Decision-Making Business Case Joint Committee 29th January 2019

Joint Committee of the two CCGs Shropshire and Telford & Wrekin CCGs have delegated decision-making authority to a Joint Committee of the two CCGs The Joint Committee has 15 members, all voting: Independent chair Two independent clinicians Six members from each CCG: Three clinicians Two lay members One executive Powys THB are represented as a non voting member The SROs for the Programme and the Programme Director are also present as non-voting members; two scribes are also present The purpose of the meeting is to receive the Future Fit Decision Making Business Case (DMBC) and consider and vote on the seven recommendations Joint Committee of the two CCGs

There will be a balance to be found, but one which can never satisfy every individual interest: The ‘common good’ as opposed to the priorities of individuals or local neighbourhoods The future as opposed to the present; Public interest as opposed to organisational interest One priority versus another when resources are limited It’s the role of senior leaders to reach decisions and to do so transparently and objectively. The Programme is a collective endeavour. All who are party to it, sponsors and stakeholders, recognise that this is the only way that the scale of the challenge and opportunity for this whole geography can be met. Working collectively, whilst still acting as separate statutory organisations, requires agreement on what we have called a ‘Moral Compass’ – ways of working designed to help navigate through when it gets difficult and when the ‘trade-offs’ have to be decided jointly. Our Moral Compass

Joint Committee Code of Conduct Duty – You have a duty to act in accordance with the law and the public trust placed in you. If you are a member of a public body, you have a duty to act in the interests of the public body of which you are a member Selflessness – You have a duty to take decisions solely in terms of public interest. Integrity – You must not place yourself under any financial, or other, obligation to any individual or organisation Accountability and Stewardship - You are accountable for your decisions and actions to the public. You have a duty to consider issues on their merits, taking account of the views of others Openness - You have a duty to be as open as possible about your decisions and actions, giving reasons for your decisions Honesty - You have a duty to act honestly. You must declare any private interests relating to your public duties and take steps to resolve any conflicts arising in a way that protects the public interest. Respect - You must respect fellow members of your working groups, treating them with courtesy at all times. Joint Committee Code of Conduct

Process to Date: Key Milestones DRAFT v0.7

Overview of Process & Assurance to date 2013 Development of clinical Model 2014 Long list of options and Feasibility Study 2015 shortlist -single site options excluded based on cost 2016 Options evaluation and IIA Dec 2016 Joint Committee-no decision 2017 W&C IIA 2017 KPMG review of options appraisal process Aug 2017 Joint Committee- preferred option Nov 2017 PCBC and NHSE Assurance Process – mitigation plans May 2018 Public Consultation and EIA commissioned May 2018 Northumbria Comparator Report Nov 2018 Conscientious consideration of findings including CCG, Shropcom, SaTH Boards, NHSE, Joint HOSC and Powys CHC Dec 2018 Draft Decision Making Business Case NHSE Assurance Checkpoint Overview of Process & Assurance to date

Decision-Making Business Case (DMBC) DRAFT v0.7

Supports CCGs and the Joint Committee in their final decision making Updates the information and progress since the PCBC Focus on CCG areas of concern and NHSE assurance Demonstrates conscientious consideration of the consultation feedback Sets out local criteria and the national tests for consideration of the feedback Provides assurance to Governing Bodies and NHSE that issues raised have been sufficiently addressed at this stage Makes a series of recommendations for consideration by the Joint Committee of the two CCGs Purpose of DMBC

Actions since the PCBC approval Comprehensive consultation with the public, including feedback from seldom heard groups, scrutiny bodies – joint HOSC and Powys CHC and key stakeholders Modelling impact on ambulance services Engaging with Specialist Commissioning Mitigating travel and transport impacts Mitigating trauma journey times Refreshed Equality Impact Assessments and mitigation plan Testing workforce models and new roles Developing out of hospital care strategies Considering UCC model and paediatric cover Considering accommodation requirements Testing any repatriation assumptions Testing affordability post consultation Actions since the PCBC approval

Consultation Process DRAFT v0.7

Reminder of key benefits Safer, high quality and sustainable services Very best care. Right place, right time Better facilities and environment Two vibrant hospitals Planned care separation from emergencies with fewer cancellations Reduced waiting times Attracting the very best staff to work at our hospitals Right level of highly skilled nurses and doctors Reminder of key benefits

The options we asked for views on We consulted on two options: Option 1: The Royal Shrewsbury Hospital becomes an Emergency Care site and the Princess Royal Hospital becomes a Planned Care site This is the CCGs’ preferred option Option 2: The Princess Royal Hospital becomes an Emergency Care site and the Royal Shrewsbury Hospital becomes a Planned Care site Under either option, patients would be able to access a 24-hour urgent care centre, midwife-led services, outpatients and tests at both hospitals The options we asked for views on

Having the Emergency Care site at RSH (Option 1) was the CCGs’ preferred option. Fewer people would have to travel further for emergency care It better meets the needs of our older population It offers the best value for money over the long term The preferred option

Consultation in numbers

Consultation Seen as a significant success and exemplar 3.2% of the population fed back 18,742 survey responses 203 letters/emails from the public and stakeholders Collation of all feedback from public events, Local Joint Committees and council meetings Joint HOSC: “A good example of a consultation” Powys Community Health Council consultation was “comprehensive” Consultation Assurance – appendix 19 of Decision Making Business Case Consultation

Key Findings DRAFT v0.7

Primary aim of consultation is not to undertake a referendum No surprises – a number of common themes High response rates from T&W and Powys (circa 5%) compared with Shropshire in support of one or other option More split response from Shropshire: Balance of concerns about emergency and planned care Some Shropshire residents look to PRH for their care The particular focus on emergency care and W&C services The lack of complete understanding of the differences between emergency care and urgent care Stakeholders responses raising similar issues to the public Rural responses Reflections

Summary of stakeholder responses Supportive of Option 1 Supportive of Option 2 No preference stated Powys Teaching Health Board Telford & Wrekin Council Shropshire Council Welsh Ambulance Service NHS Trust Healthwatch Telford & Wrekin Healthwatch Shropshire Midlands Partnership FT Robert Jones Agnes Hunt NHS Trust Royal Wolverhampton NHS Trust Wye Valley NHS Trust West Midlands Ambulance NHS Foundation Trust Summary of stakeholder responses

Survey response themes Extended travel times and safety Keeping what we have Travel and Transport Trauma influence on decision Community care Finance and affordability Ambulance pressures W&C move Pressure on workforce Population need Understanding the clinical model Alternative models Survey response themes

Scrutiny Three organisations have the statutory role to scrutinise NHS services delivered for the people of Shropshire, Telford & Wrekin and Powys: 1. Shropshire Council 2. Telford & Wrekin Council Together through the Joint Health Overview and Scrutiny Committee (HOSC) 3. Powys Community Health Council (CHC) Joint HOSC and Powys CHC have been involved and consulted throughout the process: pre, during and post-consultation The scrutiny bodies representing the three areas chose to provide feedback after considering the consultation findings Joint HOSC members disagreed with each other on several points and it was unable to make any joint recommendations Powys CHC unanimously voted in favour of supporting Option 1, with votes taken across four areas of legislation / guidance

Joint HOSC of Shropshire and Telford & Wrekin Councils: Six points raised with both HOSCs in agreement Six points raised but with the HOSCs in disagreement No formal recommendations received due to disagreement Further feedback received from the Joint HOSC Telford and Wrekin members only.

Agreement by both HOSCs Concerns around centralising time-critical services and poorer outcomes for some people due to increased travel times delays in ambulance response times in rural areas have resulted in poorer outcomes for rural residents travel and transport including travel times to a single accident and emergency unit and planned care Reducing demands of travel for patients eg tele health consultations, online booking of out-patient appointments and reducing need for follow up clinics. Need for support by properly integrated community-based care Welcomed the Implementation Oversight Group (IOG) to track mitigations put into place post decision-making

Conscientious Consideration Approach DRAFT v0.7

Joint CCG Board and Programme Board received consultation findings and themes Confirmed by consensus that consultation findings presented no new viable alternative models and no new themes or key issues that might influence preferred option Programme Board focus on themes and developing mitigations Draft Recommendations emerged; subject to 5 key mitigations set out in the DMBC CCG Boards considered draft DMBC and mitigation in December NHSE Assurance Checkpoint review of all issues raised previously at PCBC stage JHOSC and CHC response post receipt of consultation findings CCG Boards further consideration of draft DMBC in January Programme board January – final amendments to DMBC and Mitigation Plans NHSE final assurance meeting prior to Joint Committee The approach

Five Key Mitigations DRAFT v0.7

Travel and Transport Report and mitigation action plan Equalities Impact Assessment recommendations and mitigation plan - to be aligned with the previous recommendations from 2016 & 2017 IIAs, with particular focus on Women and Children’s impact Progress on Out of Hospital Care Strategies for Shropshire and Telford & Wrekin CCGs to be described and to focus on co-dependencies in assuring the delivery of the acute model assumptions A clear description of the services on each site, particularly around service provision at the Urgent Care Centres Clarifying affordability, including the patient flow assumptions since the PCBC was approved. Further refinement will be included within the OBC (expected for approval in July 2019) These will continued to be developed in the OBC and FBC 5 key mitigations

Recommendations Formation & Decision Making DRAFT v0.7

Profiling of respondents Evidence against local criteria for service reconfiguration   Local Criteria Pre-consultation evidence considered Post consultation evidence considered Access Non financial appraisal September 2016: access impact for emergency, planned and Women & Children (car and public transport) Integrated Impact Assessment 2016 Integrated W&C Impact Assessment 2017 IIA Steering Group IIA Mitigation Priorities Plan Equalities Impact Assessment 2018 Mitigation Plan Response to Consultation Findings Travel and Transport Report Travel and Transport Mitigation plan Quality:   Time critical Journeys Safety Effectiveness Patient Experience Non financial Appraisal data pack Compliance with Best practice guidance set out in PCBC WM Clinical Senate Stage 2 and review of progress against recommendations Professor Sir Keith Porter support for TU at RSH Trauma Network letter support for Option 1 Specialised commissioning letter of support Ambulance service conveyance times Task and Finish Group UCCs Pre consultation engagement report UCC Draft specification SSP Review of alignment with best practice updated in DMBC Draft Transfer Policy PICU Time critical Transfer Policy Response to Consultation Findings ORH Ambulance modelling data Ambulance services and trauma network meetings Response from other providers Outcome of Programme Board Event Nov 2018 Engagement with seldom heard groups Future Fit FAQs Profiling of respondents

Profiling of respondents Evidence against local criteria for service reconfiguration   Local Criteria Pre-consultation evidence considered Post consultation evidence considered Profiling of respondents Workforce Non financial appraisal pack Future Fit Workforce work stream PCBC workforce plans SSP Staff engagement programme STP Workforce work stream Updates on recruitment progress to Programme Board Work of the LWAB Deliverability Letters of support SaTH, Letter of support Powys THBP Letter of support WMAS Draft OBC Report on Neighbourhoods T&W Report for Shropshire Care Closer to Home PTHB Annual Plan Summary Provider responses to consultation Deliverability statement SaTH Financial Affordability Financial appraisal of options Financial Feasibility Study 2014 PCBC Financial and economic case NHSE stage 2 assurance process 2017 Review of financial plans within PCBC by STP Finance Group ORH ambulance modelling data Refresh of admission avoidance data Northumbria Comparator 2018 NHSE Assurance Process Dec 2018

Profiling of respondents Evidence against national tests for service reconfiguration National Criteria Pre-consultation evidence considered Post consultation evidence considered Strong public and patient involvement Call to Action 2013 Option Appraisal Report 2016 Patient representation Programme Board and work streams Pre consultation Engagement Report Consultation Plan Consultation Methodology Engagement with CHC and JHOSC Seldom Heard Groups Engagement and EIA Report Participate Consultation Report: Stakeholder response Report Individual Response report Patient Representation during conscientious consideration events with CCG Board and Programme Board Consistency with current and prospective need for patient choice Clinical Model set out in consultation: many services remaining on both sites; some services already exist on one site Out of county flows for specialist care will remain same as now 80% will continue to go to where they go now for urgent and Emergency care Strategies around care closer to home Development of clinical model for maternity community hubs Ambulance modelling assurance around capacity UCC both sites 24/7   Profiling of respondents

Profiling of respondents Evidence against national tests for service reconfiguration Profiling of respondents Clear clinical evidence base Clinical consensus for the model Alignment with best practice guidance WM Clinical Senate Stage 2 Review Trauma Network View NHS Transformation Unit Review   Programme Board event Nov 2018 SSP Review of alignment with best practice guidance UCC Draft specification Urgent Treatment Centres Guidance 2017 Ongoing engagement with SSP, ambulance services and trauma network Engagement with specialised commissioning Support from clinical commissioners SOC and PCBC Approval by CCGs Unanimous support for consulting on preferred option 1 and option 2 Caveats set out for further work EIA and mitigation plan SSP QIAs Travel and Transport Plan Paediatrics cover in UCC ORH Ambulance Modelling Bed/capacity requirements Growth of 2.8% included Overall bed spaces increases from 877 to 991 ( PCBC) Assumptions around circa 5,000 avoided admissions over 5 years Refresh of Neighbourhoods strategies and Care closer to home Admission avoidance assumptions retested in DMBC NHSE Assurance process

Recommendations DRAFT v0.7

Recommendation 1: Consultation Process The CCG Joint Committee is asked to confirm that the Committee and its constituent Clinical Commissioning Groups have met their statutory duties and ensured that an effective and robust public consultation process has been undertaken and will be used to inform the decisions made. Recommendation 2: On-going Engagement The CCG Joint Committee is asked to support the need for the Clinical Commissioning groups to continue to engage with and feedback to stakeholders the outcome of the consultation and the decision-making process, including those from seldom heard groups.

Recommendation 3: Principles of Consultation The CCG Joint Committee is asked to reaffirm the model underpinning the future provision of hospital services for Shropshire, Telford & Wrekin and mid Wales upon which the consultation process was based. Our patients receive safer, high quality and sustainable hospital services by creating: a separate emergency care site where specialist doctors treat the most serious cases a single planned care site where patients would not have to wait as long and beds are protected for their operations urgent care centres based at both hospitals providing care 24 hours a day, every day for illness and injuries that are not life threatening but require urgent attention a model where both sites provide most women and children’s services a model where both sites continue to provide the vast majority of outpatient services and diagnostic tests

Recommendation 4: Consultation Findings The CCG Joint Committee is asked to note that the Programme Board has confirmed by consensus that the consultation findings have presented no new viable alternative models or no new themes or key issues that might influence the preferred option.

Recommendation 5: Preferred Option The CCG Joint Committee is asked to confirm the previous unanimous decision on the preferred option, Option 1, in accordance with: the recommendation from the Programme Board; and the following mitigations within the final DMBC: Travel and Transport Report and mitigation action plan Equalities Impact Assessment recommendations and mitigation plan - to be aligned with the previous recommendations from 2016 & 2017 IIAs, with particular focus on Women and Children’s impact Progress on Out of Hospital Care Strategies for Shropshire and Telford & Wrekin CCGs to be described and to focus on co-dependencies in assuring the delivery of the acute model assumptions A clear description of the services on each site, particularly around service provision at the Urgent Care Centres Reconfirming affordability, including the patient flow assumptions since the PCBC was approved. Further refinement will be included within the OBC (expected for approval in July 2019)

Recommendation 6: Receive and approve the DMBC The Joint Committee of the CCGs is therefore asked to receive and approve the contents of the DMBC, including its key appendices. Recommendation 7: Governance The CCG Joint Committee is asked to note and approve the proposal for an Oversight Implementation Group (IOG) to be established under the STP Governance structure to take forward oversight of the development of the OBC and FBC. All Sponsor organisations will be represented on this group.