Agenda item

Councillor Vaughan welcomed the representatives of Chelsea and Westminster Hospital NHS Foundation Trust.

 

Ms McManus outlined the process, which had commenced in October 2012, with West Middlesex Hospital seeking initial expressions of interest to find a suitable partner to achieve NHS foundation trust status. Following a rigorous process, Chelsea and Westminster Hospital had been selected in April 2013.

 

Ms McManus stated that the decision represented the best option for securing the future of both organisations as major acute hospitals. The two trusts were similar culturally and both were relatively small. Acquisition would create a combined entity serving a population of around 1.1 million. A single organisation would provide greater opportunity to develop clinical services and more security for smaller services. There would be significant financial pressures for both, should they not become one organisation.

 

There was a regulatory process, but formal consultation was not required as there was not a service change: Chelsea & Westminster Trust Board would acquire West Middlesex Hospital. There was considerable discussion with the Council of Governors. The acquisition had been cleared by the Competition and Markets Authority.

 

The process was reviewed by the external regulators, the Trust Development Agency and Monitor, which would issue a risk rating. This would be considered by the Chelsea and Westminster Trust Board, which would make the formal decision to proceed. An application would be made to the Secretary of State for the transaction to take place on 1 September 2015.

 

The business case would remain confidential until the transition had been agreed by all parties. However, it would be available at the hospital for members of the PAC to view.

 

There were difficulties in terms of recruitment and retention. Three members of the Chelsea and Westminster Hospital management team had been seconded to West Middlesex Hospital.

 

Members raised concerns in respect of the lack of financial information, which should have been shared in order to facilitate proper scrutiny. Councillor Carlebach suggested that the merger was a financial transaction because the  West Middlesex PFI had become too expensive to manage.

 

Ms McManus responded that the merger was clinically driven, putting patient safety first. As one organisation, there would be a large enough population to continue to provide services and to ensure long term sustainability. It was not possible to share the financial detail as a confidentiality agreement had been signed.

 

Mr Conlin added that clinical sustainability was the catalyst of the deal. However, there were risks to the trust if the acquisition was not approved. The West Middlesex PFI was one of the smallest in London, some £2 million per annum. This would continue to be a drain until the estate was improved as an asset.  There was a short term plan to make the estate work harder.

 

There were over 100,000 attendances by Hammersmith & Fulham residents at Chelsea and Westminster Hospital annually and there would be no significant change. Those services currently provided would still be available on the Chelsea and Westminster site.

 

Councillor Holder queried patient involvement which had taken place and was planned for the future. Ms McManus responded that statutory requirements for consultation were different from expectations. Consultation had been through existing networks such as the CCGs and the Council of Governors and there had been some communication with patients and their representatives.  In hindsight, it would have been appropriate to provide reassurance that there would be no service change on 1 September.

 

Mr Conlin added that the formal guidance around transition had been followed.  The proposals had been reviewed with colleagues in Hounslow and Richmond, and there had been a number of constituency events. There would be clinical benefits going forward for a number of services. The Council of Governors and patient representatives were testing the assumptions. There would be no significant service changes.

 

In respect of maternity services, comments from patients had indicated the need for a more local model. Local services would be maintained. Systems would be improved with technology and best practice pathways developed and integrated with GP services.

 

Councillor Brown considered that the acquisition would create future risk and that West Middlesex had invited expressions of interest for financial not clinical reasons and queried which other trusts had expressed  an interest.

 

Ms Parker stated that whilst the merger was primarily clinically driven, it was also designed to reduce the pressure on West Middlesex Hospital finances. There had been two expressions of interest: Chelsea and Westminster Hospital and Imperial College Healthcare NHS Trust. The clinical synergies with Chelsea and Westminster were much stronger and would ensure no service losses for either site. The CCG was the lead commissioner representing Hammersmith and Fulham. Chelsea and Westminster had strong clinical and management leadership, and the acquisition would provide increased opportunities and access on the West Middlesex site. In addition, it would be an opportunity to attract funding to invest in one electronic patient system (EPR) across the two sites. 

 

Councillor Brown queried whether the acquisition would have proceeded without the financial incentive. Mr Conlin responded that whilst the EPR would be fully funded, this was not the reason for the acquisition. Financial settlement had been negotiated to support the new organisation to address key risks identified in the due diligence to year five, after which the Trust would stand alone. The risks associated with the PFI were significantly outweighed by other incentives.

 

Councillor Lukey considered that there was a lack of clarity in respect of management and protection of front line services. There was a significant  risk in respect of recruitment and retention. The current service was not sustainable and management change alone would not address the issues.

 

Ms McManus responded that whilst there were potentially management job losses, there would be no cuts for frontline staff involved in direct patient care. Where there were intended changes in clinical services, patient groups would be contacted.

 

Dr Chinn stated that there were clinical sustainability issues because of difficulties in retention of consultant medical staff at West Middlesex Hospital. However, it had been possible to recruit successfully to a number of different clinical specialties because of the proposed merger.

 

In respect of maternity services, together the two hospitals could offer a better model of care. West Middlesex Hospital did not have a good enough team of midwives and obstetricians. There was a need to offer new sub-specialist services. Chelsea and Westminster Hospital was providing a tertiary service for West Middlesex Hospital, but there were some unnecessary transfers. The merged service would replicate good care closer to home.

 

Currently, there was inadequate acute coronary care and it was necessary to refer patients to other providers such as Imperial College Healthcare or the Royal Brompton, where there could be considerable waiting times, or even Wycombe and Ashford hospitals.  The merged service would be able to offer a cost effective service in a more timely manner.

 

Councillor Carlebach queried the rational for developing coronary care, when Hammersmith Hospital already specialised in coronary care. Mr Conlin responded that the intention was to invest in diagnostic services. Complex cases would continue to be transferred to specialist centres.

 

Councillor Carlebach referred to a patient complaint which had been referred to him because it had not been possible to get a satisfactory response from Chelsea and Westminster Hospital. He did not consider that there was any evidence of management capacity and queried whether the proposed merger had been discussed with the Council.

 

Ms McManus responded that incidents were normally investigated quickly. Contact with patients and relatives was maintained and an explanation given. In respect of management capacity, the non-executive directors were part of the transition and together the executive and non-executive directors had significant expertise in health service management and in the private sector.

 

Ms Parker added that management capacity and clinical leadership had been one of the CCG’s key concerns, and it had been made explicit that there had to be sufficient managers on both sites. In respect of communications, the focus had been more towards West Middlesex Hospital, as the impact on Chelsea and Westminster Hospital had been deemed to be negligible. There had been a number of visits to Hounslow and also to Kensington & Chelsea.

 

Councillor Brown queried whether the organisational change had  caused the CQC rating of ‘Requires Improvement’. Ms McManus responded that whilst the CQC report was less than ideal, it was not the result of staff being distracted. Chelsea and Westminster Hospital had put in place an action plan, much  of which had already been implemented. The West Middlesex Hospital report had been similar.

 

Mr Conlin noted the commitment to improve retention rates which would also improve patient experience. The EPR would be a key enabler. The merged hospitals would provide the larger patient base necessary for some of the services which could not be provided on a stand-alone basis.

 

Councillor Carlebach suggested that Chelsea and Westminster Hospital should invest more in the services in which it specialised and roll out across the country. Professor Barton outlined the investment in sexual health services and the importance of the merger with West Middlesex Hospital. The commitment to local access for a larger population would ensure the best services for all those individuals. For Chelsea and Westminster to continue its award winning work, sufficient scale to sub-specialise was required and new models of care, enabled through information technology. It would not be possible to invest in an EPR, without significant funding from the Department of Health.

 

Mr Naylor stated that older people would ask about the difference which the merger would make and how the service would be different. Ms McManus responded that the Trust welcomed the opportunity to engage with people to discuss future models of care.

 

Councillor Vaughan queried whether the business case included the changes under the Shaping a Healthier Future (SaHF) proposals and the patient flows from Ealing and Charing Cross; if the investment due under SaHF for both sites had been factored in; and how the estate could be made to work harder.

 

Mr Conlin responded that to make the estate work harder, there needed to be more patients using the hospital. The Trust had been asked to make the base case compliant with SaHF and the patient flows assumed under SaHF had been included. Both sites would extend their Accident & Emergency departments to meet the increased activity. Ms McManus added that the Trust would look to make back office functions more efficient to protect front line staff.

 

Councillor Vaughan queried the impact on existing services should the merger not go through and whether any of  these services be regarded as unsafe in a year’s time. Mr Conlin responded that the management capacity at West Middlesex Hospital would not exist and the external financial rating would dip quickly in year two, leading to extra scrutiny of all services. Chelsea and Westminster Hospital would post a deficit for the first time in the current year and was entering even more challenging times.

 

Mr Conlin stated that should the merger not go ahead, the Trust would move quickly to discussions with other partners to put in place other solutions, and potentially plans B and C.

 

Councillor Vaughan queried why Chelsea and Westminster Hospital had not looked at other partners to develop services, rather than taking on the issues at West Middlesex Hospital, and specifically the recruitment difficulties. Ms McManus responded that a year had been spent looking at other opportunities. The recruitment difficulties were just in respect of consultant medical staff. There was a better trend in recruitment and retention of nursing and midwifery staff.

 

Chelsea and Westminster was one of the highest performing trusts, and West Middlesex represented an opportunity to work with a larger population and to sub-specialise. Both trusts had extremely similar values and behaviours, kind to patients and relatives and inviting feedback. The ability to recruit would be easier as one organisation.

 

Dr Chinn emphasised the high level of staff engagement and that staff put patients first.

 

Councillor Brown stated that assurance had not been provided around the financial case and suggested that smaller multiple changes would have lower risk. Ms McManus responded that this had been tested in the longer term financial model and repeated the invitation for members to go through this with the Chief Financial Officer at Chelsea and Westminster Hospital.

 

Councillor Carlebach considered that the PAC had been excluded from the process and that it had not been possible to adequately cover the merger in two meetings. 

 

 

RESOLVED THAT:

 

1.    The PAC did not support the merger. The main concerns were in respect of the financial case, which had not been adequately explained and had been based on patient flows as predicted in the Shaping a Healthier Future proposals.

 

2.    There had been inadequate consultation.

 

3.    There was concern in respect of the adequacy of the proposed management structure.

 

4.    There was not an alternative plan.

 

5.    There were workforce issues at both sites and there was reliance on the successful implementation of a new EPR system.

 

6.    The patient commitment at both sites was noted.

 

7.    An update report should be added to the work programme.

 

Councillor Vaughan thanked the representative of Chelsea and Westminster Hospital for their attendance.