Agenda item

[To consider a proposal to merge Urology Services at The Royal Wolverhampton NHS Trust and Walsall Healthcare NHS Trust – Report attached]. 

The Strategic Advisor to the Board of, The Royal Wolverhampton NHS Trust introduced the report on the proposal to merge Urology Services at, The Royal Wolverhampton NHS Trust and Walsall Healthcare NHS Trust.  He said that the proposal was to improve the Urology Services at both, The Royal Wolverhampton NHS Trust and Walsall Healthcare NHS Trust and for the residents of Wolverhampton and Walsall.  Both Trusts currently faced different challenges in Urology Services.  Walsall had a small department and staffing challenges to run a safe, 24-hour care service.  Wolverhampton had a larger department but struggled with demand and waiting lists.  By combining the service there would be opportunities to make better use of the Consultant and Clinical workforce.  He also believed services would be better and quicker for patients.  He did appreciate the concerns about patient access and patient travel times, which would form part of the discussion later in the meeting. 

 

The Lead Urologist Clinician from, The Royal Wolverhampton NHS Trust stated that the department’s priority was to improve the care of the patients in Wolverhampton.  They were the largest Urologist Department in the whole of the Black Country.  They had good staffing levels with ten consultants and nine specialist nurses.  Walsall only had four consultants and one specialist nurse.  They had developed a number of very specialist cancer services over the last ten years, which had some of the very best outcomes in the entire country.  As the specialist services had grown, more work had been attracted to the department and consequently they had found it difficult to increase the capacity to keep up with the demand generated.  The Covid-19 pandemic had exasperated the problems of waiting lists. 

 

The Lead Urologist Clinician remarked that the proposal was the creation of one Urology Service across both Trusts, which would give one service, with one Clinical Lead and one Management Team running a joint service over two sites.  They would create a team of 15 Consultants with other senior staff and a total of 10 specialist Nurses. The staff would move between the two sites according to their work activity. 

 

The Lead Urologist Clinician commented that for Wolverhampton residents, all emergency admissions, Urological Care requiring inpatient admission would remain at New Cross Hospital.  All children’s surgery would remain at New Cross Hospital.  Other services, such as radiology, CT Scans, MRI Scans, radiotherapy and chemotherapy would remain at New Cross Hospital.  Outpatient clinics and diagnostic procedures would also remain at New Cross Hospital.  The single change affecting Wolverhampton residents was the movement of most of the day case operations from New Cross Hospital to the Walsall Manor Hospital, instead of to Cannock.  They had been using Cannock for day case surgery for sometime and had considered expanding it, but given the situation they now faced, there was an urgent need to reconsider their previous plans. 

 

The Lead Urologist Clinician remarked that there were a number of benefits which would be gained from moving the day case surgery to Walsall, it was not just about a simple location move.  By merging the teams, there would be a bigger more sustainable team, that was more attractive for succession planning and for the recruitment of high quality candidates in the future.  By merging the two teams, it meant each Consultant would spend more time on elective work, rather than emergency work.  They had calculated that this change alone would equate to 400 more operations every year and approximately 1200 more outpatient procedures and appointments at New Cross Hospital.   This would mean reduced waiting times and better patient outcomes.  The waiting time at Walsall was currently much less than at Wolverhampton.  By concentrating the day cases together in Walsall, they would be able to develop a number of changes in the way they performed the surgery, the assessment of patients and the way they discharged them and managed their aftercare.    

 

The Lead Urologist Clinician commented that by joining the services together, the efficiency of the theatres would be increased and there would be more cost effective investment in staff.  It would also by economies of scale, enable them to purchase new technologies such as a laser to treat bladder cancer and new forms of prostate biopsies.  The way patients were treated would therefore change as a consequence of the merger and thus further improve the efficiency of the theatres.  If a greater percentage of patients were treated as a day case, it would mean the use of inpatient beds would be reduced.  This free capacity could then be released for other patients, emergency use or other specialities. 

 

The Lead Urologist Clinician remarked that concerns people may have had about the merger could have been based on historical or anecdotal information.  He sought to reassure the Panel that there was no concern at all that the merger would in any way disadvantage patients from Wolverhampton.  There was no evidence at all that the care offered by the Urology team in Walsall was in anyway different to Wolverhampton’s.  Both Trust’s had recently been visited by an external team known as the “Getting it Right First Time Team.”  The inspection team found no areas of concern about the quality of care Walsall was providing.  They did however recognise that the emergency care was limited because of the smaller team and that this in the longer term was not sustainable.  This was one of the drivers for the merger.  He was aware of a recent CQC (Care Quality Commission) report for Walsall which had suggested that there were areas which needed improvement at the Trust.  He reassured the Panel that those areas listed for improvement were not in Urology. 

 

The Lead Urologist Clinician stated that they had carried out a patient engagement exercise with Walsall patients.  There had been overwhelming support from Walsall patients for the proposed merger, by a factor of nine to one in favour.  There had also been significant compliments in the response to the engagement exercise, about the care that had been given.  

 

The Lead Urologist Clinician commented that Wolverhampton patients traveling to Walsall were likely to have their surgery carried out by Wolverhampton Consultants.  The continuity of care would therefore be maintained as much as possible.  He expected 75% of patients needing day care surgery would be asked to attend Walsall.  The numbers could change in the future.  At the beginning they would be very careful to ensure that the most frail and vulnerable patients from Wolverhampton would remain in Wolverhampton.  Patients considered at higher risk of requiring an overnight stay would remain in Wolverhampton.  For those residents asked to travel the distance from Wolverhampton to Walsall Manor Hospital, it was likely to be further for most people, but not for all.  The distance however to Walsall would be less than going to Cannock, which is what they currently offered.  The average distance from Wolverhampton to Walsall had been calculated as approximately another 3 and a half miles more than the average journey to New Cross Hospital. 

 

The Lead Urologist Clinician commented that for those patients which found travelling difficult, they would continue to provide hospital transport for those patients that were eligible.  For patients which needed financial support there was a Healthcare Transport Scheme, where patients could apply for a transport fund.  He concluded his presentation by describing it as an exciting opportunity and a positive move for the residents of Wolverhampton.  By merging the service a better service would be provided for the patients in Wolverhampton and importantly a very safe and sustainable long term future for the area including Walsall.  He did not see the merger as a compromise in anyway.  The proposal had unanimous support from all of the Urologists.  As the Senior Member of staff, he had no doubts that this was the best solution for the problems both departments currently faced.  Action needed to be taken to reduce the long waiting times. 

 

The Wolverhampton, Head of Commissioning for the Black Country and West Birmingham CCG gave a presentation on the engagement process that had taken place in Wolverhampton.  She confirmed that from a CCG perspective that they supported the merger proposal.  The merger would be particularly beneficial in the recruitment and retention of staff.  It would also address some of the longer waiting times, address the backlog of patients waiting to receive treatment and essentially bring Wolverhampton in line with some of the other Trusts.  The quality and safety of the service would be assured. 

 

The Wolverhampton Head of Commissioning for the Black Country and West Birmingham CCG remarked that the CCG had the legal obligation to ensure any proposed changes to services had the appropriate engagement.  An engagement exercise had therefore taken place on the proposal with Wolverhampton patients.  The engagement period was from Monday, 12 June to Friday, 22 June.  Letters had been sent to a random sample of 1498 patients who in the past 2 years have had or were waiting on elective Urology surgery.  The letter that had been sent included information on the proposal, a frequently asked questions document and the details on how to share views which included an online survey, telephone number for the engagement team, an email address for the engagement team and they actively called a sample of patients and inputted their responses into the survey.  The questions asked were as follows:-

 

Q1. Patient’s postcode – only first 3 characters are collected to analyse responses.

 

Q.2. Interest in Urology proposal as current patient, previous patient, family member or carer.

 

Q.3. Having read the patient letter and frequently asked questions, please give us your comments on the proposals outlined.

 

Q.4. If you would like to be considered to be involved in a patient focus group, please leave your details.

 

Q.5. Do you wish to receive a copy of the report regarding this survey?

 

There had been 123 responses. 100 of these had been through the survey, 22 by phone call and 9 through email.

 

Some responses had been in favour of the proposals.  Whilst other responses had concerns, these were often on travel/transport and quality of care.  There were also a number of neutral responses or responses that were not applicable, for instance comments about outpatient responses, which would be staying at The Royal Wolverhampton NHS Trust. 

 

The Wolverhampton Head of Commissioning for the Black Country and West Birmingham CCG commented that some patients had questions around:-

 

·        Whether their Consultant would stay the same?

·        Will they be transported to New Cross if they have to stay overnight for any reason?

·        Can they book ambulances to get to appointments?

 

In numbers the results of the engagement exercise in Wolverhampton were as follows:-

 

In favour – 36%

         

Neutral – 7%

 

Concerns – 19.5% (travel), 13% (quality), 7.5% (no reason given). Each figure applied to the total response.

 

Not applicable – 11% - Comments that were not directly related to the questions asked.

 

Appointment Chasers – 3.5%

 

Questions – 2.5%

                                     

 

Following the conclusion of the presentation the Chair opened the item up to questions from Panel Members.

 

A Panel Member commented that there was one vacant Consultant position in Urology at the Royal Wolverhampton NHS Trust.  She asked if the merger went ahead was the intention to still fill the post and if not, what would be the impact on service delivery.  The Strategic Advisor to the Board of, The Royal Wolverhampton NHS Trust confirmed that the intention was to fill the post.   The Lead Urologist Clinician added that they would be going out to advertisement in the very near future.

 

A Panel Member asked if inpatient complicated cases from Walsall would now be done in Wolverhampton if the merger was to go ahead.  He also understood why some residents had anxiety over the care they would receive in Walsall due to the CQC rating, even though Urology had not been indicated as an area of concern.  The Lead Urologist Clinician responded that Walsall did not complete the same degree of complex surgery as in Wolverhampton.  They did not do the major cancer surgery or major stone surgery.  For these patients they had been referring elsewhere.  Therefore, the complicated cases would go to Wolverhampton, some already had been.  They expected to significantly improve on the number of patients treated as a day case rather than as an overnight stay.  The Chief Executive of the Royal Wolverhampton NHS Trust on the point concerning the reputation of the Walsall Trust, stated that the CQC rating mainly had concerns about medicine and the emergency services department.  It was important to look at services independently and he had no concerns about Urology.

 

A Panel Member remarked that the merger made sense from an economies of scale point of view and also the ability to deliver better services for patients.  She asked about theatre capacity and the opinions of the nurses working in Urology on the merger proposal.   She also raised the issue of how people managed transport to hospital for those that weren’t eligible or did not know about the service.  The transport issue applied not just to Urology Services but across all hospital services.  She expressed her support for the merger proposal. 

 

The Lead Urologist Clinician responded that theatre capacity had been very carefully modelled.  Changing the way, the service worked would help and increasing the team.  When people were on holiday there would be a bigger resource of consultants to use the theatres more effectively.  There was recruitment of extra nursing staff.  Theatres in hospitals were often not used at weekends or in the evenings, but if there was increased theatre staff and consultants, the theatres could be used at other times.  He wanted to make Wolverhampton a centre of excellence for Urology, like it was for many other areas.  Attracting high quality staff to Wolverhampton and Walsall together would be far easier if the merger was to go ahead.  Smaller units across the country where Consultants were on call 3 weekends in a month were not attractive.  Attracting new candidates in Walsall had been an issue.  In a bigger unit you could employ more specialist nurses and extend their roles. 

 

The Strategic Advisor to the Board of, The Royal Wolverhampton NHS Trust on the question about transport recognised that this was a key issue and centred on the point of equitable access.  Every member of staff would be trained on the matter of hospital transport options, so patients could understand the support available to them and their individual rights.  The Chair asked about scenarios where the Ambulance Service was sometimes used to transfer people back home from hospital.  She asked about the figures for the waiting times of people who had been allocated an ambulance for transport back home.  She had heard of cases before Covid-19 where people were waiting for four or five hours for an Ambulance to return them home.  She wanted to ensure that Wolverhampton residents receiving care at Walsall Manor Hospital would not have to wait such times.  She stressed the importance of people being made aware of the help available to them for transport.  She asked for reassurance on whether hospital transport services had been considered as part of the merger.

 

The Chief Executive of The Royal Wolverhampton NHS Trust responded that a significant amount of care was already taking place at Cannock anyway.  The non-emergency hospital transfer service was therefore no different in terms of what was provided.  There had been some difficulties of late with excessive transport waiting times because the non-emergency transport service had suffered with staff isolating or being pinged by the NHS app due to the Covid-19 pandemic.  This would improve over time.  He did receive fairly regular complaints about the non-emergency hospital transfer service in relation to renal dialysis patients.  The Royal Wolverhampton NHS Trust spent a million pounds a year on taxis.  They did have to cohort patients together and this meant sometimes patients waiting whilst another patient finished their treatment.

 

The Senior Programme Manager for Strategy at The Royal Wolverhampton NHS Trust spoke on the stratification of patients.  They expected about 75% of the Wolverhampton day case patients to go to Walsall Manor Hospital.  This naturally left 25% of patients who wouldn’t.  Those that would stay in Wolverhampton would either be chosen because their surgery was higher risk and could potentially require an overnight stay.  The frail and more elderly would naturally be more likely to fall into this category.

 

A Panel Member raised the issue of the non-emergency transport service.  He had personal experience of a very long waiting time.  This was obviously frustrating when you wanted to be back home after a hospital stay.  He expressed praise for the report on the Urology Service which highlighted all the key points.  He commented that the reality was that the future was for more services to merge across hospital trusts.  Economies of scale was the driving factor for the NHS, resources had to be carefully managed.  The quality of the service would depend on the leadership and management of the service.  Retention of staff was another important factor.  He thought retention of staff would be considerably easier if the merger occurred. 

 

The Chief Executive of The Royal Wolverhampton NHS Trust suggested an item at a future Health Scrutiny Panel on the matter of non-emergency hospital transport across hospital services and not just in Urology.  It was a frustration to his own staff as to how long people were kept waiting for transport.  He added there would be a number of other proposals in the future for other specialities including radiology, cardiology and haematology services.

 

The Chair asked how they would measure the benefits and improvements to the Urology service should the merger go ahead.  The Strategic Advisor to the Board of, The Royal Wolverhampton NHS Trust responded, by being able to recruit and retain staff, seeing the activity go through that they were planning and by making an impact on the long waiting lists.  They routinely monitored any adverse surgical outcomes and the quality of the surgery.  The Lead Urologist Clinician confirmed there were a host of metrics that they routinely measured, these included length of stay, time of discharge, and readmission rate within 30 days of surgery.  There was a robust governance process in place for alerting them to complications in quality.  There was very accurate data relating to the number of patients on a waiting list and the times for referral.  There were regular weekly meetings within the organisation on the PTL (Patient Tracking List).  They could do a further patient survey looking at service users’ opinions of the new way of working.  They would also be happy to report back to the Health Scrutiny Panel in the future with the outcomes of any surveys and pertinent data. 

 

The Chair asked to see the statistics and data at a future meeting relating to the Urology Service.  She thought it was also important to see data before the Covid-19 pandemic.  She asked if there had been any changes to the merger proposals following the engagement exercise carried out.  The Strategic Advisor to the Board of, The Royal Wolverhampton NHS Trust responded that they had taken into account the patient feedback work.  The main alterations to the proposals were to reduce the number of patients that were likely to have to travel to Walsall for day case surgery.  The second one was to emphasise the need for an individual patient consultation discussion with a patient, particularly taking into account if they were elderly or frail.  This would help determine whether they should have treatment in Wolverhampton or Walsall. 

 

The Vice-Chair remarked that only 36% of Wolverhampton residents who responded to the patient engagement exercise were in favour of the proposals.  He appreciated there were some not applicable or neutral comments as well.  He asked about the point in the report regarding reducing inequalities and what this meant in practice, he also asked about local and national targets.  He cited that national guidance suggested in some parts of the country, 85% of Urological Services were performed as a day case. 

 

The Strategic Advisor to the Board of, The Royal Wolverhampton NHS Trust responded on the point regarding equalities that there was a need to do a person centred assessment of every individual.  They had also discovered through the Covid-19 pandemic that there were hidden barriers to accessing services.  As an example, he cited people from minority ethnic groups who were less likely to come forward for services or had less trust in services.  A discussion about access with patients was an improvement they could make as a Urology Service.  He stressed that this was something which could be improved not just in Urology but in other services.   The Senior Programme Manager for Strategy at, The Royal Wolverhampton NHS Trust commented that through the merger proposals they had identified another 400 theatre slots.  These slots would be used to improve the waiting times in all the cohorts.      

 

The Lead Urologist Clinician added that in reference to the national guidance stating that in some areas 85% of cases were treated as a day case, it was hard to determine what was a reasonable expectation for the population of Wolverhampton.  There was huge variation across the country in the length of stay and in the outcomes for every operation.  They looked regularly at data from a system called “Model Hospital.”  Where an individual hospital sat in terms of performance could relate to individual processes within the hospital, the case mix and the type of population around the hospital.  They did compare themselves to peer hospitals.  He did not expect them to reach 85% of cases treated as a day case in the immediate future but there was a programme of work which would change the way services worked. 

 

The Vice-Chair asked if there was a target figure for cases treated as a day case.  He thought having a target figure was a good way of ensuring that the service including access would improve.  The Strategic Advisor to the Board of, The Royal Wolverhampton NHS Trust responded that they were slightly reluctant to set a target.  They did want to encourage more day case working but not to the detriment of quality of care.  Having a target could lead to the danger of Urologists focusing solely on meeting targets rather than on the right care package for the patient.  He did however think that day cases should increase year on year and thought an improvement of, by at least 5% each year would be reasonable.  It was hard to predict the data for waiting lists because there was no way of knowing the absolute number of people who would be joining the current lists.  The Covid-19 pandemic had made it a difficult time for modelling.  1190 more outpatient appointments would be possible and 400 more operations if the merger was to proceed.

 

The Chair remarked that it was important to ensure that Wolverhampton residents did not suffer a decline in quality or access of service.  She would therefore be asking for some performance data at a future meeting of the Panel.  The Chief Executive of The Royal Wolverhampton NHS Trust gave an assurance that he would not let the merger have a negative impact on the service provided to Wolverhampton residents.  He added that the service had just taken delivery of the third robot.  He had an ambition that in the future there would be four Urological Hubs covering all of the West Midlands. 

 

 

Resolved: That the Health Scrutiny Panel accepts the report with the following recommendations :-

 

 

a)    An information pack is sent to Wolverhampton residents who are sent for Urology Treatment at Walsall Manor Hospital, containing information such as where the hospital is located, transport links, parking arrangements and where the department they need to visit is located on the site with an accompanying map.

 

b)    Asks Healthwatch Wolverhampton to assess the impact of any changes to Urology Services on Wolverhampton residents, to make sure that the changes are operating as they should and to see whether any improvements could be made.

 

 

c)     In the future the Panel receives some performance data on the Urology service to ensure that the Urology Service is performing as projected and its expected performance further into the future.

 

d)    The Panel receives a report in six months’ time with an update on the Urology Service and to see the impact of any changes that have been made by that point.

 

e)    A site visit takes place by the Panel to Urology Services at Walsall Manor Hospital at an appropriate time, by invitation of the Chief Executive of the Trust.

 

f)      The Panel wishes to scrutinise The Royal Wolverhampton NHS Trust’s Hospital Transport Service, including transport links to Walsall Manor Hospital, at a meeting in the future.

 

The Chair on behalf of the Panel thanked everyone for their contributions.  The next scheduled meeting was reported as Thursday, 7 October 2021 at 1:30pm in the Council Chamber.  The Chair thanked the Scrutiny Team for their support during the meeting. 

 

The meeting closed at 3:24pm.