NHS ENGLAND
SENATE COUNCIL DELIBERATIVE MEETING
Held on:
THURSDAY 12TH DECEMBER 2013
At:
TAUNTON RUGBY CLUB, HYDE PARK, HYDE LANE,
TAUNTON, SOMERSET, TA2 8BU
In the Chair:
DR VAUGHAN LEWIS
(Transcribed from the Verbatim Stenograph Notes by Mirella Fox, QRR,
Freelance Speech-to-Text Reporter, Member of the British Institute of Verbatim
Reporters and Member of the Association of Verbatim Speech-to-Text Reporters)
Thursday, 12th December 2013.
(10.00 am).
VAUGHAN LEWIS: Okay. Welcome. Now I have no idea what the acoustics
are like in this room. So, Virginia, can you hear me?
VIRGINIA PEARSON: I can hear you perfectly, Vaughan.
VAUGHAN LEWIS: Excellent. My name is Vaughan Lewis. I am a
paediatrician in Exeter, and I was appointed as the Chair of the Clinical Senate for
the South West earlier this year. Caroline is going to provide a little bit more
background to the Senate. First of all, I will start by welcoming everybody.
There are a couple of housekeeping things. There are no fire
alarms expected. There are two exits - the way most people came in and out
towards coffee. Could I also ask people to turn mobile phones on to silent or off.
I appreciate that life goes on back at base and if people need to take calls, then
they need to take calls, but if you could make sure your phone is on silent... he
says! {Checks mobile phone}.
So what I would like to start with is just doing a very brief
round of introductions. There are lists with names, organisations, allegiance and
speciality, but for those in the room I think it would be very helpful just to go
around literally with those three pieces of information.
I think it's probably sensible at this point to remind people that
they are here not because of where they come from. They are here to contribute
to the workings of the Senate, and, as far as is possible, to separate any
organisational allegiances. This is about the Senate's role to provide advice, to act
as a critical friend, as a conscience, as an adviser to commissioning, both specialist
commissioning and the CCGs, although the focus of course today is around
specialist commissioning.
As we go through some of the business of the Council in a
minute, we will talk about the potential for conflict of interest and so I won't say
any more about that at the moment.
So, as I say, we will start now with a round of introductions,
so that if we go around anti-clockwise. Caroline?
CAROLINE GAMLIN: Caroline Gamlin. I am the medical director for the
area team that covers Bristol, Somerset, Gloucestershire and North Somerset and
as such have the responsibility for oversight of the Senate and strategic networks
in the South West.
JOSEPH MATTHEW: I am Joseph Matthew. I am a pathologist from Truro.
ADRIAN JAMES: Adrian James. I am a forensic psychiatrist from Devon and
I am the clinical director of mental health, dementia and neurology for the South
West region.
GERAINT DAY: I am Geraint Day. In the last century I used to be in public
health and additionally attended Wiltshire. I live in Swindon. My day job is with
the Royal College of Surgeons of England, but I have been involved in patient
public involvement activity for some time.
PATRICK CANAVAN: I am Patrick Canavan. I am chair of HealthWatch
Torbay.
SANJAY VYAS: Sanjay Vyas, consultant gynaecologist, North Bristol NHS
Trust.
STUART WALKER: Stuart Walker. I am a cardiologist in Taunton and
clinical director of the Vascular South West Network.
EMMA STAPLEY: I am Emma Stapley. I am a clinical psychologist in
CAMHS and head of the Somerset Partnership, which is a community and mental
health trust here in Somerset and I am head of child psychology with
psychologists feeding into paediatric and other services.
PHIL YATES: I am Phil Yates. I am a GP in Bristol, have been for 30 years,
and I chair a big GP provider organisation of a hundred practices called GP Care.
JOANNA PARKER: Joanna Parker from South Gloucestershire HealthWatch.
STEVEN SALE: Steve Sale. I am an anaesthetist at the children's hospital and
clinical director for the surgical half of the children's hospital.
MARY BACKHOUSE: I am Mary Backhouse. I am a GP in North Somerset
and I am the accountable officer for North Somerset clinical commissioning
group.
PETER ROWE: Peter Rowe. I am a consultant nephrologist from Plymouth
and also the care group director for specialist services for Derriford Hospital.
SHELAGH MCCORMICK: I am Shelagh McCormick. I am a GP in Cornwall.
I am deputy medical director of Devon, Cornwall and the Isles of Scilly area team
and I'm the deputy chair of the Clinical Senate.
CHRIS BURTON: Chris Burton. I am here as the nominee of the Academic
Health Society Networks, and I am also medical director of the North Bristol
NHS Trust, and I have another lens I look through occasionally, which is I also sit
on the Dorset CCG governing body, so I have a commissioning hat on
occasionally.
ANDY SMITH: Andy Smith. Devon GP and medical director of the South
West Ambulance Service.
CHRISTINE TELLER: Christine Teller. I am a HealthWatch volunteer from
Bristol.
CLIFFORD PUDDY: Clifford Puddy. I am a HealthWatch volunteer. I come
from the Somerset HealthWatch and I am on the board of the re-ablement of
Somerset NHS.
DAN WILLIAMS: Dan Williams. I am a consultant orthopaedic surgeon in
Truro.
SUNITA BERRY: I am Sunita Berry. I am the associate director for the
Strategic Local Network and the Senate in the South West.
SALLY PEARSON: Sally Pearson, director of clinicial strategy,
Gloucestershire Hospitals NHS Trust.
LIZ TOY: Liz Toy, consultant clinical oncologist from the RD&E and I sit on
the {Inaudible} CRG.
JENNY WINSLADE: I am Jenny Winslade, chief nursing officer from the
North, East and West Devon CCG and I am also at the moment on secondment
part-time to SWAS as their director of nursing.
GUY ROONEY: I am Guy Rooney. I am a consultant in genitourinary
medicine and HIV and also one of the medical directors of the Great Western
Hospitals.
VAUGHAN LEWIS: Sorry, I should have said at the outset that those of us
sitting around the table are here in the capacity as Council members of the Senate,
and our colleagues exiled to the back row are here by virtue of their role in
specialist commissioning, and although in future meetings people who are here
because of the subject we are talking about would not necessarily be involved in
the business meeting part, we felt it was sensible for us all to spend the whole day
together. So, Peter, perhaps if you could go left to right there and just introduce
yourself?
PETER DAVIS: I am Peter Davis. I am a consultant in the intensive care unit
at the children's hospital in Bristol and also paediatric intensive care CRG rep for
the South West.
LINDA PROSSER: I am Linda Prosser. I am the director of commissioning in
the Bristol North Somerset South West area team, with responsibility for
specialised commissioning for the South West.
DEBBIE EVANS: Debbie Evans, senior service specialist for specialised
commissioning South West.
DOMINIC BYRNE: I am Dominic Byrne, a consultant gynaecologist from
Truro and I sit on the gynaecology clinical reference group.
ANN MILLAR: I am Ann Millar and I am here as the specialist respiratory
CRG rep for the South West and perhaps of relevance to that I previously was
involved with the NICE guidelines group and MHRA, which is relevant to some
drugs.
VAUGHAN LEWIS: Thank you. Helen?
HELEN THOMAS: I am Helen Thomas. I am the clinical director for cancer
for the South West SCN. I am also the clinical governance lead for the South
West for NHS 111.
VIRGINIA PEARSON: I am Virginia Pearson, director of public health at
Devon County Council and I'm here representing the local authority directors of
public health in the South West.
ANDREW SEYMOUR: Andy Seymour. I am deputy clinical chair of
Gloucestershire and a GP in Gloucestershire.
MARION ANDREWS-EVANS: I am Marion Andrews-Evans. I am an
executive nurse and quality lead for Gloucestershire CCG.
WILLIAM HOUSE: I am William House, been a GP for many years between
Bath and Bristol; one time commissioner in a practice based commissioning phase
of GP commissioning, and I am a primary care researcher.
JOHN GRAHAM: I am John Graham, consultant oncologist and also cancer
lead for the Trust, and also director of the National Centre for Cancer which
produces all the NICE cancer guidelines and relevant to them also on the CRG for
neurology with specialised commissioning.
SUSAN HAWKINS: I am Susan Hawkins. I am the clinical lead
physiotherapist for the Royal Cornwall Hospitals NHS Trust.
JAYNE WEARE: Jayne Weare. I am head of therapy services, University of
Bristol NHS Foundation Trust.
TREVOR BESWICK: I am Trevor Beswick and I am a pharmacist. I am the
director of the South West Medicines Information and Training Centre, which is
based in University Hospitals Bristol.
SHONA ARORA: I am Shona Arora. I am one of the centre directors for the
Public Health England in the South West and for Avon, Gloucestershire and
Wiltshire and the other centre covers Devon, Cornwall and Somerset, so I am here
on behalf of Public Health England.
PAUL EYRES: I am Paul Eyres, vascular surgeon, Taunton and Somerset NHS
Foundation Trust.
PAUL WINTERBOTTOM: I am Paul Winterbottom, psychiatrist and medical
director in 2gether, which is a mental health trust covering Gloucestershire and
Herefordshire.
MARK CALLAWAY: I am Mark Callaway and I am a consultant radiologist at
RUH Bristol, but also head of School of Radiology within the Severn Deanery.
ELLIE DEVINE: I am Ellie Devine. I am due to start in January as the Senate
Manager on the Senate team, although I currently work for the South West
Commissioning Support.
VAUGHAN LEWIS: Thank you. Mirella is here as a stenographer. I don't
know how many people have attended meetings with stenographers before certainly a first for me - and we will come on and talk about the public
attendance and the challenge of making other deliberations public and the role that
stenography might have in that a little bit later on in the agenda. Later on in the
afternoon we are planning that Mirella will put the outputs of the workshops on
the screen, so that we can all see how the afternoon progresses rather than using
the age old flip charts. So fingers crossed that works!
I am humbled I think by that round of introductions. It is an
impressive group of people who have come together. I don't know whether it's
unprecedented, but certainly if we can achieve what we are supposed to achieve,
then that will be fantastic. And if we can't achieve it, then I am not sure what
other group could.
So I thought, as Chair, I really appreciate the leap of faith that
people have made to take time out of their schedules to travel in some cases
considerable distances. I had a look last night on Google Maps and although
Taunton is, as the crow flies, the epi centre of the South West, the travel times,
even allowing for that, are up to three hours.
The South West is the largest of the ten regions. We cover
about 16% of the UK -- sorry, 16% of England, but have one of the lowest
population densities; along with that, one of the lowest levels of ethnic diversity.
I think we have a real collective challenge to make the Senate work. I have said
in meetings before that if it sounds like we are making it up as we go along, it is
because we are making it up as we along! And I make no apologies for that and I
think to be bound by too many structures, too many rules and regulations at this
point would be a mistake, because we will channel ourselves down.
As I say, our collective challenge is to make the Senate
effective and valued in the new NHS. We will only do that if we provide credible
advice to the commissioners. Where it exists, that advice needs to be evidence
based, where the evidence exists. But we need to really harness and make the best
use that we can of our multi-disciplinary constituents. As you will have heard, as
we go round, we have got representatives from a number of the HealthWatches
and I am working alongside the Clinical Senate, which is going to be a Citizens'
Senate which will further bolster that public engagement.
The area that is not particularly strong at the moment, the area
that we have struggled to get engagement with is social care. We all know the
challenge that exists around the integration of health and social care and I can
assure you that we are taking steps to improve and to increase social care
engagement. So I hope that by the time the next meeting comes there will be
more colleagues from social care.
Before I hand over to Caroline, I would just like to thank the
administration team for their considerable effort in getting to this point and to
Sunita for hours of work and I have worked with a number of people who have
sent e.mails at all hours, but I think Sunita probably tops the bill! I am not sure
whether that is a good thing or a bad thing, but it certainly indicates her
dedication to the cause. So thank you, Sunita.
Caroline?
CAROLINE GAMLIN: Yes. I am --PHILIP YATES: I just wondered whether we could have a list of members and
some contact details for them. It would be very helpful just to establish that
early.
VAUGHAN LEWIS: Yes, I think so. One of the things I think I will pick up
in the next section is around how we have identified Council members who are
here. I made reference to the fact that we are a large group. It was never our
intention to be quite this large a group for this initial meeting, but, in fact, most
of the people who were invited have attended. It was never our expectation that
that would be the case. So the number of people round the table is somewhat
larger than we had hoped. But in the spirit of wanting to be inclusive, wanting to
make this work, we felt that it would be almost churlish, having invited
somebody, to say: "You are not invited any more", because we weren't expecting
so many of you to respond! But we may decide that we should continue as an
organisation of this size. I suspect there will be a natural attrition, but the
challenge is getting the breadth and the geographical spread whilst keeping it
small enough in order to be effective.
But, yes, Phil, we will certainly send round the list of attendees
and contact details.
PHILIP YATES: Thank you.
VAUGHAN LEWIS: Okay, thank you. Caroline?
CAROLINE GAMLIN: Okay. I was just going to give a bit of background
information, but I am sure you will have all read your packs so you may be up to
speed with Senates.
It is a large group. I don't know whether you can see there,
but this is the future forum recommendations (presentation on the screen),
talking about the Senate of Rowe which actually had 300 people, so actually we
are quite small compared to that. But certainly the Senates were a
recommendation coming out of the future forum discussion on the Health and
Social Care Bill and it was felt that something similar which actually had people
there determined, as it says here, not by birth but by achievement and reputation.
So we have tried to gather a group and I think certainly, going round, I feel we
have got extremely robust groups.
So, I am going to run through the update on the Senate
presentation.
What was the purpose of the Clinical Senate? It was to engage
the statutory commissioners to identify areas with potential for improved
outcomes. The Senate is supposed to mediate for their population about how to
implement best practice; to be a source of clinical leadership and credibility, and
to play a pro-active role in promoting major service change; to link clinical
expertise and local knowledge such as patient pathways and engage with the
clinical networks, and I think it's really good that we have got the directors of the
clinical networks as well sitting around the table here.
Working with commissioners - so the questions, and we will
get on to how we discuss and agree questions for the Senate, but certainly the idea
is that they come from commissioners. So working with local commissioners to
consider the strategic impact of the proposals; to advise statutory bodies on things
like re-configurations, and we need to agree criteria for taking on topics and
providing assurance on quality impact assessments. We are not supposed to revisit
national clinical assessment team decisions and later we will talk about specialised
commissioning. We are not here to unravel the national specifications, but we are
here to look at how we might apply them locally.
The geography - I think Vaughan has alluded to the South
West and I am sure you are all familiar, but covering three area teams I think we
are quite challenged. You can see on the map there in terms of the actual
geographical size of the Senate that we are trying to cover. That also gives us, I
think, some sort of robustness in terms of the actual breadth of people that we can
bring into the decision making. But you will see that other areas, perhaps, aren't
so geographically challenged across the country; perhaps Lincolnshire up in that
area.
So, the whole point of the Senate is that it does cover a larger
geographical area than a CCG, and a more general remit that maybe the clinical
networks have. So the four strategic clinical networks have got specific areas,
apart from women and children, which is obviously a service area. The idea of
the Senate is that we maybe take more broad questions to tackle, rather than
looking at specific disease. People sitting around the table have a wide range of
clinical input and skills, but also the geographical spread and the aim of the
Senate is to have a clinical focus, perhaps more so than the health and well-being
boards, our strong links into the academic science networks and also private and
public health education England.
So the membership, as we can see, should be
multi-professional. I think we have achieved that. We need to include NHS
commissioners, providers, patients and public, social care - as we said, we need to
build on our membership from social care - professional education and third
sector and the membership is not intended to be representative of the organisation,
but more to bring up your skills and knowledge.
So how do we get to where we have got to? The first thing we
did was to appoint Vaughan as the Senate Chair. As you have heard, we have got
the Senate Manager now appointed and we then wrote out for expressions of
interest and we got 130 people across the South West who actually expressed an
interest to be on the Senate Assembly, which is a fantastic response, and all those
who wanted to be on the Assembly will be on the Assembly and they will be our
sounding board, if you like, and we will be communicating with that wider group.
For the Council, we actually then looked at people's
applications. We looked at the geographical spread and the skill mix and actually
came to a view and hence how we invited people around the table. So there is no
maximum or minimum number suggested for the Senate. So I think, as Vaughan
said, we will run with this group and we will see how we get on. We certainly
want feedback at the end of the day about how you think the day has gone.
So I think I have run through up there who is actually part of
the Senate and, as we have heard, we have got support through the manager,
through Sunita's work, and the Senate is accountable through Vaughan and myself
to the area team. But it hasn't got any statutory responsibility. It is just there to
provide good sound advice and I think our success will really be determined on
how people view the Senate. So I think that is what we are trying to achieve.
I think really that's a sort of summary of where we have got to.
I think we are going to work through in the morning about how we, as I said,
develop the questions and go forward and I am looking forward to an exciting day
and participation from everyone.
VAUGHAN LEWIS: Thank you. I am conscious we have been joined by a
handful of people. So, David, if we start with you, could you just say who you
are, where you're from and what your role is?
DAVID HALPIN: I am David Halpin. I am a chest physician in Exeter. I lead
the respiratory services in Exeter and also head the development of a number of
NICE guidelines. I am one of the regional respiratory leads on the old
Department of Health programme.
VAUGHAN LEWIS: Thank you.
CAROL GRAY: Hello, I am Carol Gray. My role is I am strategic lead for
palliative and end of life care in Torbay and Southern Devon.
SUE DOLBY: I am Sue Dolby. I am head of psychological health services at
Bristol Children's Hospital and I am also the lead on mental health professionals
on the commissioning board.
VAUGHAN LEWIS: Have I missed anybody else?
DIANE CRAWFORD: I am Diane Crawford. I am the director of medical
physics and bioengineering and also regional scientific director.
VAUGHAN LEWIS: I also have a handful of apologies. I won't go through
them all, other than to say Sarah Watson-Fisher from Health Education England,
who many of you will know, has offered her apologies because of a previously
arranged meeting. The other apologies are from three CRG members and a
couple of other clinicians from across the patch, but those will be on the
attendance list.
Before we go on to discuss and approve I hope the draft
operating principles, the terms of reference and the membership, are there any
questions following on from Caroline's presentation? No, okay.
So you should all have been sent or received, rather, a copy of
the draft operating principles or rather the operating principles in draft form, and
a terms of reference document. On the assumption that people have read these
documents, can I open up really to comments?
CHRIS BURTON: Can I ask a question? So are there other Senates in the
country that are ahead of us? And are there things that we could be learning from
them already or is everyone at the same stage?
VAUGHAN LEWIS: There are a total of ten Senates. Ten or 12?
CAROLINE GAMLIN: 12 Senates.
VAUGHAN LEWIS: 12. We are probably, in the legal table of headedness, we
are probably around about the middle. The London Senate has been up and
running for a little while. There are other Senates. There is a Senate in the north
yet to appoint a Chair. Most of the Senates are meeting this month, if they
haven't already met before. Some of them have taken the route of appointing an
Assembly first and then selecting a Council from the Assembly. Others have
appointed a Council and are then going to appoint a wider membership in that
way.
I think probably, perhaps, the most important thing that we
have learned is don't bite off more than you can chew at the start, and colleagues
in Wessex decided that the first topic would be vascular surgery, which I think has
not only hit the National, but certainly hit the HSJ that has resulted in I think
quite a significant trial by fire for that Council. I was very keen that we took a
much more gentle approach. You may feel the agenda for today is a little light in
terms of focusing on principles. But the feeling was that if we could get
consensus on how we should approach the questions that are going to come up,
then that would serve us very well when it came to answering those questions; and
the original intention had been to look at commissioning of HIV services
alongside the developing principles, but we have decided to defer that to January.
Now that may mean that we meet a little more frequently in the first few months,
but I don't think there is any harm in that.
Because the Senate is non-statutory, because there is very little
guidance from the centre about how we should operate, I think there is a real
opportunity for us to localise it, to make it work for the South West and I hope
that we have, both in the introduction and in some of the sections of the operating
principles documents, managed to capture that.
I would just like to on page 2 under Citizen's Senate, since this
document was written, there has been quite a lot of further work on the Citizen's
Senate and the decision that has been made certainly at this stage is that we should
use the 13 HealthWatches in the area as the prime method for communicating
with other PPI, PPV, public engagement bodies, disease specific interest groups,
foundation and other trust memberships. So we are proposing a Citizen's Senate
of 26 people made up of two members from each of the HealthWatches and from
that group of 26 we will identify four Council members who will be part of this
group. There will also be an appointed and remunerated Citizen's Senate Chair,
although the final details of that have yet to be determined. So that section of the
Citizen Senate will be slightly amended to reflect that.
Phil?
PHILIP YATES: It's just a discrepancy between the terms of reference and the
operating principles in the number of people not a member but from the Senate
Assembly. One says 12 and one says 26. So it is going to be quite a large group
to make it functional. So I don't know whether you had a feel for whether you
wanted to stick with 26 or make it 12?
VAUGHAN LEWIS: The original intention or -- Sunita, why don't you come
in?
SUNITA BERRY: I think the original intention was, in fact, to have something
like 12 to 14 members on the Senate Council, but I think, as Vaughan has said,
basically we didn't want to dampen down the enthusiasm of people and actually
the very strong professional interest that people had in coming to the Senate
Council. So in this first year we have decided that we will go with the large
group in order that we can get a measure of how things are going to work. Now
it is entirely dependent on this group, in fact, to decide what the membership is.
So if you were to decide that you wanted a smaller membership, part of that
discussion this morning is about how do you make that decision, what is the
process you are going to use; whether you are going to use a selection process, a
nomination process, an election process and so on.
So this is very much for the group. So, hence, this is a draft
for you until you have decided what you want to do about the group and about the
way the Senate is constructed.
MARY BACKHOUSE: I am thinking about how we judge the success of this
and for me how we are going to do the comms. So while we have got
representatives of many hospitals here, you come from enormous hospitals, and I
am just thinking about small hospitals. So, you know, there is nobody here from
Western Hospital. Actually for me one of the judges of success will be actually
the consultant body at Western Hospital feel that those people who are in the
room are doing the right thing on behalf of secondary care clinicians throughout
the South West.
VAUGHAN LEWIS: I think that's a very valid point and I am not sure I have
the answer to it. I don't know whether anybody else has experience of
engaging -- I mean, Chris, not to put you on the spot --CHRIS BURTON: Thanks!
VAUGHAN LEWIS: -- but with your MD hat on from North Bristol, and
particularly with the Western issue, do you have a view on that?
CHRIS BURTON: I think that Mary's point is probably broader than just
Western. There are other small hospitals in the South West who may not have a
voice in this group and it is absolutely right I think, Mary, that we need to look at
health care provision across the piece and part of what I am thinking about in my
membership here is what is representative down in terms of reference as
representing SHA, whereas I feel I am a nominee from a SHA and with my view
of the world and I think that we have to find a way of reflecting that. Now the
fact that Mary has brought it up as an issue means that it's an issue on our list of
concerns. But the comms of how do we get the message back that the Senate
Council has met, has deliberated and taken a view, I think there is something you
might want to think about engaging with the clinical leadership in each
organisation to set up an arrangement for getting the message back. I am sure
Nick Algos(?), in Western, would be interested to know what the Senate has
discussed and what it's going to discuss. Whether we want to identify a route in
for people I guess is another question.
CAROLINE GAMLIN: I think communication is really, really important and I
think it is also important that the people out there, not just hospitals but those
health and well-being boards and a whole range of stakeholders have really got
confidence that the decisions are credible. I think it is important to remember in
terms of the representation I think it's challenging, because people do come from
employing organisations. But the purpose is not to have each organisation
represented here.
So we need to think about how we have that credibility and
that we can pass those messages back on what we decided and agreed. So I think
it is consideration of the communication to a wide range of stakeholders, not just
acute hospitals, but I do think we need to check out that people are confident that
we have the right representative group here that can make those decisions, but we
clearly can't have somebody from every single organisation.
CHRIS BURTON: But I think the point is how do we ensure that the concerns
of a particular type of service, particularly in the South West which we have
described as being relatively under populated, density is low, how do we ensure
those concerns are appropriately represented? Because we might come with a
prejudice that small hospitals and small populations want X, whereas actually they
might be quite happy with centralising some services for good outcomes and
repatriating other services. So it is how do we get that voice in the room, I
suppose, rather than make our assumptions about what that voice would say.
VAUGHAN LEWIS: Yes, and I think we need to target, because I don't believe
there is anybody from Barnstaple, Yeovil, or Western here and I think while we
are fortunate in, perhaps, having the national clinical director for rural, I am not
quite sure what Leslie's formal title is on the patch, I appreciate that also doesn't
necessarily cover Western. There were two questions over there. Sorry Sunita.
Virginia?
VIRGINIA PEARSON: You don't mention scrutiny in this document.
VAUGHAN LEWIS: No?
VIRGINIA PEARSON: Shall I say a --VAUGHAN LEWIS: Do you want to expand?
VIRGINIA PEARSON: Yes. Although it mentions the health and well-being
boards, if there is a controversial issue in the local patch that involves the NHS,
then the scrutiny committee may call it in. Now if that happens, it is sort of
separate from the health and well-being boards, and I think there needs to be some
recognition in this document on page 6 at the top that issues might come from
scrutiny committees as well. So the Senate might have things referred to it by a
scrutiny committee, say. That's a possibility, but equally a scrutiny committee
might wish to seek advice or guidance from the Senate as well, and Caroline was
just talking about decisions and I think that needs to be very carefully thought
about because this says it is an advisory body. It is not a decision making body.
If it's an advisory body, then the best place to be is to be in a position of being
seen as an expert resource by scrutiny chairs.
So I think it picks up on the communications issue. I think
there is a communication that needs to go out, not just to health and well-being
board chairs, but also to scrutiny committee chairs which succinctly explains the
role of this group in relation to their role; otherwise, we are going to get in a huge
tangle and I suspect where there are local controls it is because scrutiny has
become involved along with clinicians and it's all got very messy. So I think that
needs real clarity.
VAUGHAN LEWIS: I am going to come back to the scrutiny issue. Sunita?
SUNITA BERRY: Can I just answer something about the scrutiny issue,
because specialised commissioners have set up a local involvement network that
includes all the scrutiny committees. What we didn't want to do was to replicate
what they already had and so there is something about the balance between us
working or of us working together, but I take your point.
VIRGINIA PEARSON: I am not talking about working together. I am talking
about a statutory role of scrutiny committees. That is not about having scrutiny
members on a network. That is about the statutory responsibility for scrutiny
committees and this is about briefing scrutiny chairs about the role of the Senate
and how they can best use the Senate, rather than seeing the Senate as something
which gets in the way or will be something that a scrutiny committee might itself
want to call in on a recommendation. I think it needs very careful handling.
Whether there are other places in the country where they have already thought
about this, but I think it is big issue.
VAUGHAN LEWIS: Can I take a couple more points and then, perhaps, I will
come back and sum that up. Peter?
PETER DAVIS: Just listening to what you have been saying, surely we need to
get --VAUGHAN LEWIS: Can you speak up a bit please?
PETER DAVIS: Surely one of the things we need to get right from today is
that if this Council is acting as an advisory role and the issues about
communicating that to various bodies involved around the region, it's having
clarity of what your guiding principles are going to be in terms of how you come
up with the advice. What are the things that we feel as a South West Senate
Council are our guiding principles in making those decisions, because there is
such a huge range of services which you are looking at on which people may have
some expertise, but many people will have no knowledge at all. But there are
certain principles by which you can stick to, which will be in terms of equity of
access and that I think is how you can move that forward.
VAUGHAN LEWIS: That, of course, is very much the purpose of the
workshop sessions this afternoon, is to try to agree by consensus what those
guiding principles should be that complement the existing principles in the various
documents, particularly from specialist commissioners.
PETER DAVIS: But I think that will help take it forward, yes.
VAUGHAN LEWIS: Yes, Ann? Sorry, can you speak up, Ann?
ANN MILLAR: In terms of getting your communication down to the smaller
trusts etc.etc., each of the regional clinical reference group members - so I am on
the respiratory group - we all discuss all the issues that are brought up the chain,
as it were, with people from every representative secondary care organisation.
So, certainly in terms of getting feedback, so Barnstaple and wherever, wherever,
that would be one way of downloading information if you went via the CRG.
VAUGHAN LEWIS: I think, particularly for specialist commissioning, that is
something that would be ill-advised, that is advice we should definitely follow.
Sorry, was there a --ADRIAN JAMES: Two points. I think it is a great document and it is a good
start and, as you said at the beginning, we need to feel our way. Just two
comments - one about membership and it picks up on Virginia's point. I think we
should have a representative on health and well-being boards, the local authority
as such around this table. They are so huge in terms of the agenda that they have
got and the use that we can actually put them to. So I think they are very big
players who definitely should be here.
My second point, and I think I raised it and you explained it
but maybe it's still in the document, but in the accountability there is a sentence
that says that the Senate can be held to account for their functioning but not for
the advice that they give. I think at the very least it needs to be rephrased because
it does make anybody picking it up and looking at it, it makes it look as though
you can do what you want and, you know, we can do what we want as a Council,
but you're not accountable for anything.
So I think we are definitely accountable for the advice that we
give and I think I know what you are getting at with that, but I think as written it
doesn't say which --VAUGHAN LEWIS: So the sentiment is right or the spirit of it is right, but it
needs refining?
ADRIAN JAMES: I think it needs explaining.
VAUGHAN LEWIS: Explaining, yes.
ADRIAN JAMES: Because to say that any reputable organisation to say we are
not accountable for our advice, I think it just makes you look ridiculous really.
VAUGHAN LEWIS: Okay, yes. Sorry, Sally?
SALLY PEARSON: Yes, I had two questions. One was around the
membership and you have acknowledged that it might be fluid and this might be
bigger than we end up with, but we don't say anything about terms of office in
here and one of the things that strikes me is if we do make recommendations and
they are acted upon, then there will be colleagues currently not sat around this
table who possibly wish they were.
So, I think we need to just think about what's the process of
election and re-election and how would we handle the conversation with an
individual who wasn't personally happy with our advice but wanted to know how
they could influence or become involved.
My second observation is having been involved in a number of
service re-configurations and been supported by the national clinical advisory
team, what is the relationship between Senates nationally, clinical Senates, and the
advice that they give and the point at which you invite the national clinical
advisory team to offer a view and their advice?
VAUGHAN LEWIS: Sunita, do you want to come back on the process around
election?
SUNITA BERRY: Yes. So, this Senate Council is appointed for a year with a
view to developing the process further as part of that year in order to get the
membership as robust as possible basically. So these appointments are for this
year. So the term of office is to go from, you know, today until December next
year basically. And alongside that, we do need as a group to think about how we
make that process. So at the moment we asked for applications and a couple of
hundred words on why people have wanted to participate in the Senate; what
experience they've brought of representing the wider network of people than their
own organisation; or whether they actually represented a professional body, for
example.
So it was to try and capture people in the breadth of their
experience as well as their knowledge and that's what we were trying to grapple
with. For this year, therefore, effectively this Council has been a nomination
process based on the evidence that you provided via the applications that you
made. It is now for this group to decide whether you continue with the process of
an application process, whether you go for an election process where the Senate
Assembly perhaps elects the members who will represent them and therefore the
wider clinical opinion, or whether we stick with some sort of nomination process.
The only bit of the Senate which is a standing group is the nominees from the
organisations which are the core of the Senate and those are mentioned here
basically, so the --VAUGHAN LEWIS: Page 4.
SUNITA BERRY: On page 4.
VAUGHAN LEWIS: Yes.
SUNITA BERRY: Everything else is up for grabs.
VAUGHAN LEWIS: Okay. Andrew, you had a question?
ANDREW SEYMOUR: Yes, thank you. Continuing on the operational
principle just look at page 6, the issues for deliberation and the bullet point says
that whilst the Clinical Senate membership should not be restricted to those
having a clinical basis, I just wondered what kind of discussions you would
consider might be discussed here which weren't clinical and why?
VAUGHAN LEWIS: I think this was, perhaps, an attempt to include sort of the
totality of care, including social care I suppose. So maybe we need to be more
explicit about that.
ANDREW SEYMOUR: Yes.
CAROLINE GAMLIN: So when we had a meeting on Senates and networks
back in September, for example, the CCGs were very keen to look at frail and
elderly. I think it's trying, as Vaughan says, to capture that. So it wouldn't just
be the clinical issues. Obviously, that's got much wider ramifications in terms of
social care.
VAUGHAN LEWIS: Geraint?
GERAINT DAY: Just one suggestion I think that might be useful internally and
in terms of communicating to the outside world is, perhaps, from existing NHS
England sources some sort of snapshot of what the range of Trust services and so
on across the South West of England is, on two or three pages, which would help
to identify gaps and non-gaps for all of us and then go forward to use that in
communicating with people who, for one reason or another, may or may not feel
unloved or under represented.
VAUGHAN LEWIS: Yes. Just briefly on the communication front, there is a
website under development. We have been slightly hamstrung by a diktat from
NHS England that we couldn't have our own website, though quite how they
envisage Senates communicating with both their membership and the wider
population is not clear. But that website is under development and will hopefully
go live early in the New Year in January.
Can I just, sorry, are there -- Guy, was that a scratch or a
question?
GUY ROONEY: Well, hopefully by the end of the day I will have some more
clarity. For me, I am still a little bit confused and I am hoping that later on I
won't be. There are certain things like the CRGs. They give advice to specialist
commissioners around specialist areas and there are members here who sit on
those CRGs and they are a collection of experts in that area. We are sort of
giving advice and I suppose my woolliness is where do those boundaries overlap?
What is our role in that advice? What is their role in that advice? If they are the
experts in their field and we are a hotchpotch of people who aren't experts in that
field technically, so I suppose I want clarity in that by the end of the day.
The other thing is you mentioned we give advice to
commissioners. We are very much talking about specialist commissioning here
and, you know, there are CCGs, there are the councils and I suppose at the end, as
you say, that's our feeling our way bit, but it's how do we give advice to CCGs
and are we going to give advice to one CCG because we feel they are not working
the same as everyone else or they have got localism now. That's the whole point
of CCGs.
So I suppose that's again more my dry paint wet paint bit. I'm
not quite sure in my head what it is going to look like and hopefully we will get
more idea of that by the end of the day. I'm not necessarily asking you to answer
that.
VAUGHAN LEWIS: I am not sure by the end of the day. I think that this is an
organisation in startup. I think if we're able to get clarity on ultimately what is
the absolute purpose of the Senate, the purpose of the Senate and the value of the
Senate will be determined by the advice that it gives. I don't think we are going
to be in a position at the end of today or the agenda today is geared towards
generating a set of principles that we will apply, particularly with reference to
specialist commissioning, and I think without wishing to -- well, what I am going
to do is actually defer that discussion to later on because Linda will lay out some
of the challenges and where we are with the number of derogations that each
organisation has requested against those service specifications.
Coming back to the CCGs, yes, I think our role is to give
advice. The idea is not to take questions from individuals CCGs, but to take
advice collectively. One of the subjects that has been raised by a number of
people is the whole issue of urgent care. Of course, we have already had what
many regard as a very successful re-configuration in terms of the major trauma
centres, but that's a small percentage of urgent care and the whole issue of how we
implement the recent Keyo statement on urgent care I think is one that I suspect
the Senate will be asked to look at. But the advice may apply more to some
CCGs than others, but I think the idea is that this is -- the HSJ sums this up in
their organagram of the new NHS structures. It talks about Senates as being
organisations that generate advice that commissioners would be ill-advised to
ignore. I am aware that doesn't absolutely answer your question.
Caroline, do you have a comment?
CAROLINE GAMLIN: I think hopefully by the end of the day both those
points will be a lot clearer. When we go through the specialised commissioning,
it will be clearer about the role of the CRG versus the role of the Senate and,
absolutely, the CCGs are the commissioners we need to work with in terms of
generating in the future the questions that we want to answer and we've got a
session on how do we actually receive, prioritise and agree the questions.
VAUGHAN LEWIS: Chris?
CHRIS BURTON: I am not clear from reading this or your conversation about
the relationship between the Assembly and the Council is we use the term "the
Senate" quite a lot in that conversation. What are we actually referring to?
Going back to the previous comments about getting people's voices in the room,
presumably the Assembly is a broader group of people. Do we have a mechanism
of getting their views into the room when we have our discussion?
VAUGHAN LEWIS: My view of this, and I think it's one shared by fellow
Chairs across England, is that the Assembly is there as a resource on which to
draw to answer specific questions and I think one of the most important functions
in generating the question is to map out the dependencies, so that those people
who are present at the meetings where the question is addressed are all those who
have a stakehold in that question, in that topic. So the Assembly is a resource.
There is no intention to try and gain consensus from the wider Assembly of the
output of Council meetings. Does that answer your question?
CHRIS BURTON: I think so, yes. I guess we will see as we go through how
the mechanics actually work.
VAUGHAN LEWIS: Would it help to articulate that more clearly in this
document?
CHRIS: I think so, because, yes, I have read it, yes.
VAUGHAN LEWIS: Yes, okay. Mark?
MARK CALLAWAY: I am not sure that that does answer the question I was
going to ask, which is very similar to Chris. I'm not clear on this relationship. If
I was a member - let me get this right - of the Assembly, I think I would be party
to all the decision making and I think one of the roles of today is we've got to
define how we ask the question, how we answer the question, what the time
course is, what the appeal mechanism is. And, you know, if the majority of the
Assembly Members were to disagree with the advice of the Council, where would
that look? Because if I was an Assembly Member and I got the groundswell of
opinion through communication that actually the advice of a considerable number
of people was at odds with what would be a small Council, where does that fit in?
And I am sitting here thinking, should we be looking it at, and this is detail I
know, but should we be looking at the Parliamentarian model where you have a
white/green paper and you see the Council very much as the Cabinet and the
Assembly is like the Parliament and that comes into play; not everyone is
involved all the time, but actually I think if I was a member of the Assembly
rather than the Council I would want my role really clearly defined, otherwise I
am not going to commit the time that is required to try and do this. And I think
that's really important because Mary's point about communication is incredibly
important. We have 140 self-nominated people around the region, which is a
high number who have committed to this process immediately and we have to
make sure that we engage those, because that's the first point of communication.
VAUGHAN LEWIS: Okay. Is it on the same subject because I think --WILLIAM HOUSE: It's on the general subject, but not that particular issue. I
am looking for a kind of allegorical story that would make sense of this
conversation to anybody in the country who doesn't have any kind of expertise
about health care at all. It may not be possible to do that, but I think it would be
helpful if we could, and I am thinking about archetypal roles in families and
communities.
At the moment what I am hearing is that we might turn out to
be a sort of grandparent role, who have been through it and made mistakes and
learnt some things and got some things right and the CCGs are the parents who
are actually having to look after the next generation and make their mistakes and
that may not be appropriate. But I think if we can think at that sort of level some
of the time, then actually that might be really useful.
VAUGHAN LEWIS: Yes. David?
DAVID HALPIN: I think there is always a danger of this sort of group of
involving lots of process and delaying actually making decisions. But having run
three NICE guideline groups, one of the real difficulties of a group like this is
actually getting everyone to agree on the day on wordings or opinions that they
actually buy into, and what we have ended up doing and it belongs to the process
slightly but in the end makes it easier I think is you have a meeting today; you
come up with a draft version; you and Sunita go and work on the wording and
that could then go out to the whole Senate and to this group for feedback. We
bring it back and then this group again agrees the final of it, but taking on board
the comments of the wider Senate and that gives us a chance to actually reflect on
the wording and make sure that we haven't missed something obvious in the
advice, but also then gives the others an opportunity if we have missed something
blindingly obvious in an area that we don't think about because it is not our field,
it's an opportunity for us not to get egg on our face. I know that means there is a
two level decision making process, but it might ultimately be safer for us.
VAUGHAN LEWIS: I would hope that from the output from today's
conversation that would be relatively non-controversial. I think the real challenge
for where it is about giving advice about particular services is that I anticipate that
the discussion will provide part of the context which will help understand the
advice and whether you can give the same context to people who are just reading
the outputs I don't know.
DAVID HALPIN: In NICE guidance again there is a section called "From
Advice to Recommendations" and it is a little bit of a narrative, a few bullet
points about why the group decided that this is what they decided and why they
ignored that particular study because they thought it was pretty good and you
could come up with something broad, but it doesn't have to be a long document,
just to help people understand how you got there.
VAUGHAN LEWIS: I think it would be absurd not to learn from other
decision making bodies like NICE, and although the advice we generate may not
be purely evidence based I think the principle is right.
SANJAY VYAS: Just going back to the issue of comms and the relationship
between Council and Senate. I get that the Assembly is bigger. It is a pool of
talent that we may draw on during our deliberations. But one of the other
advantages of having a wide pool of talent, and that comes back to geographical
and other kinds of spread, is that we can test our thinking against that pool as
well. So we might ask them for evidence, if you like, of fact during our
deliberations, but once we have reached a conclusion, I think that final conclusion
of the Council needs to be tested against another group and that I think will be
why the relationship between the Council and Assembly really has to be clearly
thought out and clearly written down, and I think we should reserve for ourselves
the option of re-drafting and fine tuning any advice that comes out once it has
been tested against the opinions of the Assembly before it is finally put out.
CAROLINE GAMLIN: I think if we are going to use the Assembly in that way,
I think we may need to consider or re-open applications for the Assembly. It is
quite skewed in terms of secondary care consultants and by geography down to
the peninsular. So if you are looking at our whole area, we cover up to the
Gloucestershire Wiltshire area. We had very far fewer applications from that
geography. So I am just sort of reflecting back. Are people happy to go with
130 people who self-nominated purely on their interest, or would you want to get
a more representative and geographical spread of both professions and bodies?
MARY BACKHOUSE: I am really conscious we are incredibly doctor
dominated in this room. There is a whole body of nurses out there who have got
more representation.
VAUGHAN LEWIS: Yes, and if we are saying that we are representational,
then we are secondary care versus primary care skewed, leaving aside the
geographical maldistribution.
NEW SPEAKER: I'm not intending to be alarmist, but could you envisage the
situation where somebody takes such exception to the advice of this group that
they would take it to judicial review? I think if that is a possibility, I think we
need to have a very, very clear process which is laid out prospectively.
VAUGHAN LEWIS: So that the --NEW SPEAKER: So no matter whether your decision is right or wrong or that
the advice from the group was right or wrong, there has been a very clear process
which we have followed to get to; and as long as the process is reasonable then the
advice will stand.
VIRGINIA PEARSON: Can we just clarify that it is advice. It is not a
decision. So you couldn't have a judicial review of advice. It would be the local
organisation that was taking the advice that would be subject to judicial review,
but it probably would be called in by scrutiny first.
VAUGHAN LEWIS: So, yes. I think I was going to make the same point.
Shona?
SHONA ARORA: That is true, but if you think it through it will very quickly
throw into light the quality of the advice and therefore, if you like, the reputation
of the role of the whole Senate process. So I think if you think that through, the
decisions are made on the advice given here, then we have to be able to provide
assurance to the people we are giving out that advice that it has been made in an
objective and sensible way and actually I think that links into the membership
point as well.
Secondly, we need to recognise that actually we might not be
helping colleagues or commissioners to make those difficult decisions and get
through them if we cannot provide them with that assurance, and I think it will
then throw sharply into what is the purpose of the Senate in terms of being a
source or a guardian of objective evidence based advice.
VAUGHAN LEWIS: One of the problems is that because of the lack of clarity
from the centre of exactly where Senates sit, exactly what the role of Senates are,
I think there is this element, as I said at the outset, of us making it up as we go
along, because we have no option but to do that; and as we sit here now there are
discussions around rewriting section 75 of the Health Act to break down some of
the barriers, some of the competition law barriers. NHS England have yet, I
think, to issue the final version of the re-configuration paper which very clearly
lays out the processes that need to be followed leading up to re-configuration,
which comes back to Virginia's point around the role of the overseeing and
scrutiny committee.
So we are living in a very uncertain NHS architecture. While
those at the top in terms of medical leadership are very quick to point out that at
no time before have there ever been so many clinicians in leadership roles in the
NHS, actually, in terms of a structure and the function of the various different
elements, we have an unprecedented pressure around the Nicholson challenge and
I think there is a general view that that can only be met by re-configuration, yet
very little either political or legal or structural air cover to support that.
SHONA ARORA: That's where actually the judicial review puts it back an
awfully long way if you get from that and the other thing I was going to add
under "Values" I think we probably do need to put something down about
equalities, because not paying due regard to equalities in the advice that we give is
actually a real potential source of, well, if that's the right thing to do, it is also
quite a source of JR.
VAUGHAN LEWIS: I will take some more questions in a second. I am
conscious of the timings and I am not sure I particularly like agendas with timings
on them. But we will aim for 11.30 for a break. I do want to steer the
conversation at some point on to the process and probably allow at least 15 to 20
minutes for the process of receiving, prioritising and agreeing questions because I
think that's important. But I think section 5 around summary and questions we
are probably in that at the moment. So if we carry on this discussion for another
five or so minutes. David, you had a point?
DAVID HALPIN: Just a brief point to build on, in that we are an evolving
organisation and what Sunita was saying about membership I think it would be
really a mistake to have everybody rotating at the same time. So I think in the
duration of membership there does need to be, perhaps, a third replaced every so
often, so that there is some corporate memory of how we have got to where we
have got to.
VAUGHAN LEWIS: Thanks. Andrew?
ANDREW SEYMOUR: Another quick word about what membership means
and whether we are representatives or members and looking at this. The only
word of representation is geographical representation, which I will accept, but in
terms of membership of our organisations we are not representing CCGs or acute
trusts. You have to remember that we are clinicians, you know, essentially and
that's the representation aspect.
VAUGHAN LEWIS: We are here as professional experts, yes. Peter?
PETER DAVIS: That comes back to, again, I think one of the things I am not
clear about, and I think it's fairly dry paint and wet paint, is what are we actually
being asked to do? What is the expectation from commissioners in terms of when
they ask the questions and that's why I was trying to say that having some very
clear guiding principles, whether it be equality, equity, all those kinds of things, is
that when your decisions are put to some degree of scrutiny you can say, well,
actually, no, we didn't have a specific expert on this field, but we judged it as
experts overall based on these very clear principles that we are all agreed on as to
why we were looking at this particular service in this particular way; because
there is no way, given all the complexity of the specialist services that we are
dealing with here, that we can get all those experts together, but we can put some
quite clear principles on those that we can then agree and feed back as advice.
VAUGHAN LEWIS: Sunita?
SUNITA BERRY: I think it may not be particularly well articulated here, but
the strength of the Senate lies in its breadth rather than its specialism. It's about
finding the ability to get the breadth of the professional opinion on what can be
quite specialist services sometimes and very broad services at other times. So the
idea is to bring the breadth of professional opinion to the table here.
VAUGHAN LEWIS: Chris?
CHRIS BURTON: I am not entirely sure where we are on the agenda, but on
3.2 you have public attendance at Senate Council for discussion. In the principles
you have got "The deliberative session will be held in camera", which I presume
means excludes the public, although I am not sure that would be in the principles
if we are going to be the transparent world that we are in.
VAUGHAN LEWIS: It is there almost to raise it as a discussion point about
how we should approach the challenge of holding these meetings in public. Now,
of course, they will never be public meetings, but they may be as many Trust
Board meetings now are meetings held in public. I think there is a challenge
around, because of the passions, the level of interest, certainly around
re-configuration, there is a real danger I think that we would be -- that the
meetings could be almost unmanageable and I think that this is what I wanted to
talk about under that section was how do we ensure transparency? Is it about
holding the meetings in camera? Is it about recording them verbatim with a
stenographer? Or should we identify a venue where we could reasonably expect
interested members of the public to attend?
MARY BACKHOUSE: We have a number of HealthWatch members in the
room. It would be really interesting to hear their views.
VAUGHAN LEWIS: I agree.
CHRISTINE TELLER: I am all for transparency. I think you actually organise
the meetings on the basis that you are going to be almost publicly scrutinised
when you have your deliberations. That would be my gut feeling.
VAUGHAN LEWIS: Which you mean we would publicise the meetings and we
would have a certain number of seats available for interested --CHRISTINE TELLER: I think, yes, if you start restricting it I think you have a
problem. I mean, I think the reality is that people will self-restrict in a sense and
I don't think that that would be necessarily a problem. If it was a problem, then
you would have to review it and you would have to set up some new sort of rules,
if you like. But I think that the unmanageable bit I am not quite sure where you
feel that that would -- how that would emerge or whether it would emerge. I
think that you will actually have systems whereby if you are going to have
interaction from the public, then you actually have that fairly well managed and
organised in terms of what the public are bringing to it. You would be aware
before, for example, the meeting starts, you know, before you have it. But I
think to start saying that you restrict it, I am wondering why you would want it in
camera actually. What issues are you going to discuss which are so secret that you
can't have it in public?
VAUGHAN LEWIS: I have to say I am not sure I did particularly want it in
camera. But I was very conscious that it needed to be open; it needed to be in the
public domain and really the purpose of putting the agenda item on was to gauge
what others' thoughts were about how best to achieve that.
Paul?
PAUL WINTERBOTTOM: Some of the things that we could potentially be
discussing in the Senate, in the Council, do have a commercial consequence and if
we are to provide advice for commissioners at an appropriate juncture perhaps
when they aren't ready to undertake a consultation process, then there is going to
be a real challenge that we set a number of hares running. I sympathise with the
arguments about transparency, but I am a little concerned that if we are to act as a
resource for a health and social care community, which is faced with the challenge
about re-configuring to make best use of the resources that are available to us,
then I think we necessarily have to provide some oversight and input and at a
point when ideas are not fully developed and perhaps communities aren't
necessarily ready to receive them because all the spade work hasn't been
undertaken. For that reason, I do think we have to think about how we marry
public scrutiny of that with work that can be managed discretely to provide the
appropriate advice at an appropriate juncture.
PATRICK CANAVAN: But who decides that?
SUNITA BERRY: I hope that you might be part in helping us understand what
we would be in the process of decision.
PATRICK CANAVAN: I'm sorry but I didn't hear that.
SUNITA BERRY: I said I hope that you would be part of helping us make that
leap, if you like, of who decides. That's the part of the discussion which is why
we hope HealthWatch --PATRICK CANAVAN: I think the gentleman at the end wants to come in.
VAUGHAN LEWIS: Sorry, can I just come back to you, Patrick? In your role
in HealthWatch, is your view the same as Christine's?
PATRICK CANAVAN: Absolutely, absolutely, yes. And the point about this,
you know, initial kind of forming of ideas is simply not valid. If you put a
member of the public in this room I dread to think what they think of this
conversation that has been taking place so far. What it seems to us is the public
wants to be able to have some say in the who, what, where, when and how of the
services that affect them. So if you are doing anything at any stage anywhere
which may have an impact or shape the way in which the services are delivered,
the public has a right to have some input into that; and it is not about the medical
profession forming initial views, which are then disseminated to the public. The
public has to be involved from the outset, because if they are not, it is not
transparent and that essential ingredient of the NHS constitution about "No
decisions about me without me" is simply not being met.
VAUGHAN LEWIS: There wasn't for a second at the outset any intention of
holding these meetings or of excluding public representation in the decision
making and reflecting on what other Senates are doing in terms of public
engagement, we may not be leading on this, but we are certainly well ahead of
most of the other Senates in terms of our PPB strategy. But I think very clearly
the message that I am getting, other than that one dissenting voice, I think I am
hearing very strongly that we should be holding the meetings in public and the
advice that we generate should be open, should be widely available once it has
been agreed.
There are a number of other questions. David, I think you
were first?
DAVID HALPIN: Yes. Again, I think there is a lesson that could be learned,
perhaps, from the NICE technology appraisal process, where the evidence
gathering part of the meeting is held in public and I think the public has the right
to hear the evidence that has been presented and to criticise if they think it's
distorted. I think there is a danger in some areas that the decision making process
could be biased by a degree of intimidation from the public being present and
there is as much risk of distortion there. So what NICE does is having heard all
the evidence, the meeting then goes into camera to form its opinion and I think
that a split like that would not necessarily be a bad thing in a meeting like that,
because this group is constituted to give the expert advice of this group, and the
process to take notice of what lots of other people and experts think. But
ultimately it is for this group to make the decision and I think if that decision
making process was in danger of being influenced by the other people in the room
and being part of it, that would weaken its role as well.
VAUGHAN LEWIS: Okay. Liz?
LIZ TOY: Fairly similar point to David's in that we are predominantly a
clinical advisory group providing opinion to commissioners, not expert opinion,
so I would favour rather it being an open public discussion; the observation that
we see it where people are welcome to observe the discussion, but we will need to
have done some background work beforehand because that point of consulting our
Assembly Members to come to the Council and then for the Council to assimilate,
that may be an appropriate group to be observed by the public, but some of the
ground work needs to be done first. But I agree with David, not for the members
of the public who have their own voice at overview and scrutiny level and also the
citizens' bureau to be able to add in questions, into what is going to be a pretty
busy agenda of what we are trying to achieve.
VAUGHAN LEWIS: I will take Paul's clear response to that and then pick up
those other two questions.
PAUL WINTERBOTTOM: I think the issue that I want to raise is where are we
going to get the subjects from for our consideration? Because if I am a
commissioner and I am looking at any re-configuration of service, I am only
going to share that with this group at the point I really worked that up and I am
ready to engage the public. So if we do make a decision that we are only going to
undertake our work entirely transparently and openly and understand the thinking
around that, then that means that we are only going to get presented to us
opportunities to influence that have already been thoroughly bottomed out because
no one is going to do anything else. They can't afford that lack of management of
the situation. So we miss an opportunity to influence early on, would be my only
observation.
CHRISTINE TELLER: Could I just respond briefly to that, because the tenor
of the discussion is coming across somewhat as a sort of us and them and there is
a threat sort of proposed by the members of the public. I would like to feel -- I
mean, that may not be where it's coming from, but it's presenting as that to my
ears -- actually I would like us to be able to move forward to the point where it is
not a free for all, and that's another thing which is coming through, but it's
actually some sort of notion of partnership here and good communication and
information between something like this body and wider members of the public.
My own view, having sat on a number of committees, boards
and all sorts of things over the years which are open to the public, is that they are
very orderly. They add value actually with the public coming in and making
comments as long as it is well managed and that it is not a detracting sort of
aspect of any meetings. So I just want to throw that in really.
VAUGHAN LEWIS: Okay. William and then Peter?
WILLIAM HOUSE: Although I learned medics and spent my life being a
medic, I now spend most of my time in community development, so I work
directly with the community in a non-clinical non-medical setting, and I've come
to be so impressed by what ordinary people can understand in terms of quite
difficult concepts. I think it's particularly important that they are there at the
discussion stage when you are trying to think about what to talk about, the
assumptions they, I think, will want to hear, the assumptions that are being made
implicitly that often we experts don't realise we are making.
So I want to make a really strong case for having the public
there or the opportunity for the public to be there, and I think it's very important.
VAUGHAN LEWIS: And should we do that by holding Council meetings in
public or should we do that by getting a better balance of HealthWatch
representatives and professionals around the table?
CHRIS BURTON: We are confusing the two issues. We are confusing the two
issues. It is very, very important that we engage with the public in the decisions
that get made, in the way we make those decisions. We have a public voice. We
have got membership of the Council that helps us with that. We will want
something broader than that and there's a whole statutory consultation process that
is likely to have to take place around any re-configuration that takes place, so
that's engagement with the public.
That, for me, is something that is quite different to holding
your meetings in a transparent and public forum. So our Trust Board, for
example, is held in public, and so members of the public can come and sit in the
Board. It's usually immensely boring and hardly anyone turns up, but it's there;
the minutes are in public. It's available. We have a private session in which we
can put those things that we have decided are commercially and confidential too,
for example, but the default is it's in public unless someone has made a very clear
case that it has to be held in private. I take the view that we are very senior
public servants sat in this room and we ought to be prepared to have our
conversation where it can be seen by the public who pay our salaries.
VAUGHAN LEWIS: Peter?
PETER DAVIS: I think there are two elements to this and I share some of
Paul's concerns, only I wear the scars of sustainable paediatric cardiac surgery not
quite like a badge of honour, but I went to some of those meetings and they were
almost impossible to manage; almost impossible to manage. And if we are talking
about re-configuration, it is going to raise some very strong passion amongst
members of the public and this comes back to: Where do we sit?
My argument is that this is an advisory group. It takes
information and it is absolutely clear that the public should be involved in some
of those discussions about what advice goes in. But this comes back to what are
the principles going to be on which we make our decisions. The public feed into
that, but I don't necessarily think that it is a broad public path of the Clinical
Senate. I don't understand what the Clinical Senate is then if it has not got a
separate role. Otherwise, as Chris says, why have all the other bits of public
engagement if you are doing the public engagement through the Clinical Senate?
I don't quite see how that fits together.
I perceived, when I originally saw this developed 12 months
ago, that this would be an advisory group of the great and the good taking a wider
view, but applying principles to those kinds of decisions. They would take in as
much information as they could from all sectors, but then would provide advice
based on some clear principles that would then go forward. That can all be laid
out in public and you can go through how those decisions are made and did you
abide by your principles, but I think trying to organise a meeting where you may
have 300, 400 people to make decisions - no, that is not a good way to go
forward. And that is what we are risking, because the re-configuration questions
that we are going to be faced with are going to be potentially controversial.
So we need to be very clear about how we are coming up with
those bits of advice, but we also need to be very clear how we get the information
on which we are going to provide that advice.
VAUGHAN LEWIS: Okay. Philip?
PHILIP YATES: My point would be alongside David's. I think if we need to
think about the potential for distortion of our debate, if we felt, for example, that
the press were likely to be reporting on the deliberations before we even formed a
view and that could actually impede the quality of openness of our discussion, that
would help us form the right view.
So I think, like Chris was saying, our PCT meetings which I
was involved with were actually largely in open session, but they had a session
where there was some deliberation of the more sensitive issues, not because we
were trying to hide the issues but you have got to manage the output that goes out
into the press and the wider world, which could otherwise actually distort your
debate.
VAUGHAN LEWIS: Shelagh, did you have a point?
SHELAGH McCORMICK: It sounds like we are getting a bit confused about
what the role of the public would be if we did decide to include them. Would it
be as witnesses, who then had an opportunity to ask questions at a specific time,
which is my understanding rather than them being able to contribute in a broader
forum which would be very difficult to manage.
VAUGHAN LEWIS: Thank you. I think that we could probably carry on this
subject for a lot longer. I think we need to draw it to a close. What I think the
challenge that we have got as the core team is to try and pull those various strands
of conversation together and work particularly on this area of public participation
with the HealthWatch representatives to come up with what I hope will be a
consensus in a revised terms of reference -- sorry, in a revised operating
principles.
What I would like to do, with respect to the terms of reference
and the operating principles, is to turn this around and then to get this out to all
those who have attended here for approval, well, ideally over the Christmas break.
Caroline, can I hand over to you just to move us on to talk about the process for
receiving, prioritising and agreeing questions?
CAROLINE GAMLIN: Yes. So, so far how have we tried to approach the
questions? The questions, as we understand it, are supposed to come from
commissioners. We had a meeting in early September where we had a day on
strategic clinical networks and Senates and we had very good attendance there,
quite a lot of the CCGs and the Trusts and social care again attended. One of the
sessions there was we did try to look at and formulate early questions for the
Senate and, hence, that is how we came up with some discussions around
specialised commissioning and certainly the people were very keen to explore
things like frail and elderly and urgent care.
I think the questions for us as a Senate are: (1) Who can ask a
question of the Senate? (2) When we get those questions, how do we actually
formulate it into something that is useful? So clearly the topic of urgent care or
frail and elderly isn't going to help unless we have a specific question that
commissioners want us to help answer. Then, thirdly, how do we sort of
prioritise the work plan? So if we get four people saying, "I really need this
question", how might we prioritise that in terms of the work of the Senate?
So, so far we have got the general principles today which we
thought would be helpful in further discussions in terms of specialised
commissioning. The HIV question came out of the discussion around the
derogation and we thought that might be a good topic to tackle because it brings
in the social care aspects, as well as health, and also might give us an answer to
something that we actually needed from specialised commissioning and the third
topic we have been approached was around spinal surgery.
So, really the general principles were specialised
commissioning, HIV, spinal surgery and then these big questions about urgent
care, frail and elderly, which we haven't actually framed a specific question, but
just a high level topic is all that we have received so far.
So really we welcome your views about (1) how do get the
questions in; (2) how do we decide what the specific question is that we can give
helpful advice to commissioners on and, (3), how would we prioritise our work
plan? I recognise it is nearly coffee time. So we have only got a few minutes to
think about that.
VAUGHAN LEWIS: Thank you. Jenny?
JENNY WINSLADE: I think it's really helpful because I think, certainly in my
CCG, there is a bit of confusion about where the discussion is best held. So what
is the role of the network, what is the role of the HSM, what is the role of the
Senate and in some ways we almost need to map out what our role is in
communicating that. So I think commissioners understand a bit better about the
added value of asking a question of the Senate.
I think the other thing is that I would caution a little bit with
urgent care and frail and elderly, because I think everybody wants a piece of that
and, actually, we really do need to hone down the question because there are lots
of people doing lots of work on those two questions and actually if we are going
to add some value, we need to have a very specific question about what to
understand about those areas.
CAROLINE GAMLIN: Yes.
VAUGHAN LEWIS: Liz?
LIZ TOY: Can I ask a question about how horizon scanning might come into
that arena? For instance, I know it's a personal interest, but the Neuberger review
that's currently the end of life strategy group we know are going to come out with
ten outcomes, which the commissioners are going to be commissioning against .
We know that's likely to be coming out in February. That seems an ideal area for
us to maybe provide some clinical guidance because what they put out isn't going
to be particularly specific, and that is an area that the clinical advisory group I
think could plan into if the commissioners felt they wanted to liaise with us over
that. So there are going to be things year on year which are going to be national
policy in the NHS mandate and how does that horizon scan fit into what we are
doing?
VIRGINIA PEARSON: I was going to build on what Jenny was saying actually.
I think that the specificity, so clarity around the group, but the specificity of the
scope is really important. The integration and translation fund that is being
broadly set up between health and social care - this is the 3.8 billion transfer from
the NHS to social care - will require major re-configuration of probably acute
hospital services to create that fund and that is in line with bringing services out
into the community. I think everybody's working very hard at the moment to
create the initial plans, but over the next 12 months there is going to be a massive
pressure on clinical commissioning groups to start to think about how they are
going to release that funding; and if you have something that is too broad, then
every single clinical commissioning group in the whole of the South West will be
wanting the Senate's advice on their integration transformation fund programme.
So I think it is probably best to think about honing it down to
specific clinical areas and keeping it as narrowly focused as possible; otherwise, I
think there will be a huge mass of stuff that will come in the direction of this
Senate and I don't think it will be possible to deal with it. So I just think maybe
trying to think about that in the early stages and it may be that that comes, but
using that experience then to build up the expertise who you need to do those
much broader multi-system multi-commissioner reviews.
VAUGHAN LEWIS: Yes, and I think the issue of resources is a really
important one. My role is remunerated to the tune of one day a week. The
Senate Manager is 0.6 whole time equivalent and we have a bit of Sunita. Then
there is some admin support. It is not a big resource. It is not geared to deal with
all of the possible questions and therefore I think there's a consensus that we need
to be really focused on the questions.
Mary?
MARY BACKHOUSE: I am sitting here with my commissioning hat on at the
moment and just thinking I don't know if you realise how onerous it's going to be
over the next few months actually developing a five year plan with a lot of detail
for the two years. All the organisations which we as clinical commissioners
already locally have to go through in terms of our membership, in terms of
HealthWatch and in terms of our health and well-being board, and the speed at
which actually we are going to have to do that. What is going to come out in the
operating framework next week we don't altogether know, but I have seen some
of the early signs of that and we are going to have to go out and consult with our
providers about outcomes.
So, I think I very much agree with Virginia. It's how can we
do the very high level big system stuff, rather than expecting necessarily the local,
unless there is something very particular --VIRGINIA PEARSON: It's less political as well. I think that's the other thing
is to keep it as high level and focused as possible; otherwise, there is a danger of
getting drawn into local politics and I think it's going to be really difficult for
clinical commissioning groups around this and for providers.
VAUGHAN LEWIS: Okay, I am conscious of time. Thank you very much
indeed to everybody who has contributed to that. I am certainly left daunted by
the task now, both of the Senate and even before we get there, of refining the
operating principles document to try and reflect those really helpful discussions.
Can we be back seated again by five to and then we will go
into the part of the meeting which will start off with the presentation of the
specialist commissioning process to date by Linda. Sorry, Sunita?
SUNITA BERRY: Just one thing - I'd quite like to go through the quorum
question, very quickly and very briefly, if you wanted to be 50% as quorate or
more than that? It is just a quick numbers thing. 60, 50? What would you like?
50?
VAUGHAN LEWIS: 50, yes. {Laughter}. I would have thought 50% of this
group would be still quite considerable.
(Short break)
(12.00pm)
VAUGHAN LEWIS: Okay. Thank you very much for coming back!
{Laughter}. I am delighted in two ways, both to welcome Linda but also to take
the focus off me for a little bit! {Laughter}.
I think the good conversation we have had this morning has
been incredibly helpful and, as I said in summing up, in the end I really do hope
that we can encapsulate that and come up with a revision to the documents that
reflects or that arrives at a consensus that reflects that conversation.
So, Linda, over to you. You're jointly billed with Steve who I
don't think is here.
LINDA PROSSER: I have lost Steve, but I have gained Debbie, who is going
to correct me if I state any matters of fact inaccurately.
VAUGHAN LEWIS: Over to you.
LINDA PROSSER: So in the hope that actually getting into a piece of work
helps to sort of gather some momentum and some understanding of the purpose
and the potential of the Senate and then potentially help you to answer some of
those questions you were wrestling with earlier, it seems timely to present this as a
question to the Senate. So it is a little bit of background. It's in your packs, but I
am just going to summarise what we have put in the packs because it is sometimes
a bit tricky to unravel.
So, specialised commissioning is undertaken by the area team
of NHS England which is based in Bristol, of which I am the director of
commissioning. So we have an £800 million budget to buy all the specialised
services across the South West, which includes things like brain surgery, cleft lip
and pallet, cystic fibrosis, very high cost cancer drugs, all of that sort of thing.
Anything that really, really doesn't make sense for the CCG to commission
because you need a population base of five million to get the critical mass.
We do that as part of a national team. This is where there has
been quite a shift in specialised commissioning since last year in that there is a
single operating model and a single set of specifications and access criteria across
the country. So that is about making it equal. I think our task is about making it
equitable, so that somebody tells us what to do and we have to decide how we do
it for this patch, and one thing that we have already articulated - Vaughan has
done so very nicely - is the uniqueness of the geography which does present the
challenges to us that other people don't have.
So, as part of the process of getting that single operating model
and the single policies across the country, we published 120 specifications in July
and the Trust have subsequently assessed themselves against those with three
outcomes. One is that we are compliant - actually that we had to be compliant
from the 1st October. One is that we are never going to be compliant so we want
to get out; and the other is that we want to apply for something that's called
"derogation", which actually means a period of an action plan to close the gap.
So it is slightly I think an unhelpful word, but it actually means a period of grace
to become compliant.
The situation we are at, at the moment, is that we have still
got, out of about what is the original thousand specifications that came in, so 120
times 30 providers but not everybody does everything - there were about a
thousand. We still have about a hundred that are outstanding where the action
plans don't really quite demonstrate that the service will be compliant by sort of
April time. Some of those applications can go on longer than that, but we are
trying to get people to a place of being compliant as soon as possible.
So, the providers - we validated those initial assessments by
using the strategic clinical networks and local CCGs, had conversations there to
make sure we have got the best intelligence we can about these specifications and
the level of compliance and we are working with the CCGs as well around how
we take forward the engagement with wider stakeholders.
Quickly on our emerging findings - on the whole, the
independent mental health providers are compliant and I think that just reflects the
specificity of their nature. They do, you know, they do the few things well. It is
where we have got acute trusts and DGHs that are doing a lot of things which then
their ability to meet the specifications immediately has been where we have got
work to do. But noting - and I think this will be a key thing for us to understand
- that there's the hubs. If you think about the big centres, on the whole they are
compliant and we specified for them but we didn't specify for what the spokes,
what supporting local services should and could be doing. So there is a lot more
work going on nationally now about defining what a spoke service should look
like. So some of our areas of derogation are where you have got a small DGH
that's providing part of the service and probably doing that bit okay, but can't
comply with the whole thing. So, there is some definition stuff there.
I think one of the things that we need to remember is that just
because a service is compliant doesn't mean that it is right or that it is sustainable
for the future and it might be at a point in time. So it might be that to keep it
compliant in a certain hospital is pretty resource intensive and that might not be
where we want to stay. So, one of the things I want to convey is that some of the
questions that we will need to answer ultimately about where we do specialise
services will be about where a service can't be compliant, but it might also be
where it might not be compliant in the future. So it is an ongoing discourse
basically. Clearly the providers that are going to be at the vulnerable end of this
are the smaller DGHs and we will talk more about that in a minute.
So, the actual services where there is a sort of, and there is a
paper, you have two sides of A4 that lists this in a bit more detail, but we haven't
got to the point with all the providers where we haven't got an absolute list of
their services that are going to need to be looked at, because we are still waiting
for the action plans to come in. So that's why the information you have got is
still relatively high level and won't give you a list by hospital of what the issues
are. We should get to that place in January, but we are just not there yet.
But, as you would expect, there are issues across the whole
South West in achieving standards for children's services and that is mostly about
economies of scale. There are also some issues in some cardiac services which
took us a little bit by surprise, but mostly about 24/7 PCI coverage - the PPCI
coverage - emergency vascular sort of triple A surgery and things like that. We
knew that was going to be an issue because, in fact, that's something that is a
hangover from last year and actually we are making good progress on that. But,
you know, we haven't entirely arrived.
So cancer is a really common theme and those of you that have
been working in these worlds before will understand some of the heat and noise
around delivering IOGs in the past and this actually resurrects some of the
questions that are raised by the specification and resurrects some of the questions
that IOGs kind of worked around. So where you have got some cancer services in
smaller hospitals that were kind of made just about okay to comply with IOG IOG is Improving Outcome Guidance, it is the previous form of specification we might have to re-open some CAMHS sadly.
Spinal surgery is an issue across the region, actually partly
because of capacity, so maybe that we have got not enough capacity in that area.
Severe asthma is seen as a thing for lots of people which I don't think we have got
to, well, I haven't got to a point of really understanding that yet; and some
services, as I say, where there are lots of providers, where it is either people
providing part of the pathway or we have got too many providers.
So, if I just then go by CCGs and, well, by area really.
Everybody's going to have issues around children's services; everybody is going to
have issues around cancer; everybody is going to have issues around neuro rehab.
Gloucestershire, Swindon and Wiltshire had some cardiac issues and in Devon,
Cornwall and Isles of Scilly that's where the cancer stuff really comes through in
terms of what I have just talked about. For BNSSSG it's mostly going to be
about the health of future works, what happens between the two main hospitals
and should things move and is there duplication that could still come out.
So, a lot of this is driven by the number of cases that you have
to -- a lot of the specifications are specific about the number of cases that an
individual surgeon or unit has to do to remain to be compliant. So that's easy
maths then to work out, you know, what population base yields the number of
cases and therefore how many units we should have compared to what we have
got.
So, the things that we want to consider today, the things that
there are implications are these: What do we need to understand about provider
impact? What is going to tip the balance for providers and/or critical services
within a provider or a town? How do we take account of that? What is the role
of the spoke versus the hub? So what can we do to retain services as locally and
at high standard as possible? And what is the relationship with the hub? In
particular, should we focus particularly on the remote pockets of our population?
Perhaps Cornwall isn't a pocket, but you know what I mean, there are parts of
Wiltshire which are more of a pocket, but obviously Cornwall is very remote.
Because of this process, we haven't got a steady stream of decisions to make.
There is going to be a kind of big bone of decisions that need to be made all at
once and how do we decide where to put our energy and which decisions to make
and who should be providers of what.
So, we absolutely need the clinical leadership around, you
know, where we need to look at the numbers of services required and to take a
long-term view, and this comes back partly to the earlier conversation, and the
question is about demonstrating the value to the population of the change in
service. How do we get the message across? How do we ensure that our
decisions are understood and that they are about good quality services?
So, there is going to need to be some changes. There is going
to need to be some decisions made, and those factors are the things that we want
some advice from, from the Senate. So hence the question which you have got in
front of you, but I am just going to state the question now - the question is: In
order to deliver excellent care which complies with NHS England service
specifications, what are the principles which the South West Clinical Senate
proposes that specialised commissioning should consider?
Shall I just pause to ensure that people have grasped the
context and what is being asked? Any questions? Yes?
GUY ROONEY: Your earlier slide about some of the things that influence it,
speaking as a provider that sits on the edge of the South West --VAUGHAN LEWIS: Sorry, but can you speak up a bit please?
GUY ROONEY: Speaking as a provider on the edge of the South West, some
of our spoke hub stuff is going outside the South West. So sometimes when we
are making decisions so, for example, I work in Swindon, it's part of Thames
Valley Cancer Network, so in fact we work all with that, but some of our
decisions are now being made in the South West and it will be other services on
the edges of other areas like Salisbury and Southampton --LINDA PROSSER: I think your colleagues in Gloucestershire and Wiltshire
would -- exactly, so --GUY ROONEY: And there is another factor in the implication in terms of how
decisions are made or advice is given.
LINDA PROSSER: Yes, there is a boundary and we need to face issues with
our colleagues; I completely agree.
VAUGHAN LEWIS: I think we also have the challenge in the South West of
having a significant population within an hour in Wales, with whom we have very
few working relationships. Ann?
ANN MILLAR: Can I just ask --VAUGHAN LEWIS: Can you speak up, please?
ANN MILLAR: One of the things I am not quite clear about is the role, I think
what you termed clinical leadership, to actual commissioning decisions; because
the fact is that you can't, I mean, you can't have specialist services and everything
within a mile of every patient. It just doesn't work. And there are difficult
decisions to be made, because in some way the specialist services are going to
have to be localised and that's going to cause consternation, as you have described,
and I am just trying to work out exactly who is going to make that decision and
how, because clinicians can say, "These are the criteria" as you have already got
for saying this should be a specialist service or this shouldn't, but there are going
to be other issues about hospitals wanting to keep their services locally and
inevitably, you know, if I was a patient in the Isles of Scilly ideally I would want
that special service to be on the Isles of Scilly, but it would be tricky to get that.
LINDA PROSSER: If we think about decision making as a process, I mean,
ultimately the decision is taken actually at, I would argue, health and well-being
and hospital level -- so health and well-being level -- so we will make
recommendations as commissioners. The actual decision making process requires
that we can justify the recommendation that we are making and I think that
process of justification starts with a very broad filter of information and advice;
some principles that we talk about here and now that filter that information into
some key, the key bits of information that drive our recommendations.
So, I am really tempted to get into an example, but I think that
will be dangerous because I think that will predetermine the discussion you are
about to have. Sunita, where is she? Are we going to talk now about how we are
going to do the next stage? Do you want me to do that?
SUNITA BERRY: Yes. So all of you have got name badges with a colour code
on it. That has been done to split you up into groups which will be happening
next door. So, as soon as Linda is finished, we will all be going next door and
sitting at tables with the colour code or shape code that you have. We then are
going to go through a hypothetical scenario which will help us arrive at some of
the principles that we need to discuss. So that's the process, if you like, of the
next steps.
LINDA PROSSER: The reason we have made up a clinical condition and
written a scenario about it and the reason that we have done that is that so nobody
is disadvantaged or advantaged by having some sort of expert knowledge about it.
So do you want to --DAVID HALPIN: Perhaps it is what comes into the discussion as well, but I
think from my perspective it is fundamentally important about the implementation
of this and that's about how the commissioning process will follow. So is it going
to be commissioning infrastructure that's irrespective of patient volumes, or is it
going to be about money flowing with patients and sort of BBR type? Because I
think how you structure your service will, to a very large extent, depend on
whether you have got security of funding or whether it's attracting business and I
think that's fairly fundamental. And also what has happened with CF where there
is a principle, but actually the reality of the money following that principle has
been a real nightmare and how we can actually work that through.
LINDA PROSSER: Yes, and I think that should be one of the principles that
comes out and I think our working assumption has been the money should follow
the patient. It would be useful to have that endorsed.
DAVID HALPIN: In terms of budgets you have got £800 million, or whatever
you said. Has that already been carved up into each of the areas or is --LINDA PROSSER: We are spending 830!
DAVID HALPIN: Has that been assessed because that, again, knowing how you
design your service depends on how much money is available to support it?
LINDA PROSSER: So the budget is based on historical spend. So, we have
inherited what we are doing. This is now about shaping the future.
SUNITA BERRY: I have one other thing to say. Each of the members of the
CRGs have been allocated to a table. So it might be helpful while you're at the
table to perhaps just quickly describe what being a member of the CRG has meant
for you, because I think that will help shape the discussions in establishing some
of those principles, okay?
LINDA PROSSER: So if there are no more questions of sort of understanding,
then let's go.
(12.25 pm to 1pm break-out groups).
(Lunch Break)
Afternoon Session.
(2.00pm)
**(Please note that where “NEW SPEAKER” appears it is because the
Stenographer was unsure of the speaker’s name as there were no name plates
on the tables for the afternoon session, and due to the size of the room it was
very difficult to hear the people at the far end as there was no roving
microphone.)**
CAROLINE GAMLIN: Thank you for all coming back after lunch. I can't wait
to hear what the tables have all come up with because there was a lot of
discussion.
What we are going to do now is try and collate all the
principles that people have come up with from each of the tables and then there
will be an opportunity for each individual person here to prioritise their top five,
well, to vote for your top five principles so we will try and rank them.
So if I start at the back and go round and just ask for one
principle from each table. Obviously, if you hear the principle, then can give us a
different one. Sue and Rebecca are going to be writing them and we have also
got Mirella, who is writing it all up on the screen as well.
So, at the end you will be able to vote on the pieces of paper.
If I start at the back?
VAUGHAN LEWIS: I think, as I said at the outset, what we don't want to do is
to replicate the principles that are already there, that are there in the
commissioning documents. So, you know, the commissioning board talks about
or NHS England talks about patient centred, outcome based, delivering improved
outcomes across each of the five domains. That is the motherhood and apple pie
of commissioning; that is not negotiable. The national role is defining what the
local function is delivering and how, and there are a number of principles which
define how we do it, which are largely driven out of the geography and the
demographics of the region. So if we can focus particularly on those issues in
providing feedback, I hope that reflects some of the conversations that have
already taken place on the tables.
CAROLINE GAMLIN: Okay. We will start at the back at that table, will you
start?
NEW SPEAKER: You have already taken my motherhood and apple pie which
I was going to use {Laughter}, but other than that, and again it's a bit of a fudge,
but I think our first point was we need to look at the spec and work out principles
and then prioritise, which I think you have said, but one of the key ones is work
out prioritisation.
CAROLINE GAMLIN: Okay. So, prioritisation of --NEW SPEAKER: Of principles.
CAROLINE GAMLIN: Okay, prioritisation of principles. Next table?
SUNITA BERRY: That table?
NEW SPEAKER: It is not just about prioritisation, is it? It's only one point
you want? It's only one point. At one point we talked about asking the clinical
reference group to prioritise the service specifications, so to get them to look at
the givens that we have and then to do that as they do, including views of a
philophobia patient {Inaudible} of patient views, and lastly on that same point
not to compromise on outcomes.
CAROLINE GAMLIN: Okay.
SUNITA BERRY: Not compromise on outcomes.
CAROLINE GAMLIN: Okay, yes. Your table?
NEW SPEAKER: You just want one thing?
SUNITA BERRY: Just one thing from each one.
NEW SPEAKER: So what we talked about and one of our principles is we
should have equity of reasonable fairness, so the idea is that we may take a local
view of what is reasonable but we are not going to define it now. We certainly
won't be going to try and solve the problem here, and that equity of reasonable
fairness would be equity of the ability around access and of the quality of the
services from the perspective of perhaps the public, the patients, their carers and
of the commissioning specialists who may want to take a four sided view of that
in order to guide the specialist commissioners. So that's one thing. It did sound
like five! {Laughter}.
CAROLINE GAMLIN: So equity of access.
NEW SPEAKER: I have four more as well.
CAROLINE GAMLIN: We are going to come around as well. Vaughan, your
table?
VAUGHAN LEWIS: So the number one that we got is around the longevity of
the commissioning decision. So although there are moves to commission on a
two year basis emerging, actually historically there has been a 12 month cycle of
commissioning and if the commissioning of a specialist service is going to result
in re-configuration, even if that is not dramatic, then it is unreasonable to expect
Trusts to hire and fire without the confidence of a long-term service provision.
CAROLINE GAMLIN: Yes?
NEW SPEAKER: Can we get rid of what we had to say. So, the idea is it may
be different for different things, but we put sustainability in what we are trying to
commission. So if you do something tor 12 months it's not going to be
sustainable because --CAROLINE GAMLIN: So sustainable commissioning. Next table?
NEW SPEAKER: We had safety and outcomes at the top of our list which has
already been said. We then talked about actually defining and putting robust
processes in place to measure outcomes to inform future evolution of the services
and re-configuration.
CAROLINE GAMLIN: So clear measurements of outcomes and robust
measurements.
NEW SPEAKER: We felt that one of our priorities was to deliver the best
possible service following specifications where appropriate, but encourage local
delivery if the model permitted. We gave an example of perhaps using Skype
consultations from somewhere remote such as the Isles of Scilly.
CAROLINE GAMLIN: Using technology. And here?
NEW SPEAKER: We didn't put ours in any particular order. But one that was
mentioned was considering work force competencies and sustainability of the
work force.
NEW SPEAKER: One of the things that we discussed was this thing about what
advice do you want from the Clinical Senate. Because if we asked that question,
then that helps the Senate know what it needs to do. Otherwise, we end up trying
to do somebody else's job, options appraisal, all of those things, which people
ought to be doing before they bring it to the Senate. Otherwise it puts duplication
into the system, duplication of effort. So there is something for us about that
absolutely crystal clarity about that question and putting that back to people so
that we know what we are supposed to be doing.
CAROLINE GAMLIN: Yes, I think clarity of the question and clarity of what
the Senate can and can't do and deliver. That's really helpful.
NEW SPEAKER: Caroline, I am not sure how you want to handle this, but we
expressed a different principle around the service spec that has been talked about.
So our principle, I think, was that you would deliver the service spec unless, you
know, there was a really strong evidence base or reason that you could not; we are
not that interested in debating service spec.
NEW SPEAKER: It is not the role of the Senate to go back and try and rewrite
the service spec. Neither is it the role of the Senate to pick and choose which bits
it likes of the service spec. The service spec is the service specification, and what
we have to do is try and see how best we can provide that service specification.
CAROLINE GAMLIN: Yes, absolutely.
NEW SPEAKER: In saying that, you have just made the point. We have to
compromise. You cannot deliver every service spec, you said as best we can, and
so the role of the Senate is to advise how far you can compromise without
compromising outcomes.
CAROLINE GAMLIN: Well, I think that is the question, because we actually
said how can we deliver the service spec. I don't know whether you want to make
a comment, but the service specs are agreed by the CRGs and I think the process
so far is if everybody disagrees with several bits of the service spec, there has
been some discussion nationally about how we can change those. But I think the
discussion for us is how we can apply that service spec locally. Do you want to
make a comment?
NEW SPEAKER: Yes, just a comment that we observe that the difficulty with
the service spec is they are input and process driven, not outcome orientated, so
there probably is some latitude in there. But that requires service specs to be
designed around outcomes.
CAROLINE GAMLIN: Yes. I think that was one of our principles on that
table. Linda?
LINDA PROSSER: To use the opportunity to do the improvement in the
service spec. Even though they are where they are, there is a recognition
particularly of a lack of consultation of wider --NEW SPEAKER: I can't hear, sorry.
CAROLINE GAMLIN: Can you speak up a bit, please?
LINDA PROSSER: Sorry -- maybe not to lose the opportunity of the Senate
being a place where some of the specs can be subjective, even though they're in
the first phase and there was an opportunity for some wider consultation, and
there is opportunity there for that iterative recruitment that we can be part of in
terms of observation of advice and feedback.
CAROLINE GAMLIN: Yes.
NEW SPEAKER: One of the things we came up with quite early was there is a
population to be served and actually does it match the population of the service
spec that is written? We know, particularly within the South West, we have a
very elderly population and it's putting it within the context of that population we
serve and where the clinical expertise often comes in terms of the feeding into the
outcomes, not just measured outcomes but the clinically significant outcomes
which is quality of life, length of life and disease free.
NEW SPEAKER: I have to say I am personally very concerned about that
conversation, in the sense that the purpose of the national specs was to prevent
post code differences across the specialised services and a whole process has been
put in place nationally to come up with the service specs, and for us to want to
unpick that locally doesn't feel like the Senate's role at all.
NEW SPEAKER: Can I clarify where we came to with that? We recognise that
a lot of the service specs are written by specific groups and CRGs, which are often
very surgically dominated, whereas actually a lot of patients in a particular disease
area may be at a more palliative end of the spectrum than a surgical end of the
spectrum. For instance, the population in Devon that we serve, particularly in
East Devon, is a very elderly population, where issues about surgical provision
may be less high on the priority than their access to symptom control measures,
which are all within the spec but the numbers might not quite match.
CAROLINE GAMLIN: Linda?
LINDA PROSSER: I wonder if there is a bit of clarification needed here
because I think we would all say we have a duty to commission the best services
we can, to deliver the best outcomes we can and if there is one person in Devon
who needs it we need to commission a service for it. So that is not the point of
compromise. I think the point where we are driven to questions of compromise is
where you can't square the circle. So the population density doesn't deliver the
economy of scale for the drive time.
So that's what the discussion on this table was about, well, can
the CRG not be pushed to give us a ranking of those inputs because, you know, if
it doesn't - I call it the Cornwall test - if the spec doesn't pass the Cornwall test,
the CRG has to be asked to take some responsibility in our view for helping us
and, in fact, one of the ways we thought that the Clinical Senate would play a role
in that is actually to have the debate here but invite someone, a responsible first
person from the CRG that could really help the Senate to rank those criteria, you
know, is 15 minutes more drive time is that a deal breaker? Or is the size of the
cohort that the treatment centre treats a deal breaker? The point is the CRG is
where the clinical excellence in that issue comes from. So that was a --CAROLINE GAMLIN: So is that a principle that when you are discussing a
particular topic you would want someone from the CRG to come and assist the
Senate in ranking --LINDA PROSSER: If the dilemma were around that, that is something that was
suggested, yes.
CAROLINE GAMLIN: Sorry, I have a hand up.
NEW SPEAKER: Yes. I think we had a similar discussion, but I think the
word we came up in the end was it has to be "pragmatic" here. If you are purely
on delivering the specification, actually you are going to need a degree of
compromise which is where you end up with a pragmatic model, which goes back
to your earlier point which is also sustainable.
CAROLINE GAMLIN: Yes. Sorry?
NEW SPEAKER: Chris and I are shaking our heads saying, no, you can't, you
can't. The whole point is about the fact that these are national standards and
specifications and this is part of where Wessex, as Chris said before, has gone to a
whole load of trouble to try and come up with something different that didn't
actually fit what was set down to be a national driver for best outcomes and we
know we have our own particular issues about geography in this region and we
know we have issues about population density, so we have to take those into
account, but it doesn't mean to say we can rewrite things because we feel that is
the way it should be done. We can go back and ask the questions, absolutely, and
we had the thing of if four minutes for 99% is what we can achieve, does it
matter if we don't achieve it for 1%? That was the way we looked at it. On the
other hand, if we didn't achieve 45 minutes for 50%, then we should understand
we have a real problem and that I understand is being pragmatic. But I think we
have to be clear how much we can interpret those specifications and how much of
it is actually just set and my understanding is that most of it is set and then you
have to come up with very, very strong reasons why you are not going to meet
those service specs.
NEW SPEAKER: One of the principles that we came up with within our group
is that deviation from the service specification should be fairly clarified and
explained.
CAROLINE GAMLIN: Yes, and I think we are very clear that the question was
about applying the service specs for that reason. I know there are a couple of
people over there who want to make a comment.
NEW SPEAKER: Well, the point that has been made about prioritising those
things within the service specification is high, but my point is who is asking the
public about that? What is the public view about that? If you have got a national
specification, and people seem to be concerned about varying it even by a
fraction, we all know that service specifications are open to local interpretation.
It is just a matter of fact. So if you have got to judge between competing
priorities on that list of things to do, where is the voice of the public being heard?
So that's one question I am posing.
Also, if whoever it is, NHS England or whoever, is then
evaluating that service specification to say is it compliant, where is the voice of
the public, where have I been able to say what I think about that as a member of
the public? And I can't see that.
CAROLINE GAMLIN: Well, there is public involvement in the CRG, but if
anyone on the CRG wants to comment, but there is input to the CRGs from the
public voice.
NEW SPEAKER: Yes, the PPI representative on the CRG.
NEW SPEAKER: One person though.
NEW SPEAKER: No, no, it is a minimum number you should have, in fact.
Ours has three and we were aiming to have four.
NEW SPEAKER: Won't many of these significant service re-configurations, if
that's what it comes to, require scrutiny and potentially be for public consultation?
So that will still be part of the process?
CAROLINE GAMLIN: Yes.
NEW SPEAKER: And squaring that circle will be a great problem down the
line.
CAROLINE GAMLIN: Yes.
NEW SPEAKER: Really counter against some other views that we should seek
to influence a national service specification either developed by NICE or the
CRGs or wherever. I just think that in my mind it doesn't square up. I don't
think that this group could ever be seen to have the expertise or the knowledge to
take on an individual CRG. That is not what we are set up to do.
Let me come back to philophobia here. I think when you look
at the issues that philophobic commissioning throws up, it strikes me this group is
really well placed for that, particularly if we maintain some link and some really
hard wired mechanism to be able to access public opinion to be able to make
difficult choices; because the thing that this throws up is the work of this Council
and the Assembly is going to centre around how to apply national best practice
principles within our own patch within the South West and the choices will
always be the same. Where is the jam going to be the thickest and where is the
jam going to be the thinnest and how do we explain that to the public and how do
we engage the public in accepting the jam is going to be thicker in some cases
than others? How do we give them also the work of the commissioners to say,
well, we understand that there are issues between consultant X and consultant Y,
which is limiting the progress of philophobia treatment in Bogsville General on
the Moors, and we would urge you to work with the providers and that is not an
issue for the Senate to work on.
So clear lines need to be drawn, but this example I think for
me clarifies why I have spent today here and why I am willing to do so looking
forward. I am not willing to spend any time in this group if it involves rewriting
guidelines which I might have been part of writing in the first place in my
speciality. It is not going to come from here.
CAROLINE GAMLIN: Yes, I think that's really helpful. Shall we try and
capture a few more of the principles? If we go to the back table I think?
NEW SPEAKER: Yes. So we had deliverability was one which I think we
covered, but I think the affordability question within the kind of the whole health
community, so affordability.
CAROLINE GAMLIN: Thank you.
NEW SPEAKER: Yes. I mean, in order to take it forward we have to have the
distinction of services hopefully against the service spec as well as against the
delivery model, taking account of this cycle of provision and in order to get from
here to wherever it may be we have to know where we were.
CAROLINE GAMLIN: A stock take of what we have got as a principle.
NEW SPEAKER: Yes.
CAROLINE GAMLIN: Thank you. Next table?
NEW SPEAKER: We were not proposing to rewrite the specification, but we
wanted to make sure that the specialist commissioners had ambitious achievability.
It is what they are proposing to deliver, is the service spec achievable? It may not
be, because you can't put a brand new philophobia {Inaudible}, but also is it
ambitious enough in what they are proposing? Are they being limited by the fact
of history and other stuff? So we want to challenge them in both directions and
to be ambitious as well.
CAROLINE GAMLIN: Tempered with ambition.
VAUGHAN LEWIS: We talked about outcome measures and the clinical
outcome measures are the easy bit. We also talked more about the quality of life
outcome measures or patient experience outcome measures and also to ensure that
patients who might be disadvantaged by virtue of the distance they have to travel
are supported in some way, so that if we do have to compromise in order to meet
the clinical service specifications we find some way of supporting those patients
who might in some situations, in some cases, make the decision not to access
treatment because they feel disadvantaged by the distance involved.
CAROLINE GAMLIN: So that's about defining outcome measures in its
widest?
VAUGHAN LEWIS: Yes, absolutely. So it's looking at outcome measures in
its totality of outcome measures.
CAROLINE GAMLIN: Thank you. This table, any more to add?
NEW SPEAKER: Yes, a couple more. The next point we wanted to mention
was around the interdependency of other services when you are considering a
re-configuration in a particular service. So how aesthetics is affected if you
re-configure certain services and any differences there may be between
interdependency amongst emergency services versus elective services.
CAROLINE GAMLIN: Okay, that's helpful; thank you. Shelagh?
NEW SPEAKER: We covered it all.
NEW SPEAKER: There may be different models of specialist services
depending on whether the care is a single episode. So a single surgical procedure
or whether it's part of a long-term illness where you need multiple attendances, so
different models of provision may need to be provided for those different sorts of
types of care.
CAROLINE GAMLIN: Yes, I think that's helpful. When we are looking at
principles we might want to weigh some principles differently depending on what
we are looking at. Any more from this table?
NEW SPEAKER: We've got a few more. We talked about not assuming that
services will continue to be delivered from the locations that they are currently
delivered from.
CAROLINE GAMLIN: Yes, okay. So any more from that?
NEW SPEAKER: Where we are re-designing the spec, whether we can look at
alternative funding flexibilities or alternatives to PBR.
CAROLINE GAMLIN: Yes, okay. Next table, any more?
NEW SPEAKER: This is about the implementation of the specifications. It's
around being creative about the delivery of care within the region and, for
example, looking at travel issues, looking at different travel modes and that might
mean using a helicopter for people in very remote areas or those provided by road
and then really audit looking at where the geographical locations of
commissioning is and could be, but the creativity must come, even if in the
specification we weren't {Inaudible}, prioritised to apply them locally it is going
to lead to differences anywhere.
CAROLINE GAMLIN: Yes, okay. So local solutions.
NEW SPEAKER: Building on that, we used the helicopter as an example. We
felt the Senate wasn't there to drive solutions. We wanted just to gain an
assurance that the commissioners have looked at all the options, so we wanted
really to have a view of all the options they would consider to solve that problem
and with those options we wanted to make sure there was equity of input so that
they had considered the public in that, they had involved the people involved in
those decisions, carers etc.etc.. We also wanted to make sure they know to flow
-- so the example I gave was London, you know, the flow of the patients in
London is like on the tube lines and there will be a flow of patients. So you need
to understand the flow before you design your options, and that they also
considered value added stuff like innovation and other stuff that may be available.
So there may be other things to make that decision so that you
have got a view of how they were choosing to make those decisions about maybe
cutting the service --CAROLINE GAMLIN: That's something else for the providers.
NEW SPEAKER: -- to make sure that's influencing what they are
commissioning. Have they actually done a full options appraisal? We haven't
necessarily come up with the answers.
NEW SPEAKER: In this particular case, statistically there would be about 300
sufferers from this condition in the South West region. Those 300 could all be
invited to a room and actually have a forum where you have all the sufferers from
the condition and pose the problems, so have they been imaginative enough? That
would be our focus.
CAROLINE GAMLIN: Okay, yes.
VAUGHAN LEWIS: We talked quite a lot about a more networked approach.
So some of the service specifications are quite clear in the specification about how
the services should be provided as part of a network. There are examples like
neo-natal care where there is already an operational delivery network. There are
plenty of other examples where the networks are less well-established and it's a
little bit like table one. We would like the commissioners to consider funding
models where the funding went into the hub, and it was the network provider that
determined the funding that went out to the spoke because, if you like, you were
almost commissioning the hub to be a commissioner of the spoke services.
So it is that kind of funding model as opposed to a more
orthodox PBR and linked with the network, and I think it picks up on Guy and
William's point, was about imaginative solutions to support patients in remote
locations. So while we didn't talk so much about helicopters, we talked more
about video physio consultations and imaginative use of technologies, which again
tends not to be reflected in many of the service specifications, but it is a way of
realising the specification in a meaningful way for patients.
CAROLINE GAMLIN: Okay.
NEW SPEAKER: Our helicopter option was to have an especially provided
philophobia helicopter, so a philophobia team that went to the patient, but just as
an example of getting your head out of the box.
CAROLINE GAMLIN: Yes, okay. Just go round the last three and we will see
if there are any more. Any more from your table?
SUNITA BERRY: I think it kind of works through the network thing, but
basically about trade-offs, especially, as Dan said, where we were looking at
emergency versus elective pathways, you know, is it going to be possible to do
trade-offs in order to sustain specialised services in a manner that's acceptable
both for patients and clinicians? But at the same time recognising that specialised
services when taking something out of one place may leave such a large hole that
actually that was no longer sustainable as an institution.
CAROLINE GAMLIN: Okay. So anything else from this table?
NEW SPEAKER: No, thank you.
NEW SPEAKER: Caroline, this sounds to me, coming at it from the outside,
like a meeting of specialist commissioners discussing specialist commissioning. It
doesn't sound to me like the sort of discussion that you would expect a Clinical
Senate to have. I hope it wouldn't be. How do you envisage the issue being
presented to the Clinical Senate for deliberation and advice? You might not be
able to answer it because I don't know the answer, but I just think if we think of
us here as a Clinical Senate and there is an issue about this condition, in what
format would it come to us for deliberation and advice if we were using these
principles to check? But it had been fully thought through, for example, but do
you have a view on that? Because I am really struggling with that at the moment.
CAROLINE GAMLIN: Well, I think it will depend on what the service is and
what, you know, what the sticking points are I suppose. But I think if you took
something like this service, it may well be that the question could be: What does
the Senate think is the optimum configuration of services for philophobia in the
South West? I don't know. What do people think? Is that a question that we can
deal with?
NEW SPEAKER: But they would present us with some options because I
wouldn't expect to be ...{All talking at once} --NEW SPEAKER: -- them designing it and giving us the option. We are
making sure we have assurance it's the right option.
NEW SPEAKER: That's exactly the point, because I think if we got down to
trying to do the specialist commissioning job for them I think we have lost it, and
I think we need to be very clear about that clear water between what specialist
commissioners do and what we as a Council do.
CAROLINE GAMLIN: I think it's very clear that we are not making up the
question. It is for commissioners to come with a question to us and we have to
say whether we think that's a reasonable question to answer. So we might have a
commissioner come and say, "Oh, I have got terrible problems with philophobia"
and we will say, "Can you articulate what it is you want the Senate to look at".
So, absolutely, and I think what we are saying here is, is there something in terms
of the principles that we would want to try and work with the commissioners on
in terms of helping them find a solution and coming up with a sensible view?
Does that sort of answer it? It is early days.
NEW SPEAKER: Yes, I think that's helpful, but I think it's really, really
important to get that right.
CAROLINE GAMLIN: Yes.
NEW SPEAKER: What we discussed was that if you had a number of options
that were on the table using the principles, using your guiding values, that we
would appraise those options and give strengths and weaknesses for each of those
options and it may be possible to rank those options based on those principles and
what we have discussed, but give some background as to why we have ranked it in
that particular way.
CAROLINE GAMLIN: Because I think one thing we have talked about is
whether we could actually rank these principles as well, how important do we
think, you know, but it might depend on different services and how --NEW SPEAKER: Yes, it will vary. As we said, for instance, involving other
agencies. For some specialist services there will be no other agencies involved.
But for others the vast majority of it will be around how does it work with other
services outside of health? We talked about fragile, elderly. Well, you know,
that's a huge impact with other services.
CAROLINE GAMLIN: Yes, yes. I think that's really helpful and I think we are
at that early stage about actually what do the questions consist of and it's key we
don't get asked a question that we can't possibly answer or help.
NEW SPEAKER: But if we look at the philophobia question then, so we might
get to a point in the South West where it is just physically impossible to have
centres that are within 45 minutes of everybody and can manage a hundred
patients. The standard is not deliverable. Therefore, we have got these options
which compromise different bits, which do we clinically think is the best?
CAROLINE GAMLIN: Yes.
NEW SPEAKER: It's going to be that type of question.
CAROLINE GAMLIN: I think so for specialised commissioning, but that is the
sort of thing. Linda?
LINDA PROSSER: Thank you. So, I think we start somewhere, don't we, and
we opted this time to start with why don't you tell us what you think the
principles should be? So that when we do bring a particular case study or a
particular specification question about an actual service, we are not starting from
some principles that we have dreamed up. You have actually helped us with
those. So this is really helpful and I have to say at least three people have come
up to me today and said, "This philophobia, this is my service, isn't
it?" {Laughter}. So these exist! These exist. There are some genuine
conundrums we are going to have to ask exactly these questions of you or you're
going to ask questions of us about whether we have considered the principles that
you're debating now and one thing I would like to give back is that, sure, I am
asking this question today as a specialised commissioner. Your scope of vision is
bigger than that. So one of the things that the Clinical Senate can do, which I
won't be doing, is positioning my question and the conundrum in the context of
the whole patient pathway and prevention and early intervention and all that stuff.
That I think is a unique offer that the Senate, Clinical Senate --NEW SPEAKER: In that case then we need to think about the membership of
this group, because one of my colleagues -- in fact, two of my colleagues on this
table said we have got the mix wrong. We haven't got the social care or enough
GPs or enough people from the primary health care teams or anybody from
community trust here, I don't think? So there is something about getting the
representation right and there is an awful lot of people here today, but there is
maybe not quite the right balance in terms of the membership.
CAROLINE GAMLIN: Yes, and of course, well, the membership, perhaps in
the organisation, but we can certainly look at that and social care, adult and
children certainly you have got a place around the table. But I think you're right
and the other thing is to not forget that if we are looking at particular issues, of
course, people will be able to come and present their evidence. So there will be a
lot of people coming along who may have experience of either receiving that care,
providing it or commissioning, whatever the topic might be as well. So, I think
it's right; we need to think about that.
Yes?
NEW SPEAKER:
Just to pick up on that from Linda, I think we need to think
about the opportunity costs of a big investment in this area, compared with what
we can do with that same money elsewhere and we have not really explored the
opportunities for prevention of admission to these units. There could be quite a
lot of community support required. That was a couple of points. Just my final
point. My name is Phil. I wonder whether you have got the opportunity to
rename this condition? {Laughter}.
CAROLINE GAMLIN: Okay. We have to try and summarise the principles.
Anyone got a burning principle they think -- Chris?
CHRIS BURTON: So I've heard very early on in this discussion the desire to
put outcome as the prime objective and I haven't quite considered in my mind
whether I think that is right or not, but I think it's important that we at least
consider all aspects of what we describe as quality. So that is outcome, and safety
and patient experience all are important. I am not clear whether outcome is more
important than the other. We all have our view on that.
CAROLINE GAMLIN: Yes.
SUNITA BERRY: We had a long discussion about outcomes on our table and I
think one of the things that we kind of didn't quite manage to square was the issue
about patients choosing outcomes in particular situations as clinical outcomes. In
other situations it has been outcomes about their lives and, you know, who they
are and the place they are in and all of those things and it is very difficult. When
things were highly specialised it was easy to separate the two. It is much harder
now within these new extensive service specifications to be able to decide and
maybe it is part of the role of the Senate, Citizen Senate, to help us decide as to
the primacy of outcomes as to which outcomes are desirable outcomes versus the
essential outcomes, and I think there is something about that debate about those
outcomes which is important for us to grapple with.
CAROLINE GAMLIN: A lot of hands. Right, David?
NEW SPEAKER: Really just to pick up on what Virginia was saying, I think
it's really important to remember why Senates were invented and my
understanding of Senates was that the clinical Senates were there to provide
specialist clinical advice to whoever wanted it, and they are counter balanced by a
number of other organisations in the new NHS that provide patient, Social
Services and primary care's input as well.
So I think it would be a mistake to lose the balance of the
organisation, of this group, and make it something that represents all those parties
because the specialist commissioners can tend to each of them in turn. We are
here to provide specialist clinical advice alongside other sources of advice that
come to the commissioners, whether they are primary commissioners or specialist
commissioners.
CAROLINE GAMLIN: It is clinical advice in its broadest sense.
NEW SPEAKER: It was to counter balance the concept that primary care was
driving all of this.
NEW SPEAKER: That's okay if it's only about specialist commissioning, but if
you take a pathway like the frail and elderly, there are many different clinicians
along that pathway and social care professionals who would be able to offer
different advice.
NEW SPEAKER: But we are not making those decisions. We are giving our
advice. The commissioners will take advice from others as well to represent those
other views.
NEW SPEAKER: But they will be asking for the advice on a pathway that
potentially we don't know, you know, you won't have the breadth of advice about
and I think there is a real issue around if this Senate is purely about specialist
clinical advice, then the questions are going to have to be very different. That
will shut out a range of CCG questions that might be asked. I think if this is
about giving clinical advice in various different circumstances, then I think we
need different representation.
CAROLINE GAMLIN: It is very much about clinical advice. So I think the
specialist bit isn't in there. I think the specialist clinical advice I think is coming
through the CRGs for the specification. I think the Senate is there to put it into
the context of a local environment, predominantly clinical, but I take that in its
broadest sense. So I think certainly there are core groups that need to be on the
Senate and that is defined as CCGs, public health, local authorities as well as
consultants.
So I think very much, even if you are a specialist in whatever
field it is, you are here to give a professional view, not necessarily on whatever
your specialist subject is because actually the way that we will function for the
next Senate and the future ones is if we have got a question.
As I say, we will have presentations from the experts, so to
speak, who will give us that information. None of us are going to be expert in the
topic and I think part of the strength of the Senate is actually we are not an expert
in philophobia, but actually we are going to give an informed view given our
breadth, and I think we need to think about the balance and makeup of the Senate.
But I thought today as we went around actually we had quite a good cross-section
and I am happy to hear thoughts about we need more GPs, we need more of this,
that and the other, but I thought we had a good balance of health professionals,
primary care and consultants. But social care I think is the bit we haven't got and
I think we do need them in because even specialised commissioning I would say
actually, even if we are thinking about a tertiary service, we want to look at the
whole pathway. It's important we don't forget.
NEW SPEAKER: The balance of five nurses and AHPs against the 35 is not,
you know, I don't think that gives you the representative advice, but that's only
my view. But coming from a CCG perspective, it would make me think
differently about how I advise my CCG to ask advice from the Senate based on
the clinical representation, because we might be asking you questions around frail
elderly pathways which are about how community nursing is provided in the
home to that particular group and at the moment the way the Senate is made up
you wouldn't get a good representation of clinical advice about that service.
CAROLINE GAMLIN: Okay.
NEW SPEAKER: But it's just about -- it comes back to my beginning point at
the beginning of the day which is about we have really got to set out what the
Senate is and what it is looking to do, because I think otherwise people will be
asking the wrong question.
CAROLINE GAMLIN: Okay, that's helpful. I think there was a hand up there?
NEW SPEAKER: Firstly, I would like to agree with the last speaker. As a GP,
much of the clinical work is grappling with the human condition. It is not to do
with drugs and diagnosis and so on. So I think it needs to include that. But I
mainly wanted to follow up on the outcome thing. The more complex the
situation, the more complex the condition, frail elderly, for instance, and
outcomes become very close to process and process becomes close to outcome and
the two begin to merge, so that being involved in the intervention is much of what
the outcome is. Even in philophobia, if you really engage with the sufferers of
this and the sufferers of it are involved in delivering the intervention in training
professionals to understand about that condition, then that process becomes part of
the outcome. And it is a mistake I think in complex conditions to try to divide
the two firmly.
CAROLINE GAMLIN: Thank you. Anything else?
SUNITA BERRY: I just had a quick comment. I think it is really vitally
important, especially in this section of the Senate, that this section of the Senate is
answering a very specific question actually asked by commissioners - we are
melting back into the morning agenda rather than the agenda for now - which is
about developing the principles that we are asked to develop. The issue about
representation, etc, we need to thrash out another time and more fundamentally
for the people who are here, can I remind them that they are here representing a
professional interest rather than the interests of their organisation.
CAROLINE GAMLIN: Okay, thank you, Sunita.
NEW SPEAKER: The other thing that we felt with our principles is we weren't
going to be influenced by history or personalities and {Inaudible} very much
want stories to appear about two people who don't get on and we wanted to have a
principle that we don't care about that; and we are driven by that and we really
want people coming up with options that say we can't merge those two
{Inaudible} ....
CAROLINE GAMLIN: Okay. Have you captured that, Sue?
NEW SPEAKER: I couldn't hear all of what was said.
CAROLINE GAMLIN: That we are not influenced by history and that we put
that to one side. Okay, any other principles? Yes?
NEW SPEAKER: Yes, a small one, but we touched on in looking beyond just
our region. So being aware of the impact on other services and, you know, we
may decide to have two centres of excellence in the region but one right up north
but somebody finds one just to the south of the next region, so we need to have a
wider view. That's another principle.
CAROLINE GAMLIN: Okay.
NEW SPEAKER: We had a few more that we have touched upon but not
necessarily captured --NEW SPEAKER: I can't hear, sorry.
NEW SPEAKER: We had a few more that we touched upon, but not necessarily
captured using geographical mapping as an evidence base, taking local views and
patient experience into account and defining relationships between routine and
emergency care needs.
CAROLINE GAMLIN: Okay.
VAUGHAN LEWIS: I think building on Guy's point about not trying to take
history into account, the other thing we talked about and it links back into our
first point which is around the longevity of the commissioning decision or the
sustainability that a solution that is in place -- the wrong solution that is in place
by the 1st April is a lot worse than the right solution that takes another 18 months
to realise.
So while we understand the imperative to meet NHS England's
time scales, actually getting the right services in place is much more important
and that doesn't mean that we should give ourselves more time and/or take time
over it. It means we need to recognise that in order to meet the specifications and
particularly when taking into account the issue of co-dependency and the risk of
potentially destabilising some providers that there would be a significant process
that will need to be followed if we are to realise the specifications and ultimately
serve the population appropriately.
CAROLINE GAMLIN: Okay. So, the next part was we were going to get each
individual - I think you had ten dots in front of you - we were going to try and
get people to prioritise these individually. Now I don't know whether -- did you
want to run through what we have actually got on here first before you do that?
Shall we just run through them?
So we have got define and put robust measures in place; use
technology to deliver and encourage local decision making -- no, no, local
provision; clarity of questions on what the Senate can and can't do. I think that's
something for the Senate to take forward, isn't it? Deviation from service spec
should be clarified and explained. Shout out if you think this isn't what you want
to capture. Interdependency of other services when considering re-configurations
and different models of provision, services delivered will - it should be "will
not" --NEW SPEAKER: It should be "may not".
CAROLINE GAMLIN: -- "services may not" or "will not continue to be
delivered ... trade-offs to ensure service specs remain". So that's about making
sure we meet the service specs. "Consider all aspects of what we describe as
quality and at all levels", so local quality and something around geographic
mapping as an evidence base. Okay. Sue, what have you got over there?
NEW SPEAKER: I have got: Work out prioritisation; suitability of outcomes;
aim not to compromise on the outcomes; take a stock take of what we have, yes,
and --CAROLINE GAMLIN: Equity.
NEW SPEAKER: -- equity of access, realisation of ambitions, sustainable
commissioning.
CAROLINE GAMLIN: And affordability; funding flexibilities; travel modes;
equity - I think we have got that twice - mapping solutions and boundaries and
time scales. Do people think that's possible? You have got ten dots each. So I
suggest to everybody that we allocate them - there's a query about whether we
have five or ten - But there is quite a lot on there. I suggest we stick with ten dots
on the things that you think are the most important if they make sense to you on
those two sheets. Is that possible? Come up and we will have a bit of a think
about it.
NEW SPEAKER: I suppose we might have paused at this point to do some
work on that, mightn't we? But I wondered if people are happy to roll with it and
put your dots on the things that you think are important, then that leads us into
some follow-up work after today. Does that make sense?
NEW SPEAKER: Even if it's just two --NEW SPEAKER: It's difficult because some of those headings have nuance
clauses kind of linked with them, like "equity of access" which was to do with
fairness as perceived by the public, which is not necessarily equal. So tricky.
CAROLINE GAMLIN: Do people want some time on the table to have a think
about it or do you want to come up and do it now? Can we take the stickers off,
please.
(Short break)
VAUGHAN LEWIS: Okay. You do need to stop talking, but you don't need to
sit down. I think we did bill 30 minutes into the end of the day for networking,
which seems to be what is happening. The original intention had been to try to
draw together the outcome of that workshop session and I think what is quite
evident, looking at the distribution of dots, is that there are clearly some
principles there that people feel very strongly about. I am not going to try and do
that and prioritise further, so Sunita and I have been talking about actually at the
same time as typing that up I am ranking them in order of dots preference. We
will also, following the discussion earlier today, send perhaps a survey monkey to
Assembly Members.
I think it has been a really valuable day. As I arrived here, I
felt daunted and that feeling of being daunted didn't settle until about lunch time!
{Laughter}. I am not sure that it hasn't risen again. I think the challenge that is
facing us all is colossal and one of the problems of course, as anybody who is
involved in any aspect of medical management (and that is the majority of people
in the room) will know, is that there is an awful lot going on, much of which we
have very little control over. Lots of people have lots of ideas, but there is very
little clarity of what the provider landscape is going to look like in two, five, ten
years' time.
Therefore, I think that an organisation like the Senate, which
has the benefit of being non-statutory, potentially has a really important role to
play, but it can only play that role if it is adaptable, to badly paraphrase Darwin,
it is not the fittest that survive or the strongest that survive, it's the most adaptable
that survive and I think, as I said at the beginning, if it sounds like we are making
it up as we go along, it is because it is. Actually I think that is the one thing that
will determine our survival and our credibility. How could we possibly get an
organisation like this right first time? We can't. We have heard a number of
comments about membership. We have heard comments about process. We have
had long discussions this morning, particularly around the public engagement, and
I think the challenge that Sunita, Caroline, Ellie, Shelagh and I have is to pull all
of that together and to circulate a revised set of operating principles, a revised
terms of reference, initially to this group and then to the broader Assembly.
Whether we can do that in time for the next meeting, again, I make the same
comment as I made about re-configuration. I think it's much better we get it right
and it takes a little bit longer than we rush something through in the next two
weeks.
So, we will get something out quickly. What I would like is to
try and get a transcript, or at least an edited highlight of the transcript, and before
I forget I would like to thank the unsung hero in the room, Mirella {Applause}.
It almost seemed at times as if what was appearing on the screen was happening in
advance of it coming out! I am not quite sure how she did that, but I am
completely sold on the idea of having a stenographer in these meetings and I look
forward to seeing the output of this meeting.
So, thank you all very much. I hope that for those of you who
are on the Council you will be back. I think that there are people here who
probably -- this isn't going to come out in the right way but I am going to say it
anyway -- there are people who probably shouldn't be here because there are other
people who should be! I think we will get the constituents right as different
questions are posed to the Senate. We will need to co-opt different members and
I think that, having been very uncertain about having a group this size, actually I
think it's worked reasonably well.
What we will try to do is to capture some of that in a feedback.
We haven't prepared feedback sheets because actually I think it's much better that
we target you after the meeting and we will aim to get something out in the next
week. In the meantime, please don't hold back on feedback. It would be nice for
that feedback to be constructive. I am very happy if people feel the need to be
more critical to do that, because I think it's really important and I don't think, as I
said, any one of us has the answers and therefore we can all learn from each other.
This Senate is not just about an individual or a small group of individuals' views.
We are here to represent the whole of the South West.
So, thank you very much and do stay for as long as there are
cakes and tea remaining and a safe drive home. {Applause}.
(3.30pm)
(Concluded)