Tomorrows NUH Phase 2 Pre-Consultation Engagement Findings – Executive Summary

Introduction

Following an initial phase of pre-consultation engagement in November and December 2020, on 7 March 2022, NHS Nottingham and Nottinghamshire Clinical Commissioning Group (CCG) launched a second phase of pre-consultation engagement on proposals to transform hospital services in Nottingham.

Nottingham and Nottinghamshire ICS has a number of ambitious plans for service and system change, to improve the health and wellbeing of our local people through the provision of high quality health care delivered in a sustainable way.

‘Reshaping Health Services in Nottinghamshire’ (RHSN) is the overarching programme which brings together all the plans that are transforming health services, and Tomorrow’s NUH (TNUH) is the single biggest component part of this programme of change.

The aim of the second phase of engagement was to continue the conversation with the public around the latest thinking about what hospital services and facilities could look like, and to gather feedback. 

In total, just under 2,000 individuals participated in the engagement that took place between 7 March and 5 April 2022 – through completing an online survey (613 responses), attending an engagement event/focus group, or providing a response to the promotion of the engagement on social media.  This builds on the 650 responses in total from November and December 2020, meaning an excess of 2500 pieces of input into the Tomorrow’s NUH plans have now been received – a strong base on which to refine and develop the proposals. 

Key findings

• 78% strongly/somewhat support the overall proposals.
• 39% felt the proposals would have a positive impact, 27% felt there would be a negative impact and 34% felt there would be no impact.
• The proposals within Tomorrow’s NUH have been divided up into the following five core areas:
• 72% strongly/somewhat support the proposals for emergency care.
• 64% strongly/somewhat support the proposals for family care.
• 80% strongly/somewhat support the proposals for elective care.
• 75% strongly/somewhat supported the proposals for cancer care.
• 69% strongly/somewhat supported the proposals for outpatient care.
• The majority felt that it would be beneficial to have similar services in one location, as this would make access to the correct treatment in the right setting much easier for patients, reduce waiting times for appointments and ensuring continuity of care.
• There were positive comments around an increase in confidence that the care needed would be available sooner, with specialised services in one place.  Positive comments were also received about the major benefits to maternity and neonatal services being on one site. Some concerns were raised about the potential negative impact on patient choice and the co-location of specific services.
• Positive comments were received from respondents that they would be willing to travel to other sites to receive the right care, first time and in the right setting.  The negative impact on patients regarding public transport issues, car parking and travel times was also raised and identified as a key theme throughout this phase of engagement.
• There were also concerns raised around how the proposals would impact staff: with specific reference to training, skills and retention to meet the capacity and demands of patients.
• There were positive and negative comments around the use of remote consultations and virtual appointments.  The negative comments related to equity of access and digital exclusion, and the potential negative impact this could have on some groups and communities.  Positive comments related to faster access in a setting appropriate to the patient, alleviating travel times and costs.

Next steps

The feedback from this engagement will be used by the CCG, alongside clinical and financial considerations, to develop a final set of options for changes to hospital facilities and services, which will be put forward to the citizens of Nottingham and Nottinghamshire in a formal public consultation.

Conclusions and recommendations

Conclusion 1: The majority of participants were supportive of the overall proposals that were outlined. 

Conclusion 2: Throughout the engagement activity it was clear there was support to have emergency care services co-located, to allow patients access to relevant treatments whilst on-site. However careful consideration around staffing and additional resources for this proposal, along with ensuring appropriate signposting to this service is required.

Recommendation 1: Consider workforce planning for future proposals, especially in the current climate with pressures within the system and services, focussing on women and children’s facilities and specialist services that may be relocated.

Recommendation 2: Ensure ongoing communications to patients, so they know where to access the right services at the right time and in the right place, to alleviate any additional pressures in emergency care services.   

Recommendation 3: Continue to work in partnership with the Stakeholder Reference Group to ensure that our communications are public facing and avoid jargon.

Recommendation 4: Continue to work with patient/citizen leaders who have extended their help and support to ensure key messages are constructed in the right way and are understood by all of the citizens in Nottingham and Nottinghamshire.

Conclusion 3: Travel, parking and access to public transport were consistent themes across the engagement.

Recommendation 5: Consider the travel impact when further developing the proposals, and work collaboratively with Nottingham City and Nottinghamshire County Council to develop a travel plan for patients.

Recommendation 6: Continue to cascade information to our neighbouring CCGs and System Partners to provide information around the proposals and programme to share with their communities and residents, as we know that people in neighbouring counties also access services in Nottingham/Nottinghamshire. 

Conclusion 4: Patient choice was strongly reflected in public feedback, especially around women’s and family needs, particularly the co-location of fertility and gynaecological services. 

Recommendation 7: Continue to work closely with our local Maternity Voice Partnership and our voluntary and community sector to ensure an ongoing dialogue with the public, as the proposals for women and children’s services progress.

Recommendation 8: Develop relationships with LGBTQ+ communities across Nottingham, Nottinghamshire and bordering counties to engage and involve this community in continuing our conversations around the proposals and their impact.

Conclusion 5: There was a mixed reaction to the prospect of more remote consultations and virtual appointments. Concerns were raised about the appropriateness for certain health conditions and patients. 

Recommendation 9: In the development of the proposals, consider the extent to which patients could be offered options of treatment locations and approaches (face to face, virtual or telephone), based on their individual needs. The proposals should focus on the accessibility needs of those who are unable to access digital and/or remote consultations.

Conclusion 6: There was support for the cancer care proposals. It was highlighted that the fatigue caused by treatment, in additional to the physical and mental impact of these treatments, meant that patients wanted to access care closer to home. The majority felt that cancer care should be located in the hospital, co-located with specialist services on one site, as it would be advantageous to alleviate pressures, concerns and the emotions of patients and families, especially those who may be undergoing cancer treatment. 

Conclusion 7: Participants were supportive of the proposals for elective care if it meant that operations would be protected and less likely to be postponed or cancelled.

Reshaping Health Services and Nottinghamshire (RHSN) Tomorrow’s NUH (TNUH)

Nottingham and Nottinghamshire ICS has a number of ambitious plans for service and system change to improve the health and wellbeing of our local people through the provision of high quality health care delivered in a sustainable way.

‘Reshaping Health Services in Nottinghamshire’ (RHSN) is the overarching programme which brings together all the plans that are transforming health services, and Tomorrow’s NUH (TNUH) is the single biggest component part of this programme of change.

TNUH is working to national timelines for the Government’s New Hospital Programme (NHP) which commits the Government to delivering 48 new hospitals by 2030. The NHP supersedes the Health Infrastructure Plan programme (HIP). TNUH was in the wave 2 (HIP2) pipeline and remains as a similar priority for the NHP. The investment available through NHP is considerable and must be spent on improvements to the NUH estate. As a result, agreeing the best way forward to modernise the Queens Medical Centre (QMC) and City Hospital is critical to this programme.

Context

Our statutory duties for public involvement

Nottingham and Nottinghamshire Clinical Commissioning Group have a statutory duty to involve the public in proposals for changes to services and a statutory duty to consult the Local Authority on any proposals for substantial variation to services:

“The CCG must make arrangements to secure that individuals … are involved (whether by being consulted or provided with information or in other ways) —

(a) in the planning of the commissioning arrangements;

(b) in the development and consideration of proposals for changes in the commissioning arrangements, where the implementation of the proposals would have an impact on the manner in which the services are delivered to the individuals or the range of health services available to them;

(c) in decisions affecting the operation of the commissioning arrangements, where the implementation of the decisions would (if made) have such an impact.”[1]

The scale of the TNUH programme will inevitably mean substantial changes to services to ensure that they are set up in the best possible way to improve people’s health and wellbeing.  This means we should expect to conduct a full public consultation before any final decisions are made. 

[1] National Health Service Act 2006 (legislation.gov.uk)

In November 2020, a programme of patient and public engagement commenced, to inform the development of the TNUH proposals. Within this engagement, the outline clinical model was described, which would provide the foundations for improvements to hospital services, centred around enabling the provision of the best possible care to ensure positive impact on people’s health and well-being.

Healthwatch Nottingham and Nottinghamshire (HWNN) and North of England Commissioning Support Unit (NECSU) were commissioned to support this engagement, which included virtual public events, focus groups and engagement with key patient groups.

At the time of this engagement, proposals were at a formative stage. People were invited to give their feedback on the outline clinical model developed for the programme. Over 650 shared their views, summarised as follows:

• Most people were supportive of our proposals.
• Access to buildings and services was important to people, in particular parking.
• People wanted to know how services would work together, inside and outside the hospital
• People were concerned about the affordability of the model and whether we would have the right staff in the right places.
• People were supportive of the proposals to split emergency and elective care but concerned about accessibility of centralised emergency care services.
• People were supportive of proposals to co-locate maternity services on one site, but concerned about the accessibility of centralised services; reducing location choice for care and birthing services; and potentially longer travel times for some people.

Our current thinking

Since the first period of pre-consultation engagement, working with clinicians and staff from across the system, our thinking about how services might be potentially be organised in the future has developed. This has involved looking at options for how and where services could be delivered. To do this, we have applied a rigorous options appraisal process that takes into account:

• The best ‘clinical model’ for services, particularly where services need to be located together.
• The impact on our patients, and their views and preferences.
• Designing services so that they have the best possible impact on reducing health inequalities.
• Financial considerations to ensure we can achieve the best value for the money available.
• The options we have for sites, buildings and equipment, considering the locations we are already occupying, and land owned by the NHS.

In addition to this, there has been considerable learning from the last two years of the pandemic, and changes to the way in which care has been delivered. Our options appraisal process has helped us identify what we believe would be the best possible configuration of services across our sites against a number of criteria, to provide the best fit with our service offer and the best value for money.

In 2020, when we talked to the public, we set out a clear steer for our aspirations for how services might look in the future across the service areas of emergency care, family care, elective (planned) care and cancer care services. The process we have been though has helped us to identify a set of proposals for each of those areas, and this is what we have tested with stakeholders and the public through a second phase of pre-consultation engagement, which took place between 7 March and 5 April 2022.

Aims and objectives

The overarching aim of the second phase of pre-consultation engagement was to continue the conversation with the public. This can be broken down into the following objectives:

• To “test” the latest iteration of the proposed clinical model, seeking the views of the public about what future hospital services and facilities could look like;
• To engage with groups and communities across Nottingham and Nottinghamshire, strengthening existing relationships and developing new ones;
• To support the delivery of a successful public consultation in the future.

Principles

All engagement activity was undertaken in line with our statutory duties and with The Gunning Principles[1], which are:

• That engagement and consultation must be a time when proposals are still at a formative stage. 
• That the proposer must give enough reasons for any proposal to permit intelligent consideration and response.
• That adequate time is given for consideration and response.
• That the product of engagement and consultation is conscientiously taken into account when finalising the decision.

Our approach

To ensure meaningful engagement with patients and the public, we:

• Tailored our methods and approaches to specific audiences as required.
• Identified and used the best ways of reaching the largest amount of people and provide opportunities for underserved groups to participate.
• Provided accessible documentation suitable for the needs of our audiences.
• Offered accessible formats, including translated versions relevant to the audiences we wanted to engage with.
• Undertook equality monitoring of participants to review the representativeness of participants and adapted activity as required.
• Used different virtual/digital methods or direct and 1-1 telephone activity to reach certain communities where we become aware of any under-representation.   
• Arranged our engagement activities so that they covered the local geographical areas that make up Nottingham and Nottinghamshire.

[1] The Gunning Principles.pdf (local.gov.uk)

As well as the patient and public engagement carried out to date, our staff, clinicians, Health Scrutiny Committees, Governing Body, NHSE/I and our regional Clinical Senate have input into the planning of this phase of engagement.

An Integrated Impact Assessment (IIA) is also being carried out on the programme, which assesses the impact of our proposals on equality, health inequalities, travel and the environment. The IIA is a live document and is being refreshed and updated as the programme develops. The IIA identified four specific key areas of populations that may be disproportionality impacted upon around the proposed changes:

• Pregnancy and Maternity
• Deprived Communities
• Ethnic Communities
• Older People

A Strategic Oversight Group has been established for the programme which has the overview of all the potential impacts on other providers, as well as neighbouring CCGs, whose patients may access some services delivered at NUH. This group oversees the work around understanding and managing the impact of the proposals across the system.

A Stakeholder Reference Group, chaired by Healthwatch, has supported and steered our public engagement work. The group is comprised of patient representatives and colleagues from voluntary and community sector organisations.

A comprehensive communications and engagement plan was populated to reference all planned activities throughout this pre-consultation engagement. 

A range of different methods were used to engage with patients and the public to understand their views. In total, 1948 individuals participated by either completing an online survey, attending an engagement event/focus group, or providing a response to the promotion of the engagement on social media (see Appendix 1).

To ensure consistent messaging across all methods utilised, a narrative describing the proposals was developed.  This formed the basis for all content in the engagement materials, including the public engagement document, stakeholder presentations, events and media briefings[1].

An easy read version of the narrative and public engagement document was also produced.

Alternative versions and formats of the public engagement document, including in languages other than English, were available upon request. 

Elected member briefings

Eight virtual/in person briefings to MPs and councillors were attended by CCG representatives, providing information about the proposals, methods of engagement and requesting any support in dissemination to constituents.  

Public engagement events

Three engagement events were hosted for members of the public to give feedback about the proposals and to ask any questions they had, to CCG and NUH representatives. These were conducted online via Microsoft Teams.

At the start of each event, attendees were given an overview of TNUH and the outline clinical model and given the opportunity to ask questions or provide any comments they had about the proposals using the chat function.

In total, 34 individuals attended the public engagement events.

A recording of the public session was made available on the CCG YouTube channel for people who were unable to join the live event[2].

Key groups and communities were identified through an extensive stakeholder mapping database undertaken by the CCG.  An invitation was sent to these stakeholders, offering a member of the Programme Team to attend community/groups meetings, provide presentations and obtain feedback. 

In total, the Programme Team attended 36 sessions and spoke to over 330 individuals.

Specific interest sessions

Individuals were given the opportunity to discuss their thoughts about the proposals for three clinical areas (cancer, family care and outpatients) through tailored sessions. These sessions were led by CCG and NUH representatives. At the start of each event, attendees were given an overview of TNUH and the details of the specific clinical area and had the opportunity to ask questions or provide any comments they had about the proposals. A discussion guide was also developed for each group to ensure that key questions were addressed.

In total, 18 individuals participated in these sessions.  

Additional sessions were offered around other interest areas but were cancelled due to low uptake.

Interviews

Where individuals were unable to complete a digital or paper survey and were unable to attend one of the sessions, the Engagement Team were available to undertake interviews, over the telephone or face-to-face.

One individual was interviewed.                  

Survey

Members of the public, NHS staff and stakeholders were invited to complete an online survey about the proposals (see Appendix 2). The survey was circulated electronically to individuals and groups whose details were held on our stakeholder database.

Paper surveys were also available on request which contained the same questions as the online survey, with a freepost return option. There were no requests for other languages or formats.

The survey comprised a number of questions, where responses could be made via rating scales or through free text. In total, 613 individuals provided a response to the survey.

Media

A press release was issued (see Appendix 3) to local and regional media, and as a result, gained coverage across the media spectrum – print, TV and radio.  The article also appeared on Nottinghamshire Live – the online edition of the Nottingham Post, attracting nearly 160 comments (see Appendix 4). 

Social media was also employed to support the engagement, with both CCG and NUH platforms being used to promote this phase of activity.  Through Facebook advertising, targeted at more deprived areas within our geography, we were able to reach 36,339 people, from which 848 engaged with the post by either clicking on the link to the TNUH website page, reacting to it (using emoticons) or sharing the post with other Facebook users.   

Communications

Internal communications were used to underpin the key messaging for the engagement and to encourage CCG staff to take part in the survey.  Information was disseminated through staff newsletters, on TeamNet and through the whole staff briefing.

Data analysis and reporting

All written notes taken during the public events, community group meetings, and qualitative responses from the survey were thematically analysed. Quantitative data was analysed to produce descriptive statistics. The findings for each of the five clinical areas are based on these analyses. Where survey respondents answered all of the demographic questions, this has enabled comparison of the four specific populations that may be disproportionally impacted by the proposed changes (hereafter referred to as “key populations”).

[1] 11153-Reshape-Nottingham-2022-Final-1.pdf (nottsccg.nhs.uk)

[2] https://www.youtube.com/watch?v=pwpMem96hnA

The findings from this report will be considered in shaping the final proposals for the programme. Once these have been developed, the CCG will consider if further engagement is required based on this feedback or whether it is now possible to undertake a formal public consultation prior to implementing any changes.

Following the conclusion of the engagement, a key number of community engagement groups have reached out to the CCG to be kept appraised of Tomorrow’s NUH.  A copy of the engagement report will be provided to the groups with a commitment to continue to engage and involve them throughout the consultation process, which will take place in due course. 

We would like to thank all of the citizens and community groups who engaged and spoke with us during this period to provide your feedback, comments and thoughts.