Agenda item

This report sets out the proposal to change the way physiotherapy services are provided at Charing Cross Hospital and asks for feedback before reaching a decision.

Councillor Richardson welcomed Toby Hyde and colleagues from Imperial.  Imperial employ 140 qualified and unqualified physiotherapists, across the Trusts five sites. An inpatient and outpatient service is provided, ranging from acute care, to rehabilitation, hand therapy, musculoskeletal, for all age groups.  The hydrotherapy pool was part of the outpatient’s service and had approximately 22 staff members (an exact figure would include part-time staff).

It was explained that the referral process worked in two ways.  Within the hospital, a patient could be referred by their consultant.  Outside the trust, a patient can be referred by their GP.  If a patient’s condition was urgent it could be red flagged, for example rheumatoid arthritis or a musculoskeletal condition.  Such referrals would be to a consultant, with a recommendation to the outpatient service.  The service could only accept patients through the referral process, and not a direct referral from a GP. 

All patients received an initial assessment at their first appointment.  Following assessment, a treatment plan was agreed.  There were several types of treatment.  “Land based” exercises included fitness classes, exercise using weights and work with physiotherapists.  The hydrotherapy service was based at Charing Cross with 3 part-time staff members.  There were three half-day sessions per week, which equated to one full-time staff member*.

The hydrotherapy service predominantly treated post-operative patients who usually experienced chronic pain from conditions such as fibromyalgia.  The Trust indicated that there were benefits to patients in terms of pain relief, improved range of movement, improved muscle tone and improved quality of life. However, while this was difficult to evidence as the true benefit of the of the therapy could not be ascertained; it was found that there was no discernible difference in benefit between the two different types of provision. 

The Trust proposed that the staff members that currently work in pool be redeployed.  They could be assigned an increased number of patients, and there could be a corresponding increase in the number of classes.  This would also allow for a smoother transition in terms of post-operative care and greater consistency in treatment. 

The intermittent closure of the pool resulted in an increased rate of cancelled appointments because of issues with the pool.  The rate of cancelled appointments had increased from 7% to 18%.  This had an impact on patient care, so that it could take longer to reach improvement targets, given the inevitable gaps between appointments, which became more staggered as a consequence.

The Trust reported that it had gone through assurance and governance protocols.  The consultation had been agreed, a quality improvement programme assessment had also been undertaken.  The Trust had written to the Chair of the PAC in March, to inform of her of the intention to engage with stakeholders.  The Trust had publicised the consultation using social media and leaflets and planned to hold patient focus group meetings.  The Trust had also written to private pool users and planned to meet with them over the coming weeks.

Councillor Coleman reported that the trusts CEO Prof. Tim Orchard had confirmed that that the consultation could be extended and that a final decision could be reached in June.

Councillor Amanda Lloyd-Harris observed that there were clearly some benefits to hydrotherapy and asked if this had changed and the evidence for this. This would suggest that there were insufficient metrics to clearly indicate the benefits.  In which case, was the proposed change attributed to maintenance issues and cost-cutting.

Elaine Sheerin explained that there was evidence to indicated that hydrotherapy was beneficial but of poor quality, so that the results were limited.  For the benefits to be properly evaluated, highly controlled, robust and rigorous trials were required.  Globally, there were hydrotherapy services in the departments of some trusts, but not available in all, which may reflect the lack of robust evidence.  Toby Hyde confirmed that the closure of the service would save little money, as there was no proposed change to the number of staff as they would be redeployed. It would cost approximately £400,000 to renovate the facility to the required standard (exact figures to be provided).

Lisa Redfern felt that the content of the papers was unclear in terms of what outcomes were being sought from the consultation. She enquired about what was the Trust seeking to achieve and what the focus of the consultation was. On the one hand, the Trust was trying to close the pool, and had commented on how ineffective it was.  She asked if the Trust was trying to improve the service, and if so, this needed be more clearly articulated.  The figure of approximate £400,000 for renovation required further context.  The Trust had not commented about making savings, but it was suggested that residents will naturally reach this conclusion.  If the Trust was not planning to make savings, then this needed to be more clearly articulated in the report, given the complexity of the issues being presented.  If the Trust was saying that hydrotherapy had no benefits, then it was felt that this point should have been highlighted much earlier.  This was not a new service.  This issue was about service improvement, savings and estates. 

Commenting further, Lisa Redfern expressed concern about the terminology used to describe physiotherapy such as “land-based”, which she felt was inappropriate and dated terminology.  It was also unclear how many people were aware of the facility, the evidence of usage and context.  The report required clearer language as it was unclear what was being communicated.

Toby Hyde welcomed the feedback and explained that the terms used were intended to make the service distinguishable from hydrotherapy. He stated that the key issue was a question of the estate. The Trust had some fantastic physiotherapists and wanted to make the most efficient use of this resource.  The issue was also about how many staff were needed in the pool, and, partly about redeploying them to other physiotherapy services.  This would allow the pool facility space to be repurposed. 

A local GP commented that there was confusion about the proposed closure and the evidence base, although he recognised that it was difficult to evidence benefits.  Hydrotherapy did help with giving better pain relief, with shorter hospital stays, being able walking further, walking up staircases, were positive outcomes.  He asked about the percentage of patients that made it to hydrotherapy.  He reported that he had never had a patient offered this service since 2009.  He said that he would be interested in hearing about the numbers who had received hydrotherapy, the conditions treated and who these patients were. Elaine Sheerin explained that shed did not dispute that there was evidence, just that it was not superior to “land-based” physiotherapy.   The issue was linked to the building estates. Pool was not fit for purpose, and the Trust did not want to enforce closure.  The pool was currently closed for a month due to issue with a pump.  The question of closing the pool was weighted against other priorities in the estate.  Post-operative patients with hip replacements used the hydrotherapy pool and hydrotherapy was not offered to all patients.  The service received approximately 6000 referrals, with 20-30% of patients being treated, amounting to 320 patients in the past year.

Lisa Redfern sought more detail about patient numbers and observed that the figure had declined from the previous financial year.  It was explained that there had been staff changes and repeated pool closures and that staff did not have confidence in the condition of the estate. LR felt the figures given were misleading and that there was demand for the service.  The presentation of the report does not clearly explain what the service offers.

The local GP commented that Trust appeared to be winding down service. He reported that he had a list of ten patients who would benefit immediately from the service. Toby Hyde confirmed that the Trust had no intention to wind down the service.  The current issue was to do with concerns about the estate and the unplanned, cancelled appointments that resulted. Fewer referrals were made for this reason, offered with the caveat that the appointment may be cancelled without notice.

Jim Grealy commented that the Trust had indicated that they did not want to lose estate space and asked what the plans were for the space, if the pool was to be closed. Toby Hyde explained that the pool, located on the ground floor, was prime real estate.  This offered a whole range of potential options, which would be reviewed and considered.  It was unlikely to be repurposed as a ward but could be used to provide an outpatient clinic. The Trust will need to consider all the options, and individual departments would need to bid for the space, which will be determined by the Trusts Board.  Jim Grealy responded that this would not be a cost neutral exercise, money would divert to setting up a new department or clinic.  It was explained that the pool cost £100,000 to maintain, and that it would cost an estimated £90,000 to refurbish.

Keith Mallinson outlined the case of a client who was referred for hydrotherapy, and who was informed that the consultant could not refer him as the pool was closed.  He was advised that he should attend Northwick Park.  This will be difficult, given the distance he will need to travel.  He asked what alternative, local provision might be available and referred to the views in European countries such as Hungary and Czechoslovakia, as to the positive benefits of hydrotherapy.  Elaine Sheerin responded that the Trust had initiated discussions with a local sports club to use their facilities.  The water temperature however, was slightly cooler.  They also hoped to make referrals to Chelsea and Westminster Hospital NHS Trust and were also trying to engage with Jack Tizard primary school.  It was also confirmed that they could only accept referrals from within the Trust and not externally.

Keith Mallinson clarified that his client was an outpatient at Charing Cross, and reminded the Trust that the local GP had indicated that he was not aware of what was available due to the lack of information about the service. Northwick Park was clearly a very difficult option for those in pain. It was accepted that there might be patients who will want to continue to use the pool and this was being explored. The Trust also hoped to find a warmer pool for the mother and toddler private pool session. 

Councillor Coleman commented that residents will be losing a valuable resource despite the alternatives that the Trust was exploring.  Given the benefits of hydrotherapy, he asked if there was a strategy to map out alternative provision. Elaine Sheerin responded that the redeployment of staff would allow the creation of more appointment slots for patients and reduce waiting times from 8 to 6 weeks. In terms of follow ups, certain new patients may have to wait 3 weeks.  It was hoped that this would be reduced to two weeks, with an increased number of general classes introduced, again to reduce waiting times. 

Victoria Brignell reported that she had received hydrotherapy for five years, which had been a huge benefit. Paid users would indicate that there was some value to the facility.  Guys and St Thomas NHS Foundation Trust maintained a facility, and she queried why the Trust was unable to do the same, and that this essentially came down to a matter of costs. Toby Hyde said that the fundamental issue was around the condition of the estate, which was in a poor state of repair.  Guys and St Thomas had better maintained estates and facilities.  He confirmed that to have the pool open and reliable, would cost approximately £400,000 and would also intensely utilise physio staff.  It was reasonable that the staff be redeployed.

Bryan Naylor commented on the beneficial aspects of hydrotherapy, about which there was a wealth of information.  Hydrotherapy was invaluable for a particular cohort.  For some older, disabled patients, water therapy offered a short period of being pain free.  The therapy helped slow down the onset of the issues that older people were likely to experience.  This made life bearable for older and disabled people with long term conditions. He asked the Trust to explain the work undertaken to ensure that this particular group was not adversely affected, compared to the rest of the community.   Elaine Sheerin confirmed that the Trust did not specifically look at the elderly, as a group.  They had considered patients that were at Charing Cross, those with e.g., fibromyalgia etc.  It was recognised that for certain patient groups, hydrotherapy was very beneficial, and that this was not disputed. There was some reported benefit, but the key outcome was improved quality of life measurement, rather than an analysis of patient benefit. In considering this, there was no obvious advantage.

Councillor Caleb-Landy also indicated confusion as to the proposed service changes.  There was no strategic context provided to understand where the service was going and no indication as to what the benefit to patients might be.  The facility had been neglected in recent years and the estate management needed to be looked at. The report should have considered the benefit and the context, and Councillor Caleb-Landy struggled to see the proposals as anything other than another attempt to cut services.  Toby Hyde welcomed the feedback and accepted that the Trust needed to understand how to better frame the proposals. The intention had been to improve the utilisation of existing staff and make more effective use of the staff resources.

A member of the public who had used the hydrotherapy services explained that it was very difficult to access but was of great benefit to her in terms of alleviating her condition.  There were in her view, not enough hydrotherapy pools accessible in London.  There were however, many places to access physiotherapy and so the proposal would further restrict access. Elaine Sheering clarified that Guys and St Thomas offered hydrotherapy and were able to justify retaining the service, and Councillor Caleb-Landy echoed earlier points, questioning why Imperial were unable to make the same commitment when there was clearly a case for keeping the pool.  He suggested that the service could be self-funding and that Imperial should further explore commercial options in order to make the service sustainable and viable from a cost perspective.  Elaine Sheering responded that the Trust had tried for five years to make the service self-funding, hiring out the pool privately, publicising paid sessions and so on.  However, due to repeated closures and cancellations, the service struggled to generate income and self-supporting

A member of the public countered that if the facility was refurbished, it would require lower maintenance costs. There was a long waiting list for private sessions.  A cost benefit analysis would demonstrate the value of continuing the service and help develop options for an outline business case. Councillor Richardson commented that there was a need for greater detail and clarity around the figures in order to properly respond to the consultation.

Olivia Clymer (Healthwatch) expressed concern about the capacity of the service and the patient journey.  Healthwatch had received a number of calls about the possible pool closure and about not being able to access the pool.  She sought clarity about whether the key issue was capacity or commissioning related. Toby Hyde responded that all therapies were commissioned by CCG on a block basis and was not paid for on a case by case basis.  Altering this would have implications about how the Trust could use the facility in future.

Jim Grealy invited the Trust to maintain an open mind about the financial and business case options being suggested. The pool required money to bring up to standard.  There was a valuable benefit in having the service, but no connection was made with what this meant for a service user.   Why would someone in pain, be sent such a distance, unless it would benefit them.  There was nothing specific or evidence based in the report that would make sense.  The report needed to explain that people were being sent a long way to use alternative pools.  Otherwise there was a failure to present a strong enough case.  The lack of clarity arose from the fact that two different cases were being presented, one was financial and the other focusing on the medical benefit, and these did not match. Toby Hyde responded that there was a finite cost to supporting the hydrotherapy service and that needed to be balanced against the cost of intervention, and against value for money. The Trust would not propose this without thinking through evidence base and would think that the physiotherapy would benefit from the changes being proposed.

Cllr Amanda Lloyd-Harris commented that the evidence was subjective.  The NHS was now prepared to accept Cognitive Behaviour Therapy as a valid therapy of choice, and this was deemed to be evidenced in terms of success rates. She therefore queried why this was acceptable for one part of the NHS but not the other and asked if this was an issue of take up and referral. Elaine Sheering confirmed that there was a link between the evidence base and finance.  Toby Hyde added that there may be an additional demand for hydrotherapy but that the key issue was whether this was the best use of finite physiotherapy resources.  The waiting list had increased, and pool closures were largely attributed to issues with the pump and microbe levels in the water, so the pool could not be used safely.

Councillor Coleman sought clarity on the figures provided.  It was noted that £100,000 cost of maintenance would be redirected into physiotherapy services and the staff redeployed.  Currently, there were 22 members of staff (it was later clarified that a portion of the 22 staff had additional, specialised roles, which equated to 15 full time equivalents). The Trust touched on staffing issues, waiting times.  The paper had provided a starting point however, Councillor Coleman felt that for purposes of the discussion this did not go far enough.  The quality of the paper lacked depth and did not provide sufficient evidence.  The Trust had tried to shut the pool in 2013 and it was subsequently reopened in 2014 and he expressed the view that the Trust had run the service down.   Councillor Coleman recommended that the Trust rewrote the paper and that the consultation be withdrawn.  It was suggested that the Trust returned to the committee with a revised paper which would address the absence of information about physiotherapy. If this was a commissioning issue or a matter of finance, then the Trust needed to make this argument more clearly.  Councillor Coleman sought confirmation that the Trust would return to the Committee with more detailed proposals that aimed to explain the cuts in hydrotherapy services. Toby Hyde welcomed Councillor Colemans comments and feedback.  He indicated that they would consider the report and presentation and would be considering next steps.

Councillor Coleman commented that the proposed service change constituted a substantial variation and therefore required the NHS to consult the Council on whether this was the case, before any formal consultation, in accordance with NHS guidance. He requested reassurance that the Trust will return to the Council to form a view on any proposed changes in future, as to whether a service change constitutes a substantial variation.  Professor Julian Redhead responded that he held a strong belief that the way forward was to continue to engage in joint dialogue and that he would feed this back to the Board.

Councillor Richardson felt that there was insufficient evidence provided to reach an informed conclusion.  More detailed evidence was needed to help determine whether the cut in service constituted a substantial variation.  It was noted that Councillor Richardson would write to the Trust on behalf of the Committee and anticipated that Trust would for further discussion about this issue.

Councillor Richardson thanked residents for supporting Charing Cross and that the Committee and residents must ensure that they continued to fight for

services.

RESOLVED

1.      That the Chair of the Committee write to the Trust setting out the Committee’s response to the consultation; and

2.      That the report be noted.