Health Scrutiny Panel Minutes

Health Scrutiny Panel Minutes

Tuesday 26 September 2017
10:00 a.m.
Mandela Room, Town Hall, Middlesbrough

Attendance Details

Councillor E Dryden (Chair), Councillor C Hobson, Councillor L McGloin, Councillor M Saunders
C Breheny, L Cook and E Kunonga
Apologies for absence:
Councillor S Biswas, Councillor R Brady, Councillor A Hellaoui, Councillor J McGee, Councillor M Walters
Declarations of interest:

None declared.

Item Number Item/Resolution

The minutes of the Health Scrutiny Panel meeting held on 25 July 2017 were approved as a correct record.


The Democratic Services Officer advised the panel that a number of senior NHS representatives were in attendance at today’s meeting to provide a presentation on Breast Services for patients in south tees. The panel was reminded that in October 2015 South Tees Hospitals NHS Foundation Trust had announced temporary changes to the Breast Radiology Services at James Cook University Hospital (JCUH). In January 2017 the Service Manager for the Planned Care Centre, Service Manager for Clinical and Diagnostic Support Services and the Clinical Director of Urology had attended a meeting of the Health Scrutiny Panel to provide the panel with an update.


At that meeting Members had been advised that the Breast Radiology Unit at JCUH had been out of use for approximately 18 months. There had been difficulties in recruiting Radiologists and patients had had to travel to University Hospital North Tees (UHNT) for diagnosis. Treatment was still being delivered at JCUH, however, at that time there was a recognised need to reopen the unit. The panel was advised that the unit was scheduled to reopen on 1 July 2017. It was also advised that a representative would attend the April meeting of the panel to confirm that the plans remained on track. Unfortunately owing to the Purdah period it was later advised that it was not possible for the Trust to provide an update during the election period.


In light of the above the Chair had requested that an invitation be extended to representatives from South Tees NHS Foundation Trust and South Tees Clinical Commissioning Group (STCCG) to attend the panel’s September meeting to provide an update on this topic. The Chair had been aware in the interim period that the unit would no longer be opening on 1 July 2017, as previously advised.


Representatives from STCCG, South Tees Hospitals NHS Foundation Trust and North Tees and Hartlepool NHS Foundation Trust were in attendance at the meeting and introduced their joint presentation.


In terms of background information the panel was advised that there had been:- 

  • A lack of consultant radiologists for Breast Services at South Tees Foundation Trust (2015)
  • A failure of mammography equipment at the James Cook University site
  • Symptomatic breast services were fragile - main challenge was the imaging side of the service (as imaging techniques involved taking specimens)
  • Collaborative approach to a Teeswide Breast Service
  • Symptomatic breast multi-disciplinary team (MDT) merged with North Tees
  • Cancer Alliance initiated a Breast Service Review (2016)

The Clinical Lead for the Northern Cancer Alliance was in attendance and advised Members that Cancer Alliance had been commissioned (in 2016) to undertake a Regional Breast Cancer Service Review for North East and Cumbria in response to a number of key concerns, namely:-

  • The multi-disciplinary workforce was aging, especially diagnostic services
  • Screening services were more able to recruit
  • At least one symptomatic service was currently fragile
  • Was the current service model the best for patient outcomes?

A regional solution was required and it was advised that currently there were a total of 6 providers of symptomatic services across the North East and Cumbria. Sunderland’s diagnostic services were now managed by Gateshead. In considering possible solutions four options were considered and these included:- 

  • Model 1 - Continue with the status quo
  • Model 2 - Support services which are currently struggling
  • Model 3 - Breast Screening Unit Hub (centralisation)
  • Model 4 - Hub and Spoke  

The review concluded that Model 1 was likely to lead to further service suspensions with need for crisis management. Model 2 was too informal for sustainability. Model 3 maybe necessary in the short term as an interim sustainable route to Model 4 for some services due to workforce challenges. Model 4 was the most patient centred (preferred model) but challenging to achieve universally in the near future with existing diagnostic workforce.


The Commissioning Manager for STCCG advised that in respect of the commissioning model for south tees patients Model 4 had been approved by STCCG and Hartlepool and Stockton (HaST) CCG Executive as the preferred model. Model 3 had also been approved by STCCG and HaST CCG Executive’s as the interim model.

In terms of current service provision by North Tees NHS Foundation Trust it was explained that screening services were provided for the whole of Teesside and parts of Durham and North Yorkshire (55,000 patients per year). Symptomatic services were provided for Stockton, Hartlepool, South Durham, Redcar and Cleveland and Middlesbrough (7,000) per year and the diagnostic symptomatic service was provided as a Teeswide service from North Tees and Hartlepool sites.


The panel was informed that all diagnostic tests were undertaken by North Tees and Hartlepool NHS Foundation Trust and the panel queried how a south tees patient’s experience differed from before. It was explained that previously the patient would have gone to JCUH for the initial diagnostic appointment. However, patients were now sent to UHNT for a triple assessment, which included clinical examination and patient history, imaging and pathology. It was emphasised that the service women were receiving at North Tees was very good and all tests were completed on the same day. If the results were negative it was the end of the patient’s journey.


If the results were positive the patient would be discussed at the joint Multi-Disciplinary Team (MDT) meeting for decision on a treatment plan. The MDT included staff from North and South Tees. Once MDT had agreed a plan the patient would meet with the clinical nurse and specialist consultant to talk through the treatment plan (South Tees). Treatment would then commence (surgery, chemotherapy, radiotherapy at South Tees NHS Foundation Trust.) Once treatment finished the patient would be passed to the 5 year surveillance programme. Currently this was undertaken at North NHS Tees Foundation Trust and the Friarage.


In response to a query from the panel it was confirmed that the vast majority of south tees patients received their treatment from the South Tees NHS Foundation Trust. The patient’s postcode was considered when allocating a clinic appointment.


Reference was made by Members to the importance of early intervention and the fact that putting in barriers only prevented people from accessing services. The point was made that they were a number of deprived areas in Middlesbrough and travelling to UHNT by bus took an awful long time. The panel requested that the 'did not attend' (DNA) figures by postcode for breast diagnostic screening appointments at UHNT be provided for Middlesbrough residents.


Patient Feedback


The Head of Radiology and Breast Services and the Breast Imaging Service Manager were in attendance and updated the panel on patient feedback to date in respect of Model 3. It was advised that a questionnaire had been developed to understand the experience of patients, who had attended the symptomatic breast clinics at UHNT and University Hospital Hartlepool (UHH). A total of 350 surveys had been distributed to patients from the Breast Units at both hospitals during August 2017. A total of 124 surveys had been completed, a response rate of 35%. The results highlighted that the majority of patients travelled between 10 and 20 miles to attend their diagnostic appointment. 55 per cent were happy to travel to the specialist breast clinic, 32 per cent were happy to some extent and 9 per cent were not happy, with 3 per cent providing no response. It was initially advised that the surveys had been completed in clinic. However, during the course of the meeting it was confirmed that the survey had been undertaken as a postal survey.


In terms of the current and future constraints it was that advised that the key issues were as follows:- 


Radiology Workforce 

  • national shortage of radiologists
  • age profile of current radiologists
  • recruitment difficulties due to geographical area
  • alternative workforce implemented however, 5 year training and still required consultant radiologist mentorship

 Interdependencies for supporting other aspects of the service 


The panel made reference to the information provided at its meeting in January 2017 and the assertion at that point that work would be undertaken to upskill Radiographers, with a view to effectively 'growing our own' Consultant Practitioners in the region. It was explained that work had been undertaken in partnership with Leeds and Nottingham University, as well as the School of Radiology to assist with this work.


With regard to the current workforce position it was explained that there were currently 6 Breast Radiologists employed in the Teeswide service. However, 4 had retired and returned to work on a part time basis and their hours made up the equivalent of 1 whole time Consultant. The remaining two Consultants also undertook other general radiology duties to maintain their skills and made up 0.75 of a Consultant post. In total there were 1.75 whole time equivalent Radiology Consultants to run the Breast Service across Tees.


In terms of workforce planning for the future a Consultant Radiologist (breast/general) had recently been appointed (September 2017). A Clinical Fellow (breast/general) had been appointed with the possibility of consolidating knowledge for a possible Consultant post in 2018. The skill mix of Radiologists v Consultant Practitioners had been maximised (lowest per cent of Radiologists in the North East & Cumbria region). Radiologists were required for expertise, mentoring and supervision, cross sectional reporting and MDT leadership.


A Consultant Practitioner had been appointed in September 2016 and was currently undergoing a preceptorship (a period of supervision). An additional Trainee Consultant Practitioner also commenced the 2 year training programme in October 2017. A well-established training programme for Radiographers to ensure succession planning in advanced clinical practice was also in place. Close links had been established with Leeds and Nottingham Universities where mammography training was provided. The School of Radiology, which provided sub specialist training in Breast Radiology provided training for the Trusts’ Radiographers. However, the point was made that nationally there were only a handful of Consultant Radiologists qualifying each year. All hospitals were competing to attract the same individuals.


The Commissioning Manager for Early Intervention and Prevention at STCCG advised that the aspiration was still to work towards Model 4, which was the ‘Hub and Spoke’ model. Work was continuing in collaboration with partners to ensure patients received the best service while planning for Model 4. Estate plans were being progressed to provide a spoke model at South Tees NHS Foundation Trust in the future. However, at present workforce recruitment and retention remained the key priority for partners and patients.


The panel queried the amount of time it would potentially take to achieve the ambition of delivering a spoke unit at JCUH. The Director of Programmes and Primary Care Development at STCCG advised that it was not possible to answer that question at present, as ultimately it depended on the workforce.


The Chair stated that the information provided to the panel in January 2017 was incorrect. The changes to breast diagnostic services in South Tees were effectively permanent and had this originally been proposed as a long term arrangement, it would have required a statutory consultation. The panel was dissatisfied that the promises made to it had not been fulfilled and 2 to 3 years on the same issues were still not resolved. The response had been unsatisfactory from the panel’s perspective. Access to services remained a key issue and given the levels of deprivation in the town the panel was concerned about the travel issue. Figures on the number of symptomatic patients from South Tees who delayed accessing their diagnostic appointment at UHNT and UHH were requested. It was highlighted that the patient survey had shown that 41 per cent of patients had given an answer other than yes definitely to the question are you happy to travel to this specialist breast clinic?


A suggestion was put forward that a brave decision be taken on a date to work towards delivering a spoke at JCUH given that it was known what was needed to achieve this ambition. The Director of Programmes and Primary Care Development at STCCG advised that North Tees and Hartlepool NHS Foundation Trust was continuously recruiting and it was not possible to put a date on delivering this service. The panel was informed that the national Director of Cancer Strategy advised that having the correct medical workforce in place was a key issue nationally. In response to the question as to when south tees patients could expect to receive breast cancer diagnostic services in the south of the region it was advised that at this stage this was simply unknown. No single organisation controlled all the variables and with the main medical schools located in Leeds and Newcastle, once people graduated they tended to stay in the big cities.

In terms of regional employment the question was posed as to whether it would be possible to have a 'moveable hub' with diagnostic services being delivered in the south of the region. North Tees and Hartlepool NHS Foundation Trust advised that unfortunately there were constraints in that the Consultant Radiologists were required to undertake theatre work and therefore it was not simply a case of arranging for them to hold a clinic in the south of the region. In terms of treatment, however, patients were still able to receive their treatment at JCUH and the majority of south tees residents underwent treatment at JCUH. In terms of how much money was following south tees patients to North Tees for the diagnostic assessment it was advised that the annual figure was in the region of £300,000.


The message was reiterated that the challenges faced in relation to delivering a Hub and Spoke model were not financial. Numerous collaborate financial agreements were in place between North Tees and Hartlepool NHS Foundation Trust and South Tees Hospitals NHS Foundation Trust. However, the crux of the issue was about ensuring the best possible service for the patient. The panel was advised that the reality of working in the NHS at present was that staff had to be creative in terms of finding solutions. An extension of staff roles where possible were used and many areas had had to reconfigure services in response to staff shortages. It was emphasised that the 2 week wait from GP to assessment continued to be monitored and that the clock was not stopped for cancer.


In respect of extending the screening service to include younger women it was advised that women across Teesside were already screened from the age of 47, and had been for a number of years. There had been an increase in the aging population resulting in an increase in demand for screening services, however, the figures for symptomatic screening were not affected. In terms of take up for screening services the panel was informed that the worst take-up rates across Teesside were for Bowel Screening, where figures were on a par with Tower Hamlets in London.


The question was posed by the panel as to why the NHS was making it harder to access services when it needed to making it easier. STCCG advised that its concerns were no less than those expressed by the panel and that it was a continuous process for STCCG to work towards the delivery of a Hub and Spoke model.


The Chair of the panel expressed the view that given the information presented at today’s meeting the panel would formulate a report for the Council’s Executive. The report would highlight the information presented at today’s meeting on the recent developments in relation to Breast Radiology Services for patients in the south tees. The report would also flag up the panel’s concerns and reference its disappointment at the fact that breast cancer diagnostic assessments were unable to be carried out in the south of the region. Patients therefore had to travel to UHNT for initial assessment. The panel’s report would seek to translate the panel’s concerns into a wish list of what it wanted to see achieved in the future.


AGREED as follows:-

  1. That a draft final report on Breast Radiology Services for patients in South Tees be prepared on behalf of the panel.
  2. That regular quarterly updates be provided to the panel to ensure that the aspiration to deliver Model 4 - a Hub and Spoke model was achieved at the earliest opportunity.
  3. That information on the 'did not attend' (DNA) figures for symptomatic patients in the South Tees be provided to the panel by STCCG.

The Democratic Services Officer presented the scrutiny panel investigation outline document for the topic of DDTHRW STP and the implications for Middlesbrough residents. In line with the information provided by key stakeholders and the debate held at the panel’s last meeting draft terms of reference for the review were provided. The documentation also outlined detailed information in respect of the proposed timetable, key witnesses and allocation of tasks. The panel discussed the information contained in the draft outline and Members were in agreement with the proposals.


AGREED as follows:-

1. That the following terms of reference be approved:-

  • To examine the STP’s joint vision and how it will translate into less health inequalities locally.
  • To consider the integration work currently taking place across South Tees.
  • To assess capacity in the independent nursing care market.
  • To consider the pros and cons of moving to a capitation based funding approach.
  • To examine the town wide focus on prevention.

2. That the necessary arrangements be made for key witnesses to attend future meetings of the panel in respect of the investigation on the DDTHRW STP and implications for Middlesbrough residents.


The Interim Head of Public Health was in attendance at the meeting to brief the panel on the Live Well Middlesbrough Strategy: A prevention strategy for adults and older people 2017-2020.The panel was advised that both health and social care systems are under significant financial demand at present and both national and local drivers were focussed on reducing health inequalities. Reference was made to the 44 Sustainable Transformation Partnerships (STPs) created across England and that Middlesbrough was part of the huge DDTHRW STP footprint. Prevention was one of the key STP priorities as well as developing a whole system approach through working collectively to tackle health inequalities. The focus was on building on strengths rather than focusing on deficits. Co-production of services was also viewed as a way of working with communities rather than simply providing services for them.

Reference was made to the extra life approach and it was explained that work was ongoing at present to roll the scheme out to schools. The Chair advised that several years ago the Health Scrutiny Panel had requested that all policy documents submitted to Council or the Executive should have a Health Impact Assessment undertaken. The question was posed as to whether this was currently the case. The Director of Public Health advised that he would gather some further information in respect of this issue and report back to the panel.

The panel was advised that real efforts were being made to ensure that all contact with the public counted with an integrated wellness approach. Reference was made to the location of the new Live Well Centre and the panel queried whether given the high level of need in North Ormesby whether it would have been more beneficial to build the centre there. The Interim Head of Public Health defended the decision to develop the Live Well Centre in the Town Centre given the footfall and ease of access, as well as high level of need in the town centre wards. In addition, it was highlighted that the development of The Live Well Centre was not about centralising services and Public Health was working closely with community hubs and Stronger Communities to ensure the further development and delivery of services within communities.

It was advised that the second priority was around ensuring people received appropriate treatment. Social prescribing and the use of physical activity, talking therapies and non-medical interventions had an important role to play in improving people’s well-being. Addressing underlying issues including, for example, benefits and welfare advice highlighted the need for the approach to be more than simply clinical. It needed to be a catch all approach. The panel queried whether there were any examples of social prescribing and the Director of Health advised that there were a number of existing schemes in operation. However, there was a need to develop a more consistent approach.

Promoting Independence

In terms of promoting independence it was explained that a significant amount of work had taken place in respect of falls prevention and the provision of appropriate adaptations. A South Tees Prevention Board was in the process of being established and a workshop session had been scheduled for October. Professionals from all sectors would be involved in the workshop and determining the governance arrangements.

A member of the panel queried whether any figures were yet available for the numbers of people using The Live Well Centre. It was confirmed that figures were available and this information would be fed back to the panel.

AGREED as follows:-

1. That the Director of Public Health updates the panel on the number of Health Impact Assessments undertaken in respect of Council policy documents prior to their approval by full Council and / or the Executive.

2. That the figures on the number of residents accessing The Live Well Centre be obtained and presented to the panel. 


The panel was advised that South Tees CCG and NHS Hartlepool and Stockton-on-Tees CCG had launched a joint consultation on proposed changes to respite opportunities for people with complex needs, learning disabilities and/or autism. The consultation was scheduled to run for 10 weeks, until Friday 10 November 2017.
Information provided by the North of England Commissioning Support Unit (NECS) was presented to the panel and contained a full overview of the consultation. It was highlighted that the CCGs were consulting on two options for the future of the services.

Option One - Involved buying a range of Bed Based Respite services to replace existing Bed Based Respite services. Changing the assessment and allocations process, making it more needs led. Buying flexible community based respite services. Buying clinically led outreach support services and closing Bankfields Court and Aysgarth.

Option Two - Continuing to buy Bed Based Respite services at 2 Bankfields Court and Aysgarth. Changing the assessment and allocations process, making it more needs led. Buying flexible community based respite services.

A Team Manager from Adult Social Care and Health Integration was also in attendance at the meeting to provide further details on the proposals.

The Team Manager advised that the consultation affected services at Bankfield Court in Normanby and Aysgarth in Stockton, as purchased by the CCG. A respite task and finish group had been set up in 2016 to look at the definition of respite, current capacity, choice, eligibility criteria, assessment, double use of facilities e.g. respite at Banksfield and attending the Orchard at the same time, alternatives to bed based respite including using shared lives schemes. It was explained that in Middlesbrough there were very few people taking part in such schemes as there had been a lot of success of moving people into the supported living centre. However, in other areas including North Yorkshire shared lives schemes had worked really well and there was merit in exploring such options.

In response to a query it was confirmed that respite provision provided at Gleneagles Resource Centre was not included as part of the consultation. It was also emphasised that this was a health consultation and the Local Authority’s role was to ensure the right outcomes were achieved.

The timeline for completion of the whole project was August 2018 and the current consultation was showing up some very strong views about what respite meant to parents and carers of current service users and those who may use the service in the future.

Trust was a big issue that had been up by the service despite some failings and this would take a long time to build up with any provider. Quality of carers was also raised with the same issue of ensuring that those with the most complex needs were looked after appropriately when receiving respite services.

The eligibility criteria for current bed based services was being looked at with the current loose criteria of a behaviour week and a complex needs week having very little boundaries around which was which. With often those who shouted loudest receiving the most bed days. Extra capacity at unit 3 was being used due to emergency respite being needed. Members were advised that the suggested rough criteria would mean that 5 people who currently received bed based services at Bankfield Court from across south tees would not be eligible. Further work to look at this would be undertaken. Shared lives was an option that was being explored to utilise shared lives carers and this had been funded separately.

The last public consultation even was scheduled for Saturday 1 October at the Trinity Centre in North Ormesby. Parents of young children that maybe affected in the future were in attendance and their views were being heard. NHS representatives would also be attending the Erimus carers group in early October to capture any more views.

AGREED as follows:-

1. That the information presented be noted and further information provided following the outcome of the public consultation.
2. That the panel’s views be fed into the regional Joint Health Scrutiny OSC’s response to the consultation.


The Chair advised that there was currently a proposal for a merger to take place between Linthorpe GP Surgery and Oakfield Medical Practice. A copy of the final communications and engagement report, which detailed the findings of the engagement activity undertaken with patients and stakeholders from both GP Practices was provided for Members attention.

The report highlighted that the proposed merger was scheduled for 1st October 2017 and that it was the wish of Dr Dave and the partners of Linthorpe Surgery that the merger would go ahead. NHS England had responsibility for making the final decision on the proposed merger following the submission of detailed business plans.
The Practice Manager at Linthorpe Surgery had advised that the proposals were due to be considered by NHS England at a forthcoming Board meeting. There was the potential that, if approved, the date for implementation would be pushed back to 1st November 2017. A copy of the report had been distributed to all Members and responses invited.

AGREED as follows:-

1. That the panel had no objections to the proposed GP Practice merger.


The Chair provided a verbal update to the Panel in relation to the business conducted at the Overview and Scrutiny Board meeting held on 12 September 2017, namely:- 

  • Scrutiny Panels’ Work Programmes.
  • Executive Forward Work Programme.
  • Scrutiny Panels’ Progress Report (verbal update).
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