Hillingdon LINk Hounslow & Richmond Neurological Partnership Hounslow Clinical Commissioning Group Imperial College Healthcare NHS Trust Jane Ellison, MP for Battersea, Balham and Wandsworth Karen Buck, MP for Westminster Kensington & Chelsea LINk Labour Group at Kensington and Chelsea Council London Borough of Hounslow Health and Adult Care Scrutiny Panel London Borough of Richmond upon Thames’ Overview and Scrutiny Committee Middlesex Pharmaceutical Committees in North NHS Central London Clinical Commissioning Group NHS West London Clinical Commissioning Group North West London Cardiovascular and stroke network North West London Critical Care Network North West London Hospitals NHS Trust North West London Joint Health Overview and Scrutiny Committee


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Onkar Sahota, London Assembly Member for Ealing and Hillingdon Paddington Green Health Centre Practice Patient Participation Group Queen's Park Area Residents Association Richmond Borough Council Richmond Clinical Commissioning Group Richmond Upon Thames LINk Royal Borough of Kensington and Chelsea Health, Environmental Health and Adult Social Care Scrutiny Committee Royal Brompton and Harefield NHS Foundation Trust Royal College of Midwives Royal College of Paediatrics and Child Health Royal College of Physicians Royal College of Surgeons Ruislip Residents Association Sarah Teather, MP for Brent Central Seema Malhotra, MP for Feltham & Heston Sir Malcolm Rifkind, MP for Kensington Southall Black Sisters St George’s Healthcare NHS Trust The College of Emergency Medicine The Community Voice The Royal Marsden NHS Foundation Trust Unite (West London branch) User Panel, NHS Central London Clinical Commissioning Group Wandsworth Borough Council Wandsworth Clinical Commissioning Group West London Mental Health NHS Trust West Middlesex University Hospital NHS Trust Westminster and City of London Liberal Democrats Westminster City Council, Adult Services and Health Policy and Scrutiny Committee Westminster City Council, Adult Services and Health Policy and Scrutiny Committee Westminster LINk White City Neighbourhood Forum A further five responses were received between the period 16 October – 2 November 2012,

the cut-off date for late responses which have been analysed at Chapter 17:

Brent Clinical Commissioning Group Hammersmith and Fulham Clinical Commissioning Group Harrow Clinical Commissioning Group Hillingdon Clinical Commissioning Group Kingston Hospital NHS Trust London Ambulance Service


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Responses using the response form

A number of respondents using the response form stated that they were representing an

organisation or group. Where they gave the name of that organisation or group, this is listed

below (where this was legible). It is not known whether these respondents were formally

responding on behalf of that organisation or group, or how they assembled the views of other

members. While this information was asked, it was not always supplied and where

information was provided, it was self reported.

Many other respondents who stated that they were responding on behalf of an organisation

or group did not provide any information or did not specify exactly which organisation they

were representing. For example, some said they were representing a hospital or particular

department with no further information. Others said they were representing their family or

local community. These responses are not listed here.

The following 24 organisations/stakeholders submitted a response using the response form.

Those marked with an asterisk (*) also submitted a separate response by letter or email:

Age UK Brent* Age UK Brent* Asian Muslim Women's Association BBH West London LIFT Company Ltd Black Disabled People's Association and Elcena Jeffers Foundation British Tamil Forum (BTF) Churchfield Community Association Cllr Nigel Bakhai, Health Spokesman, Ealing Liberal Democrats Department of Nutrition and Dietetics, Chelsea and Westminster Hospital Ealing Hospital Medical Staff Committee* Feltham Asian Women's Group Hanwell Village Green Conservation Area Residents Association Hitesh Tailor, Labour Councillor for East Acton Hounslow Council Hounslow & Richmond Neurological Partnership* MS Society NHS Hertfordshire Patient Participation Group, Mountwood Surgery QPR 1st; Queens Park Rangers Supporters' Trust Richmond LINk Royal Free London NHS Foundation Trust St Mary's with St Nicholas The Friends of the Chelsea & Westminster Hospital Westmoreland Triangle Residents' Association


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Appendix B: Demographic information

Demographic information, where this information has been recorded in the online and paper

forms, is given below, although it is important to bear in mind that this is just a subset of the

consultation respondents and cannot be taken to be representative of the consultation

respondents in general, particularly as the majority of respondents did not answer

demographic questions.

It should be noted that all percentages referred to below are rounded to the nearest whole

number, and that when two or more such figures are added, it can create rounding error; the

rounded figures given in a column, therefore, may not sum to exactly 100%.

Table B1 - Consultation responses by gender

Gender Number of responses

% of responses giving gender

Population statistics for North West London (%)5

Male 1,672 38 50 Female 2,759 62 50 Stating gender 4,431 Prefer not to say 124

TOTAL 4,555 Source: Ipsos MORI

5 Source: Office for National Statistics, Mid-2010 Population Estimates for eight North West London

boroughs (Brent, Ealing, Hammersmith and Fulham, Harrow, Hillingdon, Hounslow, Kensington and Chelsea and Westminster)


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Table B2 - Consultation responses by age

Age Number of responses

% responses giving age


Under 16 23 1 18*

16-24 155 3 14*

25-34 540 12 20

35-44 960 21 16

45-54 891 20 12

55-64 827 18 9

65+ 1,156 25 11

Stating age 4,552

Prefer not to say 79


Table B3 - Consultation responses by employment within the NHS

Experience Number of responses % of responses answering question

Currently working in the NHS 880 19

Used to work in the NHS 315 7

75 2 Currently work in the independent health sector

Used to work in the independent health sector

78 2

3,181 70 Never worked in either the NHS or independent health sector

Stating NHS employment 4,475

Don’t know 74


6 Source: 2011 Census: Usual resident population by five-year age group, local authorities in England and Wales. *Age categories are Under 15 and 15 – 24. Data are for eight North West London boroughs (Brent, Ealing, Hammersmith and Fulham, Harrow, Hillingdon, Hounslow, Kensington and Chelsea and Westminster)


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Table B4 - Consultation responses by local authority

Local authority Number of responses giving postcodes

% of responses giving postcodes

Barnet 20 1

Brent 60 2

Bromley 3 0

Camden 27 1

Chiltern 1 0

Crawley 1 0

Croydon 3 0

Dacorum 1 0

Ealing 1,713 44

East Hertfordshire 1 0

Elmbridge 7 0

Enfield 3 0

Epsom and Ewell 1 0

Hackney 2 0

Hammersmith and Fulham 290 7

Haringey 5 0

Harrow 72 2

Hillingdon 111 3

Horsham 1 0

Hounslow 888 23

Islington 8 0

Kensington and Chelsea 219 6

Kingston Upon Thames 5 0

Lambeth 15 0

Lewisham 2 0

Luton 1 0

Merton 14 0

Redbridge 1 0

Reigate and Banstead 3 0

Richmond Upon Thames 226 6

Runnymede 4 0

South Oxfordshire 1 0


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Southwark 9 0

Spelthorne 25 1

Surrey Heath 2 0

Sutton 4 0

Tower Hamlets 1 0

Wandsworth 83 2

Waverley 2 0

Wealden 3 0

Westminster 67 2

Woking 3 0

Worthing 1 0

Stating postcode 3,909

Not stated n/a

TOTAL 3,909

Source: Ipsos MORI

Respondents were assigned to a local authority using the postcode data provided. In

instances where postal districts cross local authority boundaries, respondents were assigned

to the local authority where that particular postal district is most predominant.


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Table B5 - Consultation responses by ethnicity

Ethnicity Number of responses

% of responses stating

ethnicity


White 2,724 64 66

Mixed 132 3 4

Asian or Asian British 888 21 18

Black or Black British 220 5 8

Chinese 42 1 4 (includes ‘Other’)

Other 236 6 n/a

Stating ethnicity 4,242


TOTAL 4,534

Source: Ipsos MORI

Table B6 - Consultation responses by disability

Disability Number of responses

% of responses stating disability

Yes 593 14

No 3,678 86

Stating disability 4,271


TOTAL 4,480

Source: Ipsos MORI

7 Source: Greater London Authority (2009) http://data.london.gov.uk/catalogue. Data are for eight North West London boroughs (Brent, Ealing, Hammersmith and Fulham, Harrow, Hillingdon, Hounslow, Kensington and Chelsea and Westminster)


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Table B7 - Consultation responses by parental responsibility

Gender Number of responses

% of responses stating parental responsibility

I have children 2,230 53 I am pregnant 80 2 I care for children under the age of 16

402 10

None of these 1,815 43

Stating parental responsibilities

4,186



Table B8 - Consultation responses by sexual orientation

Lesbian, gay, bi-sexual, transgender

Number of responses

% of responses stating sexual orientation

Yes 189 5 No 3,760 95 Stating sexuality 3,949 Prefer not to say 458


Table B9 - Consultation responses by caring duties for a family or friend because of

health needs

Caring duties Number of responses % of responses answering question

Yes – someone over the age of 16

868 20

Yes a child aged 16 or under 366 8

No 3,204 74

Stating NHS employment 4,475

Not stated n/a



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Appendix C: Petitions and campaigns

The text of each petition/campaign that was received is detailed here.

Petition A: Please find attached a petition signed by over 100 patients who are opposed to the proposed closure of the A & E department at Ealing Hospital. Petition B: As a resident in Hammersmith & Fulham, I am writing to ask for your support in opposing the closure of A&E services at Charing Cross and Hammersmith hospitals and the closure of the hyper-acute stroke unit at Charing Cross. Please help save these vital services by passing on our concerns to NHS North West London. Petition C: I strongly object to your plans that would see the downgrading of hospitals in North West London. I believe if would be wrong for the three neighbouring London boroughs of Ealing, Brent and Hammersmith and Fulham, which together serve a population in excess of 700,000 people to be stripped of all their major hospitals. Not only am I concerned about the time it would take for ambulances to reach patients and to convey them to the nearest major hospital, but I fear the effect on those with long-term chronic conditions who have to travel regularly to hospital for treatment. Furthermore I am unconvinced that the remaining major hospitals in North West London could be reconfigured to cope with the massive additional demand on their services. Far from Shaping a Healthier Future, I believe these proposals will have a detrimental impact on the residents of North West London and I would strongly urge, you tear up the proposals. Petition D: Following the dispatch of a postcard from Hounslow Council over the weekend we have received several people ringing up and wanting to register support for Option A. While we generally ask people to fill in the response form either online or in hard cope several simply want to register their ‘vote’ with the CRU. The details and reference numbers of callers who have done so are listed below.


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Petition E: I strongly support West Middlesex’s status as a major hospital in North West London. I feel it is vital that West Middlesex Hospital is able to continue to provide a full range of acute services including A&E, maternity, paediatric and stroke services for the following reasons:

• Hounslow has had the 5th largest population growth of all local authorities in England and Wales, with a 38% increase in the number of 0-4 year olds and a 53% increase in people over 85 expected in the next two decades (2011 Census).

• West Middlesex Hospital is a very new building and in excellent condition. This is important, as the NHS has a limited amount of money and this should be spent on improving services for patients.

• West Middlesex Hospital has an award winning maternity service – the first in London to achieve Baby Friendly Status. It also has a Charter Mark for excellence in customer care.

• West Middlesex Hospital has excellent specialist stroke services.

• West Middlesex Hospital’s proximity to Heathrow Airport means it would have a significant role in responding to any major incidents.

Petition F: We, the undersigned, are not against change or the need to make best use of taxpayers’ money, but we call upon the Government and the NHS not to proceed with hospital re-organisation in our area until new community services are properly staffed and accommodated. In particular we are deeply concerned about the proposals to downgrade services at Central Middlesex Hospital (CMH) including complete closure of the A&E Department, because:

i) Worsening the quality of services in Harlesden and Stonebridge is in direct conflict with the key objective of the new Brent Clinical Commissioning Group which is to reduce health inequalities in Brent;

ii) £70 million of recent investment in improvements at CMH will be wasted; iii) Patients needing emergency care will have much longer travel times.

Petition G: We support the recommendation of NHS West London’s “Shaping a healthier future” public consultation that Chelsea and Westminster Hospital should be one of five major hospitals, all retaining their A&E departments (Option A in the full details of the proposals at (www.healthiernorthwestlondon.nhs.uk/)


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Petition H: We the undersigned strongly pledge that West Middlesex University Hospital which is our local hospital should be granted the Status of a Major Hospital for the reasons cited below and we are strongly advocating for the OPTION A:

1. Good use of current Buildings: West Middlesex consists of very recent modern buildings with space and is suitable for both current and future requirements.

2. Value for money: this option a would not require capital spending at West Middlesex Hospital and it would leave NW London with a surplus of more that 2%. Cost reduction in running the NW London in running the NW London has been one of the prime objective of the reorganisation of the health care services.

3. Ease of delivery of services: the scale of change needed at West Middlesex Hospital to give Major Hospital Status would be minimal as the services already being delivered corresponds mostly close to a Major Hospital.

4. Support research and education: West Middlesex Hospital has the research facilities and some of the most important research in NW London is currently carried out a WMUH. All diagnostic investigations are also carried out at WMUH.

Petitions I & J Paper petition wording: NHS North West London is reorganising hospital services and is proposing closing four of the nine A&E centres in the area. The ill-thought-out proposals would mean downgrading Hammersmith hospital by closing its A&E department in the area. We, the undersigned, call on the NHS North West London to retain A&E and other clinical services at Hammersmith hospital preserving its status as a major hospital. Online petition wording: NHS North West London is reorganising hospital services and is proposing closing four of the nine A&E centres in the area. The proposals would mean closure of A&E services in the area. The proposals would mean the closure of A&E services at Hammersmith and downgrading it to a ‘local’ hospital. We, the undersigned, call on NHS NWL to retain A&E and other clinical services at Hammersmith Hospital preserving its status as a major hospital.


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Petition K & L: NHS North West London is reorganising hospital services and is proposing closing four of the nine A&E centres in the area. The proposals would mean closure of A&E services at Charing Cross and downgrading it to a ‘local hospital’. We, the undersigned, call on NHS North West London [NHS NWL in online petition] to retain A&E and other clinical services at Charing Cross hospital preserving its status as a major hospital. Petition M: We the undersigned, call upon the Secretary of State for Health to stop the closure of Hospital Services in west London, in particular the A&E Departments of Hammersmith, Charing Cross, Central Middlesex and Ealing Hospitals. Petition N & S: Vote for Chelsea and Westminster as a ‘major hospital’ with a full A&E in the Shaping A Healthier Future consultation – Option A* If we are downgraded to a ‘local hospital without a full A&E most of our services including maternity and children’s services would close Tick this box for Option A We would like to submit your vote for Option A to the full public consultation in addition to this postcard: Yes I consent for you to submit my vote for Option A. No I will complete the consultation response myself Petition O: We attach a petition signed by 58 people mostly living in our relatively small road in Shepherd’s Bush W12. We are extremely worried about the loss of the Accident and Emergency department at Hammersmith Hospital. We believe that this should be retained and indeed strengthened to include a capability to deal with children. Petition P: We at Heath Court are all choosing Option A of the Consultation which will keep the services as they are now, keep the A&E, children’s and maternity services.


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Most of the residents are elderly and use the A&E on a regular basis. It is very important that when we are ill, do not have to go far to receive treatment. Having the facilities in Isleworth saves lives. We are totally against travelling to another part of London to receive treatment. There is no doubt in our minds that people will lose their lives if West Middlesex Hospital closes down. We have contributed towards NHS during our working lives and do not want to be cheated at this time of our lives. It is very important that you take notice of what we are saying to you. Thank you. Petition Q: We oppose NHS proposals to downgrade health services in North West London, including the closure of four of the nine A&E departments in the area. We want Ealing and Central Middlesex hospitals, as well as Charing Cross and Hammersmith hospitals, to retain their status and keep all existing services, including A&E units. Petition R: NHS NW London is consulting on proposals which would mean the accident and emergency department at Central Middlesex Hospital, already closed at night, closing for ever. This could be the first step in the downgrading of the hospital, which serves some of the most deprived wards in Brent with the greatest health needs. We the undersigned demand:

• The reopening of A & E at Central Middlesex Hospital to provide a full 24 hour emergency service with all necessary back up.

• No cuts to community, mental health or other services. The government can find money for the banks, they should restore the £1billion they are cutting from NW London Health Services.

• An end to privatisation which provides an inferior service for patients and cuts in jobs, pay or worse working conditions for staff, creaming off profits for private companies.

Petition S: Please see Petition N Petition T: We, the undersigned, call upon the Secretary of State for Health to stop the closure of Hospital Services in west London, in particular the A&E Departments of Hammersmith and Charing Cross Hospitals


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Petition U: Dear NHS North West London Clinical Commissioning Group

• Protect our Accident and Emergency departments in Hammersmith and Charing Cross Hospitals

• Protect our frontline emergency care services • Keep an A&E department in our borough - don't make us travel up to 53 minutes

longer in an emergency • Charing Cross hospital has one of the best specialist stroke centres in the country -

don't let this vital life-saving unit go to waste by closing it


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Appendix D: West London Citizens form


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