Transcription of Public Inquiry Regarding

Transcription of Public Meeting:

Dewsbury Town Hall Tuesday 21st May 2013

Printed 9 April 2018 Please note, this is a verbatim transcript. To respect the privacy of the public, names of members of the audience have been removed.

M – Male speaker in audience F – Female speaker in audience

Steve Richards: …this evening. My name is Steve Richards. I'm a journalist and I will be chairing the meeting.

I've got one announcement, which is that I think some of you might want to, or need to go to pray during the evening, and a room has been set aside on the first floor at 9.15, which I'm told is the time when this will happen. So that's one logistical point I wanted to raise at the beginning.

And I thought I will also, if it helps, tell you the rough structure of the evening. We're going to hear two very brief presentations first of all, a summary of the proposals, and then what's been happening with the consultation and what will happen next, after these meetings. We're then going to structure the Q&A, the questions and answers, in a way that I think will be useful and helpful. I think the slide's up there. Proposed changes to maternity services, if you have any questions about those. You'll hear the proposals as well. Proposed changes to inpatient paediatric care; proposed changes to emergency care; and proposed changes to surgery.

And if, after that, which are the four specific areas where you will all be affected, you have other questions, I promise you, you will get the chance to ask those as well on these proposals. So let's begin. We're going to hear, first of all, from Simon Enright, who's going to give you an overview of the proposals, and then we'll hear about the consultation.

F1: Just before you begin, on behalf of our 'Save the Hospital' group, can we present you with these petitions? You have 30,000 online petitions against the downgrading, together with 5,000 paper. So that's the amount of people that are actually against. And I do hope the CCG are listening about how many people that are against these proposals.

[applause]

Steve Richards: Okay, thank you. Thank you very much. Okay, well, now let's hear those proposals. You've made your point very clearly, now let's hear the proposals. Thank you.

Simon Enright: Okay. Hi, my name's Simon Enright. I'm a doctor at Mid Yorkshire, a consultant in intensive care and I've worked at Mid Yorkshire for 15 years. I'm going to very, very briefly go through the main proposals for our clinical services strategy in the four areas.

First of all, in maternity services, we're proposing that Dewsbury retains a midwife-led birthing unit for low risk births. So, therefore, ladies who are deemed at low risk for their birth can either give birth at home, on the midwife-led unit, or at Pinderfields; and ladies who are deemed at high risk will deliver at Pinderfields. There'll be local antenatal and postnatal care on all three sites.

2 In terms of children's services, we're proposing a new assessment facility for children who attend A&E at Dewsbury, which will manage the majority of the current inpatients who go through the A&E and the children's ward. Those requiring longer care, inpatient care, will be transferred to Pinderfields. We will, therefore, have urgent assessment and outpatients at all three of our sites.

The next area is emergency care. Dewsbury accident and emergency will have open access for emergency care, and we're planning to look after around 70% of the patients that the accident and emergency department currently manages. It will be staffed by doctors and nurses who are trained in accident and emergency 24/7, with full resuscitation facilities, able to treat a wide range of conditions, with some ambulance attendances. But the majority of ambulances will go to Pinderfields.

There will be consultants in accident and emergency, they will remain present on the Dewsbury site from nine o'clock 'til eight o'clock at night, and will be on call for Dewsbury 24/7. We will also develop what we're calling emergency day care, which is a national scheme to reduce the number of patients who actually need to stay in hospital. And this is for patients who, at the moment, have a very, very short length of stay, and stay in hospital for one day or sometimes less, just waiting for a test or an investigation. And we will manage those patients still on the Dewsbury site.

Pinderfields, as now, will have the specialist trauma centre, as it has done since 2010, and will be our main emergency care centre for Mid Yorkshire, for patients requiring inpatient care.

And the fourth area is around surgery, where Dewsbury will become a major centre for routine inpatient surgery, with far more surgical specialties than we have at present. We will, as much as possible, separate emergency surgical work from planned surgery, and we will retain day surgery. It's likely there'll also be some minor unplanned surgery taking place on the Dewsbury site as day case. Pinderfields will have the majority of the emergency surgery and complex surgery requiring critical care.

In summary, therefore, the major changes for Dewsbury Hospital. It will have a midwifery-led birthing unit; it will have a new paediatric assessment facility; it will retain a 24/7 A&E for the majority of the current attendances; it will have some inpatient medical beds, these will be mainly around assessment and rehabilitation; it will be a major centre for routine inpatient and day surgery; it will have the full range of outpatients and the full range of diagnostics.

To summarise very quickly why we think that patients from North Kirklees will benefit from these changes. In terms of maternity, ladies will have access to 24/7 consultant-delivered, that's consultants actually on the labour ward for high risk births.

In terms of children's, the majority of children will be managed through the paediatric assessment facility on the Dewsbury site, but the children who do require inpatient care will have access to more specialists for longer, and on-site consultant care at Pinderfields.

For adult emergencies, the majority of the current emergencies will still be seen at the A&E in Dewsbury, but sicker patients will be seen at Pinderfields quicker, by consultants and specialist teams. In terms of surgery, routine operations, including patients who require inpatient or overnight stay, will be carried out locally on the Dewsbury site. For emergencies and very

3 complex operations and sicker patients, again, they will be seen quicker by specialist teams on the Pinderfields site. In terms of outpatients, we will have more outpatient facilities for Dewsbury residents on the Dewsbury site.

I'm going to hand over to Dr David Kelly now, who's going to discuss more about the consultation process.

David Kelly: Thank you, Simon. For those of you who don't know me, my name's David Kelly. I'm a GP in Heckmondwike. I've been a GP there for 23 years and I live locally. I'm the Chair of the CCG and I wanted to tell you a little bit about what we've heard through this consultation process so far. Bearing in mind, we've still got another ten days or so to go in the consultation.

So what have people been telling us in terms of the process? And I've obviously seen and recognise the petition that's just been handed over to us, which I was aware of anyway beforehand and have received petitions from other groups as well throughout this process. So what people have been telling us is that they want as many services as possible to stay locally. They value the local hospital, they value Dewsbury Hospital, and they do not want to see services moving from Dewsbury Hospital, if at all possible.

They're concerned about emergency transfers to Pinderfields, both in terms of the timings but also in terms of some of the safety aspects that have been mentioned to us. They're also concerned about access to services. And that's not only access to services in secondary care but also access to GP services, in terms of appointments at their local doctors, but also appointments at outpatient clinics. And general concern about travel and transport, and how it might affect patients but also their families and carers, in terms of what may happen under the proposals to those.

Some of those more specific things we've heard which, you know, we've tried to talk through during the proposals are, it's all about the money. We've also heard about the fact that actually there's a lot more discontent from patients in the North Kirklees area about the proposals, because some of these affect our local patients perhaps more than in some other areas.

So what have we done in terms of listening, in terms of the proposals? Now some of the things I'm going to talk about today are some things that we actually reflected on and are proposing may change in the development of this outlying business case, should the proposals be successful to a full business case.

So in terms of paediatric assessment, you heard from Simon earlier. The suggestion is that actually we increase the opening hours of that assessment facility to have a consultant available on site for longer hours. Now it depends on the demand and the activity, but I think in the original suggestions we were talking about 'til seven or eight o'clock at night. But I think we're talking now about ten or even 11 o'clock at night. But that will be reflected on during the next few months or year or two, as things progress, should the proposals become into practice.

We're also recognising there's going to be a need with the closure of the paediatric ward at Dewsbury, to have a service to look after children with more complex needs. So these are children with perhaps neuro-rehabilitation needs or more complex needs that might need sort of a multi-disciplinary approach. And that could actually be dealt with through the local services or out in the community.

4 In terms of surgical assessment, Simon's already outlined that the majority of elective surgery will happen locally. There'll also be the opportunity for actually some of the non-elective surgery, some of the emergency surgery that can happen without an inpatient stay, to happen on the Dewsbury site. This could include things like kidney stones, ectopic pregnancies, abscesses and minor fractures.

There's also going to be an increased use of our postoperative facilities to actually reduce length of stay, and actually more local surgery and more local follow up. Alternatives to hospital medicine out in primary care, in terms of how these patients can be dealt with post-surgery, are also going to be looked at.

In terms of emergency day care, we're looking at the hours of that service being potentially with a consultant on site nine 'til nine, initially starting probably with shorter hours but then developing as the unit progresses, with increased use of technology to deal with patients in a different way, and a range of conditions, which are listed there, that could be dealt with by patients not needing to be admitted to hospital but actually be dealt with as a day case or emergency care facility.

We're also looking at reducing the travel for frail elderly patients. We don't want them to be going to Pinderfields to be assessed when they could actually be assessed, have quick access to a consultant opinion and diagnostics locally, and actually avoid the need for admission or travel to Pinderfields.

In terms of maternity services, as you know from the proposals, the midwife-led unit locally is estimated to have about 500 births. But we'll keep an eye on the demand for those services, with a view to whether those services need to be increased. And we're certainly looking at improving and strengthening the range of antenatal services for patients out in primary care, with increased use of consultants out in primary care, but also options around how we might improve the antenatal care services in your local practice.

Outpatient appointments I think are fairly key to us, in terms of the fact that we also share the vision that we want all of our services, where possible, to be local. And we want to strive towards the majority, if not all outpatients, to happen locally at Dewsbury Hospital, unless there are very good reasons why they need to happen somewhere else.

Now a travel group has been in existence for a little while and looked at some of the concerns that have been coming out around travel. And although there's some suggestions coming from them, they haven't yet been fully costed up and presented to us as commissioners. Some of the things coming out of that are things like improved shuttle services between the two hospital sites; options around free Metro cards; alternative transport back from Pinderfields, should you need to go to Pinderfields and need to get back. But again, the full details are not yet prepared. There is going to be a big deliberative event on the 2nd July, once all the outcome of the consultation happens, when hopefully, well, some more detailed proposals will be available.

In terms of the numbers, now a lot of people have said to us they're concerned about the travel patients to Pinderfields. This slide really represents a number of changes that are in the proposals. And actually, the number of patients currently treated at Dewsbury and the number of patients, should the proposals go ahead in 2016/17 that would be treated under the proposals locally. Now you can see that in most of those areas, the actual number of patients

5 who are going to be treated locally is actually increased and the overall net effect is an increase in activity for patients locally. So that starts with outpatient services but also then moves on to day case surgery and elective inpatient surgery.

There is less in terms of emergency admissions because obviously the proposals are about having emergency inpatient facilities at Pinderfields. And there's also a reduction in terms of paediatric admissions because the paediatric assessment facility will monitor those patients and assess them, to actually avoid the need for admission. But overall, you can actually see there's an increased activity at Dewsbury to make this a thriving local hospital.

Now going on from that, as well as these hospital proposals, we've also reflected on some of the conversations we've had about the need for improvements in practices, in primary care and also in community services. And we're working with our practices to try and work towards 24/7 general practice services for local patients. But also, a 24/7 integrated health and social care team to enhance community services for our patients.

So that really just is an outline of what we've heard so far, and some of the things we're proposing to change, and actually just a clarification on some of the figures in terms of travel. Thank you.

Steve Richards: David, thank you very much. Well, we've got a big panel here, so I think it's probably best if I ask each of them to introduce themselves so you know who they are, and then we will begin questions. So we've heard from these two.

F2: [Inaudible - microphone inaccessible 0:16:01 - 0:16:05] want to know who they are, they weren't elected by us.

Steve Richards: No, they weren't elected but they might answer your questions, so you might as well know who they are…or try to answer them. Please let them.

Chris Dowse: Okay. Hello, I'm Chris Dowse. I'm Chief Officer of North Kirklees Clinical Commissioning Group.

Stephen Eames: Hi. Good evening, everyone. I'm Stephen Eames, Chief Executive of Mid Yorks NHS Trust.

M/F: Oh.

Richard Jenkins: Hello, my name's Dr Richard Jenkins. I'm the Medical Director at Mid Yorkshire.

Kathryn Fishwick: Hi, Kathryn Fishwick, consultant gynaecologist and obstetrician.

Anne Ward:

6 Anne Ward, Head of Midwifery for the Trust.

Karen Stone: Good evening, Dr Karen Stone. I'm a paediatrician in the Trust.

Matt Shepherd: Hi, Dr Matt Shepherd. I'm a consultant in accident and emergency at the Trust.

Andy Simpson: Good evening. Andy Simpson, Yorkshire Ambulance Service, Head of Emergency Operations.

Steve Richards: Great. Thanks very much. Can you leave the mic for Anne because…so we're going to divide them up into four specific areas where proposed changes are being considered. Oh, we're going to do them. We're going to deal with proposed changes to inpatient children's services. Karen.

Karen Stone: So hello. I'm just going to, very briefly, remind you what that means for children under these proposed changes, and then I'll be happy to take questions. So our proposals are that at Dewsbury Hospital, we will have a new assessment unit, a children's assessment unit, dedicated for children, co-located with the emergency department. That means that we can see children who are referred up from GPs or who the health visitors, midwives or A&E doctors require us to give an opinion on, very quickly by a senior clinician. That unit will be staffed by consultants and senior nurses. We will be able to see children quickly, make rapid assessments of them, their condition and the need for treatment.

Most children only require the decision for treatment and then treatment starting and they can go home. Some children require a short period of observation, which can be done in that unit, where we make sure that, once we've started the treatment, they are then safe to go home.

The other scenario is that a child requires treatment, and that is significant treatment that is going to require an inpatient stay. That department will be able to assess that child, make that decision and make the necessary referral and safe transfer to Pinderfields Hospital, to the inpatient children's service.

We know that if we can consolidate our services into smaller areas for inpatients, in terms of having one centre, we can deliver better care. We can get consultants available more of the time, so that when your children are very ill, we can get senior opinions to them very quickly and for longer hours than we currently can. We know in Dewsbury that we see about 3,400 children a year at the moment through our children's ward. And of those children, only between 400 and 500 actually stay more than 24 hours. So we're talking about very small numbers of children who actually need this longer stay.

The other bit of our service that we're looking at and are currently striving to make changes all the time, but we need to know and make sure that our children with complex needs, so some of those are children with neuro-disability, there are other children with long term conditions such as diabetes. We're going to be making sure that we've got the right systems in place to look after those children. We want to see most children looked after at home, as close to home as possible, and only requiring an inpatient stay when they absolutely have to have one. And by

7 making sure that our community services are moving along with the changes in our hospital services, we hope to provide that care, as I said, much closer to home.

I could talk a lot more about children services, I'm obviously very passionate about them, but I'd probably rather answer your questions.

Steve Richards: Hold on, and I promise you, you can ask the questions you wish on these specific proposals across the board. But is this specifically about…?

F3: Yeah.

Steve Richards: Yeah, okay. Sorry, the [inaudible 0:20:42] we're recording these and they will be on the website, so if you don't mind waiting for the mic. Thanks.

F3: You said you can get children seen to quicker.

Karen Stone: Yes.

F3: Quicker than you said what we can now.

Karen Stone: What makes the difference for any patient, whether it be a child or an adult patient, is the time that it takes to see a senior decision maker. So by seeing a consultant quicker, we aim to make a diagnosis, a full diagnosis quicker, start treatment quicker, and therefore start to get you getting better quicker.

F3: Does it mean then that you're going to start moving children like you are adults?

Karen Stone: No.

F3: [Inaudible - microphone inaccessible 0:21:20 - 0:21:28].

Steve Richards: Hold on. Actually, have the microphone, because the audience can't hear.

F3: And not outside Dewsbury. Because if a child's critically ill, it needs to be in one place, doesn't it?

Karen Stone:

8 If a child is critically ill, there are some different pathways. So what we will be doing in a children's assessment unit is seeing that child, a consultant making a decision about the diagnosis, the right pathway of care, the right treatment to give that child. If we have a child who is very seriously ill, and those are the sort of children who are requiring intensive care support, Dewsbury Hospital, Pinderfields Hospital and Pontefract Hospital are able to start that intensive care. But we then use our regional transport service, called Embrace, to move those children safely to the nearest available intensive care unit. The Mid Yorkshire Trust does not do intensive care for children. That is what happens now and that is what will continue to happen in the future.

There are very few children who need other specialist services, so sometimes we do send children to Leeds, Sheffield, Manchester for very specific specialties. That will continue as it does now, and would be able to happen from Dewsbury.

F3: And what happens to the out care patients that you're on about sending people out to the community? How soon, if this happens, will it take place to put that in place? You're talking about home visits obviously, aren't you?

Karen Stone: I'm not just talking about home visits. We want to make sure that our children's community nursing team, of which we have a small team at the moment, is able to help us manage more children at home. So for example, I would like to see in the future that, if you bring your child in with diarrhoea and vomiting, they're not too unwell, that after a brief period of observation in hospital, we can send you home and a children's nurse will come and make sure that you're alright at home later. That's the service that I want to provide for your children and that's what we're looking to do in the future. So…

F3: Well, you're struggling aren't you? I mean, they're struggling now to send somebody out because they've virtually all been sacked, haven't they?

Steve Richards: Okay, that's four questions and I'll get a response [voices overlap 0:23:52]. Yeah, well, I promise you I will see [voices overlap 0:23:56]. We'll get you the response now but in fairness, others will want to ask questions as well. Do you want to just give one quick response

Karen Stone: I'll try. We currently do not struggle to send children home when we need to send them home, but we would like to be able to send children home earlier if we can. The best place for children to get better when they're stable is at home in their family environment. A hospital is not the right place for them to get better totally.

F4: You've still not answered the question. This lady asked was the community service going to be in place straightaway. You have not answered that question. It's a yes or no answer [voices overlap 0:24:35]. You've done everything but answer that question.

F: Ask it again.

9 F4: This lady has asked you is there going to be the social care in place straightaway. You've not answered that question, you've done everything but.

Steve Richards: You're going to get the answer now.

Karen Stone: I think I have answered but I believe Stephen would like to…

F4: It's yes or no.

Karen Stone: I believe Stephen wants to answer it.

Stephen Eames: The answer is there already is [voices overlap 0:24:59]. Just let me answer, with respect. There already is community services for children in your area. What we're talking about is improving those services. Now they're not…

F4: Will they be instantaneous?

Stephen Eames: Well, no, let me, again, answer the question. They're not yet in place. And one of the issues about all these changes, which is quite clear from some of the things that David has said in earlier meetings, and I think hinted at this evening, is at the moment we're consulting. We wouldn't want to make any changes until the whole of the pathway that we're putting in place to support these changes have been implemented. Now understandably, we haven't put that detail into place because we're consulting.

F4: So the answer to the question is no?

Stephen Eames: No, the answer is not no, the answer is - let me finish - if the proposals go ahead, there will then be a detailed plan about how these changes will be implemented between now or to the end of this year, or something along those lines, through to 2016/17. That's not in place yet. But the simple answer to your question is, we'll be putting services in place to support the changes that are being proposed.

F4: But not straightaway?

Steve Richards: Alright. Well, yeah, so you've got the answer, even if you disagree with it. [Voices overlap 0:26:09]. Yeah, okay, well, you've at least got a response. I think I'll come to…yeah, okay, the

10 lady towards the back, and then I think the guy in front of you had his arm up for quite some time. Yeah.

F6: I'd like to know when the changes come about in A&E, and it's not going to be consultant-led, and a seriously ill child is brought into A&E department, there will be no consultant there to sort that child's problem out. And it'll be a 15-minute journey to the nearest hospital at Pinderfields, where you're putting all our resources that should be here at Dewsbury. [voices overlap 0:26:48] Yeah. So if the consultant-led area at Pinderfields is so important to people at Pinderfields, why is it not important to people in this area at Dewsbury? Because life-saving comes within ten minutes of being seen. I've had relatives that have gone to Dewsbury A&E and been seen in the critical time that should be taken. And I don't want none of my family, friends or anyone here to undergo, well, some blunder on the way down the M1, when a child dies en route to Pinderfields.

[applause]

Steve Richards: Okay, thank you very much. Just to clarify in terms of the structure, we're going to have a whole section on A&E, but you raised the specific case of children. So we'll get…yeah. And then obviously, you can all raise your concerns about A&E when we come to that. But specifically on children, Karen.

Karen Stone: Thank you, yeah. So thank you for asking about that because I appreciate that's very important. It's important to us as well. Our A&E departments, at the moment, do not have consultants in them 24/7. There are periods of the day when the middle grade staff are responsible for the care of all the patients in A&E. So that wouldn't be different at Dewsbury.

If a child or an adult patient comes into our A&E departments, the staff who work in there are trained to recognise a sick child, they are trained to start treatment and call for help if they require it, for a sick child. At Dewsbury, under these proposals, we will have a resuscitation team in the hospital that is able to deal with children 24/7 and who will be trained in the advance life support of children. If a child arrives at the Dewsbury department and is so poorly that we are starting intensive care, then that child will be stabilised in Dewsbury and taken by the transport service not to Pinderfields but to the nearest intensive care facility with a bed, which is what would happen now.

The plans under this proposal are that our ambulance service colleagues will facilitate the safe transfer of children to the right hospital first time. So if your child was so poorly and you called an ambulance, and they deemed that child to be in need of specialist children's care, they would be brought straight to Pinderfields Hospital. So there will be very few children going to Dewsbury requiring that level of support. Most children who are very ill, when they come to A&E, require what we call stabilisation, and very simple measures actually make that child a lot better and then they can be safely transferred for further help at Pinderfields, if that is what deemed to be right for that child.

Steve Richards:

11 Okay, we'll let…do you want to come back as you asked the question? But can this be the last time, not because I'm trying to stop you, because just in fairness to let other people ask. But do come back and get another response.

F6: I understand what you're saying about being moved on and stabilised, right, but at Dewsbury we do have facilities that are still existing and should be existing into the future for children and adults, which we're not talking about at the moment, it is merely children. It's a matter of life and death is the transferring system, right. And you're telling me that they would be transferred outwards anyway. We need the backup at Dewsbury, consultant-led, to help the children that come in and facilitate what needs to be done. You're trying to sort of whitewash over it, saying that they would be sent outwards anyway and transferred to another region. Yes, you are. But the thing is, Dewsbury's maintained itself for however many years. They've always had the facilities, they've always stood by the people and they've always got what they needed from this hospital here. You're wanting, because of this PFI, to move everybody out to Pinderfields. And because you've made the blunder, all you lot sat there, to be honest with you, we, the local people, are going to have to pay for it because you can't afford to keep Dewsbury with consultants because they're all at Pinderfields.

[applause]

Steve Richards: Okay. Karen, do you want to respond briefly?

Karen Stone: Yeah. I'm going to stand up because I'm struggling to see people through everybody. I feel I have answered your question. Children will still, when they arrive at our A&E department at Dewsbury, be seen by medical and nursing staff who are competent in the assessment, diagnosis and treatment of the critically ill child. That is an absolute for every A&E department that receives children. It is a standard that we have now and we will continue to have. It will be the same in the future.

Steve Richards: Okay. I promise you, you've made your point really clearly.

Karen Stone: Yeah. We do not have intensive care for children at Dewsbury. It is done regionally.

F6: [Inaudible - microphone inaccessible 0:32:09 - 0:32:12] consultant-led A&E [voices overlap 0:32:15].

Karen Stone: Consultant-led does not mean that the consultants are there 24/7.

Steve Richards:

12 Okay. And also, as I said, we're going to have a whole section in a minute on A&E, but that guy had his hand up for a long time just in front there. Yeah. Thanks.

M1: Hi there. Sorry, my question's hovering on the same issue, the boundary between A&E and children's inpatients, I'm sorry, just because my son had respiratory problems a couple of years ago, he's five, and called an ambulance. And I'm not clear at the moment where he would go when the ambulance see him because as far as I can tell, you know, it was seen as a very serious respiratory problem and that he'd now be taken to Pinderfields. Could I just confirm that, that is correct first, and if I can, just a quick follow up?

Steve Richards: Of course.

Karen Stone: Yes, of course. What will happen in the future is, if you call an ambulance and these proposed changes have happened, the ambulance crew, when they first take the call and then when they respond and see your child, will assess your child. They have criteria under which they assess any patient that they go to, they start treatment and they make a decision based on protocols as to which is the correct hospital to go to.

So they would take your child to the hospital that they felt was appropriate for your child's need at the time. They will start treatment on the way. And that's really important to remember is that our ambulance service colleagues, as soon as they arrive, are starting that pathway of care. So you're not waiting for that time to get to hospital, they've already started treatment for us. And they let us know if your child is very ill, so we can be ready and waiting for you when you get there.

M1: Thank you very much. I mean, my background is I'm sort of a health researcher at the University of Manchester, and I'm just concerned because I know a lot of the evidence around respiratory illness is that the most important thing is actually getting to the nearest hospital as soon as possible, and that the further the ambulance travels to an A&E department, the worse are the outcomes in terms of deaths. So I'm concerned that, you know, that's addressed.

Steve Richards: Okay, Karen, would…

Karen Stone: I'm going to ask Matt to, yes.

F: [Inaudible - microphone inaccessible 0:34:33 - 0:34:36].

Matt Shepherd: It's kind of you to say so. What the evidence shows, and the evidence is a paper that was done by Professor Nichols in 2007, which…

F: [Inaudible - microphone inaccessible 0:34:48 - 0:34:53].

13 Steve Richards: Hold on. Look, in fairness to the question, let him get an answer.

M1: Would you mind if I hear the answer? Thanks.

Matt Shepherd: So the paper was written in 2007, and it reviewed the data from the ambulance services I think from 1997 to 2001. And what they looked at was looking at how far people travelled and then the mortality rates based on that. And that paper suggested that, at that time, people travelling further looks like there was a greater mortality. And you're right in saying that those with respiratory disease seemed to be affected the most by travel time.

What hasn't been revised is looking at that since lots of other things have come into pass. So lots of things have changed since 1997 to 2001, not least of which is the amount of training that paramedics have to start care on the way.

What the paper also highlighted was that, that didn't take into account any changes that you might put into place about the quality or the timeliness of the care when you arrived. And I think that's the key because crossing a hospital threshold doesn't suddenly make you better. What starts making you better, as Karen's highlighted, is being seen by someone with the skills to sort the problem out.

Steve Richards: Okay.

Matt Shepherd: And that's the important thing. What we want…what we're proposing is putting the skills that can be present through greater hours of the day and get to the patients quicker. A small part of the time from the moment you become ill to the moment you get treated is the travel time. What's the key is how long it takes you from the moment you call for help to the moment you get started on treatment. And we think our proposals shorten that time, we don't think it lengthens it.

M2: Do you think? What about [inaudible - microphone inaccessible 0:36:40 - 0:36:48] 37% increase in mortality, tell me your thinking [that it's going to work 0:36:52].

F8: And their evidence is based on fact [inaudible - microphone inaccessible 0:36:52 - 0:36:58].

Matt Shepherd: I can also say to you that the Newark situation is very different. We're not closing emergency department in Dewsbury. There are…

14 [Inaudible - microphone inaccessible 0:37:04 - 0:37:08].

Matt Shepherd: You're telling me about a department that closed in Newark. We're not closing it. We will still have resuscitation facilities available. If our colleagues in the ambulance service are struggling with a patient that they don't feel can make the travel, the journey time, then the facilities at Dewsbury will be available to them to help stabilise that patient.

We also have our own local evidence of doing this before. So whether you like it or not, we have had similar changes at Pontefract for different reasons. We can demonstrate that there has not been an increase in mortality for the patients in Pontefract caused by having to travel further to Pinderfields.

Matt Shepherd: Yeah, that's what I said.

Stephen Eames: Could I just make a brief comment about the statistics on mortality between last year and this year. [Voices overlap 0:37:59] I'm just answering this gentleman's question, if you'd let me. Just over the last 12 months…because it's a very important question, absolutely, and I understand exactly what he's saying about what was reported recently in Newark. And it would be completely inappropriate for us to be making changes that worsen the mortality rates; absolutely right.

But if I could just explain, which takes account of some of what Matt's saying. The mortality rates in the Trust, across the Trust - and we can break it down by hospital - were running at about eight points above 100, when 100 is the bar, if you like, so anything above 100 is going in the wrong direction. Currently, they're running at 96, so we're going in the right direction. Now our commissioners wouldn't commission our services, I wouldn't support changes, clinical colleagues wouldn't support changes that make that go the wrong way.

Steve Richards: Okay, thanks very much. Just so everyone has a chance to address all the issues that worry them, let's move on briefly to I think it's maternity services next. And I'm going to ask Anne to summarise the proposed changes briefly. And then if any of you have got worries or questions about that area before we move onto the next one, which I know a lot of you have got worries about. Anne?

Anne Ward: Evening again. Just to remind you, my name's Anne Ward and I'm Head of Midwifery at Mid Yorkshire Hospitals Trust, which means I'm responsible for the midwifery services.

In the new proposals, currently women have antenatal and postnatal care in the community setting, given by the community midwives, if they're low risk. If they're high risk, they come to consultant clinics and they're seen by consultant obstetricians at Dewsbury. Under the proposals, that will not change at all, those services will continue.

15 The only changes will affect women when they are actually in labour or if they have a problem in the pregnancy that requires admission to hospital. If they need admission to hospital in the pregnancy, that will be to Pinderfields. If they are admitted in labour, they will have the option of, if they are low risk they can have the baby at home, as they currently can. They will also be able to choose the midwife-led unit if they are low risk. If they are high risk, then they will go to Pinderfields.

What we know from a detailed study that was completed the year before last is that midwife-led care is as safe for low risk women as consultant care, and it actually improves the experience for women and families.

Under the proposals, by centralising the delivery suite and the consultants on one delivery suite, we will be able to provide a service where, 24 hours a day, seven days a week, if you come to that delivery suite and you have a problem, there will be a consultant sat there, ready to provide care in conjunction with the junior doctors that are in training; which is a much better service for high risk women that we currently provide across the patch. Because we have two obstetric units, we currently provide 24-hour consultant cover. What that means is, from nine in the morning until eight in the evening, there's a consultant actually physically present on the delivery suite. Out of those hours, the consultant is on call at home. And the national criteria are that you have to be within 30 minutes of the unit to be able to provide an on call service if you're the consultant.

So by centralising at Pinderfields, if you need a consultant, you won't have to wait 30 minutes if it's out of hours, for them to come if they're needed in your care, because they will actually be physically present. And we know that midwife-led units significantly improve the experience for women and don't impact on outcomes for mums and babies.

Steve Richards: Okay, thank you very much. So any questions on this specific area? I'll come to you next, but that lady hasn't asked anything yet, and then I'll come to you.

F9: Thank you. Much of the proposals here seemed to be based on separating out planned and unplanned care, or low risk and high risk care. What I'd like to know is, what would happen if what is deemed to be low risk suddenly becomes high risk?

Anne Ward: Then we do what we currently do as an organisation. We have a midwife-led unit at Pontefract that has no consultant cover at all. That's been running for over two years now. As midwives, we're trained…we do give social support in labour, but actually the bottom line of our training is to recognise when things are becoming abnormal. That's why we have midwives. And we're trained to recognise when things are becoming abnormal, we have protocols in place, we work with YAS, and women are transferred currently from Pontefract to Pinderfields. And that's what would happen at Dewsbury, women would be transferred from the midwife-led unit to Pinderfields.

We know about a third of women do need to transfer, and that would be information women would be given when they're making the choice about where they're going to give birth. Because at the end of the day, it is the woman's choice where she births.

16 F9: No, it's not the choice, it's about…I mean, just from my own personal experience, my daughter in law had a placental abruption. That happens very, very quickly. At that point, you can't say, oh, I want to deliver at home, I want to be in Dewsbury, I want to be in Pinderfields. Something has to happen very, very quickly. So in that fast moving situation, how would that be addressed?

Anne Ward: She would be transferred to Pinderfields, where the consultant would be there ready to provide care. And in terms of…we know from colleagues who work in the highlands and the islands off the Scottish coast, we know that outcomes don't change, provided the transfer time doesn't exceed 40 minutes.

What we're actually doing as well, which you need to remember, if the woman has called from home, the ambulance crew will pick her up and en route they will be contacting Pinderfields delivery suite, they won't bring her to the midwife-led unit. If she's been someone we've said is low risk and during her labour that happens, which it can do, it's less likely to happen in low risk women but can happen in low risk women, then we would dial 999. What we would also be doing is ringing the consultant unit to say we have a woman who is having a placental abruption. The midwives will be trained, there will be drips in, there will be fluid running. The ambulance paramedics can support. And as the woman walks onto that delivery suite, that theatre is all ready.

If it's out of hours, currently, and with a major abruption, the College recommendation is that a consultant actually comes to the delivery suite. Currently, if that happens out of hours, you're talking 30 minutes for the consultant to get to the delivery suite, so the time difference, there would be no time difference.

F9: Well, all I can say is that from my personal experience, that transfer time would be too much.

Anne Ward: It is very scary and we acknowledge that.

Steve Richards: Your question about what if it's in the rush hour, basically half eight. So if you could bear that one in mind. I promise you there, don't worry, I've seen your hand at the back. Yeah, I'm going to ask you next. I'm just reassuring the hands at the back I've seen them. But you next, yeah.

F10: Can I just say, my niece at seven months pregnant went into…her baby went into distress. They had five minutes to get that baby out alive at Dewsbury Hospital. That baby would have been dead if it wasn't gotten out by an emergency caesarean within five minutes. That baby would have been dead had it gone to Pinderfields.

Steve Richards: Okay. Sorry.

Kathryn Fishwick: At seven months, that baby is preterm and wouldn't be suitable for midwife-led unit.

17 F10: It went to Dewsbury and it got delivered at Dewsbury. If it had have gone to Pinderfields, she wouldn't have been alive now.

F11: No, what you're presuming is that you actually knew. They didn't know.

F10: They didn't know.

F11: Everything was fine. She'd had her first baby, everything was fine. She was a low risk person who went and had to deliver and give her an emergency caesarean.

F10: They had five minutes to get that baby out. That baby would not have lived had it had to go to Pinderfields.

Kathryn Fishwick: Okay. What I'm saying is that at 27, 28, 30 weeks, whatever seven months would equate to, at that stage, the ambulance crew would not take your niece or whatever relation it was, to…

F10: Not in the new proposals it wouldn't but under the old proposals it did.

Kathryn Fishwick: Yes, but that's a false argument because what we're saying with the new proposals, if you phone an…

F10: It wouldn't have made the journey.

Steve Richards: Okay, you've made the point very, very powerfully.

Kathryn Fishwick: Well, if you went…the ambulance crew - and I'll hand over to Andy for travel times here - but the ambulance crew would not take a preterm pregnant lady to Dewsbury…

F10: Under the new proposals.

Kathryn Fishwick: …because it would be an inappropriate place to take…

F10: Under the new proposals.

Kathryn Fishwick:

18 Yes, I agree, I've said…

F11: You're not listening to what's been said.

Steve Richards: Yeah, they are listening.

Kathryn Fishwick: I'm listening to every single word that's been said so far.

F11: You're not.

Kathryn Fishwick: Well, I beg to differ.

F11: You're obviously not.

Steve Richards: Okay. Look, you've made the point very, very powerfully about time. It was implied in your question as well. I know you're not happy with the answer but let's just hear about ambulance times as well. I know it won't satisfy you with that powerful case [voices overlap 0:47:46]. And I'm going to come…yeah, we'll just hear the answer about ambulance times and then I'm going to come to the back there. Thanks.

Andy Simpson: Just regarding ambulance times, I know it's a very important issue is speed of response and also speed of transfer to the people of Dewsbury. Now I could stand here and I could quote times based on AA auto route, and I could quote times off RAC auto route. But more importantly, I've spoken to frontline clinicians because obviously I want to know how fast that transfer speed would occur. And you're quite right, is it two o'clock in the morning, is it five o'clock rush hour.

Now speaking to frontline clinicians, frontline paramedics who do this journey day in, day out, because it is a common journey, door to door they're telling me 20 minutes. Referenced off the auto route systems between 17 and 25, but frontline clinicians are telling me door to door in rush hour traffic 20 minutes is the average. Historical data that we're looking at, crews have done it as fast as 16 minutes. And I can…and that's open to scrutiny.

So a very fast transfer time.

Steve Richards: Okay. [Voices overlap 0:49:02] Can I just allow at the back there, because you've all spoken and you will get other chances. Yeah, there was someone at the back who wanted…yeah, if you just pass the mic to…no, right at the back. Oh, sorry, was it you who had your hand up first? Yeah, okay.

19 Okay. My question too on the issue of women giving birth and the transport. Have you taken into account that these women will be in distress? Have you taken into account that women don't want to be travelling 20 minutes, 16 minutes, I don't care how long it is? You wouldn't want to be travelling that long. And so, therefore, I think it isn't fair to put a mother in that position. She's already distressed because she's giving labour, to put her in the back of an ambulance because she's in distress because her baby is coming out not in the planned way is very unfair. And you haven't taken into account the mother.

Also, can I add that two years ago, a friend of my mother's, she was giving birth, if it wasn't for my mother screaming at the consultant, the woman wouldn't even have had the caesarean in the first place. She needed the caesarean straightaway. It was my mother that told the midwife and the midwife wasn't even listening to her, wasn't listening to the mother. And the mother had already had a caesarean before in a previous birth, right. She was having complications throughout it and they were suggesting, oh, no, let's send her back home. So how are you taking into account patients, their needs, anything? You haven't taken into account what the mothers are feeling.

[applause]

Steve Richards: Okay, thank you very much. I mean, in a way that kind of echoes your point that some people are saying even five minutes is too long to travel.

Anne Ward: So if I can answer your question. What we've got to be clear on is that for low risk women, there will be three options for places where you can have your baby; home, the midwife-led unit or the consultant obstetric unit.

F12: That is not the point we are making.

Anne Ward: Well, you've asked a question, will you please let me answer?

F12: No, I'm sorry but I do not appreciate that tone. Every person on this [voices overlap 0:51:15] has taken a very rude tone towards this audience. You are there making the decisions for us. None of this audience is happy about these decisions, so do not take a rude tone with any of the audience because we are frustrated and we are getting angry that we are getting a rubbish deal from the maternity, from any department in this hospital and in the GP practices as well.

[applause]

Steve Richards: Okay, thanks. Well, look, you've made your point, you’ve seen the response here. I don't think they're being rude actually, they are trying to answer. You might not like the answer [voices overlap 0:51:45] let's see this point about time.

F12: They are being rude.

20 Steve Richards: I don't think they're being rude. But anyway, we won't get into a debate about who's being rude because we'll waste time and you want to hear…we want to move on to the next subject in a minute.

Anne Ward: It may well be that I am not saying what you want to hear but as a midwife, which is my passion, I am professionally accountable to not lie to the people I provide services for. If I lie, I can get struck off. You're absolutely right about women being distressed, being transferred from a midwife-led unit to a consultant unit, which is why absolutely we do not make the decision for low risk women about where they want to birth. The women make that decision themselves.

If they choose the midwife-led unit, they have the information that a third of the women will need transferring. The woman herself will decide whether it's right for her during labour to potentially need to be in an ambulance. If she doesn't, only a third of women who are low risk will actually choose to birth the babies in midwife-led units. Only a third of women who are low risk nationally make that choice. We would support those women. If a low risk woman wants to birth in the consultant-led unit, then that is where she will go to have her baby because it's her choice.

F12: [Inaudible - microphone inaccessible 0:53;12 - 0:53:20] you're not answering the question.

Kathryn Fishwick: Excuse me…

Anne Ward: You're not listening.

Steve Richards: Hold on. Look, you've all…every questioner has made the powerful point about time and [voices overlap 0:53:25] but those…there have been answers. You might not like them and I'm sorry about that. [Voices overlap 0:53:32] No, I'm sorry if you don't like them. But look, let's give other people briefly the chance to ask questions.

F13: Can I ask, can you guarantee that the low risk patient is going to be a low risk? What if that becomes a high risk and she needs a caesarean straightaway, what are you going to do? 20 minutes ambulance ride, is that the answer?

Anne Ward: That has happened at Pontefract, women have chosen [voices overlap 0:54:00]…women have chosen, because they are low risk, to have their babies at the midwife-led unit at Pontefract. In the last two years, eight of those women have developed an emergency that has required immediate transfer to the consultant unit at Pinderfields. Of those eight women, the outcome for them and their babies has been good, because we have protocols in place so that communication and clear communication is taking place while the woman's actually en route in the ambulance. While she's en route, staff are getting theatres ready, they're calling the

21 consultants if it's during the day, and they are ready the minute that the woman comes onto that unit to deliver her baby.

What we know from…and eight women doesn't sound very many, but what we know from national studies is, if you are low risk, you may need transferring, but the outcomes for women and babies in midwife-led units is no different to if they were actually being cared for in a consultant unit, but the experience for families is much, much better. So having a baby in a midwife-led unit, yes, you can develop complications but what we know from national studies is, that doesn't increase the risk of your baby dying or the mother having profound complications because she hasn't received treatment quickly enough. And she chooses that herself. She's given all this information in her pregnancy before she even decides where to have her baby.

Steve Richards: Right, okay. [Voices overlap 0:55:44]. Okay, look…

Kathryn Fishwick: Can I just turn it around slightly, because obviously we've been talking about the midwife-led unit which is for ladies who are very low risk. But actually, part of this is about making facilities better for those women who are high risk. Because at the moment, we have…as does most hospitals around the country, we don't have consultant presence around the clock. As we've said, we provide 60 hours of presence during the week, which is nine 'til eight, Monday to Friday and nine to 12 Saturday, Sunday. The rest of the time, we are available at the end of a phone to come in and within 30 minutes, but we're not present.

The proposals change that so that we pool together all our consultants into one area, so we can provide 24/7 cover for those women who require a doctor present. I think sometimes when we talk about the low risk end, we forget about actually the improved service for those women at the high risk end.

Steve Richards: Okay, thanks. Look, what I'm going to do, I'm fully aware that some of you want to ask more questions. I'm also deeply aware we've got these two other vital areas which I know you'll want to ask questions on as well. So can we just move on and there will also be time at the end for broader questions.

Let's hear a brief overview of changes to accident and emergency, which has already come up on one of the other discussions. And I know many of you want to come in on this, so that’s why we're moving on. But I've clocked that you at the back had your hand up for a long time and I promise you, you'll get your question in. But let's briefly, from Matt, hear an overview to the proposed changes, and then we'll open it up on A&E.

Matt Shepherd: Okay. So we are talking about accident and emergency but we're also talking about the care of people with critical illness and critical injury beyond just the accident and emergency department. What we're going to do if these proposals go through is maintain at Dewsbury a consultant-led accident and emergency department, with consultants present on the shop floor, seeing patients from nine in a morning 'til eight at night Monday to Friday, and from nine in the morning 'til three o'clock on Saturdays and Sundays; which is exactly what happens now.

22 Outside of those hours, the consultants currently are on call to come back to the department if they're required. And what is in place to be able to look after you when you come to A&E outside of the times when consultants are there is experienced, middle grade doctors who are trained in accident and emergency medicine, to make sure you are stabilised, treated and set on the right treatment pathway. That will continue.

What we're offering though, a bit like in maternity, is for those patients who are the sickest group, the critically ill, critically injured patients, will be able to be transferred to a department that has consultants not just in accident and emergency but in the wider range of medical and surgical specialties present and available to get to those patients much quicker than we can currently. Because currently, we can't have those consultants standing by ready for the number of hours in the day that we would like.

These proposals are about putting those consultant teams and the accident and emergency medicine teams there and more available for those critically ill and injured patients. So we want to shorten the time it takes from the moment you call for help to the moment you get seen by someone who has all the skills you need to get you on the road to recovery. And that's what we're proposing.

But at Dewsbury, we want to make sure that the majority of people who come to accident and emergency who don't fit into that category of critically ill and critically injured, are able to be managed, as they are now, close in Dewsbury in their accident and emergency department. We will still have the same skilled nurses, the same skilled middle grade doctors and consultant support as we currently do for those patients who come with the cuts, the broken bones, the sniffles, the colds, the children who are a little bit unwell, the bumps and head injuries. So 70% of those patients who aren't in that critically ill and injured category will still go to Dewsbury and still be treated there.

What Simon's also talked about at the beginning was something new that we want to develop at all of our sites, and that's emergency day care. So for patients who have certain conditions, as medical technology has moved on, we know now, if we get the tests done and the right specialist there, actually we can treat those patients much more quickly and much more effectively without them having to stay in hospital. And we want to make sure that, that's part of what we offer at Dewsbury, which currently we don't.

So I think that covers what we're proposing. I'm happy to answer questions.

Steve Richards: Thanks very much. Now I've clocked that you've got your arm up, I can hardly miss it. I promise I'll come to you but I think, in fairness, I'm sure you'd agree with this, that you've all come out to this meeting, so anyone who hasn't asked a question yet, would they like to begin this session? Because there are lots of people who I think will ask questions but there are some…great, the guy there. I promise you, you'll get your question.

M3: Thank you. Can you hear me?

Steve Richards: Yeah, thanks.

23 M3: I wonder if you've actually seen the BBC website today. There's a quote from somebody called Mike Farrar, the NHS Federation Chief Executive, who says 'The recent headlines do not lie. The pressures are growing and we're getting closer and closer to the cliff edge. If we continue with this trend, we will see another extra half a million patients cramming into our A&E departments in the next three years. This will be simply impossible for our hospital services to cope with, despite the heroic efforts of staff'.

Now there's two questions that I have. If we're going to have this massive surge, why are we reducing A&E? And the second thing I would say is, my maths aren't wonderful but in your figures, you said that there were now 16,000 people being seen and in 2016 there are going to be 7,000. That is not a 30% reduction in anybody's money.

Steve Richards: Okay. Matt, do you want to respond to that?

Matt Shepherd: I'll do the second one first around the numbers. What the numbers that were presented on the first slide were in terms of emergency admissions. That wasn't the total attendances at the Dewsbury department. So that's closer to 80,000 attendances and what we know is that 70% of those will be able to continue to use Dewsbury. So that explains why the numbers were different to what I was just saying.

In terms of the national pressures on the emergency departments across the country, the last two or three weeks have seen lots of news coverage of how pressured emergency departments have been over this winter and the increasing number of attendances. The bottom line is that we all, as a health service across the country, need to work as to how we're going to make A&E a sustainable service. What we're proposing is probably what the national solution is going to be towards that, which is having the senior decision makers present 24 hours of the day, supporting those A&E trained doctors by probably integrating primary care specialists too, so perhaps GPs who have an interest and want to work in that environment, to enable the A&E departments to cope with the number of people that attend.

What we also want to look at doing is working with our colleagues out in the community, so that they get services out in the community actually right close to their homes, so that they don't need to come to A&E in the first place. And all of those things are part of the proposals that we're putting forward.

Steve Richards: I'll let you come back but I think Richard just wants to answer your first part about how they respond to the broader national picture, and your observation that seems to be going down here in spite of demand going up.

Richard Jenkins: Yeah. I mean, I think the point you're making is exactly the reason we're arguing for these changes. It isn't sustainable to continue in the way we're going. Even if there isn't change, we need to change in order to improve the services.

F: We can't hear you.

24 Steve Richards: Are you mic'd up?

Richard Jenkins: I'll start again. What we're saying is, we agree with the point you're making that the very reason why we're proposing these changes is because the rising demand that has been seen isn't sustainable and needs to be dealt with differently. So whilst we've concentrated a lot tonight on the hospital bits of this, actually this proposal is around the whole pathway from the community, in hospital and out of hospital.

We know that there are lots of people who come to A&E who could actually be seen by their GP if they could get the access they need. We know there's people who come into hospital who predominantly have social care needs, and those could be addressed. We get many elderly people who fall, who are frail and they come into hospital because they perhaps need some social care, as much as anything else. We're looking to try and develop pathways for all of those conditions so that less people will come to A&E. A&E isn't necessarily the right place to go for many people who currently go there.

At the moment, there aren't all the alternatives in place in the community from GPs and primary care that we plan to be in there in the future. Consequently then, we will have less people coming to A&E in the future, and that's the intention. That's exactly what Mike Farrar and other people have been saying recently about the direction of travel. Not just Mike Farrar, we've had Jeremy Hunt and others making the case that the future for sustainable healthcare across the country, including this area, is a better model of primary care linking to hospitals. And also, so there's integration with social care, so that when people have come into hospital and got better, they can go home promptly when they're well. And at the moment, we have quite a lot of people sitting in Mid Yorkshire beds in all our hospitals who aren't going home for social reasons, that we intend to change.

Steve Richards: Okay, thank you. I'll let you come. Yeah, just one second. I've been asked to say that the Mayor's reception room upstairs is open for prayers, if any of you want to leave the meeting to go for prayers. The Mayor's reception room upstairs is the place for that. So I just want to pause for that. I'm going to…I promise you, I've clocked that you will ask a question in a minute. David Kelly wants to come in and then I'll get your response.

David Kelly: I just wanted to add a bit more to what Richard was saying about primary care. The majority of NHS services and healthcare does actually happen out in primary care and not in secondary care. We're already working with our practices to improve access to primary care. We've got many of our practices using an advanced access scheme and looking at how we can improve that for same day or immediate access.

But also, practices are actually seeing patients who otherwise would have gone to A&E with minor injuries. We're also, in the proposals, suggesting that this 24/7 integrated health and social care team would be the first responders for patients such as frail elderly patients in a crisis, to actually avoid admission and avoid attendance at A&E. So that's part of the solution, the changes that we are planning in practices and in primary care and out in community services, which are needed to solve some of this crisis. And also, the issues that have been

25 raised around out of hours and GPs used to providing out of hours cover, and some of the solutions that will be needed. And the addition, as has just been mentioned, of a 24/7 primary care integrated service within that Dewsbury service is going to be essential to manage some of these patients.

Steve Richards: Okay. Do you want to come back on those answers?

M3: Please. I think that what I'd like to say is, there's an awful lot of aspirations in what's just been proposed. The concrete thing seems to be the vast reduction in A&E, whether the other works or not. And also, since we're quoting Mr Hunt, he said that basically, the problem was that you can't get doctors because of the contracts that were introduced about five, six years ago, to provide that out of hours service. So there's got to be a major sea change to get anything of what you're proposing as being the solution, whereas the A&E seems to have been a done and dusted shut, full stop.

Steve Richards: Yeah. I wish we had Jeremy Hunt on the panel and then we could have a brilliant debate about their proposals. But obviously, the point you're making is how, to some extent, you are adapting to the climate he's described and the prescriptions over which you have no power, but obviously you have power over how you respond locally.

David Kelly: We've got some power over some of the things you've just referred to. And obviously, looking at the training and also the staffing levels within practices and primary care, and the staffing levels that are going to be needed to run the 24/7 community services. So we absolutely recognise that we need to look at those staffing levels to match the level of demand for the level of patients that won't be actually attending the hospital services. So we've got absolute sight on that, and the outline business cases we've prepared around some of these proposals take all those into consideration.

Steve Richards: Okay, before I come to you, yeah…no, that guy hasn't asked a question yet, and then I'm coming to you because you've been sat for a long time…

M4: Thank you. Very, very smooth and suave presentations from the panel, I thought you'd like someone to say something nice about you. My concern is about acute medical admissions, which is the largest group of admissions during a day and it's gone up enormously over the last 30 years to almost unmanageable amounts. And patients are regularly transferred between towns, like between Wakefield and Dewsbury, in order to cope with this.

The idea that this demand is going to diminish is a little strange. With an increasingly older population with multiple diseases, it is not going to be a matter of sorting most of these people out with a little bit of slick technology in a side room in A&E. And the plan, as I understand it, is for there to be just - I may be wrong - to be a 20-bedded clinical decision unit at Dewsbury, where people might stay for up to two days. But it'll be full by lunchtime on the first day and with the numbers, we're talking about 100 patients a day between the two towns.

26 Steve Richards: And what happens then. Richard Jenkins is going to answer that one.

Richard Jenkins: Yeah, I mean, it's a really good point. I work in acute medicine at Dewsbury at the moment, and I think what I see when I work on the acute medical unit is that we have patients coming in who actually could be managed in other ways. And I'm sure you'll recall that. We get people coming in who have relatively minor problems often, because the alternatives aren't there.

So our intention is to make sure we put those alternatives in place. So part of the solution to that is the emergency day care model that Dr Enright introduced earlier. So many patients don't need to just sit in a bed to have a blood test done every couple of days, and sometimes we do that. Sometimes we have people sitting in beds waiting for scans. The intention of this is that people will be getting those scans and other tests that they need on a sort of day attender type basis, more quickly.

As well as that, we know that some people come into hospital because they couldn't get early treatment in the community. And so part of the model is that there will be better access earlier for that. We know that some people come in because, as I said earlier, they have social care needs, particularly the frail elderly, and we're looking at developing pathways with geriatric specialist consultants going into the community, working with GPs, social workers and others, to support people in their own homes. We know that many of the patients in the medical beds Dr Kelly talked about are actually, as I said before, waiting to go home. Actually, they've had their treatment, they're better and they're still in hospital because there's various social needs need sorting out.

We intend to tackle all those issues, so that the need for beds goes down and the improvement of care goes up. We've got a track record of doing that over recent years, and we've progressively reduced the length of stay that people had in hospital. So if I think back over the 11 years I've been a consultant, when I started, we would have people with conditions such as deep vein thrombosis coming into hospital and spending five days having scans and being anti- coagulated. Now they come into hospital for a scan on the first day, they go home straightaway. and they come back and have their treatment as a sort of day attender. So they don't…they get the treatment's that better, they get to sleep in their own bed, eat their own food, and they don't stay in hospital. We're looking to move that sort of model of care to a much wider range of people.

So I agree with the point being made that the demand won't necessarily go down, but we're intending to deal with that demand in a better way.

Steve Richards: Okay, thank you. I promise you next. Do you mind waiting for the mic? Thanks a lot.

F14: Eight weeks ago, I was admitted to…I was taken into A&E at Dewsbury Hospital. I was admitted to the [MAU], there was four people on the ward I was on. One person on that ward had been taken to Pontefract Hospital, been redirected from the ambulance because there was no room to Pinderfields Hospital, been directed from there to Dewsbury Hospital. Then the other lady on the ward had gone to Pinderfields Hospital, had been redirected to Dewsbury Hospital because there was no room. Both of them two ladies have gone through A&E and got admitted

27 to the ward. How are you going to cope if Dewsbury's not open? Plus I got discharged at one o'clock in the morning. How would I have got myself home as a 50 year old female, on my own, at one o'clock in the morning from Pinderfields?

[applause]

And why were them from Pinderfields and Pontefract in that hospital, if you're going to close it?

Stephen Eames: I think Richard may want to…just on your point about being discharged at night without any support. I mean, that's not our protocol, so if that happened to you, I'm really - just let me finish…

F14: No, can I just say something because I've not completed it?

Stephen Eames: Let me finish and then you can come back. What I'm just saying is, if that…

F14: No, I've not completed it, you need a little bit more information.

Stephen Eames: Alright, give me a bit more information briefly then.

F14: I could have stayed…no, you need a little bit more information. I could have stayed 'til the next morning, had I chose to, but I would not take up an hospital bed that another patient may have needed, just because it was one o'clock in the morning. I could have stayed in that bed 'til eight o'clock the next morning but why should I when a poorly patient needs it and I was well?

Stephen Eames: Well, I respect your values on that. I was simply making the point though, because it could mislead the audience to think that we let people go out at one o'clock in the morning without support. We don't do that. We have a whole protocol if people are going home, particularly people who might be elderly or on their own.

F14: So you want me to take up a bed 'til eight o'clock the next morning?

Stephen Eames: No, I didn't say that. I was just saying…your concern is a genuine concern about what could happen to somebody in any of our hospitals actually who may have to go home or want to go home, we've got certain protocols that we follow, because obviously we don't want any of our patients who we're treating to be at risk in the community.

F14: [Like what] protocol?

Stephen Eames:

28 I mean, we could pick up your specific point afterwards if there are some issues to follow up but just to be clear to everybody in the audience, that's not our policy.

F14: Well, what about the redirection from Pinderfields to Pontefract to Dewsbury?

Stephen Eames: Richard's going to say something about that.

Richard Jenkins: You're right, that has happened and we don't want that to happen. Part of our proposals here are trying to stop that.

F14: That's only eight weeks ago.

Richard Jenkins: No, I'm agreeing with you, it's happened. It still happens. We want to stop that happening and these proposals are part of the way of doing it. So what we've been doing…what we're proposing is that we'll separate out the planned care, so the elective care, from the emergencies. So we'll have more of the planned care in Dewsbury and we've already moved a lot of beds out of Pinderfields into…

F14: All three of us weren't planned.

Richard Jenkins: I'm telling you what we're planning to do in the future to address this problem so that it won't happen in the future. So we're going to move…we already have moved an orthopaedic elective unit from Pinderfields to Pontefract recently, which has created a ward full of space at Pinderfields, to cope with the emergencies that you're just describing. We're implementing…

F14: So why are they still landing in Dewsbury?

Richard Jenkins: We've only just done that. We're implementing the emergency day care model that we've just described a few times across the Trust, so for people from all the areas that we serve in the near future, with the intention of then reducing the number of beds that are being used. So we're doing a number of things to tackle that. The point is - and it's a similar theme for the last few questions - we can't continue as we are now into the future in a way that will be good quality. We need to change to improve the quality…

F14: So what you're going to have to do, you're going to end up paying for out of area beds because there's no room at Pinderfields, there's no room at Pontefract, so we're going to have to go even further out of area.

Steve Richards:

29 You've made your point very clear with another vivid personal example. Now I can see lots of… right, we've got one other theme and general questions as well to get through. I'm going to ask you…so what I'm going to [voices overlap 1:17:05]. Yeah, don't worry, I'm going to call you… what I'm going to suggest…

F15: [Inaudible - microphone inaccessible 1:17:06 - 1:17:13]

Steve Richards: Yeah, ask your question and I'm going to make sure…I'm going to ask each of you briefly to ask your questions and then you'll all get the chance…

F15: Can I just say, roughly, Dewsbury A&E department statistically sees as many patients as they do at Pinderfields. Yes, they do, Mr Eames because I've seen the statistics.

M: Yeah, they do.

F: Yes, they do.

F15: Now how can Pinderfields A&E cope [voices overlap 1:17:35]. Yes, how can Pinderfields A&E cope without the backup of Dewsbury? Are we going to revert back to the old Dewsbury, Staincliffe and wherever else there was, Batley at one time when we had three local hospitals? It's just ridiculous and ludicrous. And the hospital ward that I work on gets readmissions because people are scurried out before they're properly healed. And the high incidence of MRSA is because of the absolute increased turnover when patients aren't really well enough to go home and there's no backup in the community and they come back in. End of story.

[applause]

Steve Richards: Matt, sorry, you wanted to answer that one.

Matt Shepherd: Just in terms of the numbers. The Dewsbury and Pinderfields department see different numbers, but the difference is only small. Pinderfields is slightly more over the last two years. Prior to that, Dewsbury saw slightly more than Pinderfields. So there isn't a great deal of difference but Pinderfields does, over the last two years, see more patients than Dewsbury.

US: [Inaudible - microphone inaccessible 1:18:40 - 1:18:44]

Matt Shepherd: Actually, she was challenging our statistics over whether Dewsbury saw more than Pinderfields. Then the lady asked how is it going to cope. Well, part of it coping is what we're proposing; part of it is having more senior doctors available; part of it is integrating doctors with primary care experience; and part of it is expanding the footprint of the emergency department. Whilst

30 maintaining an emergency department here at Dewsbury that can cope with 70% of what it currently does.

And also, the other measures that both David Kelly and Richard have talked about, which is trying to manage more patients away from hospitals because some patients that come to A&E don't need to be in A&E and could have better care and more consistent care away from the emergency departments.

US: [Inaudible - microphone inaccessible 1:19:30 - 1:19:33].

Steve Richards: Okay. Look, I want to bring in that lady over there because she hasn't asked a question yet. Could you just wait for the mic?

US: [Inaudible - microphone inaccessible 1:19:42 - 1:19:45].

Steve Richards: Well, just in fairness to people who have turned up, I think they should have their question.

F16: I'd just like to ask how many years is it going to take to build up the care in the community that Dr Kelly's talking about? It's not going to happen like that, so.

Steve Richards: Okay. Who should answer that one? Dr Kelly, okay.

David Kelly: Okay. Well, first of all, we've done a lot already in terms of improving care in the community…

F16: Nowhere near enough, Dr Kelly. Nowhere near.

David Kelly: No, I absolutely agree. And that's why we need to change. And the first thing that needs to happen in these proposals is the plans we've got in place for that community service provision enhancement to be in place, because if we don't get that in place first, and it's not years, it'll be the first thing that needs to happen, because otherwise how can we do all the rest of the proposals without the community services in place.

F16: That's correct.

David Kelly: So I absolutely agree with you and you've hit the nail right on the spot.

F16: But it's going to take you a long, long time to get the staff, the resources, everything, the plans.

31 David Kelly: No, I don't think it will.

F16: Yes, it will.

David Kelly: We've got the outlines of those proposals already in paper.

F16: But this has been done, Dr Kelly, in the 1990s, care in the community…

US: We’re going backwards.

F16: …it did not work. So how are you going to get it to work now?

David Kelly: Because this is truly integration of health and social care in conjunction with primary care, which is completely different. There's many models around the country, in Torbay and places like that, where this has worked extremely well in terms of keeping people [voices overlap 1:21:21]. I know but I'm just quoting that as an example of where these sorts of symptoms have worked very well.

F16: But it takes years to get it into practice.

David Kelly: Well, it won't.

F16: It will.

Steve Richards: You think it'll take years, you don't, but you've made the point very clearly, it's a very important point as well. I promised you a question, then you and then we will get on to other changes proposed.

F17: My question is to three of them. It's about the care.

Steve Richards: So wait for the mic, so everyone can hear the question.

F17: The three of them have all mentioned, even Anne on maternity, and like Susan's just said, you're going to have to hurry up and get this care organised because there is no care. And you're on about social workers, they don't give toss nor button really because it takes you months to get hold of a social worker. And I have dealt with it, so I do know.

32 Steve Richards: Okay, so it's sort of echoing your point.

F17: So you need to get your fingers out, the three of you and get it sorted.

Steve Richards: [Voices overlap 1:22:25] Okay, the two of you have made the point very, very powerfully. The guy at the end there. Oh, sorry, yeah, I will do. Sorry, I will, I promise you.

M5: Is that working? Yes. If Pinderfields and Dewsbury are roughly the same size, which I just assumed Pinderfields was larger, why couldn't Pinderfields keep 70% and why can't we have the consultants 24/7?

[applause]

Steve Richards: Who's best to answer that? Right, who's going to…? Okay. [Voices overlap 1:23:05] Right, okay, Richard's going to give you why Pinderfields.

Richard Jenkins: They're not the same size. What Matt said is that the number of people attending the A&E departments are similar but slightly higher at Pinderfields. What we know is that the types of patients attending are quite different. So we know that the proportion of people attending Dewsbury have got more minor concerns is a lot higher than the proportion attending Pinderfields. And there's good reasons for that. Partly that's [voices overlap 1:23:35] If you'd like…I'd like to tell you what the reason is.

Steve Richards: Look, the guy who asked the question does want to hear the answer, you might not like it, but.

Richard Jenkins: The reason is that we have changed the way that we deliver A&E at Pontefract as well. So Pinderfields takes the sickest patients from the Pontefract area and the Wakefield area into the Pinderfields department. So the mix of patients there that are sicker is a lot higher than at Dewsbury.

F: [Inaudible - microphone inaccessible 1:23:54 - 1:23:56] Pinderfields can't cope [voices overlap 1:23:58].

Richard Jenkins: A very small number are.

Stephen Eames: Sorry, could I just get back to the central point in your question, which is a bit broader than accident and emergency, wasn't it, which was why can't we do all this at Dewsbury rather than at Pinderfields, I mean, not just…

33 M5: That was exactly the question, yes.

Stephen Eames: That was the essence of your question. Well, the simple reason, in answer to that, is that already - and I think it's an important point generally to get across - is thousands of people from this community use Pinderfields as their local hospital, for a whole range of services [voices overlap 1:24:30]. Okay, look, it actually is through choice.

[Voices overlap 1:24:38]

Steve Richards: Hold on, just…please. Yeah, okay.

Stephen Eames: If you don't want me to answer the gentleman's question, I won't.

[Voices overlap 1:24:47].

M5: Well, I'm listening.

Stephen Eames: Okay, alright.

Steve Richards: Hold on, look I promise you…

M5: Well, I'm listening.

Steve Richards: Okay, let's just have [voices overlap 1:24:57]. Hold on, hold on, hold on, I promise you, you all collectively have made the point and the case for Dewsbury. And just let Stephen Eames finish because I promise you, you've made the point. [Voices overlap 1:25:12] Just let him answer.

Stephen Eames: Okay, can I…just let me answer the gentleman's question because otherwise.

Steve Richards: There's no point in us all being here [voices overlap 1:25:14].

Stephen Eames: Alright, I mean, if you don't want me to answer, that’s fine, I won't answer.

M5: I would like you to answer the question please. Even if there's only you and me listening, I'd like to hear.

34 Stephen Eames: Thank you very much. So can you show some respect to this gentleman's question.

Steve Richards: He'd like to hear the answer, let's just…

Stephen Eames: And can I also just make a brief point before that, which is, I've showed you all a lot of respect, I haven't accused you of lying about what you're saying, I can see you're very passionate about it. So please don't…treat me with the same respect as well.

But back to your question, so the answer to the question is, at Pinderfields, there is a burns unit; there is a specialist plastic surgery unit; there's a specialist spinal surgery unit; there's a specialist unit for children. All the children in this area who require surgery go to Pinderfields already. And I could add on a number of other specialties that don't exist at Dewsbury. Therefore, you could theoretically say, let's - which is your question - let's move all that to Dewsbury. That is unaffordable. That's the answer, it's unaffordable to do that. The money isn't there to make that happen.

[Voices overlap 1:26:18].

M5: Do I get to come back?

Stephen Eames: Please do, yeah.

Steve Richards: Yeah, absolutely. I think you're absolutely [guaranteed 1:26:21].

M5: What you're really saying is that, you know, Pinderfields has got a bigger, better hospital with more units and therefore…

Stephen Eames: Correct, yeah.

M5: …to separate planned and unplanned, you've got to toss a coin and decide which is the best to send the extra 30% to.

Stephen Eames: I'm saying…

M5: And it just seems always that Dewsbury ends up with the poor end of the stick.

Stephen Eames: Well, I think the point is that if we were starting at a different point where we are, there might be a different debate, mightn't there? The point I'm making is, that proposition that you're making

35 is not possible to do, yet we still have all these challenges that we're describing. So I think there's…you know, I understand that completely because my family, I come from this area, I know that. So if decisions have been taken [voices overlap 1:27:05] - let me finish - if decisions have been taken 15 years ago, 20 years ago to have specialist services in Dewsbury rather than Pinderfields, yes, that argument would stand up. It doesn't stand up today, it's not economically possible to do that. That’s the…

And the final point I'd like to make, and I make no bones about it, is what we need to understand in this whole debate everywhere, whilst I understand the local passions, and we've had them in Pontefract and we've had them in Wakefield, these are your hospitals, all of them. And as Matt said earlier on, the hospital is a building, what really matters is the quality of the clinical teams. And you've got some of the best clinical teams in the country working in these hospitals, providing some of the best care, which they can't continue to do in the current arrangement. So there is a trade-off between getting better care and better outcomes and access to some services.

M5: Can I come back a second one on that please? Can I have a chance to come back again?

Steve Richards: Yeah, okay. Just briefly.

M5: What you're really saying is you wouldn't start from here. But, of course, we are starting from here in life. What I really need to know from each of you in turn is, is this the best possible proposal or, as these people are saying, are you all telling lies?

Steve Richards: Well, I tell you what, that's a sort of general question which we can put…

Stephen Eames: Can we come back to at the end, yeah.

Steve Richards: Come back to at the end. [Voices overlap 1:28:35] Have you got a specific question in this area before we move on to proposed changes to surgery? Yeah, thank you.

F18: Right. First of all, before I ask the question, can I just have a show of hands, is there anybody here that is in favour of the downgrading of the services in Dewsbury Hospital? Anybody? Anybody at all? Right, that's very interesting because not one single member of the panel put their hand up then.

[applause] [laugh]

Steve Richards: You should be in the House of Commons, they do that. Okay, what's your question, because there's lots of…?

36 Right, well, first of all, I'd like to refer to the NCAT Review in January 2013, which I'm sure you're fully aware of. I'll quote point three two. Your first one - and this was written in January 2013 - 'We have had lots of meetings with patients and the public over the last one to two years, to make sure that these plans, i.e., option two have their support'. I never heard of this before this consultation. I spent yesterday asking hundreds of people in both Dewsbury and Wakefield had they heard of this prior to it, and every single person said no. Not one single person. So that's my first point.

Secondly, to Dr Matt Shepherd. In a previous meeting, you led us to believe that one of the reasons for downgrading was that you couldn't recruit A&E doctors. I now refer to point three two one of this document that was written by NCAT. And they state, 'Already these plans have triggered a loss of medical staff from the Dewsbury site. We think these doctors left because of the downgrading of the services planned for Dewsbury'.

And also, at this point - can I finish because you allowed him to finish - and also, it would appear that your own staff did not believe that this consultation would be fair. And indeed, their actions suggest that even they thought that it was a done deal because they would not have left if it had.

Steve Richards: Okay, alright.

F18: No, can I…?

Steve Richards: No, enough. Look…

F18: No, I've not finished. Will you let me finish?

Steve Richards: Yeah, I did, but I want to get other people in. Look, we're running out of time.

F18: Well, will you…I've not finished and you let him go on for ages. Can I finish?

Steve Richards: Alright. How much longer is it, because I'm just…

F18: I've got one paragraph left.

Steve Richards: Okay. I'm just concerned for the rest of the people here, I promise you.

F18: Right, okay. [Voices overlap 1:31:19] Well, be as rigorous with those when they're talking.

Steve Richards:

37 I know. Alright, okay, just ask one more point and then…

F18: Right. Next, interestingly, I will now refer to an article that Stephen Eames wrote himself in the Health Journal. I'm not going to read it all, I'm just going to quote to you a short passage from it. Quote, he says, 'Cash is king. That may seem counter cultural in a patient-centred public service environment, but we all know that a positive cash flow is an absolute requirement in surviving and thriving'. Well, you're right, Stephen Eames, cash is king, and I believe these changes are all due to cash. The financial burden of the PFI, which is costing the Trust around £40 million a year and will continue to do for so many years, well, can I say to you all, instead of playing your jokers in the pack by trying to strip Dewsbury Hospital of its vital services, remember that cash may be king but an ace trumps a king, so play your ace card. And instead of doing this, channel your energies into pressurising the Government to take over the PFI, so that the people of West Yorkshire will continue to be served by three fully functioning hospitals.

[applause]

Steve Richards: Okay. There you go, you had the whole…you got through a series of points there. Let me ask Matt about the point you made that doctors are already leaving because of all…sorry, left [voices overlap 1:32:56] but do you want a response? [Voices overlap 1:32:55] Okay. Let me ask Matt then, is it the case that doctors are leaving because of these proposals in Dewsbury already?

Steve Richards: Yeah, but you wanted an answer, so let's hear it. Hold on, there's a mic coming.

Matt Shepherd: Hello. First of all, you said I led…

F18: How dare you say I made it up? It is true and I can prove it. Has anybody got an Internet access here? [Voices overlap 1:33:32].

Steve Richards: Look, hold on. Look…

F18: How dare you [voices overlap 1:33:35].

Steve Richards: Look, in fairness to everyone else who's been here today…

F18: [Inaudible - microphone inaccessible 1:33:39 - 1:33:50] it's a disgrace.

Steve Richards:

38 Right. Hold on, let's just…you know, you had a very long series of points, let's try and…let's get Matt to answer the one, have doctors left because of these proposals. I know you think they have but you did [voices overlap 1:34:04]. Okay, well, let's get a response or else there's no point in this meeting if we don't get a response, so let's get a response.

Matt Shepherd: Right. First, you said I led you to believe that there was a shortage of doctors in emergency medicine. I've nothing to say that, that isn't the case. There is a national shortage of doctors trained in emergency medicine. So that hasn't changed, I'm not changing my view on that.

In terms of have doctors left our Trust, or more specifically the Dewsbury site, in response to these consultation plans. That was raised by staff who were concerned as we started the initial talking about what we were planning. I've personally interviewed the consultants that left emergency medicine because it's my job to…

F18: [And they got a reference from you, so 1:34:57].

Matt Shepherd: Well, not necessarily actually. The two consultants, one consultant left to go to Australia which, again, was a personal choice; and one consultant lives the other side of Bradford and was finding the commute too difficult, and therefore chose to take an opportunity when a job came up in Bradford. Neither of those consultants raised issues that this was about the future of Dewsbury.

F19: I can't believe you've just said that, he can't commute from Bradford but we can commute to Pinderfields. I can't believe you've just said that.

Steve Richards: Right, okay. Sorry, do you want to say something?

Kathryn Fishwick: Yeah. Can I just say, from the obstetric point of view, that it's probably going back now about six years when Mr Parkes was Chief Executive, way back, before the new PFI even started. We were asked what we thought about obstetric units, and at that time, myself and all my colleagues wanted to have one centralised unit because it was a better way of giving care.

F19: [Inaudible - microphone inaccessible 1:36:06 - 1:36:09] six years ago then?

Kathryn Fishwick: Well, that was what we wanted, it wasn't what we were allowed, for lots of different reasons and political reasons, at the time. But what I'm saying is, this is nothing to do with the finances to do with this, it was what, as obstetricians, we felt was the best care. So it's nothing to do with the state of the PFI. We wanted that prior to all of this.

Steve Richards: Okay. Well, look, I'm going to ask…I know in advance that you won't like the answer but I'm going to ask Stephen Eames to address the point about the degree to which this is about cash.

39 Please let him…in case the rest of the audience want to hear the answer. I know you won't like it.

F18: [Inaudible 1:36:49] he called me a liar?

Stephen Eames: No.

Steve Richards: No, he won't but he will answer the question. I know you won't like it but the rest of the audience might want to hear, so I'd really appreciate if you do let him answer.

Stephen Eames: Okay. I've got the mic, that's fine. Well, I'm flattered that you read my articles, of which there are 36. And I think you're quoting - just to make the point - that one sentence out of a document that actually speaks quite a lot about quality as well as cash, and you're taking it out of context, but anyway…

F18: I am not taking it out of context.

Stephen Eames: What I'm going to do is ask my colleagues, which I'm sure they will, is to put that article on the website so everybody can see it. But back to the point about the cash and the PFI, which we've talked about here before.

F18: Can you also put the NCAT Review on the website?

Stephen Eames: The NCAT Review is on there, I don't recognise the things you're quoting. Okay, so…

F18: [Voices overlap 1:37:38] Well, it's funny because in that, Dr Kelly was present, you were present and somebody called Robert Flack.

Stephen Eames: I don't think so. Robert Flack, yes.

Steve Richards: The rest of the audience might want to hear the degree to which this is being cash driven.

Stephen Eames: Let me just come back to your point about cash. This is not driven by money because money…

F18: You're a liar.

Steve Richards:

40 Hey, you got really cross when he called you that, so don't call him. Let him finish the point and then we're going to hear briefly about the proposals, very important, which some of you might have come to hear on surgery. So let's just briefly, Stephen, and then we're going to move on.

Stephen Eames: So if I can just say very quickly, these proposals are about all the issues that my clinical colleagues have raised, which I passionately support because I believe it's better for local people. However, if we implement these proposals, we think we'll save about £10 million, which is good for the taxpayer because they'll get a better service at less cost. If we're unable to make changes across the whole board of the Trust, it will cost more money that our commissioners can't afford. So there are…so in that sense, cash is king. And as a public servant who serves people like yourself, you would expect me to make the best use of public money, which is what we're proposing to do.

F18: Exactly [voices overlap 1:38:57].

Steve Richards: I promised that guy at the back I'd ask him, so let's have the question from the guy at the back. And then we're going to hear briefly about proposed changes in the surgery area. Yes. I think it works, does it? Ah, right. Okay, hold on a second.

M6: I've been to a number of these consultations now, and every time I come, it seems like the goalposts have been moving. The first time Stephen said it was £38 million, the next meeting I went to they said £25 million. So every time we come to one of these consultations, there's always the goalposts are moving. So why should we trust you in the first place because you're not saying what you're saying? And when you do say it, you're then changing it. The first consultation meeting I went to, you said 15 minutes for transfer. Now you're saying 20, 25 to 30 minutes to transfer. Now in terms of maternity, would it not make sense to get the consultant to come to the ladies, rather than asking the ladies to go to see the consultant? Yeah?

[applause]

So number of times you keep changing your story all the time. Now these proposals and the CCG, I'm going to pinpoint blame here to the CCG because your commissioners, our commissioners are spending our money in Wakefield. And what they're doing is they're selling Dewsbury down the river. And that's all I'm saying.

[applause]

Steve Richards: Right, okay. [Voices overlap 1:40:31] Well, he's raised a series of points. What I'm going to do actually because I know some of you will want to hear about the proposed changes…I know some of you have been to other meetings and know about them but some of you might be here for the first time. So I'm going to ask Simon Enright just to briefly talk about the proposed changes to surgery, and then if any of you have got questions about that, we might just have time to get it in. Where's Simon?

Simon Enright:

41 I'm here.

Steve Richards: Oh, he's at that end, right, okay.

Simon Enright: Yes, just expanding on what I said right at the beginning some time ago now, what we're planning is for straightforward planned surgery, including those patients who require an inpatient stay as well as day case surgery, which is the majority of planned surgery, those operations will be done at Dewsbury under these proposals. And at the moment, we have only three surgical specialties who have operations on the Dewsbury site for inpatient surgery. Under these proposals, we'll have far more, we'll have seven or eight surgical specialties represented at Dewsbury for inpatient surgery. So that's for planned straightforward surgery, including the majority of inpatient surgery for Dewsbury residents.

For the very sick surgical patients, those requiring emergency surgery, complex surgery and those patients who require critical care, those operations will be carried out at Pinderfields, where we'll have more specialist teams on site for more hours of the day, for more of the time. They'll be seen quicker by the appropriate specialist and they'll be operated on quicker by the appropriate specialist.

This is just building on what happens now, where the majority of urgent and emergency surgery is carried out on the Pinderfields site. The advantages of that are really separating the planned surgery from emergency surgery. And there are some real advantages which are recognised worldwide in splitting planned surgery from emergency and urgent surgery. And it's better for both patient groups.

In terms of the planned surgery, it means you will have shorter lengths of stay, you'll have less chance of being cancelled. Because at the moment, we have situations where, when urgent and emergency operations are kind of fighting for space with planned surgery, well, often the patient who's having the planned surgery has that operation cancelled. We try and minimise that as much as possible but it does happen. So your risk of cancellation will be less, your length of stay will be less. Patients prefer it. And that's for the planned surgical group. For the emergency surgical group, as I've said, the sicker patients will be seen quicker by senior specialists, will be operated on by the correct team.

Now we've already started this type of split. We opened up an elective orthopaedic centre for orthopaedic planned surgery on the Pontefract site, a couple of weeks ago. Already, the surgeons who are operating in that unit are seeing that their patients who are having some pretty big surgery, some hip replacements, some knee replacements, are already having a reduced length of stay by up to one day. So we are working on this model already and there are real advantages in splitting the emergency and urgent surgery from your planned surgery.

Steve Richards: Okay, thank you. Now what I want to do, first of all, is ask has anyone got a question who hasn't asked a question this evening, who's come here and would like to ask a question? Yeah, the guy there.

42 Thank you. I wish to ask a question about primary care. A friend of mine has a brother in law who lives in North Lincolnshire, and he recently had pains in his chest. So naturally, he was worried because he had a very stressful job, he was a teacher, so he went to see his GP. And the GP said, oh, nothing serious, come back in a week and I'll give you some tablets. So this man was concerned, so he asked this friend of mine, because he knew that this friend of mine had a daughter who worked as a nurse at the heart hospital at Leeds LGI. So this nurse said, would you refer or ask the GP to refer you to Leeds LGI Hospital. So he immediately went back to the surgery as he was concerned because his family had a history of heart disease, and his father died when he was 48. So he was obviously concerned. So he went back to the GP and said, I want to be referred to Leeds General Infirmary, whereupon the doctor said, oh, I'm sorry, I can't refer you to the LGI because I haven't got a contract for LGI. So the man was very concerned…

Steve Richards: Sorry, could you…it's a very important story and things but we're really running out of time.

M7 No, I want to finish please.

Steve Richards: Could you keep it very brief.

M7: I want to finish, I'm nearly finished.

Steve Richards: Okay.

M7: So the person went back to his GP and said, I've been in contact with a nurse in the hospital at the LGI and she said, you must refer me to LGI Hospital. And the doctor said, no, I can't refer you, I've told you that last week, I cannot refer you to LGI. So he phoned the nurse again and the nurse said, he must refer you to the LGI and if he doesn't, tell him that any patient going to a GP has, by right, by the [209 1:47:12] Act, he can go to any hospital he wishes. So he went back to the doctor and said, I want referring to the LGI. So the doctor said, are you accusing me of lying, I told you I couldn't last week because I don't have a contract.

Steve Richards: So what happened in the end?

M7: Right. The doctor went...after numerous discussions, the doctor went out of the room, spoke to other doctors, came back and said, oh, I'll refer you to the LGI. Now then…

Steve Richards: No, I'm sorry, we've got to move on.

43 Now I come to my point. Dr Kelly said - and I read it in the Bradford Spendra News that when doctors surgeries are privatised - or words to that effect, and it was in quotes - I will resign from the CCG. Why didn't he say if, not when?

Steve Richards: Right, do you want to respond?

David Kelly: I'm quite happy. It's slightly off the subject of surgery and the consultation is some of this, but I'll just briefly answer. Every GP can refer, under the Choose and Book scheme, to any hospital, any Trust in the entire country. So I'm sorry that your friend or your relative had a bad experience because maybe that GP didn't fully understand the system. But we're ensuring all our practices utilise Choose and Book, give patients the choice of hospital, which actually, with all these service proposals, is important.

Steve Richards: Okay, thank you. Yeah, I promised you a question and I haven't forgotten the question you asked, which we're going to end with. Was it someone over there? The gentleman at the back, yeah.

M8: Right, this is a question for Dr Kelly. I'd like to ask him a question in relation to why is it that he has actually awarded £181,000 for primary care where he's actually given £260,000 for voluntary and community schemes? So can he actually shed light on this, why he's actually prioritising voluntary and community schemes at the expense of primary care?

David Kelly: Again, I don't think that's a part of this consultation for tonight. As a CCG, I'm happy to answer that. I'll answer it if the Chair wishes me to answer it today.

Steve Richards: Just very briefly, it's just he had his hand up for a long time but it's not relevant.

David Kelly: Very briefly, we looked at schemes from a number of people, not only primary care, but also from third sector or voluntary agencies, and judged each one on its merit. And we had a list of conditions we wanted to address and we had a certain pot of money. And it could have gone either way and it wasn't a case of directing money towards particularly, you know, the sort of third sector over primary care, it was about the schemes that were being developed that we want to commission.

Steve Richards: Yeah. Right, we've almost run out of time but the guy there who I said would ask the last question, can you remind us again, it was about the degree to which this is aspiration…was that it, your question earlier? Sorry which one?

M9: I'll ask the question? Shall I ask a question? If we are finishing up, I would just like to ask - are we still on, yeah? I would like to ask each of you - never mind Mr Eames - each of you, you're all fairly switched on kind of people, there's obviously a divergence of opinion. You've all got

44 [inaudible 1:50:58] you're all professional people. Can you look us in the eye, can you look us in the eye, can you look us in the eye, maybe not Mr Eames, all those over there, can you all look us in the eye, maybe one by one or pick a few out, and tell us that even without cash constraints, even without cash constraints, you would or would not do this? And if Mr Eames… and would you do it if…are you doing it for career advancement, are you doing it for extra pay, are you doing it because Mr Eames is a bully, he's nasty to you? And if Mr Eames was a bully and was nasty to you, would you, as an obstetrician consultant, an A&E consultant, would you still, still say what you have said?

Steve Richards: Right, okay. I don't think [voices overlap 1:51:50]. Okay, who [voices overlap 1:51:59].

Kathryn Fishwick: I actually think I've already perhaps answered it from the obstetric side of things because I said, a number of years ago we were asked, and as a group of obstetricians, that's what we wanted. So from the obstetric point of view, pooling together obstetricians and making a 24/7 consultant- present service is what me and my colleagues have wanted for a long time. So from my point of view, absolutely.

And with my gynaecology hat on, it is much, much better to have the elective separated from the acutes because every morning I rush round trying to find beds. Sometimes you get your list doctored by somebody coming in that needs to be…there's an emergency operation. So with both my obstetric and gynae hats on, yes.

[voices overlap 1:52:49]

Steve Richards: You all liked the question but you've got to give him a chance to answer.

Anne Ward: From my perspective, as I've said before to people who have been in the audience, I live in Dewsbury, I live on Dewsbury Moor. My family use the services. You're absolutely right, if Mr Eames doesn't like what I do, he can sack me, but what he cannot do is remove my professional registration which I'm passionate about. The Code of Conduct, you can go onto the NMC website, says we have to be honest to those we are providing care for. I have been called a liar by members of this audience but absolutely I am not lying. This is a better service for my family, for my nieces, for my nephews and their partners. And I'm passionate about midwife-led care. The problem is that for 30 decades [voices overlap 1:53:39]…for three decades, the Health Service has told women that it's safer to have your babies in hospital, and that's not necessarily true.

F10: Yeah, you're letting her go on and on, you're not…

Anne Ward: Please don't point.

F10: My [inaudible 1:53:50] would have been dead. If what you're saying is right, my niece was low risk, my niece was [voices overlap 1:53:59].

45 Anne Ward: She wasn’t low risk if she was in preterm labour. Preterm labour's a high risk situation. [Voices overlap 1:54:03] I'm happy to discuss it with you on an individual basis.

Steve Richards: Yeah, you made your point very powerfully early on. I'm afraid we've run out of time, but…

M10: [Inaudible - microphone inaccessible 1:54:12 - 1:54:15].

Steve Richards: You had about eight last night. No, we have run out of time but yeah.

M10: [Voices overlap 1:54:22] This is a Public Meeting and a lot of people here want to have a say. I gave a paper to the Scrutiny Committee last month and I want to let people, if you like, encapsulate these people's views tonight because I've [voices overlap 1:54:37].

Steve Richards: Alright, briefly summarise it, yeah, if you want to summarise it. Is that alright?

M10: Is that alright with you guys?

M9: No, it isn't, you had a go before, I haven't. I haven't had a go.

Steve Richards: Hold on a second, you want some more people to answer your question, do you?

M9: Thank you.

Steve Richards: Yeah, okay. Well, hold on, before you do, I promise you will, you will end the meeting with your summary, okay?

M10: Right.

Steve Richards: Who else do you want to answer the question?

Simon Enright: Stephen, do you want me to…?

Karen Stone:

46 I think you're still wanting us to talk about…I absolutely believe this is right for children. I've spent my working life…I qualified in 1990 as a doctor, I've spent my working life as a paediatrician. I have strived to provide, every day that I come to work, good, high quality care for children. I need to be able to continue that, to be able to continue professionally. I believe that this is going to give your children good care that I can sustain into the future with the difficulties we're facing. I don't want children to experience what I experienced as a child, which was a long period of hospitalisation which was horrible. This is going to be good for our children.

Steve Richards: Right, okay. Oh, do you want any more?

M9: [Inaudible - microphone inaccessible 1:55:46 - 1:55:48].

Simon Enright: Yes, I mean, there were no questions about surgery, so hopefully I can answer your question. I think there were two parts to your question. One, do we honestly support the proposals; and also, would we be doing this or would we support it clinically if money wasn't an issue.

The answer to both of those from my perspective is yes. Obviously, we've got a number of specialists from their own specialist areas. My specialist area is intensive care and anaesthesia, but as the clinical lead, I've also looked into all of the four major areas in some detail. And with that broad view on all of the areas, I fully support these proposals clinically. Money not coming into it.

M10: Thanks very much.

F: [Voices overlap 1:56:37] cash is king, money's not in it.

Steve Richards: Okay, alright, we've addressed that point.

M10: Right, I'm going to finish this off and I'm going to try and encapsulate what everybody's views are, okay?

Steve Richards: One of your allies is speaking, so why don't you hear…?

M10: Right, for those people who didn't see me at the last meeting. I'm retired and I've lived in Dewsbury all my life, and I'm very concerned about some of the proposals that are being planned.

47 Ever since Dewsbury Hospital was a workhouse infirmary back in the mid-19th century, it's motivational resin d'etre has been to provide a health service fit for the people of Dewsbury and surrounding districts. Back then, some 50,000 people had access to its care. By the middle of the 20th century, the hospital site had grown fivefold and was a far cry from its early years, continually expanding its service and expertise to accommodate the massive growth in the population. And this was fuelled primarily by our heavy woollen industry. Dewsbury was a vibrant, prosperous and prestigious parliamentary borough, a town to be proud of.

Today, Dewsbury Hospital is a lifeline to around 200,000 people, many of them vulnerable; youngsters in their early years or elderly patients aligned to our aging population. But also, the much needed A&E department, who, like the rest of the hospital, give a brilliant service. The 30,000 people who've signed the 'Save the Hospital' petition give testament to that.

However, my concern is not one of financial expedience for the Trust, but one of local access to healthcare. In order to be accessible, geographic location is absolutely vital. The distance to Pinderfields may be only nine miles but getting there can be a nightmare at certain times of the day. So if you're the emergency, it doesn't matter how good the hospital service may be if you can't get there for the necessary treatment, then your life is literally in the hands of your maker and not the NHS.

An example of what the future holds was in the Reporter last week, or last month. 80 years of age, told to report to Pinderfields for surgery to remove a pelvic cyst. What time should you be there? 7.00 am. No regard for age, time or transport considerations or anything. This elderly and incapacitated lady would have had to catch three buses and leave home at 5.15 in the morning. And that's just one recent example.

Whilst I'm on the subject of location and transport, it gets worse. The ambulance service has to cut £45 million from its budget, so can you see the service getting any better? In fuel and time costs alone, it's more economical taking a patient from North Kirklees to Dewsbury rather than to the other side of Wakefield.

Research at Sheffield University has put a direct correlation between increased mortality rates and distance, time taken to reach hospital. I've already mentioned Newark, so I won't go through that, I'll save a bit of time. But the death rate did go up by 37%.

Dr Clare Gerada, Chairman of the Royal College of General Practitioners, was quite clear last week when she said - and I quote - 'We are facing a national crisis in emergency healthcare. The whole system is under great strain. And this crisis is not limited to hospitals, it also affects community and primary care. Patients are waiting much longer to be seen in emergency departments and general practitioners have seen consultation rates explode, and routinely see up to 60 patients a day'. She's also supported not just by passionate people here tonight but by the powerful lobby of 140 senior physicians, academics and surgeons, who have all signed an open letter to David Cameron, calling for an end to the indiscriminate closure and downgrading of A&E units across the country. And I genuinely believe that lives will be put at unnecessary risk. And if we lose the facilities and expertise at Dewsbury, then there's no going back, it's lost forever.

And I think you've been less than honest with the good people of North Kirklees. This item was in the Daily Mail last week, 'Shocking proof A&E closures cost lives'. I didn't write that, that

48 came from specialists. You want us to have confidence in what you're saying but the numbers just don't add up.

The Mid Yorkshire Trust has lost 520 beds. That's nearly a third of its capacity since 2004. Community-based services and primary care plan to relieve pressure on hospital beds, they've just not coped, as emergency admissions and hospital caseloads during 2012 were 12% or 12.7% higher than ten years earlier. While overall admissions were 7% higher.

And looking at maternity requirements, Dewsbury handles 2,500 births a year. Now I understand around 1,400 or 56% of these cases are in the high risk category. Now this will mean transporting the vulnerable patient to an already pressured Pinderfields some nine miles away. And that's if they have a bed, and indeed available transport, with the proposed £45 million cut. So if Dewsbury loses 34 out of its 40 maternity beds, which I understand is the plan, and Pontefract only have four, how on earth can Pinderfields accommodate the increased numbers with the necessary degree of specialist care? This is downright insanity, as far as I'm concerned.

North Kirklees is one of the 10% most deprived areas within the UK, and is a much needed healthcare requirement for mother and baby. Dewsbury just cannot afford to lose any of its medical services. I know you're rushing to try and get me finished, I've got about two minutes to go. This is the thin end of the wedge, as far as I'm concerned. The catastrophic PFI index- linked interest payments will continue to bleed the very heart out of the Mid Yorkshire Trust, resulting in yet more frontline cuts to Dewsbury, Pontefract and, yes, Wakefield.

The debt is unsustainable and Dewsbury should divorce itself from this nightmare, and fight for its independence before it's too late. But the biggest worry to me, and this is from personal experience, is the complete closure of the children's ward, in particular, will take this region back 60 years. As a young boy, I contracted TB of the spine, synonymous with the post-war deprivation in the area. After assessment at Staincliffe, which is now Dewsbury General, I was taken to Pinderfields and remained there, on a plaster-cast, looking at the ceiling for the next two years. My parents were relatively poor and came to see me once a week on a Saturday or a Sunday by public transport. At the end of two years, I was transferred back to Staincliffe for a further six months. This allowed my family to visit me more regularly and, according to the specialist, contributed to a speedier recovery; two and a half years, speedy recovery. So thanks to the wonderful doctors and nurses at both Pinderfields and Dewsbury, I made a full recovery.

But the issues today are not dissimilar to 60 years ago. So what am I trying to say? Regular and ongoing family support is vital in reassuring the young and vulnerable patient, and ensuring better recovery time.

Whilst there's no denying that Pinderfields is a state of the art facility, Dewsbury serves the health needs of nearly 200,000 people and deserves a fully operational hospital if it's going to complement the newly formed KCCG with its future objectives. Pinderfields is already under pressure, having cases from both Pontefract and Dewsbury referred, and now serving around a million people. Dewsbury's been classed as a deprived area and travelling costs to Pinderfields will have a severe impact on family budgets.

I won't go on because, to be fair to you, it's been a good meeting and I think I've encapsulated what I think most people are thinking. So thanks very much for that.

49 [applause]

F: [Voices overlap 2:04:44] keep services at Dewsbury.

Steve Richards: Well, as you were saying, it's been a good meeting and I think you would all agree that does, rather brilliantly, encapsulate all the themes that have come up during the evening. So I think we will end it at that point because I think it's a brilliant summary of your concerns. And thank you all very much indeed for coming tonight. Thank you.

[applause]

End of recording

50 Registered Address: PO Box 28956, Gorebridge, Midlothian, EH22 9BP

Tel/Fax: 0131 510 5105

Email: [email protected] www.1stclass.uk.com

1st Class is the trading name of Lawson Hardwick Limited Registered in Scotland, number SC311027