Governing Body Meeting in Public

Thursday 24th October 2019 [Intentionally left blank] Governing Body Public Meeting Thursday 26th October 2019, 18:00-20:00 Focolare Centre (Meeting Room 1) – Welwyn Garden City

AGENDA

Item Time Subject Report Action

1. 18:00 Welcome and Apologies for Absence - Chair Verbal

2. Declarations of Interests - . To receive any new declarations of interest Chair Verbal or declarations relating to matters on the Agenda. . To reconfirm current declarations on the Register of Interests are accurate and up-to- date. 3. 18:05 Introduction - . To set out the format of the meeting Chair Verbal

4. 18:10 Statements from members of the public Governing Body to hear statements from Public - Verbal members of the public submitted in advance. Each statement to be no longer than 3 minutes.

5. 18:25 Background to the proposal - Verbal Accountable Officer

6. 18:35 Findings from the engagement process . A presentation by Opinion Research ORS Note Enclosed Services outlining the results of the engagement process . Opportunity for questions to ORS from Governing Body Members

7. 19:15 Equality Impact Assessment . The revised EIA to be presented and Director of Note Enclosed discussed Nursing and Quality

8. 19:25 Discussion and decision All Approve Verbal

9. 19:55 Next steps Accountable Note Verbal Officer

Page 1 of 2 Item Time Subject Report Action

10. 20.00 Any Other Urgent Business . To consider any other matters which, in the All Discuss Verbal opinion of the Chair, should be considered as a matter of urgency.

11. - Date Of Next Meeting - - - 28th November 2019 09:00am – 11:00am - Public Session Focolare Centre, Meeting Room 1

Page 2 of 2 Agenda Item No: 2

Date of Meeting: 24th October 2019

Governing Body Meeting in Public

Paper Title: Registers of Interest

Decision or Approval Discussion Information

Report author: Maryla Hart, Governing Body Administrator

Report signed off by: Sarah Feal, Company Secretary

Executive Summary: The purpose of this paper is to receive any new declarations of interest or declarations relating to matters on the Agenda.

Members to reconfirm their current declarations on the Declarations of Interests Register are accurate and up-to-date (see Governance Report – Appendix 3).

In addition, members are asked to confirm that all offers of Gifts and Hospitality received in the last 28 days have been registered with the Governance and Corporate Affairs Team.

Recommendations . To review the Register of Interests of the Governing Body or to the members: relevant committee membership, and highlight any potential conflicts, which the Chair needs to manage: http://www.enhertsccg.nhs.uk/declarations-interest

. To declare those interests at the start of the meeting. . To complete a declaration form available from the Company Secretary. This will be recorded in the Minutes of the meeting.

Conflicts of Interest . There are none identified. involved:

Page | 1 Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Type Description Financial Interests This is where an individual may get direct financial benefits from the consequences of a commissioning decision. Non-Financial This is where an individual may obtain a non-financial professional Professional benefit from the consequences of a commissioning decision, such Interests as increasing their professional reputation or status or promoting their professional career. Non-Financial This is where an individual may benefit personally in ways which are Personal Interests not directly linked to their professional career and do not give rise to a direct financial benefit. Indirect Interests This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non-financial personal interest in a commissioning decision.

Page | 2 18/10/2019 Declarations of Interest Register 2019-20

Locality GP Surgery (If appropriate) First Name Last Name Current position(s) held in Declared Interest Type of interest: Is the Nature of Interest Date of Interest: Action taken to mitigate risk the CCG (Name of the organisation and interest i.e. Governing Body nature of business) direct or member; Committee indirect? member; Member practice; CCG employee or other Financial Non- Non- Indirect From: To: Date most Date no change financial financial interest recent form form received professio personal received nal NH PORTMILL SURGERY Tara Belcher GP Governing Body The Portmill Surgery y Direct GP Partner providing commissioned 01/04/2007 Ongoing Declaration 17/01/2018 Member representing North 114 Queen Street, Hitchin, Herts services Mitigation embedded in GGC 18/03/2019 Herts Locality SG4 9TH processes for all GP GB members.

NH PORTMILL SURGERY Tara Belcher GP Governing Body 12 Point Care Ltd (company y Direct The Portmill Surgery has a share in the 25/09/2014 Ongoing Will declare before relevant 17/01/2018 Member representing North number 09214266) local Federation, 12 Point Care Ltd which discussions. 18/03/2019 Herts Locality Kingston Smith LLP may provide bid for services Orbital House, 20 Eastern Road, commissioned by the CCG Romford, Essex RM1 3PJ

NH PORTMILL SURGERY Tara Belcher GP Governing Body Health Education England (Eastern y Direct GP Trainer (Health Education England) 03/10/2012 Ongoing Declaration 17/01/2018 Member representing North Deanery) 18/03/2019 Herts Locality

NH PORTMILL SURGERY Tara Belcher GP Governing Body Portmill Surgery y Direct The Portmill Surgery holds the contract for 01/04/2017 Ongoing Declaration 25/09/2019 Member representing North the Special Allocation Scheme for ENHerts Herts Locality and Herts Valleys CCGs.

NH PORTMILL SURGERY Tara Belcher GP Governing Body Mills and Reeve LLP (company y Indirect Spouse Christopher Belcher is a Partner at 01/10/2009 Ongoing Declaration 25/09/2019 Member representing North number OC326165) Mills & Reeve LLP who have a contract with Abstain from any discussion / Herts Locality 4th Floor, Monument Place, 24 ENHerts CCG and may bid for other legal votes in which Mills and Reeve Monument Street, London EC3R work from this and other CCGs and have a financial interest 8AJ Hospital Trusts.

NH PORTMILL SURGERY Tara Belcher GP Governing Body Hitchin & Whitwell Primary Care y Direct Clinical Director of Hitchin & Whitwell 11/09/2019 Ongoing Declaration 25/09/2019 Member representing North Network (PCN) Primary Care Network Herts Locality

LLV Director for Primary Care Denise Boardman Director for Primary Care Occupational Therapist y Direct As a registered Occupational Therapist and Sep-17 Ongoing Any requests received are 16/04/2018 09/01/2019 Development, ENHCCG Development Royal College of Occupational former member of the Royal College of discussed in 1:1 meetings with Therapy Occupational Therapy Professional my line manager prior Practice Board, I receive “ad hoc” requests acceptance. to deliver presentations to specialist sections of the Royal College of Occupational Therapy.

Dianne Desmulie Lay Member - Co- Pieve Solutions Ltd Company y Direct & Director of my own company: Pieve Nov-14 Ongoing Provide new declaration of 21/02/2018 05/02/2019 Commissioning No, 5600186. Registered Indirect Solutions Ltd. I have worked through this interest in event of either myself address: Orchard House, Park company as a freelance Management or my husband entering into a Lane, REIGATE, Surrey, RH2 8JX. Consultant. consultancy contract with a Nature of business: I have worked My husband, Robert Pinkham, is a supplier to the CCG through this company as a freelance management consultant and also freelance Management Consultant. a director of this company

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Locality GP Surgery (If appropriate) First Name Last Name Current position(s) held in Declared Interest Type of interest: Is the Nature of Interest Date of Interest: Action taken to mitigate risk the CCG (Name of the organisation and interest i.e. Governing Body nature of business) direct or member; Committee indirect? member; Member practice; CCG employee or other Financial Non- Non- Indirect From: To: Date most Date no change financial financial interest recent form form received professio personal received nal Dianne Desmulie Lay Member - Co- Hoddesdon Carers' Support Hub y Direct I am the Volunteer Hub Lead for the Feb-16 Ongoing Declare non financial personal 21/02/2018 05/02/2019 Commissioning Hoddesdon Carers' Support Hub. This is interest at any meeting where part of Carers in Hertfordshire, a charity contract or performance of CinH which contracts with Herts County Council (Carers in Hertfordshire) is to be and the CCG and NHS locally. This discussed particular project is funded by the Big Lottery.

Dianne Desmulie Lay Member - Co- Hanscombe House Patient y Direct I am a practice patient and a Member of Nov-14 Ongoing Declare non financial personal 21/02/2018 05/02/2019 Commissioning Participation Core Group Hanscombe House Patient Participation interest where funding or Core Group. I am acting secretary for the performance of Hanscombe group. House practice is to be discussed

SVV SOUTH STREET SURGERY Sarah Dixon GP Governing Body Member South Street Surgery y Direct GP Partner, South Street Surgery. Apr-18 Ongoing Declare conflict at meetings when 20/11/2018 29/01/2019 representing Stort Valley necessary and Villages

SVV SOUTH STREET SURGERY Sarah Dixon GP Governing Body Member Stort Valley and Villages (SVV) y Direct GP Workforce and Education Lead for Stort Apr-18 Ongoing Declare conflict at meetings when 20/11/2018 29/01/2019 representing Stort Valley Locality Valley and Villages (SVV) necessary and Villages

SVV SOUTH STREET SURGERY Sarah Dixon GP Governing Body Member STORT VALLEY HEALTHCARE y Direct South Street Surgery Practice is a member Apr-18 Ongoing Declare conflict at meetings when 20/11/2018 29/01/2019 representing Stort Valley LIMITED of Locality Federation. necessary and Villages Registered office address - C/O GP Partner Dr Kwasi Appiah is a Federation Parsonage Surgery Hertfordshire Director & Essex Community Hospital, Cavell Drive, Bishops Stortford, Hertfordshire, United Kingdom, CM23 5JH Company number 09489615 (Locality Federation)

Page 2 of 9 18/10/2019 Declarations of Interest Register 2019-20

Locality GP Surgery (If appropriate) First Name Last Name Current position(s) held in Declared Interest Type of interest: Is the Nature of Interest Date of Interest: Action taken to mitigate risk the CCG (Name of the organisation and interest i.e. Governing Body nature of business) direct or member; Committee indirect? member; Member practice; CCG employee or other Financial Non- Non- Indirect From: To: Date most Date no change financial financial interest recent form form received professio personal received nal SVV SOUTH STREET SURGERY Sarah Dixon GP Governing Body Member West Essex Vocational Training y Direct GP Trainer West Essex Vocational Training Apr-18 Ongoing Declare conflict at meetings when 20/11/2018 29/01/2019 representing Stort Valley Scheme Scheme and Princess Alexandra Hospital necessary and Villages and Foundation Programme Princess Alexandra Hospital Foundation Programme

SVV SOUTH STREET SURGERY Sarah Dixon GP Governing Body Member NHS England – Midlands and East y Direct GP Appraiser Apr-18 Ongoing Declare conflict at meetings when 20/11/2018 29/01/2019 representing Stort Valley necessary and Villages

SVV Director of Operations, Sharn Elton Director of Operations Nil 20/12/2017 09/01/2019 ENHCCG

Linda Farrant Lay Member, Governance Audit Committee of Care Quality y Direct Independent Member of Audit Committee Jul-15 Ongoing As appropriate to situation 08/07/2019 12/01/2019 and Audit Commission (CQC) of Care Quality Commission (CQC)

Beverley Flowers Accountable Officer East Herts at Home Ltd. Company y Direct Non remunerated Non-Executive Director 01/02/2019 Ongoing Declare at meetings where 19/06/2019 and North Herts CCG and number 11360947. Registered role with Herts at Home Ltd a company relevant. Joint STP Lead for Herts and office address County Hall, Pegs established and fully owned by West Essex Lane, Hertford, United Kingdom, Hertfordshire County Council to provide SG13 8DE. . care and support within the County.

Beverley Flowers Accountable Officer East Hertfordshire Criminal Justice y Direct Member of the Hertfordshire Criminal 31/01/2017 Ongoing None 19/06/2019 and North Herts CCG and Board Justice Board representing the NHS Joint STP Lead for Herts and West Essex

Alison Gardner Lay Member for Public and Herts Valleys CCG y Member of HVCCG Board (Lay Member – 01/08/2019 Ongonig Full transparancy with both 02/08/2019 Patient Engagement Public and Patient Engagement) organisations on both roles

Stevenage CHELLS SURGERY Russell Hall GP Board Member / Locality GP Practice, Chells Way, y Direct GP Partner, Chells Way Surgery. GP May-00 Ongoing Declare at meetings 01/02/2018 14/01/2019 Co-Chair Stevenage Stevenage, SG2 0NH Partner and Provider - GMS Services.

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Locality GP Surgery (If appropriate) First Name Last Name Current position(s) held in Declared Interest Type of interest: Is the Nature of Interest Date of Interest: Action taken to mitigate risk the CCG (Name of the organisation and interest i.e. Governing Body nature of business) direct or member; Committee indirect? member; Member practice; CCG employee or other Financial Non- Non- Indirect From: To: Date most Date no change financial financial interest recent form form received professio personal received nal Stevenage CHELLS SURGERY Russell Hall GP Board Member / Locality Stevenage Health Ltd (Stevenage y Direct Chells Practice is a member of Stevenage Jul-15 Ongoing Declare at meetings 01/02/2018 14/01/2019 Co-Chair Stevenage Federation) Federation, a private company.

Medical Director, ENHCCG Rachel Joyce Medical Director Spire Harpenden Hospital and y y Direct/ Married to Ear, Nose and Throat Surgeon 2000 Ongoing Will declare any 07/05/2019 Pinehill Ramsay Hospital In Indirect who works at these hospitals. Income from potential interest at Hitchin, One Hatfield Hospital Private Practice is shared. the start of any (Private Hospitals) Locally. relevant meeting, to allow the Chair to manage the conflict. Will not be on any procurement panels for this specialty.

Rachel Joyce Medical Director Herts and West Essex y Direct Clinical and Professional Director of the Apr-19 Mar-20 Will declare any potential interest 07/05/2019 Sustainability and Tranformation Herts and West Essex STP with any relevant agenda items Partnership (STP)

Pragasen Moodley Chair, East and North Herts Stanmore Medical Group y Direct Principal GP Partner, 01/09/2018 Ongoing I declare this at meetings where 01/10/2018 10/01/2019 CCG 5 Stanmore Road, Stevenage, SG1 Stanmore Medical Group relevant according to the statutory 3QA [Canterbury Way Surgery & St Nicholas guidelines. Health Centre have both fully merged with the Stanmore Medical Group] Both provider and commissioner

Pragasen Moodley Chair, East and North Herts AVM Medical. Suite 3 Middlesex y Direct Director: AVM Medical 01/09/2018 Ongoing I declare this at meetings where 01/10/2018 10/01/2019 CCG House, Rutherford Close, relevant. Stevenage, Hertfordshire, United Kingdom, SG1 2EF. Company number 10507387 I use this company to carry out private medicals and nursing home ward rounds

Pragasen Moodley Chair, East and North Herts Stevenage Health Limited, Dr. Raj y Direct My Practice is part of the Federation. 01/09/2018 Ongoing I declare this at meetings where 01/10/2018 10/01/2019 CCG Kaja, The Health Centre, Stanmore Stevenage Health Limited. I am not directly relevant. Road, Stevenage, Hertfordshire, involved. England, SG1 3QA. Company number 08877494

Page 4 of 9 18/10/2019 Declarations of Interest Register 2019-20

Locality GP Surgery (If appropriate) First Name Last Name Current position(s) held in Declared Interest Type of interest: Is the Nature of Interest Date of Interest: Action taken to mitigate risk the CCG (Name of the organisation and interest i.e. Governing Body nature of business) direct or member; Committee indirect? member; Member practice; CCG employee or other Financial Non- Non- Indirect From: To: Date most Date no change financial financial interest recent form form received professio personal received nal Pragasen Moodley Chair, East and North Herts Dr Anindita Saha, known as Dr y I am in a relationship with Dr Saha, who is a 01/09/2018 Ongoing Written declaration made. 01/10/2018 10/01/2019 CCG Rini Saha GP in Stevenage and a GP Governing Body Member for Stevenage as of 01/10/2018.

Dermot O'Riordan Secondary Care West Suffolk NHS Foundation y Direct Consultant Surgeon & Chief Clinical Sep-01 Ongoing Declare in line with conflict of 01/08/2019 Representative on the Trust Information Officer, West Suffolk NHS FT interest policy. Governing Body

Dermot O'Riordan Secondary Care West Suffolk NHS Foundation Trust y Indirect My wife works for West Suffolk NHS Apr-19 Ongoing Declare in line with conflict of 01/08/2019 Representative on the Foundation Trust as a consultant in learning interest policy. Governing Body from deaths. Dermot O'Riordan Secondary Care Kheiron Medical y y Indirect My wife does sessional advisory work for 2018 Ongoing Declare in line with conflict of 01/08/2019 Representative on the Kheiron Medical. Nature of business: interest policy. Governing Body involved in use artificial intelligence in interpreting mammograms

NH Chief Finance Officer, Alan Pond Chief Finance Officer GP Partner in Herts Valleys CCG y y Indirect Partner (Corina Ciobanu) 01/08/2010 Ongoing If ENHCCG ever seeks to procure 11/12/2017 09/01/2019 ULV ENHCCG (Haverfield Surgery, Kings services from GPs and/or GP WH Langley) and Chair of Dacorum Surgeries outside the CCG, I will Locality keep confidential any information I receive that could be of benefit to Haverfield Surgery and/or Corina Ciobanu. Should Haverfield Surgery and/or Corina Ciobanu submit a proposal to undertake any work for ENHCCG I will declare this interest and will not take part in any discussions and/or decisions on any appointment.

NH Chief Finance Officer, Alan Pond Chief Finance Officer Director of Assemble Community y Direct These companies form the LIFT (Local Jul-08 Ongoing My role on the Board of the LIFT 11/12/2017 09/01/2019 ULV ENHCCG Partnership Ltd (Company Number Improvement Finance Trust) for South East Company Group is to represent WH 06471276) and associated Midlands which was created to develop the interests of the local public companies community premises for the NHS. The sector, provide insight, but also to Assemble Fundco 2 Ltd (Company shares in the companies are held by oversee the financial and Number 08309498) Guildhouse Ltd and Community Health governance arrangements of the Assemble Holdco 2 Ltd (Company Partnership, the latter being a company companies. Number 08309495) wholly owned by the Department of Health. The Group of Companies was Wolverton Holdings (Company The directorship is unpaid, nominated by created to provide benefits to the Number 08307564) Community Health Partnerships and NHS locally and a conflict is Wolverton Fundco 1 Ltd (Company represents the interests of the CCGs in the highly unlikely to occur. Should Number 08306830 LIFT area, including East and North any conflict of interest arise, I Assemble Fundco 1 Ltd (Company Hertfordshire CCG. would excuse myself from both Number 06471659) parties for the relevant matter and Assemble Holdco 1 Ltd (Company should an Ongoing conflict arise Number 06471233) would resign my director position All of 128 Buckingham Palace with the Group of Companies Road, London, SW1W 9SA.

Page 5 of 9 18/10/2019 Declarations of Interest Register 2019-20

Locality GP Surgery (If appropriate) First Name Last Name Current position(s) held in Declared Interest Type of interest: Is the Nature of Interest Date of Interest: Action taken to mitigate risk the CCG (Name of the organisation and interest i.e. Governing Body nature of business) direct or member; Committee indirect? member; Member practice; CCG employee or other Financial Non- Non- Indirect From: To: Date most Date no change financial financial interest recent form form received professio personal received nal Stevenage Director of Nursing & Sheilagh Reavey Director of Nursing & Daughter y Indirect Daughter undertaking bank admin work 01/10/2019 Ongoing Not a decision making post and 07/02/2019 Quality, ENHCCG Quality within Prior Approval/IFR Team line management, time sheets HR issues etc through AD not Director. Independent CCG Director oversaw recruitment.

S KING GEORGES SURGERY Anindita "Rini" Saha GP Governing Body King George Surgery y Direct GP Partner, Kind George Surgery since 01/10/2018 Ongoing Declare all interests at meetings 16/01/2019 Member, Stevenage Locality 2007/08 where relevant and follow Both commissioner and provider statutory guidelines.

S KING GEORGES SURGERY Anindita "Rini" Saha GP Governing Body Stevenage Health Limited, y Direct King George Surgery is a member of 01/10/2018 Ongoing Declare all interests at meetings 16/01/2019 Member, Stevenage Locality Registered office address Stevenage Health Limited – which is the where relevant and follow The Health Centre, Stanmore Stevenage Locality Federation. I am not a statutory guidelines. Road, Stevenage, Hertfordshire, director. I am not a direct shareholder England, SG1 3QA Company number 08877494

S KING GEORGES SURGERY Anindita "Rini" Saha GP Governing Body Dr Prag Moodley, Chair of East y Indirect I am in a relationship with Dr Prag Moodley, 01/10/2018 Ongoing Written declaration made. 16/01/2019 Member, Stevenage Locality and North Herts CCG the Chair of East and North Herts CCG.

WH WRAFTON HOUSE SURGERY Ashish Shah Vice-Chair of ENHCCG. Wrafton House Surgery y Direct Principal GP and GP Trainer 01/11/2014 Ongoing Any conflict arising out of 01/05/2019 GP Governing Body Member 9-11 Wellfield Road Wrafton House Surgery. Both provider and discussions regarding same at representing WelHat Hatfield commissioner. meetings will be raised at the Locality. Locality Chair – AL1 OBS meeting. WelHat Locality.

WH WRAFTON HOUSE SURGERY Ashish Shah Vice-Chair of ENHCCG. Abhirush Limited. y Direct Director (Joined) of Abhirush Limited. I 01/11/2014 Ongoing Any conflict arising out of 01/05/2019 GP Governing Body Member Company registered address work through the Limited Company as an discussions regarding same at representing WelHat 5 Chedburgh Out of Hours GP at Herts Urgent Care. meetings will be raised at the Locality. Locality Chair – Welwyn Garden City meeting. WelHat Locality. AL7 2PU. Company No: 07998120 Nature of Business: I work through the Limited Company as an Out of Hours GP at Herts Urgent Care.

Page 6 of 9 18/10/2019 Declarations of Interest Register 2019-20

Locality GP Surgery (If appropriate) First Name Last Name Current position(s) held in Declared Interest Type of interest: Is the Nature of Interest Date of Interest: Action taken to mitigate risk the CCG (Name of the organisation and interest i.e. Governing Body nature of business) direct or member; Committee indirect? member; Member practice; CCG employee or other Financial Non- Non- Indirect From: To: Date most Date no change financial financial interest recent form form received professio personal received nal WH WRAFTON HOUSE SURGERY Ashish Shah Vice-Chair of ENHCCG. Ephedra Healthcare Ltd, Suite 3, y Direct Principal GP at Wrafton House Surgery. 01/11/2014 Ongoing Any conflict arising out of 01/05/2019 GP Governing Body Member Middlesex House, Rutherford Practice is a Shareholder of Ephedra discussions regarding same at representing WelHat Close, Stevenage, Herts, SG1 2EF. Healthcare Limited, which is a local meetings will be raised at the Locality. Locality Chair – Company no: 06560722 federation for WelHat Locality. meeting. WelHat Locality. Ephedra Healthcare Ltd.

WH WRAFTON HOUSE SURGERY Ashish Shah Vice-Chair of ENHCCG. Locality Lead for Workforce y Direct I Work as a Locality Lead for Workforce 01/01/2016 Ongoing Any conflict arising out of 01/05/2019 GP Governing Body Member Planning and Educational Network Planning and Educational Network for discussions regarding same at representing WelHat for Welwyn and Hatfield Locality Welwyn and Hatfield Locality meetings will be raised at the Locality. Locality Chair – meeting. WelHat Locality.

WH WRAFTON HOUSE SURGERY Ashish Shah Vice-Chair of ENHCCG. Spouse y Indirect Spouse works a GP in Hertford and 01/05/2019 Ongoing Any conflict arising out of 01/05/2019 GP Governing Body Member Corporate GP lead for ULV on ENHCCG discussions regarding same at representing WelHat Governing Body. meetings will be raised at the Locality. Locality Chair – meeting. WelHat Locality.

ULV Rupal Shah GP Governing Body Member Hanscombe House Surgery, 52A Salaried GP – Hanscombe House Surgery. 01/05/2019 Ongoing None perceived necessary as I am 19/07/2019 Representing ULV Locality. St Andrews Street, Hertford, SG14 a salaried GP and do not perceive Locality Co-Chair: ULV 1JA a conflict Locality

ULV Rupal Shah GP Governing Body Member GENERATING HEALTHCARE Hanscombe House is a shareholder of 01/05/2019 Ongoing None perceived necessary as I am 19/07/2019 Representing ULV Locality. LIMITED – Upper Lea Valley GENERATING HEALTHCARE LIMITED a salaried GP and do not perceive Locality Co-Chair: ULV Company number 08830754 I am not a director or a shareholder a conflict Locality Registered office address 2 Tower House, Tower Centre, Hoddesdon, Hertfordshire, England, EN11 8UR.

ULV Rupal Shah GP Governing Body Member Abhirush Limited. y Direct Director (Joined) of Abhirush Limited. 01/05/2019 Ongoing Any conflict arising out of 19/07/2019 Representing ULV Locality. Company registered address discussions regarding same at the Locality Co-Chair ULV 5 Chedburgh meeting will be raised at the Locality Welwyn Garden City meeting. AL7 2PU. Company No: 07998120 Nature of Business: I work as a locum GP via the limited company.

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Locality GP Surgery (If appropriate) First Name Last Name Current position(s) held in Declared Interest Type of interest: Is the Nature of Interest Date of Interest: Action taken to mitigate risk the CCG (Name of the organisation and interest i.e. Governing Body nature of business) direct or member; Committee indirect? member; Member practice; CCG employee or other Financial Non- Non- Indirect From: To: Date most Date no change financial financial interest recent form form received professio personal received nal ULV Rupal Shah GP Governing Body Member Upper Lea Valley Locality Provider y Direct I work as a GP Representative for Hertford 01/05/2019 Ongoing Any conflict arising out of 19/07/2019 Representing ULV Locality. Board on the Provider Board at ULV Locality discussions regarding same at the Locality Co-Chair ULV meeting will be raised at the Locality meeting.

ULV Rupal Shah GP Governing Body Member Spouse y Indirect Spouse works as a GP in Hatfield and 01/05/2019 Ongoing Any conflict arising out of 19/07/2019 Representing ULV Locality. Deputy Chair and Corporate GP Lead on discussions regarding same at the Locality Co-Chair ULV ENHCCG Governing Body. meeting will be raised at the Locality meeting.

SVV SOUTH STREET SURGERY Nabeil Shukur GP Governing Body South Street Surgery y Direct GP Partner, South Street Surgery 2001 Ongoing I need to declare when any 24/02/2018 21/02/2019 Member,Stort Valley and 83 South Street Nature of conflict: Primary Care Provider discussion about the benefit to Villages Locality Bishops Stortford practices and CCG investment in Herts Bishops Stortford primary care CM23 3AP

SVV SOUTH STREET SURGERY Nabeil Shukur GP Governing Body NHA Medical Ltd y Direct & Director and 20% shareholder. NHA Medical 2012 Ongoing I need to declare when any 24/02/2018 21/02/2019 Member,Stort Valley and 4 Beech Drive Indirect Ltd discussion is related to the above Villages Locality Sawbridgeworth two specialities and if for any CM21 0AA Provides Musculoskeletal Services and reason there is a discussion about Co No: 08386895. Dermatology services. I am MSK provider. NHA medical Provides Musculoskeletal My wife a is a dermatology provider. Services (MSK) and Dermatology services.

SVV SOUTH STREET SURGERY Nabeil Shukur GP Governing Body NHA Medical Ltd y Indirect Wife and son are both directors and 2012 Ongoing I will declare if there is any thing 24/02/2018 21/02/2019 Member,Stort Valley and 4 Beech Drive shareholders. related to NHA medical or the Villages Locality Sawbridgeworth above two specialities mentioned CM21 0AA Co No: 08386895. Provides Musculoskeletal Services and Dermatology services.

SVV SOUTH STREET SURGERY Nabeil Shukur GP Governing Body GP with Special Interest in y Direct GP with Special Interest in orthopaedics. 2006 Ongoing Need to be declare if there is any 24/02/2018 21/02/2019 Member,Stort Valley and orthopaedics. service redesign or procurement Villages Locality for MSK service

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Locality GP Surgery (If appropriate) First Name Last Name Current position(s) held in Declared Interest Type of interest: Is the Nature of Interest Date of Interest: Action taken to mitigate risk the CCG (Name of the organisation and interest i.e. Governing Body nature of business) direct or member; Committee indirect? member; Member practice; CCG employee or other Financial Non- Non- Indirect From: To: Date most Date no change financial financial interest recent form form received professio personal received nal SVV SOUTH STREET SURGERY Nabeil Shukur GP Governing Body Clinical Referral Service. Provided y Indirect GPSI (GP with Special Interest) contracted 2013 Ongoing As above with contracts related to 24/02/2018 21/02/2019 Member,Stort Valley and by Stellar Health Care Ltd, by the Stellar Health Care MSK Villages Locality 4 Spencer Close, Epping, Essex, I am not employed by Stellar CM16 6TN. Health Care

SVV SOUTH STREET SURGERY Nabeil Shukur GP Governing Body STORT VALLEY HEALTHCARE y Indirect My practice is part of federation: 2014 Ongoing I will need to declare if there is 24/02/2018 21/02/2019 Member,Stort Valley and LIMITED STORT VALLEY HEALTHCARE LIMITED discussion bout awarding Villages Locality Orbital House, 20 Eastern Road, contract to Stort Valley Health or Romford, Essex, RM1 3PJ any discussion about making Company number 09114753 changes which makes them favourable

Page 9 of 9

Agenda Item No: 6

Date of Meeting: 24th October 2019

Governing Body Meeting

Proposal to change the opening hours of the Urgent Care Paper Title: Centre at the New QEII Hospital, Welwyn Garden City

Decision or Approval Discussion Information

Report author: Jodie Rettie, Project Officer Phil Lumbard, Assistant Director Urgent Care Susan Haigh, Communications Manager Report signed off by: Beverley Flowers, Chief Executive

Executive Summary: The purpose of this paper is to support the Governing Body to determine the future opening hours of the New QEII Urgent Care Centre (UCC). A proposal to close the UCC between 10pm and 8am was brought forward for a period of public engagement by the CCG in the summer of 2019.

A background briefing paper summarising the reasons why this proposal was put forward by the CCG is attached as appendix 1.

The public engagement period ran from 13 June until 4 September 2019. During this time, residents and stakeholders were invited to discuss the CCG’s proposals at drop-in sessions and public meetings and encouraged to provide their views through a wide range of methods.

An independent research company ORS (Opinion Research Services) was commissioned to undertake and analyse the feedback gathered during the engagement process. Their full final report can be found in appendix 2, which includes a list of engagement events.

Themes from the engagement process

The main themes to come out of the public engagement process are:

 57% of respondents agreed that the CCG needs to make changes in response to the challenges facing the UCC.  69% of respondents agreed that the aims and principles regarding urgent care provision identified by the CCG are appropriate.  58% of the public disagreed with the proposal to close the UCC between the hours of 10pm and 8am.

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 Increased awareness of the challenges facing the UCC and alternative out-of-hours services tended to be accompanied by increased openness to the proposed changes.  Not everyone is aware of the range of NHS services that are available to them if their needs are urgent. This could mean that people are choosing to attend the Lister Hospital. Accident and Emergency department who could have had their needs met at the UCC.  Concerns were raised about travel and access to alternative facilities for groups such as the elderly, disabled and children, should the UCC close overnight.  Concerns were raised about the quality of care and capacity limits of other urgent and emergency services.  More general concerns were raised about the loss of NHS services in Welwyn Hatfield.

Following the public engagement period, the Equality Impact Assessment (EIA) is being reviewed, taking into account the findings of the engagement report. A copy of this EIA will follow.

The public engagement documentation can be found at appendix 3.

Recommendations Governing Body Members are asked to: to the members:  Discuss and note: - the findings of the public engagement exercise - the reasons behind the CCG’s proposal to close the UCC between 10pm and 8am - the revised EIA.

 Make a decision between options 1 and 2.

Option 1 Close the Urgent Care Centre at the New QEII Hospital overnight between 10pm and 8am, as proposed.

Option 2 Keep the Urgent Care Centre at the New QEII Hospital open overnight until 31 March 2020 and implement a communications campaign to raise public awareness of the service and the wider urgent care and out-of-hours services available to the public.

Any plan to retain the 24/7 opening hours at the UCC would need to demonstrate that the service remains viable, with sufficient, appropriate activity to justify the service remaining open through the night. The CCG will work with East and North Hertfordshire NHS Trust to quantify what levels of overnight activity represent a viable ongoing service.

As such, patient activity numbers at the UCC would be reviewed at

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the end of March 2020 in order for the Governing Body to make a final decision on opening hours in April 2020.

Conflicts of Interest There were no conflicts of interest identified in the development of involved: this paper.

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Type Description Financial Interests This is where an individual may get direct financial benefits from the consequences of a commissioning decision. Non-Financial This is where an individual may obtain a non-financial professional benefit Professional Interests from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. Non-Financial This is where an individual may benefit personally in ways which are not Personal Interests directly linked to their professional career and do not give rise to a direct financial benefit. Indirect Interests This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non- financial personal interest in a commissioning decision.

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1. Executive summary

See cover sheet.

2. Background (see also appendix 1)

National context

The Next Steps on the NHS Five Year Forward View (5YFV) document was published on 31 March 2017. One of the elements was to roll-out standardised new Urgent Treatment Centres (UTCs) across the country.

In July 2017 NHS England published further guidance for implementation of these UTCs. Nationally, it is intended that by November 2019 patients and the public will:

 be able to access UTCs that are open at least 12 hours a day, GP-led, staffed by GPs, nurses and other clinicians with access to simple diagnostics e.g. urinalysis, ECG and in some cases x-ray;

 have a consistent route to access urgent appointments offered within 4 hours and booked through NHS111, ambulance services and general practice. A walk-in option will also be retained;

 increasingly be able to access routine and same-day appointments, and out of hours general practice, for both urgent and routine appointments, at the same facility where geographically appropriate;

 know that the UTC is part of locally integrated urgent and emergency care services working in conjunction with the ambulance service, NHS111, local GPs, hospital A&E services and other local providers.

Local Strategic Direction

The CCG’s Urgent and Emergency Care Strategy focusses on the move towards NHS 111 and the Integrated Urgent Care (IUC) service as the single point of contact for accessing and co-ordinating urgent care to ensure patients’ access to the ‘right care, right place, first time’.

In order to achieve this it is necessary to look at how services are delivered and accessed across the whole system. This will allow limited NHS staffing resource to be used most effectively to meet patient needs.

The Urgent Care Centre at the New QEII meets the requirements of the national guidance and as we know, is very well used during the day. However, the number of people using the UCC has been low overnight for a prolonged period, which led the CCG to agree a period of engagement on the opening hours of the UCC overnight to test public views on making better use of available clinical resource.

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Engagement process

Between 13 June and 4 September 2019, the CCG conducted an extensive public engagement campaign in order to gather the views of patients, the wider public and stakeholders about the proposal to close the Urgent Care Centre overnight, when it is used by, on average, less than one person an hour.

During this time, residents and stakeholders were invited to discuss the proposals with CCG representatives and GP Governing Body members at drop-in sessions and public meetings and provide their views through a wide range of methods. Where possible, representatives of East and North Hertfordshire NHS Trust, the providers of the UCC service, were also present at events to give their perspective on the proposal. Two, independently-facilitated focus groups were also held featuring a representative sample of the CCG’s population. The majority of focus group members were from the Welwyn Hatfield area.

The Governing Body would like to thank everyone who took time to give their feedback. A lot of very detailed conversations were held and we gained a lot from hearing about people’s understanding and experiences of local health services.

An independent research company, Opinion Research Services (ORS) analysed all the responses received during the engagement period and produced a report which they will present at this meeting. A copy of the full findings is at appendix 2.

Proposal that was put to the public The proposal and options put forward by East and North Hertfordshire CCG were as follows:  To close the UCC overnight between the hours of 10pm and 8am;  To reassign nursing staff, currently working at the UCC overnight, to the Accident & Emergency Department at Lister Hospital in Stevenage; and  To introduce Advanced Nurse Practitioners at the New QEII UCC during the new opening hours of 8am until 10pm.

Summary of findings

Open engagement Deliberative focus Written submissions Petitions questionnaires groups

Representative 1 petition with 964 valid sample of E&N approximately responses (inc. Herts residents 9 Responses 2,800 5 from named organisations) signatures 20 participants

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As a well-established and specialist social research practice with wide-ranging experience of high-profile public engagements and statutory engagements across the UK, ORS has confirmed that the engagement process undertaken by East and North Hertfordshire CCG meets their standards and was “comprehensive and conscientious”.

Themes from the engagement feedback

The main themes to emerge from questionnaires, letters and feedback given at events are:

 57% of respondents agreed that the CCG needs to make changes in response to the challenges facing the UCC.  69% of respondents agreed that the aims and principles regarding urgent care provision identified by the CCG are appropriate.  58% of the public disagreed with the proposal to close the UCC between the hours of 10pm and 8am.  Increased awareness of the challenges facing the UCC and alternative out-of-hours services tended to be accompanied by increased openness to the proposed changes.  Not everyone is aware of the range of NHS services that are available to them if their needs are urgent.  Concerns were raised about travel and access to alternative facilities for groups such as the elderly, disabled and children, should the UCC close overnight.  Concerns were raised about the quality of care and capacity limits of other urgent and emergency services.  More general concerns were raised about the loss of NHS services in Welwyn Hatfield.

Nine stakeholders provided written submissions during the engagement period.

- The Rt. Hon. Grant Shapps MP, Welwyn Hatfield Borough Council, Hatfield Town Council and North Mymms Parish Council disagreed with the CCG’s proposal.

- Letters of agreement were received from representatives of Hertfordshire County Council, Stort Valley and Villages GP surgeries and the North Hertfordshire locality commissioning committee.

- Bridge Cottage Surgery in Welwyn felt that they would require additional information before they could make an informed decision.

- East and North Hertfordshire NHS Trust and the Hertfordshire Health Scrutiny Committee expressed their support for the engagement process undertaken by the CCG.

The CCG was presented with a petition organised by the Welwyn Hatfield Labour Party which included approximately 2,800 signatures. Entitled ‘Hands off our Urgent Care Centre’, the wording of the questionnaire refers to plans to “completely remove” the overnight care that residents currently get.

Current usage of the Urgent Care Centre

The CCG’s expectation during the engagement process would be that public awareness of the UCC service might increase due to increased publicity about it in local newspapers and

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on social media. However, no notable increase in activity between the hours of 10pm and 8am has been observed.

This means that the staff currently provided by East and North Hertfordshire NHS Trust to work at the UCC overnight continue to be under-utilised. However, should a decision be made by the Governing Body to reduce the opening hours at the UCC, there will be a requirement for East and North Hertfordshire NHS Trust to undertake appropriate consultation with affected staff prior to any change in rotas.

3. Options for discussion

Governing Body Members are asked to discuss and note the findings from the public engagement exercise and decide which of the following options it will support:

Option 1 Move to close the Urgent Care Centre at the New QEII Hospital overnight between 10pm and 8am, as proposed.

Option 2 Keep the Urgent Care Centre at the New QEII Hospital open overnight until 31 March 2020 and implement a communications campaign to raise public awareness of the service during this period.

Patient activity numbers at the UCC would then be reviewed in order for the Governing Body to make a final decision on opening hours in April 2020. Any proposal to retain the 24/7 opening hours would need to demonstrate that the QEII UTC is viable, with sufficient, appropriate patient activity to justify the service remaining open through the night. The CCG will work with East and North Hertfordshire NHS Trust to quantify what levels of overnight activity represent a viable ongoing service.

4. Risks/Mitigation Measures

It is important for the Governing Body to note the following risks:

 If option one is supported:

o the new service model would not be introduced immediately as there would need to be a period of time to consult with affected Trust staff and recruit and appoint additional staff.

o some patients may still come to the UCC, unaware that the service is shut. While this risk should be noted, it is expected that this would not be a common occurrence as we know very few people have previously attended overnight, and those that did had low acuity injuries and illnesses. A comprehensive communications plan would aim to mitigate this risk by heightening public awareness of the NHS services available to them in Welwyn Hatfield.

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 If option two is supported:

o the staffing model overnight will continue to be nurse-led as recruitment of a GP to work overnight remains challenging. Anyone needing to see a doctor overnight will still have to call NHS 111 for a local appointment in the GP out of hours service which is currently located on the New QEII site, instead of walking in to the UCC. This also means that children and those with complex illnesses will continue to be redirected either to NHS 111 or to the Lister Hospital overnight.

o East and North Hertfordshire NHS Trust’s ability to provide staff overnight could potentially be compromised by winter pressures and short-notice emergency closures of the service are possible. If this situation occurs, the only way to communicate any short-term closures to the public quickly would be through digital channels and through signage on the UCC door.

5. Resources

For either option, a comprehensive communications campaign will need to be put in place in order to ensure as many people as possible are aware of the services available at the UCC, as well as alternative sources of out-of-hours advice and help. A costed publicity plan will be produced by the communications and engagement team in the next few weeks.

6. Recommendations

In the light of the outcomes of the engagement process, it is recommended that the CCG: - delays the decision on the reduction of opening hours at the QEII UCC overnight until the end of March 2020 and raises public awareness of the services available there during this period

- asks local stakeholders to support this public awareness campaign, using their own networks and communications channels.

7. Next Steps

If the recommendation is supported, the CCG will:

 Design and implement a communications plan to raise awareness of the range of NHS services available in the local area.

 Work with East and North Hertfordshire NHS Trust to source activity data from the Urgent Care Centre, in order to enable the governing body to make an informed decision when it meets in April 2020.

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Appendices

Appendix 1

Background briefing

Appendix 2

ORS Report

Appendix 3

Engagement document and questionnaire

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Appendix 1

REVIEW OF OPENING HOURS AT THE URGENT CARE CENTRE, WELWYN GARDEN CITY

Background briefing

1. Purpose of background briefing

1.1 This background briefing seeks to:

 Summarise the reasons why the Governing Body of East and North Hertfordshire CCG (the CCG) put forward a proposal to close the Urgent Care Centre (UCC) for minor illnesses and minor injuries at the New QEII Hospital in Welwyn Garden City between 10pm and 8am.

 Outline the local and national urgent and emergency care policy context

 Bring together information about the range of local urgent and emergency and ‘out-of-hours’ health services that are available to residents living in the east and north of Hertfordshire.

2. Why the overnight closure proposal was suggested

2.1 NHS East and North Hertfordshire Clinical Commissioning Group (the CCG) is the organisation responsible for making sure that the 597,000 people in our area get the medical help, care and treatment that they need. This includes GP services, most planned hospital and community health services, mental health services and urgent and emergency care.

2.2 The CCG commissioned the Urgent Care Centre (UCC) for minor injuries and minor illness at the New QEII Hospital. The service opened in 2015 and is very well used overall, with an average of 118 people attending the centre every 24 hours.

2.3 However, data collected locally and verified by the national body, NHS England, shows that the service is not well used overnight. Between 10pm and 8am, less than one person per hour on average uses the UCC. Of those who do go to the UCC, the vast majority who see a GP (86%) do not require any further tests, scans, medicine or onward referral to another NHS service. Their needs are met by clinical reassurance only.

2.4 This pattern of low overnight urgent and emergency care attendances in Welwyn Garden City is not new and has been in evidence since before the UCC was in operation, when the local area was served by the Accident and Emergency department of the former QEII hospital.

2.5 Due to ongoing recruitment difficulties, there is currently no doctor at the Urgent Care Centre after midnight. People who need to see a doctor between midnight and 8am therefore cannot ‘drop in’ to see one as they do during the day. However, via the free NHS 111 telephone and online advice service, patients can access an out-of- hours GP consultation and a range of other 1

services, if this is clinically appropriate for their needs. These consultations are made on an appointment basis at one of the out-of-hours GP bases across the East and North Hertfordshire CCG area. In the Welwyn Hatfield area, GP appointments are generally offered at the New QEII, with other nearby bases including Hertford and Cheshunt.

2.6 The UCC is staffed overnight by highly skilled nursing staff from East and North Hertfordshire NHS Trust, with a minimum of two clinical staff on duty at all times for patient and staff safety reasons. These staff treat an average of one patient each every two hours between 10pm and 8am. The same staff members would be expected to treat between 3-6 patients per hour in an Accident and Emergency department, depending on the acuity of the needs of those patients.

2.7 The current staffing model means that children cannot be seen by the UCC’s nurses between midnight and 8am. Out-of-hours GP appointments for children can be accessed via NHS 111, as above.

2.8 X-rays are not available at the Urgent Care Centre after 11pm. Patients with minor injuries requiring an X-ray after 11pm need to attend an alternative location, such as the Lister Hospital in Stevenage, or wait until services resume at 8am.

2.9 The change in services available during the day and overnight at the UCC is not always widely understood by people in the local area. This means that some patients attend the centre with a need that cannot be met at that time and have to be directed to an alternative service, such as NHS 111 or the Lister Hospital.

2.10 During these very quiet overnight hours, these nurses - who are employed to work at both the UCC and the Lister Hospital Accident and Emergency (A&E) department - could alternatively be deployed to support seriously ill patients with a life-threatening condition or emergency at the area’s A&E service at the Lister Hospital.

2.11 We know that some patients currently wait longer to be seen at the Lister Hospital A&E department than is ideal. For this reason, East and North Hertfordshire NHS Trust supports the principle of re-allocating its scarce nursing resource from the UCC to the Lister Hospital overnight to help to meet demand.

2.12 For the reasons outlined above, between June and September 2019, the CCG engaged with the public, stakeholders and NHS staff on a proposal to close the UCC between 10pm and 8am. Under this proposal, patients who arrived before 10pm would be treated before the Urgent Care Centre closed for the night.

3. The urgent and emergency care policy context

3.1 The national context: improving urgent and emergency care is one of the top priorities of the NHS. There is a continued focus on the need to treat all patients with an urgent or emergency care need in a timely way, in a setting that is 2

appropriate to their needs. Local pilot projects are also underway to test new national treatment standards for those with the most serious and life-threatening injuries. Our CCG works very closely with social care, acute hospital, ambulance service and GP colleagues to meet this requirement, against a difficult background of increasing demand, an ageing population and recruitment challenges.

3.2 Our CCG is absolutely committed to ensuring that our whole population has access to high quality care, whilst making the very best use of the highly-trained clinical staff available in our area.

3.3 New national guidance has been introduced by NHS England which requires all centres like the UCC to offer a standard set of services and to open for at least 12 hours a day, taking into account local demand:

3.4 “Urgent treatment centres should be open for at least 12 hours a day, seven days a week, including bank holidays, to maximise their ability to receive streamed patients who would otherwise attend an A&E department. Typically this will be an 8-8 service, but commissioners will wish to tailor to local requirements based on locally determined demand.”

3.5 The aim of this national guidance is to make it easier for the public to understand the services on offer, and to use them appropriately.

3.6 The local context: the CCG proposed to close the Urgent Care Centre at 10pm every night and re-open it at 8am each morning. In this model, everyone who attends before 10pm will be treated.

3.7 This would mean that the UCC would remain open for 14 hours a day, exceeding the national requirement and providing longer opening hours than similar urgent treatment centres in neighbouring areas, such as Enfield, Hemel Hempstead, Luton and Bedford.

3.8 East and North Hertfordshire NHS Trust has plans in place to recruit additional expert nursing staff called ‘advanced nurse practitioners’ to join the team at the Urgent Care Centre. Advanced nurse practitioners can undertake a wide range of consultations and treatments that currently only the GPs working at the UCC can carry out. They are very senior nurses who have undertaken further study at Masters level and use their expertise and experience to work autonomously, seeing and treating patients with a wide range of symptoms. They can also work alongside GPs to provide safe and effective care to patients presenting with a wide range of ailments. This change should help to reduce waiting times and is in line with new national service specifications.

4 Local urgent, emergency and out-of-hours care available in the area

4.1 The Urgent Care Centre is just one of the ways in which Welwyn Hatfield patients can get medical help outside of normal GP surgery hours.

4.2 During the 12-week engagement campaign, designed to seek out and listen to the views of the public and stakeholders about our proposal, the CCG worked to raise awareness of the full range of urgent and emergency care services 3

which are now available in the area in the evening, overnight and at weekends.

4.3 The NHS 111 service is available 24 hours a day, 7 days a week, by either calling 111 for free from a landline or mobile, or going online to www.111.nhs.uk

4.4 Patients contacting the NHS 111 service have their symptoms immediately assessed and, if they need one, a GP appointment is booked for them that day/night to take place at a base in Welwyn Garden City, at another convenient location, or at home if they are too unwell to travel.

Call handlers are supported around the clock by a team of clinicians and patients are able to speak to a GP in the contact centre if this is needed. Patients can also speak to a nurse, dentist, or mental health professional by calling NHS 111. An ambulance can be called by the service if this is the most appropriate support needed for a patient.

4.5 Hertfordshire’s NHS 111 service, based in Welwyn Garden City, is high- performing and nationally recognised and the CCG continues to actively promote the service to its population.

4.6 Over the past 12 months, the CCG has worked with the GP practices across our area to introduce evening and weekend appointments which anyone can book.

4.7 These extra appointments are known as ‘extended access’ appointments and enable patients to book either a routine or an urgent ‘same day’ appointment with a GP at a local hub until 8pm on weekdays, from 8am-4pm on Saturdays, and 8am-12pm on Sundays.

4.8 Patients are taking up the option of these appointments when they are offered, although there is some variation in take-up rates across east and north Hertfordshire. We are working with practices in areas where there are low take- up rates to further promote appointments to patients.

4

NHS East and North Hertfordshire Clinical Commissioning Group:

Patients’ views on the proposed changes to opening hours at the New QEII Hospital Urgent

Care Centre

Report of findings

Opinion Research Services

The Strand  Swansea  SA1 1AF 01792 535300 | www.ors.org.uk | [email protected]

This project was carried out in compliance with ISO 20252:2012

As with all our studies, findings from this report are subject to Opinion Research Services’ Standard Terms and Conditions of Contract Any press release or publication of the findings of this report requires the advance approval of ORS: such approval will only be refused on the grounds of inaccuracy or misrepresentation

© Copyright October 2019

Opinion Research Services | The Strand • Swansea • SA1 1AF | 01792 535300 | www.ors.org.uk | [email protected]

NHS East and North Hertfordshire Clinical Commissioning Group:

Patients’ views on the proposed changes to opening hours at the New QEII Hospital Urgent Care Centre

Report of findings

Opinion Research Services

The Strand  Swansea  SA1 1AF 01792 535300 | www.ors.org.uk | [email protected]

This project was carried out in compliance with ISO 20252:2012 As with all our studies, findings from this report are subject to Opinion Research Services’ Standard Terms and Conditions of Contract Any press release or publication of the findings of this report requires the advance approval of ORS: such approval will only be refused on the grounds of inaccuracy or misrepresentation

© Copyright October 2019

Opinion Research Services | The Strand • Swansea • SA1 1AF | 01792 535300 | www.ors.org.uk | [email protected] Opinion Research Services | NHS East and North Hertfordshire CCG: Patient Views and Urgent Care Centres October 2019

Contents page

1. Executive summary ...... 6 The commission ...... 6 The engagement process ...... 6 Nature of public engagement ...... 7 The proposal ...... 8 Key findings ...... 8 Final considerations ...... 15

2. Engagement overview ...... 17 The commission ...... 17 The engagement process ...... 17 Nature of public engagement ...... 20 The proposal ...... 21

3. Open engagement questionnaire ...... 22 The open engagement questionnaire ...... 22 Findings from the open engagement questionnaire ...... 28 Residents’ views and concerns in relation to the CCG’s proposal ...... 45 Respondents who disagreed with the proposal ...... 46 General comments on the proposal ...... 47 Travel and access to alternative overnight services ...... 48 Quality and safety impacts of the proposal ...... 49 Staffing at the Urgent Care Centre ...... 50 Equalities impacts ...... 51 Other comments and alternative solutions ...... 53

4. Residents focus groups ...... 55 Introduction ...... 55 Attendance and representativeness ...... 55 Discussion agenda...... 57 Outputs and reporting ...... 58 Findings ...... 58 Summary ...... 66

5. Petition ...... 68 Overview ...... 68 Note on petitions ...... 68

6. Written submissions ...... 69 Overview ...... 69

3 Opinion Research Services | NHS East and North Hertfordshire CCG: Patient Views and Urgent Care Centres October 2019

Summaries ...... 69 The Right Honourable Grant Shapps, MP for Welwyn Hatfield ...... 69 Hertfordshire County Councillor Richard Roberts, Executive Member for Adult Care and Health and Chairman of the Hertfordshire Health and Wellbeing Board ...... 71 Councillor Tony Kingsbury, Leader of Welwyn Hatfield Borough Council ...... 71 Hatfield Town Council ...... 73 North Mymms Parish Council ...... 73 Stort Valley & Villages GP Surgeries ...... 73 Dr Tara Belcher and Dr Simon Chatfield, on behalf of North Hertfordshire LCC ...... 74 Bridge Cottage Surgery, Welwyn ...... 74 Nick Carver, Chief Executive, East and North Hertfordshire NHS Trust ...... 74 Counsellor Seamus Quilty, Chair of the Hertfordshire County Council Health Scrutiny Committee ...... 74

Appendix I: Table of figures ...... 76

Appendix II: Text comments from the open engagement questionnaire ...... 78

Appendix III: Meetings and activities hosted or attended by the CCG ...... 83 Introduction ...... 83 Meetings and other activities ...... 84 East and North Hertfordshire NHS Trust Annual General Meeting ...... 85 Public meetings with members of the CCG Governing Body ...... 85 Drop-ins and information stands ...... 88

4 Opinion Research Services | NHS East and North Hertfordshire CCG: Patient Views and Urgent Care Centres October 2019

The ORS Project Team

Project management Fieldwork management and reporting Robyn Griffiths Kester Holmes Amy Bone Charlie Wilson

Data analysis Richard Harris

Sheng Yang

5 Opinion Research Services | NHS East and North Hertfordshire CCG: Patient Views and Urgent Care Centres October 2019

1. Executive summary Summary of main findings

The commission

1.1 NHS East and North Hertfordshire Clinical Commissioning Group (henceforth NHS East and North Hertfordshire CCG or ‘the CCG’) has undertaken a public engagement process to examine the views of members of the public and other stakeholders on its proposal to make change to the opening hours of the Urgent Care Centre (UCC) at the New QEII Hospital in Welwyn Garden City, as well as to the staffing of the UCC and Lister Hospital.

1.2 Opinion Research Services (ORS) is a spin-out company from Swansea University with a UK-wide reputation for social research and major statutory engagements. ORS was appointed to advise on and independently manage and report important aspects of the engagement programme.

The engagement process

1.3 The engagement period was launched on 13th June 2019 and ended on 4th September 2019. During this period, residents and other stakeholders were invited to provide feedback through a wide range of methods, including all of the following as reported here: » An open engagement questionnaire for all residents, stakeholders and organisations: the questionnaire was available online and paper questionnaires were widely circulated and available on request. An easy read version was also available; » Two deliberative focus groups with members of the public: both held at the NHS East & North Hertfordshire CCG’s office at Charter House, Welwyn Garden City; » Written submissions: residents, stakeholders and organisations were able to provide their views by writing to NHS East and North Hertfordshire CCG or ORS; » A petition; and » Additional engagement activities hosted by or attended by CCG representatives.

1.4 The engagement programme as reported here by ORS received the following levels of response:

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Open Additional Deliberative Written engagement Petitions engagement focus groups submissions questionnaires activities 17 drop-ins and stands Representative 963 valid sample of east 3 public 1 petition with meetings responses and north 12 approximately (inc. 5 from Hertfordshire responses 2,800 1 AGM named residents signatures 3,732 organisations) 20 participants engagements via social media

1.5 In terms of the additional engagement activities organised by the CCG, these included more than 20 additional events and activities to engage with and inform the public about the proposal and to encourage participation in the engagement process. More than 1,000 individuals were engaged with in different ways, from distribution of paper questionnaires and leaflets containing details of the online engagement website, to in-depth conversations and discussions with CCG staff members. The CCG also made considerable effort to engage with members of the public via social media channels and through more traditional media.

Proportional and fair 1.6 The key good practice requirements for engagement programmes are that they should: » Be conducted at a formative stage, before decisions are taken; » Allow sufficient time for people to participate and respond; » Provide the public and stakeholders with enough background information to allow them to consider the issues and any proposals intelligently and critically; and » Be properly taken into consideration before decisions are finally taken.

1.7 As a well-established and specialist social research practice with wide-ranging experience of controversial public engagements and statutory consultations across the UK, ORS can confirm that the engagement process undertaken by NHS East and North Hertfordshire CCG meets these standards. Overall, ORS has no doubt that the engagement programme has been conscientious, competent and comprehensive in eliciting the opinions of stakeholders and many members of the public. It was open, accessible and fair to all people and organisations across east and north Hertfordshire; and it conforms with ‘best practice’ in both its scale and the balance of elements used. The engagement was also proportional to the importance of the issues.

Nature of public engagement

Accountability 1.8 Accountability means that public authorities should give an account of their plans and take into account public views: they should conduct fair and accessible deliberative engagement while reporting the outcomes openly and considering them fully. This does not mean that the majority views should automatically decide public policy; and the popularity or unpopularity of proposals should not displace professional and political judgement about what is the right or best decision in the circumstances. The levels of, and reasons for, public support or opposition are very important, but as considerations to be

7 Opinion Research Services | NHS East and North Hertfordshire CCG: Patient Views and Urgent Care Centres October 2019

taken into account, rather than as factors that necessarily determine authorities’ decisions. Above all, public bodies have to consider the relevance and cogency of the arguments put forward during public engagements, not just count heads.

The report 1.9 This executive summary summarises the engagement outcomes to highlight the overall balance of opinions. We trust that this summary is a sound guide to these outcomes and how they might be interpreted, but readers are urged to consult our full report for more detailed insights and understanding of the assumptions, arguments, conclusions and feelings about the possible changes to the opening hours of the UCC at the new QEII Hospital. In contrast to the more thematic approach in this executive summary, the full report considers the feedback from each element of the engagement in turn because it is important that the full report provides a full evidence-base for those considering the engagement and its findings. We trust that this report will be helpful to all concerned.

1.10 ORS is clear that its role is to analyse and explain the opinions and arguments of the many different interests participating in the engagement, but not to ‘make a case’ for any option or variant. In this report, we seek to profile the opinions and arguments of those who have responded to the engagement, but not to make any recommendations as to how NHS East and North Hertfordshire CCG should make use of the reported results.

1.11 It should be noted at this stage that reports such as this may appear more ‘critical’ than really is the case because: critics are often more motivated to respond to a public engagements; and ORS has an obligation to report criticisms in order for the CCG to carefully consider the issues. This does not mean that its decisions should be determined only by engagement. Indeed, whilst this report brings together a wide range of feedback and views for consideration, it is for the CCG to take decisions based on all the evidence available.

The proposal

Proposed changes at the New QEII Hospital UCC 1.12 The proposal and options put forward by NHS East and North Hertfordshire CCG were as follows: » To close the UCC overnight between the hours of 10pm and 8am; » To reassign nursing staff, currently working at the UCC overnight, to the Accident & Emergency Department at Lister Hospital in Stevenage; and » To introduce Advanced Nurse Practitioners at the New QEII UCC during the new opening hours of 8am until 10pm.

Key findings

The proposal

Open engagement questionnaire

1.13 More than half (57%) of open questionnaire respondents agreed that the CCG needs to make changes to address the challenges facing the UCC and more than two thirds (69%) agreed that the principles and aims

8 Opinion Research Services | NHS East and North Hertfordshire CCG: Patient Views and Urgent Care Centres October 2019

regarding urgent care provision identified by the CCG are appropriate. Of the 963 individuals and organisations who completed the questionnaire, however, 470 respondents (58%) disagreed with the specific changes to the UCC opening hours proposed by the CCG.

1.14 It should be noted, though, that there was considerable difference in levels of agreement and disagreement between different groups of respondents. More than two thirds (70%) of Welwyn Hatfield residents, for example, disagreed with the proposed changes; by contrast, nearly two thirds of respondents living elsewhere in east and north Hertfordshire and the surrounding area agreed that the UCC should be closed overnight and nursing staff moved to Lister Hospital.

1.15 More than four fifths (85%) of respondents who had used the UCC overnight in the last 12 months disagreed with the proposed changes, whereas more than half (57%) of those who had not done so agreed that the UCC should close between 10pm and 8am. NHS employees were more supportive of the proposal, with more than half (54%) agreeing, whereas three fifths (60%) of those respondents not working for the NHS disagreed with the proposed changes.

Residents focus groups

1.16 The majority of focus group participants agreed that changes need to be made to address the challenges faced by the UCC, and that the principles and aims identified by the CCG are appropriate. Furthermore, when given the opportunity to hear the evidence presented by the CCG in relation to current usage of the UCC overnight, and the implications of the changes in terms of reassigning nursing staff to work at the busy A&E department at Lister Hospital, the majority of attendees were inclined to support the proposal – albeit with some concerns about the quality and safety of alternative services, and issues related to travel and access to Lister Hospital in particular (see below).

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Written submissions

1.17 Written submissions received from representatives of local government bodies and NHS organisations varied in their responses to the proposal. The local MP, Welwyn Hatfield Borough Council, Hatfield Town Council and North Mymms Parish Council expressed strong opposition to the proposed changes, raising concerns about negative consequences for local residents should the UCC close overnight.

1.18 By contrast, Hertfordshire County Council, local GP’s groups and East and North Hertfordshire NHS Trust recognised the need for changes to be made and agreed that the proposal put forward by the CCG was an appropriate response and the right way forward in the interest of patients.

1.19 Hertfordshire County Council’s Health Scrutiny Committee did not express a judgement on the proposal itself but acknowledged that the challenges need to be addressed, and agreed that the most effective use of available staff resources in the interest of patients with urgent care needs must be achieved.

Petition

1.20 A petition was received by the CCG, organised and delivered by Welwyn Hatfield Labour Party, titled, “Hands off our Urgent Care Centre” which expressed opposition to the, “planned cut backs to the Urgent Care Centre (QE2)”. The petition comprised approximately 2,800 signatures.

Additional CCG-hosted or attended engagement activities

1.21 Members of the public, NHS and local government employees, and other stakeholders with whom the CCG team interacted at the various engagement events and activities were, on balance, more likely to support the proposed changes. It should be noted, however, that many remained opposed to the proposal, even when given the opportunity to find out more details about the rationale and principles on which the proposal was based.

1.22 One noteworthy outcome from many of the conversations between members of the public and CCG staff was the number of individuals who reported having seen an out-of-hours GP at the New QEII Hospital at an appointment arranged via NHS 111.

1.23 The response through social media channels was, by contrast, largely (although not universally) negative in response to the proposed changes at the UCC. The fast-moving and responsive nature of online debate makes it challenging to draw out conclusions about the rationale behind people’s views, with some discussions in this case quickly moving on to broader socio-political issues (e.g. NHS funding, government cuts and political debate, among others). These interactions do, however, provide a colourful insight into the views and concerns of those responding, and as such are acknowledged, if not fully explored, in this report.

The reasons for disagreeing with the proposal

Open engagement questionnaire

1.24 Respondents to the open questionnaire who either tended to disagree or strongly disagreed with the proposed changes at the UCC were given the opportunity to give their reasons for doing so. Of these, more than two thirds (69%) expressed general disagreement, including around one third (32%) who said that the service should remain as it is, and slightly less than one fifth (18%) who felt that the urgent care services and emergency care in Welwyn Hatfield should be increased rather than reduced (up to and including

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reinstating a full A&E department at the New QEII Hospital). A similar proportion of respondents (19%), when explaining their reasons for disagreeing, cited concerns that the proposed overnight closure would put residents’ safety and lives at risk. One in six respondents (16%) cited the growing population of the area as a concern.

1.25 By a considerable margin, the most common specific areas of concern expressed by opponents of the proposal related to travel and access to alternative services, and the potential negative outcomes in relation to the quality and safety of urgent and emergency care available for patients overnight.

1.26 Just under a third of respondents who disagreed with the proposal (30%) specifically mentioned the distance and difficulty of travelling to Lister Hospital as a reason for opposing the changes, while almost a fifth (18%) expressed more general concerns about increased travel and/or the need for local services. One in ten (11%) were concerned about the cost of travel, and the potential difficulties faced by people without access to a vehicle (mentioned by 14% of those opposed to the change), and vulnerable groups such as older people and those on low-incomes were mentioned by a smaller proportion (5%) of those who disagreed.

1.27 Almost a third (29%) of opponents of the proposed changes expressed concerns about long waiting times and/or overstretched services at Lister Hospital, with approximately one in six (14%) stating that the local services in general were already under pressure and that the proposed changes would make things worse. A small proportion (7%) of those who disagreed with the proposal were worried that pressure on the ambulance service would increase if the UCC were to close overnight.

Residents’ focus groups

1.28 While the balance of opinion among focus group attendees was that the proposed changes to opening hours at the UCC are necessary, if not ideal, the participants were asked to share their concerns and given the opportunity to address those to the representative of the CCG who was present.

1.29 Concerns raised at the focus groups were, by and large, similar to those emerging from the open engagement questionnaire. Considerable time was to given discussion around the issue of transport and travel to Lister Hospital (generally viewed, at least at first, as the likely alternative to the UCC overnight). Waiting times and overcrowding at the A&E in Stevenage were also major points of discussion. There was, however, general agreement that the low number of overnight users at the UCC did justify the proposed changes, provided that additional staff were definitely going to be made available at Lister Hospital’s A&E department.

1.30 While attendees had a broad understanding of the different Extended Access GP services in Welwyn Hatfield, and were aware of the NHS 111 service, it was notable that being able to ask questions about access to out-of-hours GPs, both at the New QEII Hospital and through home visits, as well as telephone consultations with nurses and doctors, did lead to increased understanding among participants about the extent and variety of alternative services available. This was another factor which influenced the attendees’ overall tendency to agree with the proposed overnight closure.

Written submissions

1.31 The letters received from stakeholders who disagreed with the proposal, namely the local MP, Rt. Hon Grant Shapps, Welwyn Hatfield Borough Council, Hatfield Town Council and North Mymms Parish Council,

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all raised general concerns about the impact of the overnight closure of the UCC on local residents, before going on the address specific issues, including: » The time required and distance to be travel to reach Lister Hospital in Stevenage, as well as the prospect of additional costs to patients which could lead to additional hardship; » Waiting times at the Lister Hospital A&E; » Concerns that the data presented by the CCG about overnight use of the UCC was incomplete and not up to date; and » Concern that the overnight closure of the UCC might lead to the service being: “further downgraded or cut entirely”.

Petition

1.32 The petition organised by Welwyn Hatfield Labour Party stated that the proposal to, “completely remove the overnight care that residents currently get”, would lead to lengthy and costly travel to Lister Hospital in Stevenage, echoing concerns raised in response to other elements of the engagement process. It should be noted, however, that the petition text does not make reference to the availability of out-of-hours appointments and the New QEII Hospital and other out-of-hours bases, and home visits, which will continue to be available if needed via the NHS 111 service.

Additional CCG-hosted or attended engagement activities

1.33 The concerns raised by members of the public and other individuals in discussions with CCG staff and meetings and information stands were broadly similar to those raised elsewhere. A strong theme from those who were intransigently opposed to the proposed changes was a desire to see emergency care being made available in Welwyn Hatfield. Others wanted to be able to access GP or consultant advice. Other common views related to travel, transport links, capacity and waiting time in relation to alternatives such as Lister Hospital.

Equalities impacts of the proposal

Open engagement questionnaire

1.34 All respondents to the open engagement questionnaire were given the opportunity to share their views about the potential for the proposed changes to impact, whether positively or negatively, any groups protected under the Equality Act 2010. Overall, half of respondents (50%) who answered the question said that they did believe that one or more of those groups would be affected. Most commonly, older people and those with disabilities were specifically mentioned, with about one in three respondents who expressed concern about equalities impacts (36% and 33% respectively) saying that either or both of those groups were likely to be negatively affected as a result of an overnight closure.

1.35 Other groups identified by smaller proportions of respondents included vulnerable people and those on low incomes, expectant mothers and children and parents. It should be noted, in this context, that children are not able to be treated overnight at the UCC under the current nurse-led service and have to access alternative services instead. Perhaps more related to the proposed changes themselves, a few respondents did relate concerns that parents who needed urgent care would find it more difficult to arrange for their children to be cared for if required to travel further.

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Residents’ focus groups

1.36 At the residents’ focus groups, the groups identified as being vulnerable to negative impacts as a result of the proposals were generally the same as in the questionnaire responses. There was considerable (and often positive) discussion around NHS 111 as a route to accessing out-of-hours care – including GP appointments. There was some concern, however, that older people would be less confident in using NHS 111; one attendee raised a specific concern that people for whom communicating in English was challenging might also be reluctant or unable to use the service and so would be particularly affect by the proposal.

1.37 In the context of using NHS 111 as an alternative route to receiving urgent or out-of-hours care, there was some agreement that the telephone (and online) services could benefit parents who currently travel to Stevenage or elsewhere if their children need to see a doctor overnight. The prospect of telephone consultations, home visits and appointments at the New QEII Hospital or other out-of-hours bases was viewed positively, and there was a general view that ensuring that the general public are fully aware of the breadth of services available via NHS 111 was vital if the proposed changes were to go ahead.

Written submissions

1.38 Submissions from stakeholders expressing concern about and opposition to the CCG’s proposal raised concerns about the impacts of the changes, should they take place, on groups such as older people and those with mental health needs. The response from Hatfield Town Council, in particular, raised concerns that the closure of the UCC overnight would mean the loss of a “safe space” where GPs and patients with mental health needs (and their families) can meet.

1.39 Hatfield Town Council, Welwyn Hatfield Borough Council and the local MP all called on the CCG to ensure that sufficient time and effort was given to fully assess the potential impacts on groups with protected characteristics in under the Equality Act 2010.

1.40 The Health Scrutiny Committee of Hertfordshire County Council, however, specifically noted, “the CCG’s commitment to seeking a wide range of views, with the aim of ensuring that the engagement process is as demographically representative of local communities as possible.”

Additional CCG-hosted or attended engagement activities

1.41 For those people who engaged with CCG staff in other ways – at meetings, events and information stands, or online – a similar range of concerns about vulnerable groups was expressed. At two public meetings in July and August, during which members of the public had the opportunity to ask members of the CCG’s governing body about the proposal, questions included specific mentions of children, patients with mental health needs and those without access to their own transport were mentioned.

Additional comments and alternatives

Open engagement questionnaire

1.42 While all respondents to the open engagement questionnaire were asked to add other comments and/or suggest alternative solutions which the CCG could consider in relation to the challenges facing the UCC, fewer than two fifths (39%) did so. Many comments from those opposed to the proposal tended to reiterate the concerns related elsewhere (e.g. travel and access to other services). There were, however, a

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few respondents who suggested that the service should be better advertised (3%), and that the public should be better informed about which NHS service would best meet their needs (2%).

1.43 Just under one in six (15%) of respondents focused on staffing of the UCC, and the NHS in general, as an issue which needs to be addressed. Some respondents focused on the need to increase the effort to find suitable people through, for example, better advertising (5%) whereas others suggested offering higher salaries or additional benefits to clinical staff (5%).

Residents focus groups

1.44 It was in the deliberative discussions of the focus groups that it was most possible to explore different perspectives on the challenges facing the UCC, including the alternatives available to patients, should the proposed changes go ahead. The types of topics that were discussed included: » The urgent need to raise public awareness of the NHS 111 service, in particular in regard to the availability of home visits and out-of-hours GP appointments at the New QEII Hospital for those who need it; » The need to address confusion about the specific services available at different locations overnight, with some attendees accepting, albeit reluctantly, that closing the UCC overnight would solve this; » The need for a specific effort to ensure that hard-to-reach groups, as well as other residents, be informed as soon as possible if the CCG were to go ahead with the overnight closure; » Whether opening slightly earlier each morning would be possible, if the changes go ahead; and » If a concerted push to promote the current services might result in increased use, meaning that the service would be able to stay open.

1.45 Generally speaking, once attendees felt able to accept the need for change to happen, the discussion tended to focus on how the CCG and other public sector bodies (e.g. the Council, in relation to public transport) ought to act to minimise any potential negative impacts. This is not to say that there were not people who continued to oppose the proposed change, but rather that the perceived priority would be to ensure that residents would still be able to access care when needed, if the UCC closes overnight.

Written submissions

1.46 Suggestions for alternative or additional actions from stakeholders responding in writing were influenced strongly by their agreement or disagreement with the proposal itself. Those who opposed the change (the local MP, Welwyn Hatfield Borough Council and Hatfield Town Council in particular) requested a variety of different actions to be taken by the CCG, including: » Additional efforts to promote the overnight service at the UCC, and subsequent assessment of whether this would increase use to a level which made the service viable; » Reference to the most up-to-date and consistent data available about attendance at the UCC; » Additional equality impact assessment, particularly in regard to older patients, those with disabilities and residents with mental health needs; and

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» Research to find out if some patients currently attending Lister Hospital overnight could, in fact, be redirected to the UCC with the twin aims of increasing usage of the service at the New QEII Hospital, and relieving pressure on the A&E in Stevenage.

1.47 In contrast, those stakeholders who agreed with the need for the UCC to close overnight to enable other services (the A&E at Lister Hospital and the daytime UCC service) to receive additional staffing resources, highlighted their readiness to assist the CCG in ensuring that members of the public were as well informed as possible of both the changes (should they go ahead) and the alternative services available.

Additional CCG-hosted or attended engagement activities

1.48 The additional comments and alternatives raised by members of the public via the various additional engagement activities undertaken by the CCG tended to match those raised elsewhere; these ranged from recruiting more staff (including doctors) to the UCC in order to encourage more people to attend and promoting the current service, to extending the proposed opening hours so that the UCC would be open earlier and/or later, and using the UCC to ease pressure at the Lister Hospital A&E department.

1.49 The major difference to the majority of the questionnaire respondents, and more in line with the focus groups, was a general acceptance of the need for change and that the CCG’s proposal was acceptable, if not desirable. It should be noted that this was even the case when CCG staff spoke to patients and staff attending the New QEII Hospital itself, and at many of the other activities taking place in Welwyn Garden City and Hatfield.

Final considerations

1.50 On emotive issues around any changes to hospital services, it is almost inevitable that people who choose to make the effort to complete the engagement questionnaire are more likely to be those with particularly strong feelings (while those who are less concerned about the changes are much less likely to give their views). Participants at the focus groups with a randomly selected cross-section of the general public (and to some extent participants at the various events and meetings convened by the CCG) had the opportunity to spend a significant amount of time hearing about the background to the current situation, the aims and the rationale for the CCG’s proposal, asking questions to clarify various details, and were ultimately more accepting of the possible change to opening hours and alternative options for obtaining our of hours care.

1.51 If a decision is eventually taken to alter the overnight opening hours at the UCC, the insights gained at the focus groups strongly suggests that greater publicity targeted at Welwyn Hatfield residents to raise awareness of the alternative out-of-hours services that are already available (e.g. NHS 111 etc.) could be beneficial.

1.52 Across all engagement activities, it is not solely the numbers agreeing or disagreeing with any proposal that is critical; it is of arguably greater importance for decision-makers to carefully consider the reasons, concerns and any fundamental evidence or arguments put forward in support of or opposition to the proposed changes. The concerns raised around travel and access to care are expected in any health engagement related to local services and should not be disregarded, and any possible mitigations should be considered.

1.53 It is worth noting, however, that some of the concerns raised about difficulties accessing overnight care for particular groups (e.g. older residents and those without vehicles) tended to be raised by respondents who were not themselves in those groups, but rather perceived a risk of negative impacts on others. While

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these concerns should in no way be dismissed, more than half of older questionnaire respondents (65+ years) agreed with the proposal, and CCG data shows that the majority of attendees at the UCC arrive by car, rather than other forms of transport. The CCG will therefore need to weigh up both public opinion and other evidence when making a decision.

1.54 Other key points that the CCG may need to consider could include: » An assessment of the most recent available overnight activity levels at the UCC – to determine whether increased awareness of the service during the engagement process led to increased attendances; » An understanding of what level of overnight attendances at the UCC would justify keeping it open overnight; » Assessment of presentations at Lister that could instead potentially seen at the UCC, and how many of those patients may or may not have actually chosen to go to the UCC instead.

1.55 In conclusion, ORS is clear that the CCG has carried out a conscientious programme of engagement that has achieved an understanding of the range of feedback from the public and other important stakeholders. It is for the CCG to make the final decision based upon all available information, of which the feedback from the public engagement is one part.

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2. Engagement overview Commission and methodology

The commission

2.1 In June 2019, NHS East and North Hertfordshire Clinical Commissioning Group (henceforth NHS East and North Hertfordshire CCG or ‘the CCG’) proposed changes to the opening hours of the Urgent Care Centre (UCC) at the New QEII Hospital in Welwyn Garden City, and to the staffing of the UCC and Lister Hospital.

2.2 The proposed changes are: to close the Urgent Care Centre at 10pm every night, re-opening at 8am each morning; to reassign nursing staff to work at the area’s Accident and Emergency service at the Lister Hospital; and to introduce new ‘advanced nurse practitioners’ to join the team at the New QEII UCC.

2.3 Opinion Research Services (ORS) is a spin-out company from Swansea University with a UK-wide reputation for social research and major statutory engagements. ORS was appointed to advise on and independently manage and report important aspects of the engagement programme.

The engagement process

2.4 The engagement period was launched on 13th June 2019 and ended on 4th September 2019. During this period, residents and other stakeholders were invited to provide feedback through a wide range of methods, including all of the following as reported here: » An open engagement questionnaire for all residents, stakeholders and organisations: the questionnaire was available online and paper questionnaires were widely circulated and available on request. An easy read version was also available; » Two deliberative focus groups with members of the public: both held at the NHS East & North Hertfordshire CCG’s office at Charter House, Welwyn Garden City; » Written submissions: residents, stakeholders and organisations were able to provide their views by writing to NHS East and North Hertfordshire CCG or ORS; and » A petition organised by the Welwyn Hatfield Labour Party.

2.5 The engagement programme as reported here by ORS received the following levels of response:

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Open Additional Deliberative Written engagement Petitions engagement focus groups submissions questionnaires activities 17 drop-ins and stands Representative 963 valid sample of east 3 public 1 petition with meetings responses and north 12 approximately (inc. 5 from Hertfordshire responses 2,800 1 AGM named residents signatures 3,732 organisations) 20 participants engagements via social media

2.6 It should also be noted that many meetings and events across east and north Hertfordshire’s geography and beyond (Figure 1), were either organised and hosted or attended by the CCG during the engagement period, in order to provide people with information about the proposed changes to the New QEII UCC overnight opening hours and to give members of the public the opportunity to take part in the engagement. These included: 17 drop-in events and “engagement pop-ups” in local hospitals, community venues and supermarkets; 3 public meetings; and the East and North Hertfordshire NHS Trust Annual General Meeting. Representatives of the CCG also attended meetings with key stakeholders including the local MP, political parties and local councillors.

Social media 2.7 The CCG made a considerable effort to engage with members of the public via social media channels, promoting the engagement as a whole, the open questionnaire, public meetings and events and, where possible, responding to specific questions and concerns. Analytics showed that online advertisement by the CCG encouraging the public to share their views on the proposal reached over 40,000 social media users, and those posts were engaged with over 3,700 times in different ways including “likes” and shares, as well as individual comments.

2.8 When social media users shared their views, it was clear that the topic of the UCC in particular, and NHS services in general, was emotive and engendered passionate debate and the sharing of strongly held views, not all of which were directly related to the proposal. When views were related to the proposal, the CCG made an effort to engage with those making comments, addressing concerns and providing additional information if needed, and always encouraging people to make use of the formal engagement questionnaire to have their say.

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Figure 1: Map showing the locations of the engagement events and meetings hosted or attended by the CCG

2.9 The main focus of the CCG-hosted engagement activities was not to gather views but to provide information and the opportunity for members of the public to ask questions. However, some feedback was provided, including observations, questions and reflections from both local people and staff. It is recognised that these are subjective and so have not been reported in the main body of this report, but they will be included as an appendix to the main report to provide a snapshot of some of the issues that were raised consistently.

Proportional and fair 2.10 The key good practice requirements for engagement programmes are that they should: » Be conducted at a formative stage, before decisions are taken; » Allow sufficient time for people to participate and respond; » Provide the public and stakeholders with enough background information to allow them to consider the issues and any proposals intelligently and critically; and » Be properly taken into consideration before decisions are finally taken.

2.11 As a well-established and specialist social research practice with wide-ranging experience of controversial public engagements and statutory consultations across the UK, ORS can confirm that the process undertaken by NHS East and North Hertfordshire CCG meets these standards. Overall, ORS has no doubt that the engagement programme has been conscientious, competent and comprehensive in eliciting the opinions of stakeholders and many members of the public. It was open, accessible and fair to all people and organisations across east and north Hertfordshire; and it conforms with ‘best practice’ in both its scale and the balance of elements and methods used. The engagement was also proportional to the importance of the issues.

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Nature of public engagement

Accountability 2.12 Accountability means that public authorities should give an account of their plans and take into account public views: they should conduct fair and accessible deliberative engagement while reporting the outcomes openly and considering them fully. This does not mean that the majority views should automatically decide public policy; and the popularity or unpopularity of proposals should not displace professional and political judgement about what is the right or best decision in the circumstances. The levels of, and reasons for, public support or opposition are very important, but as considerations to be taken into account, rather than as factors that necessarily determine authorities’ decisions.

2.13 Above all, public bodies have to consider the relevance and cogency of the arguments put forward during public engagements, not just count heads. In this context, it was helpful that the engagement included both ‘open’ and deliberative elements; many people could take part via the open questionnaire, while informed engagement and discussion was possible in the deliberative focus groups.

Interpreting the outcomes 2.14 Importantly, the various elements of the engagement and the responses forthcoming cannot just be combined to yield a single point of view. The methods differ and their outcomes cannot be aggregated into a single result. Furthermore, respondents from different geographic areas and sub-groups will inevitably have different perspectives on the proposal; there is no formula in the engagement process that can reconcile everyone’s differences and points to a way forward which is acceptable to all stakeholders.

2.15 It is also important to recognise that the outcomes of the engagement process will need to be considered alongside other information available about the likely impact of the CCG’s proposal. Whilst the process highlights aspects of this information that stakeholders consider to be important, appropriate emphasis should be placed on each element. In this sense there can be no single ‘correct’ interpretation of all the engagement elements and other information in the decision-making process.

The report 2.16 This report summarises the feedback on NHS East and North Hertfordshire CCG’s proposal. In addition to data and analysis, verbatim quotations are used (in indented italics), not because ORS agrees or disagrees with them, but for their vividness in capturing recurrent points of view. We do not endorse opinions but seek only to portray them accurately and clearly. Our role is to analyse and explain the opinions and arguments of the many different interests participating in the engagement, but not to ‘make a case’ for a particular course of action, or any recommendations as to how NHS East and North Hertfordshire CCG should make use of the reported results.

2.17 Finally, it should be noted at this stage that reports such as this may appear more ‘critical’ than really is the case for two reasons: critics are often more motivated to respond to an engagement; and ORS has an obligation to report criticisms in order for the CCG to carefully consider the issues. This does not mean that its decisions should be determined only by engagement. Indeed, whilst this report brings together a wide range of feedback and views for consideration, it is for NHS East and North Hertfordshire CCG to take decisions based on all the evidence available.

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The proposal

2.18 The proposals put forward by NHS East and North Hertfordshire CCG were as follows: » To close the UCC overnight between the hours of 10pm and 8am; » To reassign nursing staff, currently working at the UCC overnight, to the Accident & Emergency Department at Lister Hospital in Stevenage; and » To introduce Advanced Nurse Practitioners at the New QEII UCC during the new opening hours of 8am until 10pm.

The evidence, rationale and principles and aims 2.19 To provide information to the public and stakeholders, the CCG created an engagement document, available online at https://qeiiucc.enhertsccg.nhs.uk/ and in print (including an easy read version) to accompany the engagement questionnaire.

2.20 The engagement document provided information about: » The current services provided at the UCC; » Key statistics about the way the services are currently used by patients; » The challenges facing the CCG with regards to staffing the UCC overnight; » National changes to urgent care services in England and Wales; » The principles and aims of the CCG in relation to urgent care and emergency services in east and north Hertfordshire; and » The proposed changes and outcomes.

2.21 The engagement document also provided details of the alternative services available to patients, including extended access GP appointments provided by local surgeries, and out-of-hours GP appointments via NHS 111.

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3. Open engagement questionnaire

The open engagement questionnaire

3.1 An engagement document outlining the issues under consideration was produced by NHS East and North Hertfordshire CCG. Based on this document, ORS (in conjunction with the CCG) designed a corresponding engagement questionnaire which included questions intended to examine the case for change to the opening hours of the UCC at the New QEII Hospital, public perceptions of the challenges facing the CCG in relation to the UCC, the principles underlying the proposal, and the proposal itself. Additional sections allowed respondents to add any further comments or make alternative suggestions to the proposals, and captured information about the type of response being submitted and respondent demographics.

3.2 The questionnaire included abbreviated information from the CCG’s engagement document, with a link provided to the main document which was published online by the CCG at https://qeiiucc.enhertsccg.nhs.uk and was available throughout and beyond the entire engagement period, commencing on 13th June 2019.

3.3 The open questionnaire was available online, hosted by ORS, for 12 weeks until 4th September 2019. The links to both the engagement document and questionnaire were well advertised on the CCG and the New QEII Hospital websites, social and print media, through public engagement activities run by the CCG, at GP surgeries and at the New QEII Hospital and other medical centres in the area. Paper versions were also made available across east and north Hertfordshire for those who were unable to fill in the questionnaire online and were available by post on request. An “easy read” version of the engagement document was also available.

3.4 The open questionnaire could be completed by individuals and on behalf of organisations. In total, 979 responses were received to the open questionnaire, including 115 from NHS staff, 858 from other individuals and 6 responses from organisations. One of the latter, however, did not provide a name for the organisation and so has been treated as an individual response, bringing the totals to 115, 859 and 5 respectively.

Duplicate and co-ordinated responses

3.5 It is important that engagement questionnaires are open and accessible to all, while being alert to the possibility of multiple completions (by the same people) distorting the analysis. Therefore, while making it easy to complete the survey online, ORS monitors the IP addresses through which surveys are completed. On this occasion, the monitoring showed that only a handful of responses came from identical IP addresses.

3.6 A similar analysis of “cookies” was also undertaken to identify where responses originated from the same computer using the same browser and the same credentials (e.g. user account). Duplicate cookies can occur when two or more respondents have used the same device to complete their questionnaires (in which case all responses are included in the data). However, it can also occur when a user has part- completed the questionnaire and then returned later, starting again from the beginning and completing it in full.

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3.7 After careful analysis of the dataset, only 16 responses were excluded on the latter basis and the final number of responses used in the analysis reported below is 963, comprising 958 individual respondents and 5 from organisations. Due to the low number of organisational responses (less than 0.7% of the total number) they have been included in with the individual responses during reporting, unless otherwise stated.

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Respondent profile

3.8 Table 1 provides a breakdown of the respondent profile from the open engagement questionnaire, both online and on paper. Figures for east and north Hertfordshire’s population, provided for comparison, are based on Office for National Statistics (ONS) 2017 population estimates (for age and gender) and Census 2011 data (for ethnicity and disability). ORS prefers to report ONS population estimates (over Census 2011 data) where possible as we believe this more accurately reflects the current state of the population. Where this is not possible due to data being unavailable (e.g. for ethnicity and disability data), Census 2011 data has been used instead. As a result, the total number of occurrences in the population across the two data sources will not match exactly.

Table 1: Socio-demographic characteristics of respondents to the open engagement questionnaire, and the east and north Hertfordshire population (Note: Percentages may not sum due to rounding)

E&N Herts population estimate, All responses aged 16+ years1 (2017) Characteristic Number of % of Valid Number of % of Responses Responses occurrences population Under 25 33 4% 63,348 13% 25 to 34 88 11% 75,861 16% 35 to 44 158 20% 79,182 17% 45 to 54 143 19% 85,851 18% BY AGE 55 to 64 147 19% 67,209 14% 65 or over 202 26% 100,341 21% Total valid responses 771 100% 471,792 100% Not known 192 - - - Male 232 30% 228,891 49% BY Female 541 70% 242,901 51% GENDER Total valid responses 773 100% 471,792 100% Not known 190 - - -

All responses E&N Herts population (2011) Characteristic Number of % of Valid Number of % of Responses Responses occurrences population White 676 92% 496,275 90% Mixed or multiple ethnic groups 8 1% 12,793 2% Asian or Asian British 29 4% 25,244 5% BY ETHNIC Black, African, Caribbean or 13 2% 15,257 3% GROUP Black British Any other ethnic group 6 1% 3,333 1% Total valid responses 732 100% 552,902 100% Not known 231 - - - Have disability 112 15% 80,624 15% BY No disability 638 85% 472,279 85% DISABILITY Total valid responses 750 100% 552,902 100% Not known 213 - - -

1 Open engagement questionnaire responses from those aged under 16 years tend to be very low, despite accounting for c.19% of the population of the UK (ONS, 2017). When comparing the demographic profile of respondents to the general population of the area, under-16s are not included in the latter.

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Table 1 continued…

All Responses Characteristic Number of % of Valid Responses Responses With children aged under 18 267 35% BY Without children aged under 18 497 65% DEPENDENT CHILDREN Total valid responses 764 100% Not known 199 - Performs a caring role 309 41% Not a carer 453 59% BY CARER Total valid responses 762 100% Not known 201 - Currently pregnant or providing maternity care 33 4% BY Not pregnant or providing maternity care 725 96% MATERNITY CARE Total valid responses 758 100% Not known 205 - NHS employee 115 15% BY NHS Not an NHS employee 657 85% EMPLOYEE Total valid responses 772 100% Not known 191 -

Geographical spread of respondents

3.9 Table 2 provides a breakdown of the respondents by area of residence using data taken from the open engagement questionnaire, both online and on paper. Figures for the entire east and north Hertfordshire population are also included for comparison. Respondents could choose to not provide a postcode when completing the questionnaire, and those who did not do so are not included.

3.10 Of those respondents who did provide a postcode, two thirds (66%) live in Welwyn Hatfield. The second largest group of respondents, approximately one in six (15%) of those who provided a postcode, were residents of the East Hertfordshire District Council area.

Table 2: Geographical spread of respondents to the open engagement questionnaire, and the east and north Hertfordshire population (Note: Percentages may not sum due to rounding)

E&N Herts population estimate All responses aged 16+ years (ONS, 2017) District or borough Number of % of Valid Number of % of Responses Responses occurrences population Broxbourne 14 2% 77,234 16% East Hertfordshire 110 15% 118,093 25% North Hertfordshire 47 7% 107,123 23% Stevenage 21 3% 69,674 15% Welwyn Hatfield 478 66% 99,668 21% Central Bedfordshire 6 1% - - Harlow 1 * - - St Albans 29 4% - - Other 14 2% - - Total valid responses 720 100% 471,792 100% Not Known 243 - - -

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Demographic differences between postal and online questionnaire respondents

3.11 There are several key demographic groups which are represented by significantly different proportions of postal versus online respondents (Figure 2). For example, whereas just over a quarter (26%) of all questionnaire responses come from people aged 65 years and over, that proportion rises to more than half (52%) of postal responses. Likewise, and possibly linked to age, postal respondents are significantly less likely to have dependent children than respondents who completed the questionnaire online.

3.12 It is reasonable to suggest that postal questionnaire responses are more geographically diverse than online responses, with nearly three quarters of the online responses (73%) being completed by Welwyn Hatfield residents compared to fewer than half (45%) of the postal questionnaires.

Figure 2: Demographic differences in type of questionnaire response. (Number of respondents in each group in brackets)

Responses from organisations

3.13 Respondents had the option of responding as an individual or on behalf of an organisation. If responding on behalf of an organisation, they were asked to provide the name of the organisation and any specific group or department; they were also asked to provide information about who the organisation represents, what area it covers and how the views of members were gathered. Overall, six respondents said that they were responding on behalf of organisations.

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3.14 Respondents acting on behalf of organisations were informed that, “Where feedback is from representatives of organisations or someone acting in an official capacity, it may be attributed to them”.

3.15 The organisations who responded to the engagement questionnaire are shown in Table 3 below. All responses from organisations were completed online; unfortunately, none of them provided information regarding how the views were gathered so it is difficult to ascertain the extent to which the opinions shared are representative of members of the organisation as a whole, or simply those of the respondent.

Table 3: Organisational responses to the open engagement questionnaire.

Organisation Department/group Additional information Hertfordshire County Council Written submission also received Hertfordshire County Council Older People’s Team Hatfield Town Council Written submission also received Welwyn Hatfield Borough Council Written submission also received Welwyn Hatfield Labour Party Petition submitted

3.16 The level of response from organisations is somewhat disappointing, particularly in light of the effort made by the CCG to promote the engagement questionnaire as widely as possible. However, with the exception of the Welwyn Hatfield Labour Party, all of the organisations above also submitted written responses which are included separately elsewhere in this report.

3.17 Welwyn Hatfield Labour Party did not submit a written response to the CCG’s proposal; it did, however, organise its own petition, also covered later in this report.

Interpretation of the data

3.18 The results for the open engagement questionnaire are presented in a largely graphical format. The bar charts and other graphics show the proportions (percentages) of respondents making responses, unless otherwise stated.

3.19 Where possible, the colours of the charts have been standardised with a ‘traffic light’ system in which green shades represent positive responses, red shades represent negative responses, and beige shades represent neither positive nor negative responses. The bolder shades are used to highlight responses at the ‘extremes’, for example, strongly agree or strongly disagree.

3.20 Where percentages do not sum to 100%, this may be due to rounding, the exclusion of “don’t know” categories, or multiple answers. Throughout the report, an asterisk (*) denotes any value less than half of one per cent.

3.21 Individual percentages, such as those for ‘strongly agree/disagree’ or ‘tend to agree/disagree’, and grouped percentages showing overall levels of agreement and disagreement are presented here rounded to the nearest whole number. Because of this, the sum of the rounded individual percentages may not equal the percentage shown for overall agreement and disagreement.

3.22 All open-ended responses have been read, and then classified (coded) using a standardised approach (code frame). This approach helps ensure consistency when classifying different comments and the resulting codes represent themes that have been repeatedly mentioned in a more quantifiable manner. The various comments provided by a respondent to any single text question may present a number of different points or arguments, therefore in many cases the overall number of coded comments counted in a particular question may be higher than the number of people who responded to that open-ended question.

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Further analysis by sub-group

3.23 For some questions, further analysis revealed differences in responses by key demographic and other variables e.g. respondents’ use of the UCC overnight, or nearest out-of-hours (OOH) base. Such analysis highlights how sub-groups within key variables (e.g. within ‘age’, those aged 45-54) provided different levels of agreement or disagreement compared to the overall average.

3.24 Where results are particularly higher or particularly lower for certain sub-groups in comparison to the overall score, they are further discussed in the report text. This will also be the case where there is a significant difference in respondents’ views between postal and online responses.

Findings from the open engagement questionnaire

Respondents’ use of UCC services in 2018-19

The Urgent Care Centre for minor injuries and illness at the New QEII Hospital in Welwyn Garden City opened in May 2015.

In the last 12 months, when have you used this service, if at all...?

During the daytime (Between 8am and 10pm)?

Overnight (Between 10pm and 8am)?

3.25 Respondents were asked to say whether or not they had used the UCC service in the previous 12 months.

3.26 More than half (51%) of questionnaire responses were completed by people who reported using the UCC service during the day for a family member or someone that they look after (Figure 3) and over two fifths (42%) had used the service themselves by day.

Figure 3: Open engagement questionnaire respondents by daytime (8am to 10pm) UCC service use. Additional breakdown by area of residence. (Number of respondents in brackets)

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3.27 When completing the questionnaire, respondents were given the option of entering their postcode. This enables analysis of the differences between respondents from different geographic areas. As this was optional, not all respondents chose to do so, and the numbers of respondents in each group reflect this. The data reveals that respondents from Welwyn Hatfield were more likely to have used the UCC in the daytime than those living elsewhere.

3.28 In respect to use of the UCC overnight, more than half (54%) of all respondents reported never using the UCC at the New QEII hospital between 10pm - 8am, with around one third (35%) using the service overnight for a family member or person that they care for, and approximately one fifth (21%) of respondents using the UCC themselves overnight (Figure 4: Open engagement questionnaire respondents by overnight (10pm to 8am) UCC service use. Additional breakdown by area of residence. (Number of respondents in brackets).

Figure 4: Open engagement questionnaire respondents by overnight (10pm to 8am) UCC service use. Additional breakdown by area of residence. (Number of respondents in brackets)

3.29 Again, the percentages are significantly different for residents of Welwyn Hatfield compared to those living elsewhere. Nearly a quarter (24%) of Welwyn Hatfield residents who responded reported using the UCC themselves overnight, and two fifths (40%) had used it for a family member or someone that they care for. Respondents residing elsewhere in Hertfordshire, however, were much less likely to have used the service overnight, with three quarters (75%) reporting that they had not done so.

3.30 These differences in service use are particularly relevant when considering the outcomes of the questionnaire; as is frequently the case with open engagement questionnaires, it is those people who are likely to feel most affected by the proposal who tend to respond. This does not serve to give less or extra significance to the outcomes but should simply be born in mind when interpreting the results and drawing conclusions to inform the decision-making process.

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The challenges facing the Urgent Care Centre at the New QEII Hospital

NHS East and North Hertfordshire CCG is concerned about several challenges related to keeping the Urgent Care Centre (UCC) for minor injuries and illness at the New QEII Hospital open all the time. These challenges are:

 There is a national shortage of doctors and nurses that affects NHS services across the whole area. This has an impact on the care that East and North Hertfordshire NHS Trust, the organisation which runs the Lister Hospital in Stevenage and the UCC in Welwyn Garden City, can deliver.

 Because of recruitment difficulties, there is no GP at the Urgent Care Centre after midnight so patients who need to see a doctor are referred elsewhere.

 The local Accident and Emergency service at the Lister Hospital treats more serious cases but is already understaffed and facing significant ongoing staffing challenges.

 Even though less than one person an hour uses the Urgent Care Centre between 10pm and 6am, two highly trained clinical staff must be on duty at all times.

 From 11pm onwards, patients cannot be X-rayed at the Urgent Care Centre.

 Between midnight and 8am, children cannot be treated at the Urgent Care Centre.

To what extent do you agree or disagree that NHS East and North Hertfordshire CCG needs to make changes to respond to these challenges?

3.31 Respondents were initially directed to read the engagement document or alternatively to go to https://qeiiucc.enhertsccg.nhs.uk/ for more information.

3.32 The questionnaire was designed to help find out about the respondents’ views regarding the background and rationale for the proposed changes, as well as the proposal itself. It first sought to establish the extent of support or opposition for the principle of the CCG taking action to address the challenges facing the UCC at the New QEII Hospital.

Figure 5: Agreement and disagreement that NHS East and North Hertfordshire CCG needs to make changes in response to the challenges facing the UCC. (All respondents)

3.33 As noted above, when responses are grouped into “agree” and “disagree” categories, the percentage figure given for the grouped responses may not be equal to the sum of the component responses due to rounding. Therefore, in Figure 5 above, 30% of respondents Strongly agree with the statement, while 28% Tend to agree; however, the overall percentage of those who “agree” with the statement is 57% (Figure 5).

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3.34 The extent of respondents’ agreement that the CCG needs to make changes in response to the challenges facing the UCC differs significantly depending on where they live (Figure 6), from just over half of those who live in Welwyn Hatfield (53%) to three quarters of those residing elsewhere (75%).

Figure 6: Agreement and disagreement that NHS East and North Hertfordshire CCG needs to make changes in response to the challenges facing the UCC. Breakdown by location of residence. (Base number of respondents in brackets)

3.35 Respondents who had used the UCC during the day were less likely to agree that the CCG needed to make changes to address the challenges facing the service (Figure 7), with half (50%) of those who reporting using the UCC for both themselves and someone else disagreeing with the statement.

3.36 By contrast, more than three quarters (77%) of those respondents who had never used the UCC during the day agreed that changes need to be made by the CCG.

Figure 7: Agreement and disagreement that NHS East and North Hertfordshire CCG needs to make changes in response to the challenges facing the UCC. Breakdown by UCC use during the day. (Number of respondents in brackets)

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3.37 Respondents who reported having used the UCC overnight, whether for themselves or for family members of somebody they care for, did not agree with the need to make changes to the service (Figure 8), with more than two thirds (68%) of those who had used it for both themselves and others disagreeing.

Figure 8: Agreement and disagreement that NHS East and North Hertfordshire CCG needs to make changes in response to the challenges facing the UCC. Breakdown by UCC use overnight. (Number of respondents in brackets)

3.38 The majority of respondents (54%, Figure 4 above) said that they had not used the UCC at all between 10pm and 8am, and they were significantly more favourable to changes being made, with nearly three quarters (72%) agreeing that the CCG needed to act to address the challenges facing the UCC service at the New QEII Hospital.

3.39 In their comments, some respondents to the questionnaire said that they or their child had seen a doctor at the UCC overnight in the last 12 months, something which has not been possible due to the current challenges regarding staffing the service at night. One factor may be confusion regarding the overnight services available at the New QEII Hospital, which is also a base for out-of-hours (OOH) GP appointments accessed via NHS 111 (a service which will not be affected by this proposal).

3.40 Discussions taking place at the residents focus groups, facilitated by ORS, and conversation taking place at CCG-hosted public engagement events seem to corroborate the above; the outcomes of the deliberative research activities will be discussed in detail below.

3.41 Other differences in opinion between different groups regarding the question of whether or not the CCG needs to make changes to the UCC at the New QEII Hospital were evident. 45-54-year olds where less likely to agree with the need for change compared to other age groups, most notably the under 35s and over 65s (Figure 9).

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Figure 9: Agreement and disagreement that NHS East and North Hertfordshire CCG needs to make changes in response to the challenges facing the UCC. Breakdown by age of respondent. (Number of respondents in brackets)

3.42 Respondents living closer to other hospitals with A&E departments or Minor Injuries Units tended to be more positive about the need for change than those living closest to the New QEII Hospital. This was also the generally the case for respondents who lived closer to other out-of-hours bases (Figure 10) compared to those who lived closest to the New QEII Hospital.

Figure 10: Agreement and disagreement that NHS East and North Hertfordshire CCG needs to make changes in response to the challenges facing the UCC. Breakdown by location of closest OOH base. (Number of respondents in brackets)

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3.43 Understanding the views of different demographic groups in relation to proposed changes to health services is a key element of social research and public engagements. Upon completing the questionnaire, individual respondents were given the option of answering questions about their gender, health (disability) and ethnicity. They could also choose to say whether or not they were pregnant or caring for a new-born baby, had dependent children aged under 18 years, or performed a caring role for a family member or someone else. Finally, respondents were asked if they were employed by the NHS.

3.44 Among all demographic groups, there was overall agreement that the CCG needs to take action to address the challenges facing the UCC (Figure 11). Some groups such as, for example, people with disabilities, who perform a caring role, have dependent children, or who are pregnant or providing maternity care, agreed less strongly than other respondents.

3.45 By contrast, NHS employees were more likely to agree strongly that the CCG should make changes (41%) than non-NHS employees (29% strongly agreed).

Figure 11: Demographic differences in agreement and disagreement that NHS East and North Hertfordshire CCG needs to make changes in response to the challenges facing the UCC. (Number of respondents in brackets)

3.46 There was a significant difference in the degree of agreement with the need for change between respondents who completed the questionnaire online with those who completed postal questionnaires (Figure 12), with more than three quarters (78%) of postal respondents agreeing that the CCG needs to act compared with just over half (52%) of online respondents.

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Figure 12: Agreement and disagreement that NHS East and North Hertfordshire CCG needs to make changes to respond to these challenges. Breakdown by questionnaire type. (Number of respondents in brackets)

3.47 As would be expected, those respondents who were opposed to the CCG’s proposal to close the Urgent Care Centre at the New QEII Hospital between 10pm and 8am were least likely to agree with the need for changes to be made at all (Figure 13). This was most marked among those who strongly disagreed with the proposal, more than half of whom (51%) also strongly disagreed that the CCG needed to make any changes to address the challenges at the UCC.

Figure 13: Agreement and disagreement that the CCG needs to make changes to respond to these challenges. Breakdown by view on the CCG’s proposal to close the UCC overnight. (Number of respondents in brackets)

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Aims and principles regarding urgent care provision in the NHS East and North Hertfordshire CCG area

The CCG is considering making changes to the opening hours of the Urgent Care Centre at the New QEII Hospital to address the challenges facing the UCC.

In considering the proposed changes, the CCG will bear in mind these aims and principles:

 Urgent care and emergency health services should be high quality and reliable.

 Advice should be readily available and health services should be easy to use and understand.

 We should make the best use of clinically trained staff to treat as many patients as possible.

 Highly skilled staff should be available to care for patients who are very ill and facing life- threatening emergencies.

 A consistent range of services should be provided whenever the UCC is open to reduce confusion.

 The UCC should be open in excess of the government’s 12-hour minimum guidelines.

 The UCC should be open during the early evening when it is well used by patients.

To what extent do you agree or disagree that the principles identified by the CCG are appropriate?

3.48 The questionnaire next sought to establish the extent of agreement or disagreement that the principles and aims the CCG will bear in mind, when considering the proposed changes at the UCC, are appropriate.

3.49 Overall, respondents were supportive of these aims and principles, with more than two thirds (69%) agreeing that they were appropriate.

Figure 14: Agreement and disagreement that the principles and aims that the CCG will bear in mind, when considering the proposal, are appropriate. (All respondents)

3.50 As with the need for change, the extent of respondents’ agreement with the principles and aims outlined in the engagement document differed significantly depending on the area in which they live (Figure 15), with just less than two thirds (65%) of respondents from Welwyn Hatfield in agreement, compared to more than four fifths (83%) of those living elsewhere.

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Figure 15: Agreement and disagreement that the principles and aims that the CCG will bear in mind, when considering the proposal, are appropriate. Breakdown by location of residence. (Base number of respondents in brackets)

3.51 Although to a lesser extent than with the questions related to the need for changes to be made by the CCG, UCC users were also less likely to agree with the principles and aims that the CCG will bear in mind, when considering the proposal, than non-service users (Figure 16).

Figure 16: Agreement and disagreement that the principles and aims that the CCG will bear in mind, when considering the proposal, are appropriate. Breakdown by UCC use during the day. (Number of respondents in brackets)

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3.52 The difference of opinion regarding the principles and aims of the CCG is more significant between those who have used the service overnight and those respondents who have not (Figure 17), with fewer than half (49%) of those who have used the service for both themselves and someone else agreeing that they are appropriate.

Figure 17: Agreement and disagreement that the principles and aims that the CCG will bear in mind, when considering the proposal, are appropriate. Breakdown by UCC use overnight. (Number of respondents in brackets)

3.53 Although there was some variation in the extent to which different demographic groups expressed agreement with the aims and principles set out by the CCG, opinion was favourable overall, with the majority of all demographic groups holding the view that they are appropriate.

3.54 As with the previous question, it was those who were opposed to overnight closure of the UCC who were least likely to agree with the principles and aims of the CCG in considering the proposal, with views among those who strongly disagree with the proposals evenly split in regard of the CCG’s principle and aims (46% agreed that they were appropriate, 46% disagreed).

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Proposed changes to UCC opening hours at the New QEII Hospital

To address the challenges identified and achieve its aims, the CCG is proposing to close the Urgent Care Centre between 10pm and 8am each night.

Under this proposed change:

 The UCC would be open from 8am until 10pm every day, treating people of any age.

 Patients arriving before 10pm would be seen and treated for up to two hours after closing time.

 Additional highly skilled medical staff would be made available when the UCC is open.

 Patients with minor injuries may have to travel further to receive medical treatment overnight.

 Urgent GP appointments would still be available out-of-hours in the local area for people who need them, through calling NHS 111.

 East and North Hertfordshire NHS Trust could relocate UCC staff to the Lister Hospital’s Accident and Emergency department in Stevenage overnight, where they could help more patients.

To what extent do you agree or disagree with the proposal to reduce the New QEII Urgent Care Centre’s opening hours so that it is only open between 8am – 10pm each day?

3.55 When asked to give their view on the proposed changes to opening hours at the UCC, a clear majority (58%) of respondents disagreed with them (Figure 18), with almost half (47%) strongly disagreeing with the proposal to close the UCC between 10pm and 8am each night.

Figure 18: Agreement and disagreement with the proposal to close the UCC at the New QEII Hospital between 10pm and 8am each night. (Number of respondents in brackets)

3.56 As previously, the views of respondents regarding the CCG’s proposal varied, often significantly, depending on factors such as area of residence, experience using the UCC, age etc.

3.57 The difference in views based on the area in which respondents lived was significant (Figure 19), with three fifths of those from Welwyn Hatfield strongly disagreeing with the proposal (60%) and approximately one in ten (11%) tending to disagree. Just over one quarter (28%) of Welwyn Hatfield residents agreed with the proposed changes.

3.58 The views of respondents living outside of Welwyn Hatfield were very significantly different, however, with nearly two thirds (64%) expressing agreement compared to one third (33%) who disagreed with the proposal put forward by the CCG.

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Figure 19: Agreement and disagreement with the proposal to close the UCC at the New QEII Hospital between 10pm and 8am each night. Breakdown by location of residence. (Number of respondents in brackets)

3.59 These stark differences in opinion between different geographical areas are revealed in more detail when considering responses from east and north Hertfordshire residents from the five districts and boroughs that make up the area (Figure 20).

Figure 20: Agreement and disagreement with the proposal to close the UCC at the New QEII Hospital between 10pm and 8am each night. Breakdown by district/borough in east and north Hertfordshire. (Number of respondents in brackets)

3.60 As would be reasonably expected, those respondents who had used the UCC in the last 12 months, whether during the day or overnight, were in strong disagreement with the proposed changes.

3.61 Overall, more than two thirds (67%) of respondents who reported using the UCC during the day (either for themselves, or for a family member or somebody they care for, or both) disagreed with the proposed changes (Figure 21), compared to less than one third (29%) who agreed with the proposal. This was, again, in stark contrast to non-service users among the respondents, over two fifths of whom (62%) agreed with the proposed changes.

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Figure 21: Agreement and disagreement with the proposal to close the UCC at the New QEII Hospital between 10pm and 8am each night. Breakdown by UCC use during the day. (Number of respondents in brackets)

3.62 Respondents who had used the UCC overnight in the last 12 months were even more strongly opposed to the proposal (Figure 22), with more than four fifths (85%) disagreeing; the majority of non-service users, however, agreed with the proposed changes with almost three fifths (57%) either tending to agree or strongly agreeing.

3.63 Again, it was those respondents who reported using the UCC for themselves and others who disagreed most strongly, with two thirds (66%) of those who had done so during the day being strongly opposed to the changes, and four fifths (81%) of those who had done so night at night holding the same view.

Figure 22: Agreement and disagreement with the proposal to close the UCC at the New QEII Hospital between 10pm and 8am each night. Breakdown by UCC use overnight. (Number of respondents in brackets)

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3.64 As was discussed briefly above, some of those most strongly opposed to the proposed changes reported in their responses that they had seen a doctor at the UCC overnight, something which is at odds with the current staffing of the services, which is manned solely by nurses. This and other apparent discrepancies between CCG data and the views of respondents will be considered below.

3.65 Although the overall view of engagement questionnaire respondents was one of disagreement with the proposal, there were two important demographic groups which expressed agreement with the proposal. The first is, perhaps, somewhat surprising; the balance of opinion among respondents aged over 65 years was positive (Figure 23), with more than half (52%) agreeing with the proposed changes. Just over one third (34%) of the same age group strongly disagreed, compared to nearly half (47%) of all respondents.

Figure 23: Agreement and disagreement with the proposal to close the UCC at the New QEII Hospital between 10pm and 8am each night. Breakdown by age of respondent. (Number of respondents in brackets)

3.66 The second group of respondents to express approval for the CCG’s proposal was NHS employees (Figure 24), with more than half (54%) agreeing with a reduction in overnight opening hours, and more than a third (34%) saying that they strongly disagreed.

3.67 Across other demographic groups, there was some difference in strength of agreement and disagreement with the proposed changes (Figure 24), with the three groups who were most strongly opposed being those with responsibility for dependent children (54% strongly opposed), performing a caring role (55%), or pregnant or caring for a new-born (59%). Respondents who considered themselves to have a disability and those who described themselves as Asian or Black, or from minority ethnic groups, were also more likely to strongly disagree with the proposal.

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Figure 24: Demographic differences in agreement and disagreement with the proposal to close the UCC at the New QEII Hospital between 10pm and 8am each night. (Number of respondents in brackets)

3.68 Finally, as was the case with the previous questions, there was a clear difference between postal and online questionnaire responses (Figure 25), with nearly two thirds (65%) of postal respondents agreeing with the CCG’s proposal, compared to less than one third (31%) of those who completed the questionnaire online.

Figure 25: Agreement and disagreement with the proposal to close the UCC at the New QEII Hospital between 10pm and 8am each night. Breakdown by questionnaire type. (Number of respondents in brackets)

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Questionnaire responses from respondents representing organisations

3.69 Five questionnaire responses were received from named organisations and the results are presented in Table 4 below. Three organisations, Hertfordshire County Council, Hatfield Town Council and Welwyn Hatfield Borough Council also provided written submissions which are reported in a following chapter.

Table 4: Organisational responses to the open engagement questionnaire.

Organisation/department Summary of responses

The questionnaire response from Hertfordshire County Council was strongly Hertfordshire County Council supportive of proposal put forward by the CCG. The council also provided a detailed written submission. Hertfordshire County Council The response from the Older People’s Team was strongly supportive of the Older People’s Team proposal. The response from a representative of Hatfield Town Council disagreed with the proposal, and raised concerns about:  Oversubscribed GP practices in Hatfield which make it difficult for residents to see a doctor in the evening or at weekends;  The need for a local overnight service, rather than residents needing to travel to Stevenage (including concerns about travel and access for older people, those with disabilities, vulnerable and low-income families and individuals, and those without their own vehicles);  Mental health needs in the community – including suggesting that Hatfield Town Council the UCC be adapted to provide a “safe space” for patients and families facing crises; and  Confusion about the care available overnight, and the view that better publicity could lead to an increase in service use. The respondent went on to suggest other alternative solutions which they felt might both increase use of the service and attract more staff to work there:  That the UCC could be used as a training centre for nurses (linked to the University of Hertfordshire); and  Liaison between the CCG and HCT to use the UCC as a triage centre for mental health patients at night. The respondent from Welwyn Hatfield Borough Council disagreed with the proposal and highlighted several groups with protected characteristics under the Equalities Act 2010 which they felt would be negatively affected, particularly in the light of longer distances and greater expense for residents Welwyn Hatfield Borough Council who would need to travel to other locations. These groups were:  Older people and children, particularly those with low incomes;  People with disabilities or long-term or chronic illness; and  Pregnant mothers. The response from Welwyn Hatfield Labour Party, while agreeing that action is needed to address the challenges faced by the UCC, disagreed with the CCG’s proposal, stating that Welwyn Hatfield needs, “a fully functioning hospital, Welwyn Hatfield Labour Party including A&E”. It highlighted older people, children and people with mental health needs as being negatively affected by the proposed changes. The Welwyn Hatfield Labour Party did not submit a written response but did organise a petition of local residents which is reported in a following chapter).

Summary

3.70 The majority of respondents to the open engagement questionnaire agreed both with the need for changes to take place to address the challenges facing the UCC at the New QEII Hospital, and with the principles and aims the CCG will bear in mind when considering the proposal. The majority, however, disagreed with the proposed changes to opening hours at the Urgent Care Centre.

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3.71 There was considerable variation in the strength of agreement and disagreement with each of the questions between different groups of respondents, suggesting that there are a variety of factors informing respondents’ views. Some of these may be as simple as how often the respondent has used the UCC in the past, or how close they live to the New QEII Hospital or another urgent care, emergency or out-of-hours service.

3.72 It is likely, however, that there are more complex factors at play as well. It is therefore necessary to understand as much as possible about the specific concerns of those who disagree with the proposal. Equally, it is important to understand the views of those who hold a different opinion. This forms a vital part of any decision-making process because, as outlined in the introduction to this report, it is not only the opinions, but also the reasoning behind the opinions of the public, experts and stakeholders which needs to inform the final decision.

3.73 The remainder of this report, therefore, is dedicated to analysing and communicating the text comments, discussions, written submissions and other views of members of the public and other stakeholders who responded to or participated in this engagement process. This will provide an insight into the depth and breadth of opinion which will help the CCG to consider their course of action.

Residents’ views and concerns in relation to the CCG’s proposal

Overview of text comments

3.74 The engagement questionnaire gave respondents three opportunities to comment on the proposal in their own words, specifically:

If they disagreed with the proposals, asking them to explain why they disagree

If they believe that any particular groups under the Equalities Act 2010 will be positively or negatively affected by the proposed change, to explain which groups and why

If they had any other comments or alternative suggestions on how the CCG should address the challenges caused by staff shortages at the UCC

3.75 To analyse the text comments, responses were categorised in themes so that the proportion of respondents who expressed common views could be determined. This data is presented in full in Appendix I and summarised below. The data is presented graphically, with some accompanying explanation where appropriate, to highlight particularly cogent points made.

3.76 In order to present a comprehensive picture of the views of the public, all of the themes are included in this report. It should be noted, however, that some of the concerns expressed by respondents are only tangentially related to the proposal and in several cases related to issues outside of the remit of the CCG and/or the NHS (e.g. UK Government finding of health and transport services in general).

3.77 Other common concerns were around a perceived need for additional emergency care services at the New QEII Hospital, and disappointment and anger that there is not a full A&E in Welwyn Garden City. A significant number of comments therefore do not relate directly to the service provided by Urgent Care Centres in England and Wales generally, and specifically overnight at the UUC at the New QEII Hospital.

3.78 While comments and concerns which do not relate directly to the UCC and the CCG’s proposal to close the service between 10pm and 8am each night may not directly inform a decision-making process, it is nonetheless important to understand the background concerns of members of the public in relation to

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local NHS services in general. This background is also helpful in providing a context for the reporting of the engagement events hosted by the CCG and the focus groups run by ORS which are covered in later chapters.

3.79 Finally, many respondents related their concerns to specific personal circumstances. For obvious reasons, these cannot be reported in detail but where possible the comments have been related to the themes below and are therefore included in the reported figures. It is worth mentioning, however, that it is these personal stories that highlight that there exists some confusion and uncertainty in relation to the exact services currently available at the UCC overnight, with some individuals reporting being seen by and/or treated by doctors after midnight at the New QEII Hospital. It is possible that some of these accounts refer to incidents in the past, or to people seeing an out-of-hours GP at the hospital organised via NHS 111 or similar, but unless specifically stated it is not possible to be certain.

Respondents who disagreed with the proposal

If you disagree, please explain the reasons in the box below.

3.80 In total, 435 respondents (including two organisations: Welwyn Hatfield Labour Party and a representative of Hatfield Town Council) made comments to explain their reasons for disagreeing with the CCG’s proposal.

3.81 More than two thirds (69%) of respondents expressed general concerns about the proposals (Figure 26), ranging from generalised statements of disagreement with the proposed changes to the view that the UCC would be better used overnight if the service was better advertised.

Figure 26: The primary themes arising from comments made by open engagement questionnaire respondents who disagreed with the proposal. (Base: 435)

3.82 More than half (54%) of respondents highlighted concerns about travel and access to an alternative location, should the UCC close overnight, and just under half (46%) highlighted concerns about impacts on the quality and safety of urgent care that patients affected by the closure would receive, or commented on perceived shortcomings of alternative services.

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3.83 Other themes arising included suggestions for alternative solutions to the challenges facing the UCC (or amendments to the proposal which might lessen the impact), and comments related to staffing challenges facing the UCC and other local NHS services. A few respondents were critical of the engagement in general.

3.84 Some comments could not be easily themed. Where these are particularly relevant or insightful, they are reported separately at the end of this section.

General comments on the proposal

3.85 Almost one third of respondents (31%) expressed the general view that the proposals were not a good idea and a similar proportion (32%) specifically said that the services should be maintained and/or remain open for 24 hours each day (Figure 27). About one fifth (18%) felt that more emergency and urgent care cover was needed rather than less.

Figure 27: The most common concerns and comments made by open engagement questionnaire respondents who disagreed with the proposal. (Base: 435)

3.86 As mentioned above, there was considerable concern about the need for local access to emergency care. Just under a fifth (19%) of respondents were concerned that the proposal would be putting lives at risk in the case of, for example, serious accidents, heart attacks etc. Others in this group were less specific in their

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references to emergency and urgent care, but the general theme was that accidents and emergencies can happen at any time and that the Welwyn Hatfield community needs access to necessary services.

3.87 Just under one in six (16%) respondents commented on the need for adequate urgent care services in Welwyn Hatfield, and in many of these cases reference was made to the growing population of the area. A related theme - concern about the pressures on other services in east and north Hertfordshire, particularly Lister Hospital’s A&E department – is reported below.

3.88 Other general comments made included concerns that the use of the UCC overnight might increase if the service was better advertised, and that the low numbers of overnight urgent care service users was related directly to the reduction of services available since the New QEII Hospital opened.

Travel and access to alternative overnight services

3.89 As stated above, more than half of respondents who disagreed with the proposal put forward by the CCG were concerned about issues related to access to alternative overnight services in lieu of those currently available at the UCC (Figure 28).

Figure 28: The most common concerns and comments about travel and access from questionnaire respondents who disagreed with the proposal. (Base: 435)

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3.90 Nearly a third (30%) of respondents to the question specifically expressed concerns about having to travel to the Lister Hospital in Stevenage, seen by most as the first alternative, and about one in five (18%) shared more general concerns about the impact of loss of local services, such as increased travelling time to alternative services elsewhere.

3.91 One in ten respondents (11%) commented on the likelihood of increased costs related to travelling to and parking at the Lister Hospital and/or other locations; concern was also expressed about the impact on people without access to vehicles (14%) and the lack of public transport services (6%). Some specific groups were mentioned, including older and disabled people, and vulnerable groups or people and families with low incomes who might not be able to afford a car or the costs of travel.

3.92 Concerns about treatment for children as a result of the overnight closure of the UCC was raised in some cases, although children have not been able to be treated at the UCC for some time. It should be noted that a number of the comments focussed strongly on the lack of a full A&E in Welwyn Garden City and the need to travel elsewhere, rather than relating directly to the proposed overnight closure of the Urgent Care Centre which is the subject of this engagement programme.

Quality and safety impacts of the proposal

3.93 A large proportion of comments made by respondents who disagreed with the proposed changes to the UCC centred on concerns about the quality and safety of the alternatives. Almost a third (29%) of comments referred to the Lister Hospital, with concerns ranging from long waiting times and overcrowding at the Emergency Department, to reports of poor treatment outcomes.

Figure 29: The most common general comments made about quality and safety by questionnaire respondents who disagreed with the proposal. (Base 435)

3.94 Other respondents echoed the theme of overstretched services elsewhere in east and north Hertfordshire and the surrounding area, without mentioning Lister specifically, including increased pressure on the

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ambulance service if people unable to travel independently outside Welwyn Hatfield were calling 999 or NHS 111 instead.

3.95 Concerns about the quality of the NHS 111 service were raised by around one in twenty (6%) of respondents – this is worthy of mention as NHS 111 and other out-of-hours and urgent but non-emergency services were discussed in detail at the focus groups, reported below.

3.96 Some respondents objecting to the proposal referred to their own and others’ positive experiences of visiting the UCC when giving their reasons for objecting, although others felt that services at the New QEII Hospital are also overstretched and under pressure, like NHS services elsewhere.

Staffing at the Urgent Care Centre

3.97 Some respondents who disagreed with the proposal commented specifically on the challenges of staffing the UCC overnight (Figure 30). The majority of these comments were about the need for adequate or increased staff numbers, with a few recommending that the CCG and the NHS in general needed to work harder to recruit more staff.

Figure 30: The most common comments about staffing of the UCC and other health services by questionnaire respondents who disagreed with the proposal. (Base: 435)

Other reasons given for disagreeing with the proposal

3.98 A few respondents, around 3% of those who disagreed with the proposal (Appendix I), questioned the volume and quality of the data and information presented in the engagement document, with a very small number criticising the process itself.

Suggestions for alternatives to the proposal

3.99 A few respondents, around 4% of those who disagreed with the proposal (Appendix I), suggested that rather than closing the UCC, the service should in fact be upgraded to a full A&E department. A handful of people suggested that, rather than increasing pressure on Lister Hospital by closing the UCC, patients visiting the A&E in Stevenage should instead be redirected to the New QEII Hospital to ease waiting times and increase use of the UCC.

3.100 Some respondents, while tending to disagree with the proposal, did suggest that shutting it for a shorter period overnight might be more acceptable. Approximately 3% said that the proposal should be changed so

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that the UCC would open at 7am instead of 8am, and a similar proportion suggested closing at 12am each night instead of 10pm. Other opening and closing times were also mentioned.

Equalities impacts

Are there any groups protected under the Equality Act 2010 which you believe will be positively or negatively affected by the proposed changes? If so, what could be done to enhance the positive impacts or reduce any negative impacts?

3.101 Respondents to the questionnaire were asked which, if any, groups protected under the Equalities Act 2010 might be particularly affected by the proposed changes.

3.102 Overall, half of respondents (50%) who answered this question believed that one or more of these protected groups might be affected by the proposed changes. Of those, almost a third (31%) did not specify which groups in particularly they believed would be impacted. Around one in twenty (6%) said that they thought that all protected groups would be affected (Figure 31) and a slightly smaller proportion (4%) said that everybody in the area would be affected, regardless of whether they fell into an specific protected group.

Groups with protected characteristics affected by the proposals

3.103 Two specific age groups were mentioned by respondents who felt that specific protected groups might be affected by the proposal, with more than a third (36%) highlighting older people and just over one in ten (12%) saying that children would be impacted. Related to the latter, (3%) highlighted parents and families while a slightly larger proportion (6%) said that pregnant women would be impacted by the changes.

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Figure 31: The most common groups highlighted as potentially being impacted by the proposed changes at the UCC. (Base: 461)

3.104 One third of respondents (33%) who answered this question said that people with disabilities would be affected by the proposed changes at the UCC, with particular concerns about travel being expressed by many (see below). One respondent specifically mentioned that difficulty faced by people with autism would face if they had to spend time in a busy, overcrowded A&E department such as that at Lister Hospital.

3.105 Other groups mentioned by some respondents, although not necessarily covered by the Equalities Act, were low-income households and vulnerable people.

Comments and concerns about equalities impacts

3.106 Some comments from respondents concerned about equalities impacts repeated some of the same general concerns expressed elsewhere, e.g. disagreement with the proposal, the need for current services to be maintained and worries about risks to patients if the UCC were to be closed overnight.

3.107 The majority of comments were related to travel and access to urgent and emergency care services if the UCC is no longer available overnight (Figure 32). Many of these echoed the concerns shared previously, with around a sixth (16%) making general comments about increased distances, travel times and costs for patients and more than one in ten (12%) of respondents who answered the question saying specifically that Lister Hospital is too far away to be a good alternative.

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Figure 32: The most common comments made about travel and access in relation to equalities impacts. (Base: 461)

3.108 Approximately one in six (15%) of respondents answering the question related to equalities issues raised concerns about access to urgent care services overnight for disabled people; one in ten (11%) mentioned access for older people and the same proportion said that people without access to vehicles would be impacted.

Other comments and alternative solutions

If you have any other comments or alternative suggestions on how the CCG should address the challenges caused by staff shortages, please type in the box below.

3.109 All respondents were given the opportunity to make other comments and suggest alternative solutions to the challenges facing the CCG because of staff shortages. Just under two fifths of respondents (39%) took this opportunity. The comments covered a range of topics and were grouped according to theme. The data is presented in Appendix I and summarised below.

3.110 The majority of comments related to issues which were raised in answers to the previous questions (Figure 33), with almost a fifth (18%) of respondents to the question raising general concerns about the proposal: from overall disagreement and calls for maintained or increased levels of urgent and emergency care services at the New QEII Hospital, to calls to increase funding and to advertise the UCC more widely.

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Figure 33: Themes of additional comments and alternative suggestions to the proposal (Base: 372)

3.111 Just under one in six responses (15%) related to staffing, and the majority of these were calls for the CCG/NHS to recruit more staff, provide additional training and offer better pay and conditions in order to improve staffing levels at the UCC and other local hospitals and facilities.

3.112 Other comments repeated previously reported concerns about travel and access, and quality and safety impacts as a result of the CCG’s proposal.

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4. Residents focus groups

Introduction

4.1 In order to provide thoughtful consideration of the CCG’s proposals by a representative sample of ‘ordinary’ members of the public, ORS recruited and facilitated two focus groups in August 2019. The purpose of these deliberative sessions was to allow ORS and NHS East and North Hertfordshire CCG to engage with, and listen to, members of the public about the proposed changes to the UCC and related issues - so that the participants would become more informed about the process, the case for change and the principles that form the basis of the proposal.

4.2 In this context, ORS’ role was to design and facilitate the focus groups and report the findings. We worked in collaboration with the CCG to prepare an engaging discussion guide and desk-based activities for the meetings before facilitating the discussions and preparing this independent report of findings.

4.3 Although, like other forms of qualitative engagement, deliberative focus groups cannot be certified as statistically representative, these meetings gave a range of people the opportunity to discuss the CCG’s proposals in detail - and we believe the meetings do provide an indication of how informed members of the public are regarding the UCC and other urgent care and out-of-hours service.

4.4 The focus groups also helped participants to formulate and express their views. ORS believes, therefore, that the two meetings are particularly important within the context of the whole engagement process, because the focus groups were inclusive (encompassing a representative sample of the population of east and north Hertfordshire), not self-selecting (randomly recruited), relatively well-informed (following a presentation of the key issues and potential options by an expert CCG staff member with responsibility of urgent care services) and fairly conducted (through careful facilitation by ORS).

Attendance and representativeness

4.5 In total, there were 20 participants at the focus groups. The dates of the meetings and attendance levels by members of the public were as follows:

Table 5: Residents focus groups.

Date and time Location Number of attendees Tuesday 13th August 2019 NHS East and North Hertfordshire CCG, 9 19:00 – 21:00 Charter House, Parkway, Welwyn Garden Wednesday 14th August 2019 City, AL8 6JL 11 19:00 – 21:00

4.6 Participants were recruited by random-digit telephone dialling from ORS’ Social Research Call Centre. Such recruitment by telephone is an effective way of ensuring that the participants are independent and broadly representative of the wider community (Figure 34). To ensure that certain hard-to-reach groups were included, a mobile telephone sample was used to target hard-to-reach groups (e.g. young people and

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BAME). The aim was to achieve between eight and 12 participants for each session, which was achieved in both cases.

4.7 In recruitment, care was taken to ensure that no potential participants were disqualified or disadvantaged by disabilities or any other factors, and the venue at which the focus groups met was readily accessible. Individuals who perform a caring role for a family member, friend or other person (because of long-term physical or mental ill-health or disability, or problems related to old age) were particularly targeted in the recruitment process; this was in recognition of the importance of gathering their views in more detail, in light of the high rate of response from this group to the open engagement questionnaire.

Figure 34: Demographic profile of residents focus groups attendees

4.8 Current NHS employees and their close family members were not invited to attend the focus groups; this was to ensure that the groups were representative of the general public, rather than those with a professional’s perspective on the subject. NHS employees were well represented in the open questionnaire responses and at events hosted or attended by the CCG.

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4.9 Retired NHS employees and private healthcare workers were invited to attend; individuals contacted by the ORS call centre, but not ultimately invited to the focus groups, were invited to take part in the open engagement questionnaire and given the necessary details to be able to do so.

Discussion agenda

4.10 The workshops began with an introductory presentation by ORS to provide context. The participants were then asked to work in pairs or groups of three to discuss various issues. The first topic for discussion was the respondents’ knowledge and experience of using the UCC at the New QEII Hospital and other out-of- hours services, and related topics, to provide a background to later discussions.

4.11 Following the first small group sessions, a short plenary presentation was given by the Assistant Director of Urgent Care at the CCG to outline the proposal, including the challenges facing the UCC, the principles and aims of the CCG, the evidence base and, briefly, the alternative services available. Opportunity was given for participants to ask questions for clarification.

4.12 Following the presentation, the participants returned to the same pairs and small groups as previously. They were invited to discuss the proposal, giving particular consideration to: Their views and concerns regarding the potential impacts (positive and negative) of the proposed changes; The reasons behind their views; Their views (agreement or disagreement) on the themes arising from the open questionnaire.

4.13 To facilitate the discussions, worksheets were made available to prompt and capture discussions (Figure 35). The CCG staff member remained present to answer questions and provide points of clarification if requested, but in order to ensure that the focus groups gave the best opportunity for residents to share their own views and concerns, intervention was kept to a minimum and caution was used to avoid unnecessary “corrections” of misconceptions, unless it was important to avoid unnecessary confusion in the groups.

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Figure 35: Participants used stickers to indicate which of the most common views and themes emerging from the open questionnaire responses they particularly agreed with.

Outputs and reporting

4.14 The group discussions were audio recorded and the worksheets and other outputs were collected at the end of the workshops for use in reporting.

4.15 This report reviews the opinions and judgements of the workshop participants before and after consideration of and discussion about the proposal put forward by the CCG in regarded to reducing opening hours at the UCC.

4.16 Some quotations from participants are used, in indented italics, not because ORS agrees or disagrees with them, but for their vividness in capturing points of view. We do not endorse any specific opinions, seeking only to portray them accurately. While quotations are used, this chapter is not a verbatim transcript, but an interpretative summary of the issues raised by participants in free-ranging discussions.

Findings

Knowledge about the UCC and other OOH and urgent care services

4.17 The attendees were asked to discuss which, if any, sources of information they were aware of or had used in order to find out about urgent care and out-of-hours services. The participants identified a variety of channels of information, including the internet (search engines and the NHS website), social media, GP surgeries, advice groups (e.g. Citizens Advice), NHS 111 and patient participation groups. One participant specifically mentioned “Health for Hertfordshire” as a source of information.

4.18 Many participants were positive about using the internet to find out about available services, but a few raised concerns that there are particular groups of people who would be less able or comfortable to do this:

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Go to the web, its easy and pretty much all the information you want is out there.

I think for me and my wife going on the web is [easy] …my mum and dad not so much and that’s where there is a little divide. Even with my father-in-law when he was ill, he didn’t know where to go or really what to do. He was happy to wait to book an appointment with the GP and wait for two weeks but there is that sort of difference sometimes, not knowing where to go.

I think people assume that everybody has a laptop and that they are able to use it and do anything they want on it which I’m afraid is not the case. I’ve got an aunt who will be 97 shortly and she wouldn’t even know what one looked like and you can’t expect people with ageing years to keep up with everything.

4.19 When asked to identify different urgent care, out-of-hours and emergency care services in and around the area, participants were able to list the majority of those available locally. These included extended access appointments at GP surgeries (e.g. Spring House Medical Centre, Peartree Group Practice), the UCC at the New QEII Hospital, NHS 111 and out-of-hours appointments, A&E departments (e.g. Lister Hospital, Barnet Hospital), Minor Injuries Units and pharmacists.

4.20 Other healthcare provision mentioned included specialist services for treatment of drug and alcohol addiction, mental health support groups, hospices and charities such as the Alzheimer’s Association.

Experiences of using the UCC

4.21 When asked to share their experiences of using the UCC, many of the participants had never done so. All but one of those who had used the service had done so during the day or in the evening, and their views on the service were generally positive:

I’ve had several visits to the New QEII with broken bones and they were very good. I wasn’t in an urgent situation. I had to go to Lister for a foot injury, but they dealt with all the upper body stuff there. The first one was a Sunday morning which was about 8 o’clock, the others were daytime.

I found that the linkup between them and the Lister [was good]; they arranged all the appointments and it was really organised.

I’ve used the Urgent Care Centre at the QEII once in the early evening […] for my wife, the service was good.

4.22 One participant had used the UCC at night for another person and, because there was not a doctor available, they had subsequently been redirected to the Lister hospital in Stevenage:

A young person wasn’t well, I phoned 111, the advice was to go to the New QEII [Hospital] They were actually just 18 so they were an adult overnight, but having got there, the only service available was a nurse practitioner who did a quick check over and said we had to go to Lister. Frankly if I had known it was just a nurse practitioner there, I would have gone straight to Lister and I spent 5 hours overnight waiting in Lister A&E because there only seemed to be one doctor available, but it was a Friday night and it was one of those things.

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Experiences of using NHS 111 and other OOH services

4.23 A significant point for discussion at both focus groups was the use of NHS 111 to access advice and/or out- of-hours appointments. This was particularly the case in the context of the NHS 111 telephone and online services becoming one of the main access points for non-emergency medical care (alongside GPs and 999).

4.24 The respondents were eager to share their experiences of using NHS 111, with many relating positive experiences and saying that they would be happy to use it more:

…they made me an appointment for about 10pm at the QEII and [my child] saw a doctor.

I rang up 111... They said that was very serious and got a doctor straight away. We took him to Lister and [he] was operated on that night.

…you don’t need to leave your home if you’ve got young kids … it gives you peace of mind if they say that’s nothing out of the ordinary, you can see your doctor in the next couple of days. Maybe you might need antibiotics but it’s nothing life threatening … or they tell you [that] you need to take action; they call you an ambulance or say to go to the Lister. I quite like the idea, when it’s the middle of the night and someone’s ill you panic a little bit. What am I going to do with the kids when I take this one to the hospital? And you want an answer and you want it quick. It’s all about someone making a decision about what to do next, so I quite like that idea.

I spoke to [a family member] and he sounded funny. I phoned the service and [the NHS staff member] phoned him up, spoke to him on the phone, within 20 minutes, there was an ambulance coming to pick him up and take him to the hospital. It was fantastic.

I find it very useful because sometimes I have to use it because I have to write detailed notes for any medical issues or for young people, it’s actually my first line is to phone there so that you can quickly check any issues or potential issues.

4.25 Following discussions about recent improvements to NHS 111, and the prospect of more to come, some focus group attendees were enthusiastic about the future of the service, although others were more sceptical:

The new enhanced 111 looks good, easy access to many more options, I didn’t actually realise you could access a GP through that service.

Some people aren’t able to use the technology the same way the younger people (in this room) can. I don’t mind using it, but I’d still prefer to see someone face-to-face. Over anything else. I’m a firm believer. … I’ve got a rash. But you can’t really see it on a video screen.

Over the phone I can talk to my parish priest but not to a GP or a nurse or something like that. Something doesn’t feel right to me.

4.26 For some, their negative experiences in the past made the wary of using it to access out-of-hours care if the UCC were to close overnight:

I’m very sceptical to be honest with you, my wife is not. Actually, she uses it quite a lot as we have to ring when a child is not well. I’m worried sometimes that if someone on the other side of the phone is not a GP, is not properly trained then I’m going to get the wrong advice, that he or she won’t actually understand the seriousness of my problem (whatever it is). I’m in my late thirties, I’m old fashioned, I still prefer to see if it’s possible to knock on the door of my GP’s

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surgery, have a chat with the receptionist, explain what it is and see if I can get an appointment. I know sometimes it is not possible.

[For a client in need of a wound dressing] I phoned 111 and through them I had to get the district nurse. I couldn’t go to the district nurse directly, they said I had to go through 111 and get it as new referral.

4.27 Communication over the phone was of particular concern to some individuals when thinking about the NHS 111 services:

As English is not my first language, I’m relatively confident as a person but I know a lot of people wouldn’t call 111 because even though their English is very good, they will struggle to express themselves. I’m not suggesting that someone comes here from another country and doesn’t speak English or anything like that, that’s not the case but you have to be confident to make that phone call.

I would like to make sure that this service is accessible, simplistic language is used so people can communicate with it effectively.

4.28 Concern about data security in relation to online NHS 111 services was also raised by one attendee:

…the things you can do with that, clever people find weak links in this technology and can see things that we don’t want people to see. It could be targeted, it’s not black and white. The technology is only as clever as the person who creates it. … I think sometimes technology isn’t always the answer, it would be better to see someone.

4.29 Finally, some attendees related their concerns that using GP surgeries and medical centres to provide extended access appointments and OOH services was putting pressure on them, to the detriment of registered patients:

Spring House is our surgery; we’ve been registered there for years, but now we find [since it became an OOH base] our service is worse. Because we don’t have the availability we had before. Trying to get an appointment there as a normal surgery is ridiculous.

We were at Peartree then we got moved to Spring House. They did a survey saying, “You’ve got these really good services; do you want everyone else to have them?” We said yes, but the way it works is we suffer because they all come to us. So, we don’t have the good service we used to have.

Now if you want to get an appointment with the GP surgery, you have to wait potentially up to two weeks, equally we hear sometimes you have to wait two or three hours before you are seen by someone. If we could reduce that, it would be great. I understand there is a lot of pressure on each of the services, it’s not always easy, however I think sometimes people need to be seen a little bit quicker. The waiting times are sometimes quite long.

4.30 One resident cited the length of time it could take to get appointments at their GPs’ surgeries as a reason that people might use walk-in services like UCCs and MIUs instead, even if it was not the most appropriate location:

It’s really hard to get a lot of appointments with any of the surgeries. You’re looking at four to five weeks. My fear with urgent care is I can’t get an appointment … what do I do if I’ve got

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something that needs to be seen? I’d automatically go to [the UCC] but I’m aware it might not be where I should be going.

Views on the challenges facing the UCC

4.31 Following the presentation by the Assistant Director of Urgent Care, the attendees were asked for their views on the different aspects of the engagement and proposals, starting with the challenges facing the UCC.

4.32 In relation to low usage of the service overnight, there were questions about the extent to which the service had been promoted. At one group, only two of the attendees had been aware that it was currently open 24-hours per day. When given information about the extent to which the UCC had been advertised when it opened, however, the majority agreed that the low usage was an important issue to be addressed.

4.33 Echoing comments made in several open questionnaire responses, one attendee felt that the lack of doctors at the UCC was a reason for the low numbers of people using the service overnight:

I’m saying that, having experienced overnight going to the New QEII and there not being a doctor there and being sent to Lister. You talk to people and therefore your friends who you talk to - they say, ‘There is no point going there, I will go straight to Lister’ so that affects the stats as well.

4.34 Unlike some respondents to the questionnaire, the focus group attendees tended to accept that recruiting doctors to work at the UCC was not something that could be easily solved – with one person specifically pointing out that working somewhere for several hours with very few patients to treat would not be an attractive role.

4.35 Overall, residents understood the rationale behind the need for change. One person questioned why the data for overnight users of the UCC wasn’t up to date, and the CCG representative explained that at the start of the engagement period the latest figures had not been available, but that they now were and continued to show a pattern of low numbers of visitors overnight. In this light, attendees agreed that action needed to be taken.

Views on the principles and aims that the CCG would bear in mind in considering the proposal

4.36 Although there was not an in-depth discussion of the principles and aims that the CCG would be bearing in mind in putting forward the proposal, there was agreement voiced in several key areas, particularly around the points related to the need for services to be high-quality, reliable, consistent and easy to understand, and in relation to making the best use of staff as possible.

Views on the CCG’s proposal to shut the UCC at the New QEII Hospital between 10pm and 8am

4.37 Overall, the focus groups participants were in agreement with the proposal put forward by the CCG, with around half of the participants specifically in agreement with the principle that staff should be moved to where they are needed most, namely to Lister Hospital’s A&E Department.

4.38 This in part reflects the view of many of the attendees that Lister Hospital is the default alternative to the UCC for Welwyn Hatfield residents (who made up 90% of the attendees):

We thought the benefit of the proposal is that probably ultimately, we will get better care and the whole care process might be quicker and if that’s the case then no problem going to Lister

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out of hours … better than being shuffled between places, but the underlying issue is that if resources are definitely increased at Lister.

4.39 For some, while they tended to agree with the proposal, there was some concern that having extra nurses at Lister Hospital might not improve things, given the perception that there are too few doctors at the A&E overnight:

On the top of the sheet it says move the nursing staff to Lister, my experience of Lister seemed to be that there were plenty of nursing staff, it was the lack of doctors that were there because the doctor who was in the … not the resus part of the A&E … in the more general area, there was one doctor, he just kept getting called to resus. Every time he went through those doors, the 40 people waiting were just going to be waiting another 20-30 minutes until he came back so I’m not necessarily sure if it’s just the nursing staff that needs consideration, I think it’s the doctors.

It seemed to be that everybody was waiting to see this one doctor before they were allowed to go unless they had signed and discharged themselves…

(written note) Can advanced nurse practitioners discharge patients at Lister, or do [patients] have to wait to see a doctor?

4.40 Some of those present said that they had been negative about the proposal before coming to the group, but that they tended to agree with it following the presentation and discussion. They expressed concern that other residents would not benefit from the same information:

When I came today, I was quite concerned; but having listened to what else is available, I’m maybe not so concerned. But that’s from sitting [in the focus group] and having quite a frank discussion. How are you going to get that out to everybody else [so that] they understand in the same way that we do?

I didn’t know you could get an appointment with a doctor overnight through 111, I thought they could just book one in the morning.

The second question is how you ensure this information is cascaded and disseminated appropriately to everyone to avoid any confusion?

After this discussion, I’m finding out that the QEII did a lot more than I thought it did…There’s a lot of disbelievers out there – how are you going to convince them?

And how will you let Joe Public, or my 80-odd year-old sister find out about it?

Communicate with the public about the proposed changes and alternative services

4.41 From the worksheets that were collected at the end of the focus groups, it was clear that – while the proposal was generally supported, there was a consensus that the public locally need to be better informed about different NHS services in general:

(Worksheet comment) I feel the general public do not know or understand the difference between UCC and A&E.

4.42 There were animated discussions about the need for a concerted effort to ensure that the public would be informed, if the changes were to go ahead, so that people would know that the UCC was no longer available overnight, and what services they should use instead (e.g. NHS 111, Lister Hospital). Suggestions

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included leaflet drops, social media, local council magazines, surgeries and pharmacies, and in busy public locations such as supermarkets.

4.43 One attendee highlighted the need to target information at certain groups, e.g. the eastern European communities, to make sure that the information about the changes reaches people. Another suggested patients’ groups as a channel of communication:

Depending on your capacity and resources, I would be inclined to spend a bit of time talking to … they are often called ‘hard-to-reach’ or, as I call them, the ‘easy-to-ignore’… Maybe try to talk to some of the minority groups. They would have contacts with leaders within those communities and that would help as well to disseminate that message further.

There is some inconsistency in Hertfordshire and also in Welwyn Hatfield, but a good source of information is patients’ participation groups …

4.44 The potential to reduce confusion by closing the UCC overnight was seen, by some participants, as a benefit as there would be more clarity about where patients should go if, for example, they had a child who needed to be seen by a doctor or the condition could not be dealt with by nurses at the UCC.

Closing the New QEII [UCC] at 10pm makes sure that everyone knows that is not an option, that it’s the Lister or the out-of-hours GP.

(Worksheet comment) Closing at 10pm for [everyone] is clear – there’s no confusion of where to go.

4.45 Finally, for some attendees, there was simply a reluctant acceptance that insufficient NHS funding would lead to changes in services:

It’s one of those things, the NHS is like a listed building no matter how much money you throw at it it’ll always need the endless pot.

I’ve used the urgent care at QEII once in the early evening, well not for me but for my wife; the service was good [but] there is a finite amount of money isn’t there…

Concerns about travel and access

4.46 As was the case in the open questionnaire responses, the focus group participants – while broadly in support of the proposal, in the light of the rationale put forward by the CCG – had concerns about travel and access to alternative services overnight.

4.47 Many of these concerns related to people who may not have access to their own vehicle, e.g. young people, those with low incomes and older residents:

..if I’m looking to care for somebody, going to Lister in the middle of the night is not an issue but I also know a lot of young people who live on their own … [for them] to get to Lister, if it’s night time, actually that is an issue.

I visit a lot of elderly people … that are more likely to need NHS services. These people don’t have cars anymore, because they’ve lost their eyesight or they’re just too old to drive anymore… I know they could phone 111 but these elderly people, they’re anxious and they need someone to speak to face-to-face. They need to see a human being and they certainly aren’t going to do that online.

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…the parking and cost of parking at Lister. I appreciate that overnight you can park on the roads but that’s actually not that easy sometimes and the cost of parking at Lister is a lot, particularly if you are thinking about the elderly, the young, the vulnerable and those who are financially strapped for cash. How are they going to get there at 10 o’clock?

Thinking of the more elderly person who might phone 111, be told that they should go to Lister – probably they are not going to pick up the phone and ask someone to take them at 3am in the morning.

4.48 A lot of attendees wanted to discuss measures that could be put in place which would help people to travel to Lister if they needed to, from shuttle buses to encouraging use of voluntary services (e.g. CVS) which might be able to help:

We felt that there could possibly be a shuttle bus [from the New QEII to Lister] because people who haven’t got transport can travel [there]. Even if the New QEII isn’t open, people could get to that main point […] even if we had to contribute a couple of pounds each.

I suppose what we are saying is if somebody had to pay a couple of pounds, it’s a lot more manageable than £25 in a taxi.

Perhaps there needs to be some system that maybe from their records you can tell they are a real person in need … that there is some arrangement with local taxi companies, volunteers – something like that to get those who are in genuine need to the right place.

4.49 The discussions in both focus groups did go on to consider some of the existing options for patients who needed to be seen overnight, including returning to the topic of the NHS 111 services and ambulances, as well the occasional availability of voluntary drivers through the Community Volunteer Service.

4.50 In direct relation to the proposal to move nursing staff to Lister A&E, the issue of wasted time if staff moved during their shift was raised at the focus groups:

They’re closing 10pm – 8am and then moving staff around. So, let’s say you’re doing an eight- hour shift - 4 hours at the QEII and then another 4 at Lister. Who’s paying for [staff] to travel up there? Do we have to foot the bill for them to travel, get settled in and figure out what they’re going at Lister. That could be an hour of time that they could have been somewhere else.

Concerns about quality and safety of urgent care and emergency services

4.51 One of the major points of discussion was the concern that Lister Hospital is already under pressure as a service, although it should be noted that often this was a general observation rather than being specifically related to the proposal to close the UCC.

4.52 As with the open questionnaire, some attendees shared the view that a growing and aging population in Welwyn Hatfield and east and north Hertfordshire more generally was a serious issue:

Around here we’ve got countless elderly homes being built within the area. Obviously, there’s an aging population, we’re all living longer.

4.53 Some people expressed frustration that the different services in the area were not better linked up (e.g. GP surgeries and emergency departments) or that ‘red tape’ was causing problems:

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I had a friend who couldn’t walk. They gave her antibiotics, and this was on a Sunday … she went back on Monday and they were like, “That’s not working. Go and see your doctor, you need an X- Ray.” …you are in the Lister, and they told you to see the doctor to get the letter for an X-Ray. What a waste of time and effort on everyone’s part … and that [Lister] is where you go back to get the X-Ray.

Six visits [to Lister] in less than six weeks but my biggest gripe is they don’t access any previous records, so the records are created or centralised somewhere or other and then it can take a week for them to get that information back to Lister; by which time you’ve been discharged and two days later, you start the process again.

4.54 Increased pressure on the ambulance services was raised by a few attendees as an area for concern, with residents asking if the fact that people who needed to see a doctor overnight would need to travel further would result in more ambulances being called out for non-emergency cases:

The idea of moving the staff over to Lister, you are absolutely right, more nurses rather than doctors which is probably what we need more of; but would it have a detrimental effect on other services such as ambulances […] now that cost of moving people over [to Lister Hospital], there is now on the ambulance service? Is that going to be a cost impact to them?

4.55 Attendees were, however, generally reassured that, through NHS 111, patients who needed to see a doctor would still be able to either at home or at an OOH base, or that they would be directed to the right service straightaway. Likewise, the fact that, through NHS 111, an ambulance could be arranged if the situation was serious enough to mean that the person did need to go to and A&E gave people more confidence that the care that might be needed overnight would still be available:

I rang 111, one of my kids had stomach pains for a long period of time and they suspected it was getting worse… So, they made me an appointment about 10pm at the QEII and saw a doctor…

…You want an answer and you want it quick.

… if you’re dying, you’re going to go to the Lister. When an ambulance comes to my house, we’re taken to the Lister...

I rang up 111 and it was completely different. They said that was very serious and got a doctor straight away. Very serious – “take your son to A&E as soon as possible”. So, we took him to Lister, and it was operated on that night…

Alternative opening hours were suggested

4.56 There was agreement from a number of participants that opening the UCC an hour earlier would help make the overnight closure work better for some residents:

People that have work or school – exams or something - would benefit if it opened earlier, for instance, at 7am.

Summary

4.57 The focus groups had strong representation (90%) of Welwyn Hatfield residents for whom the UCC at the New QEII Hospital is their closest and most convenient walk-in services. However, in contrast to the open questionnaire, the majority of attendee did agree with the proposals, albeit with some concerns.

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4.58 For a number of the participants, being able to attend and hear and discuss the proposals in detail had led to them changing their views in favour of the proposal; there was a consensus that communicating the same information, and in particular letting the public know about the alternatives to the UCC, is vital.

4.59 Some attendees, however, remained unconvinced and – despite acknowledging the case made for the change – felt that the UCC should remain open. Others felt that the overnight closure would be more acceptable if the hours were adjusted so that it opened earlier in the morning (echoing a view put forward in the open questionnaire).

4.60 Similar concerns to those arising from the questionnaire came up, particularly in relation to travel and access to alternative locations and the perception, often based on personal experience, that the A&E Department at Lister Hospital was not an ideal alternative and faces challenges of its own. Nonetheless, there was considerable support for the principle of moving underused staff from the UCC to somewhere where they would be needed and better used.

4.61 Although there were some concerns about using NHS 111 as an access point to local OOH services, in lieu of the UCC being available, a number of the attendees were positive about the service. In general, being able to hear more about NHS 111 – and in particular improvements, past and future, to the services – was a factor in people being reassured that if the UCC did close overnight then residents would still have access to the care they needed.

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5. Petition

Overview

5.1 One petition was organised during the engagement period by the Welwyn Hatfield Labour Party. The petition was submitted over a period of several weeks to the CCG.

5.2 At the last count given to the CCG, approximately 2,800 people had signed the petition with the following wording:

“HANDS OFF OUR URGENT CARE CENTRE”

Summary: There are currently plans to cut the services at our local Urgent Care Centre (QE2) and completely remove the overnight care that residents currently get. This would mean lengthy and costly travel to the Lister Hospital

Petition to: Stop the planned cut backs to the Urgent Care Centre (QE2) and to keep our valuable overnight service

Note on petitions

5.3 Petitions are clearly important in indicating public anxiety about proposals for changes to public services and NHS East and North Hertfordshire CCG must take it seriously. Nonetheless, it should also be noted that petitions can exaggerate general public sentiments if organised by motivated opponents.

5.4 The Labour Party petition says that the proposals for the UCC will “completely remove the overnight care that residents currently need” and “that this would mean lengthy and costly travel to the Lister Hospital”. The statement does not reflect the alternative overnight services that residents can access.

5.5 The petition also does not mention that there will continue to be OOH services in Welwyn Hatfield via NHS 111, including GP appointments (currently unavailable at the UCC), via NHS 111. This service, which will not be affected by this proposal, enables residents who need to do so to see a doctor at a local OOH base (including the New QEII Hospital, as well as access to telephone consultations and arrange home visits if necessary).

5.6 Petitions are important as they show local feelings. The observations above are not intended to devalue the petition itself, but rather to provide a context within which it should be interpreted.

5.7 It is not known to what extent the petition organisers also encouraged signatories to read the engagement document and complete the online questionnaire which would have provided respondents the opportunity give specific feedback on the proposal and its rationale, as well as to voice any concerns regarding potential impacts of the changes.

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6. Written submissions

Overview

6.1 During the engagement period, twelve written submissions were received by ORS and the CCG. ORS has read all of the written submissions and they are summarised below.

It is important to note that the following section is a report of the views expressed by submission contributors. In some cases, these views may not be supported by the available evidence - and while ORS has not sought to highlight or correct those that make incorrect statements or assumptions, this should be borne in mind when considering the submissions.

6.2 The table below shows the breakdown of the contributors by type.

Table 6: Contributors of written submissions

Number of Type of correspondent Name of organisation(s) respondents

Member of Parliament 1 Rt Hon. Grant Shapps (2 letters)

Hertfordshire County Council Welwyn Hatfield Borough Council (2 letters) Local Government 4 Hatfield Town Council North Mymms Parish Council Stort Valley & Villages GP Surgeries GPs groups 2 North Hertfordshire Locality Commissioning Committee Bridge Cottage Surgery, Welwyn East and North Hertfordshire NHS Trust Other 2 Hertfordshire County Council’s Health Scrutiny Committee

Summaries

The Right Honourable Grant Shapps, MP for Welwyn Hatfield 6.3 The local Member of Parliament for Welwyn Hatfield, the Rt Hon. Grant Shapps MP, wrote to the Chief Executive Officer of the CCG on two occasions. On both occasions he expressed concern about and opposition to the proposal to reduce the opening hours at the UCC at the New QEII Hospital to between 8am and 10pm.

6.4 In the first letter, dated 17th June 2019, he stated that: » He was dismayed to receive the CCGs letter regarding the proposed overnight closure; and

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» That residents of Welwyn Hatfield had been let down with regard to the closure of the A&E in Welwyn Garden City and that, following later agreement by the NHS Trust and CCG to encourage patients who use Lister hospital at night for non-emergency cases, that the proposed change, “flies in the face of the original commitment, and the further assurances received.”

6.5 In the same letter, the Mr Shapps went on to ask questions regarding the process by which the CCG had formulated the proposal, including, but not limited to: » When CCG officials first discussed the possibility of closing the UCC; » Which dates the analysis of patient use of the UCC covered; » The process from the data collection to the decision being made to launch the public engagement; » What analysis/assessment had been made of the potential impacts on elderly or vulnerable Welwyn Hatfield residents in terms of transport and expenses related to traveling to Lister Hospital; and » What reassurance the CCG was able to offer regarding the future of the UCC if the outcome of the engagement was firm opposition to the proposal.

6.6 The letter closed by stating that Welwyn Hatfield residents had repeatedly been let down by NHS managers and by requesting a response to the questions in the letter prior to a meeting taking place on 27th June 2019.

6.7 Following his meeting with representatives of the CCG and having received answers to the questions raised in his first letter, Mr Shapps wrote to the CCG for a second time on 3rd July 2019. He again raised concerns about the proposal in general, the process by which the proposal had been formulated, the evidence presented by the CCG, and the potential impact on residents of his constituency. The letter concluded by describing the proposal as “flawed”.

6.8 The letter raised the following concerns: » That the CCG had not consulted with the elected member for Welwyn Hatfield during the 18 months from proposal to public engagement; » Concern about numbers of people shown to use the UCC, between the hours of 7-8am and 10- 11pm annually (around 3000); » Inconsistency in use of data around UCC usage by patients from other CCG areas; » Concerns about public perceptions, “Having been promised a super-hospital, which was then downgraded to a 24-hour local A&E, which was then downgraded to an Urgent Care Centre and is now being downgraded yet again to daytime use only…”; » Concern that a 10pm cut-off will, in effect become a 9pm cut-off for accepting patients; » Concern about waiting times at Lister A&E, where some more urgent cases may need to attend; » Criticism of the ‘Impact Assessment’ as containing “no meaningful data” and failing to mention older people, and a request for the data behind the month-long transport statement to be publicly shared; » Concerns about the transport costs for people having to travel to Lister A&E at night; and

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» Concern about the lack of guarantees that the UCC will not be further downgraded or cut entirely.

6.9 The local MP concluded the second letter with comments referencing the recent £20bn NHS budget expansion, stating that “In the light of this significant funding increase, my constituents might expect that local health services would be improved and expanded, rather than hollowed out and removed from our area.”

Hertfordshire County Councillor Richard Roberts, Executive Member for Adult Care and Health and Chairman of the Hertfordshire Health and Wellbeing Board 6.10 Councillor Roberts wrote to the Chief Executive and CCG Chair on the 16th July 2019 voicing support for the plans, and for the “efficient use” of the “finite resources” available to the NHS. He also made a commitment that the County Council would play a part in communicating with the public about, “…other services that are available to help the people who currently present at the QEII…to ensure they know the most effective ways to receive treatment.”

Councillor Tony Kingsbury, Leader of Welwyn Hatfield Borough Council 6.11 The Council Leader wrote to the Chief Executive on two occasions, and on both occasions expressed concerns regarding the proposal and its potential impact on residents.

6.12 The first letter, dated 26th July 2019 details a motion passed by the Borough Council on the 22nd July 2019 and requested that the CGG: » Withdraw their proposal to close the QEII Urgent Case Centre; » Investigate why the current facility is not better used; » Consider a wider offer to encourage better use of the facility; and » That CCG representatives attend a meeting open to all councillors

6.13 The Council leader also committed to a further formal engagement response from the Council.

6.14 The second letter is in response to the Chief Executive of the CCG’s reply to the first letter. It reiterated the Borough Council’s concerns and makes the following statements:

As a Council we are disappointed by the CCGs response not to withdraw the proposal.

The Council is disappointed that the CCG has not sought to understand why the facility is not used overnight. In our opinion there is still a lot of confusion from residents about where to go and what services are available at the different sites.

The Council repeats our request to provide additional services. Whilst we note that the CCG have cited that lack of funding is not a reason for the proposed closure, we are concerned that going forwards, especially with the proposed increase in housing across the borough that the closure now will have a negative impact on our residents.

6.15 The Borough Council’s response went on to say that Welwyn Hatfield is both diverse and, according to the recent Health Profiles (PHE), has areas of high deprivation. It states that, “the statistics stated on the NHS Digital website that relate to A&E admissions (2017-18) [show that] 10% of all attendance is from those

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living in the deprived wards. Closure of this [the UCC] will, we believe, have an even greater impact on our residents living in these areas of high deprivation”.

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Hatfield Town Council 6.16 Hatfield Town Council wrote to express its serious concern about and strong disagreement to the proposal, and makes the following points: » Concern that the data refers only to patients from the local area using the UCC, not all use; » There is a lack of reference to elderly people in the Impact Assessment; » No data is currently gathered by the CCG for the protected characteristics other than age sex and race, so we question how the CCG has concluded that there will be no impact on these groups; and » Concern that the proposal will cause ‘significant hardship’ to Hatfield residents, arising from night-time travel costs to Lister A&E;

6.17 The Town Council response stated that:

The Council does not believe that transferring a small number of staff from the QEII to Stevenage does anything to address the underlying staff retention problems at Lister and, if anything, could lead to increased numbers of staff leaving if forced to travel further for work on a more regular basis.

We are worried that the closure of the UCC at the QEII removes a ‘safe space’ where out-of-hours GPs can meet with mental health patients and/or their families overnight. The council believes a ‘safe space’ in the area must be available for patients where it is not appropriate for them to be visited at home.

6.18 The Town Council also requested that the CCG publish their assessment of the impact of the proposal will have on Hatfield’s elderly residents and urged NHS East and North Hertfordshire to reconsider the proposals.

North Mymms Parish Council 6.19 The Parish Council wrote to the CCG on 15th July 2019 and stated that the Council had serious concerns about the proposed changes and their impact, going on to say that:

The services provided by the QEII are invaluable and any reduction in their available hours would be detrimental to the health and well-being of the local community, and should not be cut.

Stort Valley & Villages GP Surgeries 6.20 On the 1st September, a submission was received by the CCG on behalf of Stort Valley and Villages GP Practices, stating that:

The practices in Stort Valley and Villages are happy to support the proposed changes to the opening hours at the New QEII hospital. We agree that it is better to close the urgent treatment centre overnight and improve A&E staffing using the same resource.

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Dr Tara Belcher and Dr Simon Chatfield, on behalf of North Hertfordshire LCC 6.21 The North Herts Locality Commissioning Committee (LCC) met on Wednesday 4th September 2019. It made the following statement:

The collective response from the locality is to support the CCG decision to close the QEII (UCC) overnight.

North Herts felt it was not a good use of resources to have two experienced nurses seeing so few patients and that the population as a whole would be better served if the staff were at Lister Hospital overnight. We discussed ongoing availability of GP out of hours at the site; we also discussed how the majority of patients drive to the walk-in centre and that 111 could arrange a visit, if appropriate, for housebound patients.

Bridge Cottage Surgery, Welwyn 6.22 The partners at Bridge Cottage Surgery in Welwyn made a short response, simply stating that they had “not seen the clinical data needed to make an informed decision about the proposal to close the QE2 UCC overnight”.

Nick Carver, Chief Executive, East and North Hertfordshire NHS Trust 6.23 The Chief Executive of the NHS Trust wrote to confirm the Trust’s support for the hours of opening being proposed, before adding:

The Trust has maintained a presence at the public engagement events from the launch back in June 2019 through to the close of the engagement process today 4 September 2019. There has been no further information or evidence that has come to light which has changed the Trust’s view that the proposed change is the right thing for patients and staff.

Counsellor Seamus Quilty, Chair of the Hertfordshire County Council Health Scrutiny Committee 6.24 The Chair of the Healthy Scrutiny Committee wrote to the CCG following a briefing about the proposal. The letter stated that a strong case had been made by the CCG for the proposal, including data about the low number of service users and the provision of alternative health services. It went on to say that:

Hertfordshire County Council’s Health Scrutiny Committee members are well aware of the difficulties that our acute trusts encounter in recruiting GPs and other clinicians to staff emergency care settings. We know that very effective use must be made of all available staff resources, in the interests of patients with urgent healthcare needs.

6.25 The submission noted the CCG’s plans for a robust engagement process with local people and stated that the Committee was reassured that using ORS, and expert and independent research organisation, would help to ensure impartiality and transparency.

6.26 The Chairman concluded by stating that:

The Committee is encouraged by the CCG’s commitment to seeking a wide range of views, with the aim of ensuring that the engagement process is as demographically representative of local communities as possible.

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Appendix I: Table of figures

Figure 1: Map showing the locations of the engagement events and meetings hosted or attended by the CCG ...... 19 Figure 2: Demographic differences in type of questionnaire response. (Number of respondents in each group in brackets) ...... 26 Figure 3: Open engagement questionnaire respondents by daytime (8am to 10pm) UCC service use. Additional breakdown by area of residence. (Number of respondents in brackets) ...... 28 Figure 4: Open engagement questionnaire respondents by overnight (10pm to 8am) UCC service use. Additional breakdown by area of residence. (Number of respondents in brackets) ...... 29 Figure 5: Agreement and disagreement that NHS East and North Hertfordshire CCG needs to make changes in response to the challenges facing the UCC. (All respondents) ...... 30 Figure 6: Agreement and disagreement that NHS East and North Hertfordshire CCG needs to make changes in response to the challenges facing the UCC. Breakdown by location of residence. (Base number of respondents in brackets) ...... 31 Figure 7: Agreement and disagreement that NHS East and North Hertfordshire CCG needs to make changes in response to the challenges facing the UCC. Breakdown by UCC use during the day. (Number of respondents in brackets) ...... 31 Figure 8: Agreement and disagreement that NHS East and North Hertfordshire CCG needs to make changes in response to the challenges facing the UCC. Breakdown by UCC use overnight. (Number of respondents in brackets) ...... 32 Figure 9: Agreement and disagreement that NHS East and North Hertfordshire CCG needs to make changes in response to the challenges facing the UCC. Breakdown by age of respondent. (Number of respondents in brackets) ...... 33 Figure 10: Agreement and disagreement that NHS East and North Hertfordshire CCG needs to make changes in response to the challenges facing the UCC. Breakdown by location of closest OOH base. (Number of respondents in brackets) ...... 33 Figure 11: Demographic differences in agreement and disagreement that NHS East and North Hertfordshire CCG needs to make changes in response to the challenges facing the UCC. (Number of respondents in brackets) ...... 34 Figure 12: Agreement and disagreement that NHS East and North Hertfordshire CCG needs to make changes to respond to these challenges. Breakdown by questionnaire type. (Number of respondents in brackets) ...... 35 Figure 13: Agreement and disagreement that the CCG needs to make changes to respond to these challenges. Breakdown by view on the CCG’s proposal to close the UCC overnight. (Number of respondents in brackets) ...... 35 Figure 14: Agreement and disagreement that the principles and aims that the CCG will bear in mind, when considering the proposal, are appropriate. (All respondents) ...... 36 Figure 15: Agreement and disagreement that the principles and aims that the CCG will bear in mind, when considering the proposal, are appropriate. Breakdown by location of residence. (Base number of respondents in brackets) ...... 37 Figure 16: Agreement and disagreement that the principles and aims that the CCG will bear in mind, when considering the proposal, are appropriate. Breakdown by UCC use during the day. (Number of respondents in brackets) ...... 37 Figure 17: Agreement and disagreement that the principles and aims that the CCG will bear in mind, when considering the proposal, are appropriate. Breakdown by UCC use overnight. (Number of respondents in brackets) ...... 38 Figure 18: Agreement and disagreement with the proposal to close the UCC at the New QEII Hospital between 10pm and 8am each night. (Number of respondents in brackets) ...... 39 Figure 19: Agreement and disagreement with the proposal to close the UCC at the New QEII Hospital between 10pm and 8am each night. Breakdown by location of residence. (Number of respondents in brackets) ...... 40

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Figure 20: Agreement and disagreement with the proposal to close the UCC at the New QEII Hospital between 10pm and 8am each night. Breakdown by district/borough in east and north Hertfordshire. (Number of respondents in brackets) ...... 40 Figure 21: Agreement and disagreement with the proposal to close the UCC at the New QEII Hospital between 10pm and 8am each night. Breakdown by UCC use during the day. (Number of respondents in brackets) ...... 41 Figure 22: Agreement and disagreement with the proposal to close the UCC at the New QEII Hospital between 10pm and 8am each night. Breakdown by UCC use overnight. (Number of respondents in brackets) ...... 41 Figure 23: Agreement and disagreement with the proposal to close the UCC at the New QEII Hospital between 10pm and 8am each night. Breakdown by age of respondent. (Number of respondents in brackets) ...... 42 Figure 24: Demographic differences in agreement and disagreement with the proposal to close the UCC at the New QEII Hospital between 10pm and 8am each night. (Number of respondents in brackets) ...... 43 Figure 25: Agreement and disagreement with the proposal to close the UCC at the New QEII Hospital between 10pm and 8am each night. Breakdown by questionnaire type. (Number of respondents in brackets) ...... 43 Figure 26: The primary themes arising from comments made by open engagement questionnaire respondents who disagreed with the proposal. (Base: 435) ...... 46 Figure 27: The most common concerns and comments made by open engagement questionnaire respondents who disagreed with the proposal. (Base: 435) ...... 47 Figure 28: The most common concerns and comments about travel and access from questionnaire respondents who disagreed with the proposal. (Base: 435) ...... 48 Figure 29: The most common general comments made about quality and safety by questionnaire respondents who disagreed with the proposal. (Base 435) ...... 49 Figure 30: The most common comments about staffing of the UCC and other health services by questionnaire respondents who disagreed with the proposal. (Base: 435) ...... 50 Figure 31: The most common groups highlighted as potentially being impacted by the proposed changes at the UCC. (Base: 461) ...... 52 Figure 32: The most common comments made about travel and access in relation to equalities impacts. (Base: 461) ...... 53 Figure 33: Themes of additional comments and alternative suggestions to the proposal (Base: 372) ...... 54 Figure 34: Demographic profile of residents focus groups attendees ...... 56 Figure 35: Participants used stickers to indicate which of the most common views and themes emerging from the open questionnaire responses they particularly agreed with...... 58

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Appendix II: Text comments from the open engagement questionnaire

Question: If you disagree with the proposed changes, please explain the reasons why.

Comments Valid responses

Base (Number of respondents making comments) 435

GENERAL COMMENTS Need to keep New QEII Hospital 24 hour/maintain services as they are 32% Disagree with the proposal/don't think they are a good idea 31% Proposals are putting people's safety/lives at risk/accidents and emergencies can happen at 19% anytime Need more cover not less/should be increasing services not taking them away/already had 18% facilities taken away i.e. A+E taken away Welwyn Hatfield needs adequate cover/is a growing area i.e. new homes being built 16% Advertise to general public about QEII facilities i.e. overnight services 6% Just an excuse for cutting funding/money making exercise 4% Lack of use down to poor access to facilities/medical staff 3% Changing of times/different facilities/differences between UCC and A&E is confusing 2% More education/awareness of where to go with what problems 1% More money needs to be invested in services/need more funding from government 1% More information needed i.e. what would happen if went over two hours waiting time limit. 1% Promised a new hospital which wasn't delivered 1% Understand the need for change/under current economic climate N=2

TRAVEL AND ACCESS Difficulty in accessing Stevenage/Lister hospital is too far way 30% General concerns about increased travel times/distance/need local services 18% Concerns about access for people without access to a vehicle 14% Concerns about the increased cost of travel 11% Concerns about public transport/need to improve public transport 6% Poor access to GP appointments is forcing people to access hospital services 6% Concerns about access for the elderly 5% Concerns about access for vulnerable/deprived background/low income people 5% Concerns about access for children/children should have access to treatment 24 hour 4% Concerns about access for disabled people 2% Concerns about traffic congestion affecting travel times 1% Concerns about parking/need to improve/more parking 1%

QUALITY AND SAFETY Lister hospital has long waiting times/already overstretched 29%

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Proposals will put additional pressure on existing facilities/surrounding hospitals/already have 14% long waiting times/already over stretched Proposals will force people to call ambulances which will be a waste of resources/take 7% ambulances away from people who really need them Positive personal experience at QEII/previously needed to be treated after 10pm 7% Poor quality service provided by NHS 111 number i.e. always busy, don’t get back to you etc. 6% QEII hospital has long waiting times/already overstretched 3% Good quality of facilities in QEII currently 1% Positive experience of service provided by NHS 111 number N=1

STAFFING Need adequate staffing levels/need to increase staff, not move them elsewhere 6% Focus on recruitment of staff/advertise to gain more staff recruitment/lack of staff at hospitals 2% currently Managers are overpaid 1% Good quality of staff at New QEII Hospital currently 1% Offer more pay/benefits to attract more staff i.e. free housing/free travel etc. N=2 Train more staff/if can't recruit staff need to train current staff N=2 Reduce number of staffing at night to keep facilities open/have only skeleton staff available N=2 Reduce number of unnecessary staff members i.e. agency, admin staff etc. N=2 Cut down on number of unnecessary managers N=1

CRITICISM OF ENGAGEMENT Incorrect/out of date/not thorough enough data 3% Engagement is biased/flawed/leading questions 1% More information/evidence needed 1% Other criticism of engagement/CCG 1% Minds already made up/this is a paper exercise N=2

ALTERNATIVE TO PROPOSAL New QEII Hospital should be upgraded from a UCC to an A&E 4% Different opening times to the proposal - Open at 7am 3% Different closing times to the proposal - Close at 12am 3% Direct patients from Lister hospital if non-emergency to New QEII Hospital to ease busy periods 2% at Lister Different opening times to the proposal - Open at 6am 2% Increase funding from the government 1% Different closing times to the proposal - Close at 11pm 1% Money needs to be saved in alternative ways N=2 Other alternative proposal N=2 Dedicated phone line between closing hours acting as an overflow N=1

OTHER COMMENTS Other 9%

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Are there any groups protected under the Equality Act 2010 which you believe will be positively or Question: negatively affected by the proposed changes? If so, what could be done to enhance the positive impacts or reduce any negative impacts?

Comments Valid responses

Base (Number of respondents making comments) 461

TYPE OF GROUP Elderly 36% Disabled 33% Children 12% Low income 8% Pregnant women 6% Everyone listed in the Equality act i.e. age, disability, gender reassignment, marriage and civil 6% partner Vulnerable people 4% Everybody will be affected/doesn't matter what group/it will happen to everyone 4% Parents/Families 3% People who live alone N=1

GENERAL COMMENTS Need to keep QEII 24 hour/maintain services as they are 8% Disagree with the proposal/don't think they are a good idea 5% Hospitals already have long waiting times/already overstretched 3% Proposals are putting people's safety/lives at risk/accidents and emergencies can happen at 2% anytime Proposals will force people to call ambulances which will be a waste of resources/take 2% ambulances away from people who really need them People have rights/pay taxes towards health care 1% Overcrowded A&Es increase stress/hard to move N=2

TRAVEL AND ACCESS General concerns about increased travel times/distance/need local services 16% Concerns about access for disabled people 15% Stevenage/Lister hospital is too far away 12% Concerns about access for the elderly 11% Concerns about access for people without access to a vehicle 11% Concerns about the increased cost of travel 7% Concerns about public transport/need to improve public transport 5% Concerns about access for vulnerable/deprived background/low income people 2% Children should have access to treatment 24 hour 1% Concerns about parking/need to improve/more parking N=1

OTHER COMMENTS Other 9%

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If you have any other comments or alternative suggestions on how the CCG should address the Question: challenges caused by staff shortages.

Comments Valid responses

Base (Number of respondents making comments) 372

GENERAL COMMENTS Need to keep QEII 24 hour/maintain services as they are 4% Disagree with the proposal/don't think they are a good idea 4% Need more cover not less/should be increasing services not taking them away/already had 3% facilities taken away i.e. A&E taken away Advertise to general public about QEII facilities i.e. overnight services 3% Agree with the proposal/think they are a good idea 3% Welwyn Hatfield needs adequate cover/is a growing area i.e. new homes being built 2% Proposals are putting people's safety/lives at risk/accidents and emergencies can happen at 2% anytime More money needs to be invested in services/need more funding from government 2% More education/awareness of where to go with what problems 2% Understand the need for change/under current economic climate 1% Reduce admin/waste/too much red tape/bureaucracy 1% Promised a new hospital which wasn't delivered 1% Changing of times/different facilities/differences between UCC and A&E is confusing 1% Just an excuse for cutting funding/money making exercise N=3 More information needed i.e. what would happen if went over two hours waiting time limit. N=3 More up-to-date use of technology i.e. online booking system etc. N=4 Lack of use down to poor access to facilities/medical staff N=4

TRAVEL AND ACCESS General concerns about increased travel times/distance/need local services 2% Difficulty in accessing Stevenage/Lister hospital is too far way 2% Concerns about public transport/need to improve public transport 1% Concerns about access for vulnerable/deprived background/low income people 1% Concerns about access for the elderly 1% Concerns about access for people without access to a vehicle 1% Poor access to GP appointments is forcing people to access hospital services 1% Concerns about traffic congestion affecting travel times N=1 Concerns about parking/need to improve/more parking N=3 Concerns about access for children/children should have access to treatment 24 hour N=3 Concerns about the increased cost of travel N=4 Concerns about access for disabled people N=4

QUALITY AND SAFETY Lister hospital has long waiting times/already overstretched 3% Proposals will put additional pressure on existing facilities/surrounding hospitals/already have 2% long waiting times/already overstretched Proposals will force people to call ambulances which will be a waste of resources/take 1% ambulances away from people who really need them Positive personal experience at QEII/previously needed to be treated after 10pm 1% Poor quality service provided by NHS 111 number i.e. always busy, don’t get back to you etc. 1%

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QEII hospital has long waiting times/already overstretched N=4 Good quality of facilities in QEII currently N=2

STAFFING Offer more pay/benefits to attract more staff i.e. free housing/free travel etc. 5% Focus on recruitment of staff/advertise to gain more staff recruitment/lack of staff at hospitals 5% currently Need adequate staffing levels/need to increase staff not move them elsewhere 4% Train more staff/if can't recruit staff need to train current staff 2% Need to look after staff more i.e. treat them better, better working conditions, focus on staff 2% morale etc. Reduce number of unnecessary staff members i.e. agency, admin staff etc. 1% Reduce number of staffing at night to keep facilities open/have only skeleton staff available 1% Managers are overpaid 1% Cut down on number of unnecessary managers 1% Attract more staff by being more efficiently run/organised 1% Good quality of staff at QEII currently N=2

CRITICISM OF ENGAGEMENT Minds already made up/this is a paper exercise 1% Other criticism of engagement/CCG 1% Engagement is biased/flawed/leading questions N=1 Incorrect/out of date/not thorough enough data N=2 More information/evidence needed N=3

ALTERNATIVE TO PROPOSAL QEII should be upgraded from a UCC to an A&E 1% Money needs to be saved in alternative ways 1% Increase funding from the government 1% Direct patients from Lister hospital if non-emergency to QEII to ease busy periods at Lister 1% Different opening times to the proposal - Open at 6am 1% Different closing times to the proposal - Close at 12am 1% Different opening times to the proposal - Open at 7am N=2 Dedicated phone line between closing hours acting as an overflow N=2 Different closing times to the proposal - Close at 11pm N=3

OTHER COMMENTS Other 12%

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Appendix III: Meetings and activities hosted or attended by the CCG

Introduction

During the engagement period, many meetings and events in east and north Hertfordshire and the surrounding area were either hosted or attended by the CCG to provide people with information about the engagement and the opportunity to take part.

The engagement activities were primarily intended as an opportunity for the public to find out about the proposal and ask any questions, and for the CCG to promote broader engagement and signpost stakeholders to the open questionnaire. However, ORS provided the CCG with a meeting record template and some participant feedback was captured by CCG staff/event organisers, including observations, questions and reflections from both local people and NHS staff. It is recognised that these are subjective and, as they were collected by the CCG rather than ORS, do not form part of the main report. This appendix is intended to provide a snapshot of some of the issues that were raised. It is nevertheless interesting to reflect that these issues are generally consistent with feedback provided in other ways. It is important to note that all members of the public who spoke to CCG staff or attended meetings were informed and encouraged to use official response channels (such as the open engagement questionnaire) to submit their views. While accurate numbers are not possible to provide, a reasonable estimate is that over 1,000 people were engaged in some way through these meetings and activities listed below.

Social media

The CCG worked hard to engage the public via social media channels. This included advertising the engagement process itself (reaching more than 40,000 users) including the engagement website and questionnaire, public meetings and other events and activities. In addition, members of the CCG Communications Team responded to specific questions and concerns when possible, providing additional information and points of clarity if needed. Online analytics showed that the CCG’s and other users’ posts were engaged with over 3,700 times, from “likes” and shares, to individual comments. Social media, by its nature, invites users to share their views immediately and, while helpful in providing indication of the opinions and strength of feeling of those engaging in debate, it is perhaps less useful in seeking to gain a balanced view of public opinion in a broader sense. This does not mean, however, that the comments made, and opinions shared, should be dismissed and the CCG made considerable effort to identify specific areas of concern – in particular if there were issues raised that had not been addressed elsewhere. In this case, the views and concerns shared online were largely similar to those raised via the more formal aspects of the engagement which are covered in detail in the main body of this report.

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Meetings and other activities

Three public meetings were held, two hosted by the CCG and intended to give people the opportunity to discuss the proposal with doctors, clinicians and operatives from the CCG and from East and North Hertfordshire NHS Trust. The third was the Welwyn Hatfield Borough Council meeting at which representatives from the CCG were present. The details of all of the events are in the table below:

Event Location Date & Time Duration

ANNUAL GENERAL MEETING East and North Hertfordshire NHS Trust Wednesday 17 July 2019 Stevenage 3.5 hours Annual General Meeting 16:30 – 20:00

PUBLIC MEETING Monday 22 July 2019 Welwyn Hatfield Borough Council Meeting Welwyn Garden City 2 hours 19:30 – 21:30 Public meeting with members of the CCG Thursday 25 July 2019 Welwyn Garden City 2 hours Governing Body 12:30 – 14:30 Public meeting with members of the CCG Thursday 15 August 2019 Welwyn Garden City 2 hours Governing Body 19:00 – 21:00

DROP-IN EVENT Wednesday 19 June 2019 New QEII Hospital Welwyn Garden City 2.5 hours 10:30 – 14:00 Saturday 22 June 2019 Hertford Theatre - The River Room Hertford 3.5 hours 10:30 – 14:00 Monday 24 June 2019 Welwyn Garden City Library Welwyn Garden City 1.5 hours 14:30 – 16:00 Thursday 27 June 2019 North Mymms Memorial Hall Welham Green 1.5 hours 18:30 – 20:00 Monday 8 July 2019 London Colney Community Centre St Albans 2.5 hours 11:00 – 13:30 Friday 12 July 2019 New QEII Hospital Welwyn Garden City 3.5 hours 10:30 – 14:00 Wednesday 17 July 2019 St Francis Church Hall Welwyn Garden City 2.5 hours 12:30 – 15:00 Saturday 20 July 2019 St Martin's Parish Centre Knebworth 2.5 hours 13:00 – 15:30 Tuesday 23 July 2019 Hertfordshire County Council Stevenage 2 hours 12:00 – 14:00 Thursday 1 August 2019 Welwyn Garden City Town Centre Welwyn Garden City 2 hours 12:00 – 14:00 Wednesday 7 August 2019 Wheathampstead Memorial Hall Wheathampstead 2.5 hours 12:30 – 14:00 Friday 9 August 2019 The Lister Hospital Community Hub Stevenage 3.5 hours 10:30 – 14:00 Wednesday 21 August 2019 Hertfordshire County Council Hertford 2.5 hours 11:30 – 14:30

INFORMATION STAND Thursday 20 June 2019 Asda supermarket Hatfield 2.5 hours 16:30 – 19:00 Thursday 4 July 2019 Sainsbury's supermarket Welwyn Garden City 2.5 hours 10:30 – 13:00 Friday 2 August 2019 Asda supermarket Hatfield 1.5 hours 12:30 – 14:00 Tuesday 13 August 2019 Sainsbury's supermarket Welwyn Garden City 2.5 hours 16:30 – 19:00

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The CCG’s activities were designed to offer as many people as possible the chance to be informed and ask questions, and to encourage them to take part in the engagement process. At the drop-ins and information stands, information was presented on a one-to-one basis and engagement materials were available to review and take away, as well as paper copies of the open questionnaire and postcard-sized information cards with the link to the online engagement documentation and questionnaire.

In response to requests, private briefings were also addressed to:

 representatives of Hatfield Town Council and the Labour Party’s Prospective Parliamentary Candidate for the Welwyn Hatfield constituency, Rowena Newbigging,  a senior leadership group from Welwyn Hatfield Borough Council,  and an open invitation meeting for Welwyn Hatfield District Councillors,  the Rt. Hon. Grant Shapps, MP for Welwyn Hatfield.

The following report has been collated by ORS based on notes and minutes provided by East and North Hertfordshire CCG. Notes based on conversations with members of the public were, where possible, separated into themes using the same code frame as was used for the text comments from the open questionnaire (as reported in Chapter 3 of this report). It should be noted, however, that this does not mean that the data presented in the charts below can be viewed as equally valid as the data in the main section of the report; rather, it is included for information and to provide a brief overview of the opinions shared with CCG staff in relation to the proposal regarding overnight closure of the UCC, and of urgent, emergency and out-of-hours NHS services in east and north Hertfordshire in general.

East and North Hertfordshire NHS Trust Annual General Meeting

The AGM of the East and North Hertfordshire NHS Trust (ENHT, the body responsible for providing care at the UCC at the New QEII Hospital), took place on Wednesday 17th July 2019. Prior to the AGM, East and North Hertfordshire CCG staff manned a stand to engage with the attendees (predominantly staff from ENHT and staff and volunteers from other local health and social care organisations).

Overall, there was strong agreement among NHS staff that they would be happy to work at Lister Hospital overnight, rather than the UCC, as their skills would be better utilised.

Public meetings with members of the CCG Governing Body

Two public meetings took place to allow members of the public and other stakeholders to discuss the proposal with doctors, clinicians and operatives from the CCG and from East and North Hertfordshire NHS Trust.

Attendees were able to put forward questions in relation to the proposal. Broadly speaking, the questions raised reflected the comments and concerns raised through the open engagement questionnaire. Typical questions, such as those from 15th August 2019 (reported verbatim below) addressed:

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NHS 111 and overnight GP appointments 1. Where are the out-of-hours GPs based overnight? 2. Does NHS 111 direct appropriate people to the UCC rather than Lister? 3. Will there be better sharing of your GP record with urgent care services so that your history is known? 4. Is HUC [Herts Urgent Care] a private company? Are HUC paid [based on the] amount of patients they refer or phone calls they take? Data and understanding how patients use services 5. Why is the UCC not better used overnight? 6. How many people who attend Lister A&E could go to the UCC instead? 7. What has changed since 2015 to need to reduce the service? 8. Have you spoken to other urgent care providers around the country about how they manage patient demand? 9. What research have you done on people who are using the A&E in Stevenage? How many travel from Welwyn Hatfield? 10. Why are you using 2016/17 figures and has there been any change since then? 11. Is there a difference in attendance on different days of the week? 12. Is there any variation in attendance on different days of the week? 13. Can we see utilisation breakdown by day of the week? If usage [is] higher on some days, would you consider varying opening schedule? 14. Is there profiling of people who use the QEII Urgent Care Centre? 15. Is there any focus on, or analysis of, categories of people who are frequent users of urgent care and/or A&E? 16. Do you have data on overnight use for Welwyn-based patients?

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Publicity and communicating information about health services 17. Can we add ‘urgent care available’ to the ‘No A&E’ road signs around the QEII? 18. Could it be better advertised? 19. Given the huge concern we have found that people have about this proposed closure and the fact that many do not even know there is currently an overnight service at the QEII UCC, would the trust spend the next year advertising the fact it’s open and what it does and use this year-long pilot study to identify whether actually it could be kept open because more people were using it as a result of this publicity? 20. How many people know that the QEII UCC is open overnight? What is being done to promote it?

The engagement process 21. How many responses have your received so far? 22. Are you at risk of judicial reviews as the CCG has not consulted? (Corby CCG was taken to judicial review for failing to consult on UCC downgrade) 23. How much has this engagement exercise cost? Wouldn’t money be better used tackling cancer waits? 24. How will this engagement deal with opposition (to the proposal)?

Future of the New QEII 25. Please can the QEII overnight be reviewed and considered as the complementary service to the new NHS 111. Mental health and paediatric care overnight is best dealt with face to face. 26. Is there a possibility that the UCC could close completely? 27. Will you review the opening hours further down the line if demand increases? 28. How can we be sure this is not the thin end of the wedge for the QEII? 29. What would need to be added to the UCC service to make it work overnight? X-ray? Paediatrics? 30. Is this the inevitable starting point to losing the QEII entirely? 31. Why aren’t we exploring the options to increase provision at the Urgent Care Centre to ease the congestion at Lister and this includes promotion of services etc.

Population growth 32. Why are you reducing access to services when the population is growing? 33. Is the CCG aware of the impact of planned population growth and how the need for urgent care may change? 34. Why isn’t the CCG long term planning for a new district general hospital serving Welwyn Garden City / St Albans / Hatfield? (Population of 120,000; 20,000 homes in Welwyn Hatfield Local Plan and St Albans population of 140,000). 35. Is population growth in Welwyn Hatfield and Hertfordshire in general accounted for? 36. There are 16-20,000 houses in the Welwyn Hatfield Local Plan. And 100,000 people in homes planned to be built along the A414 corridor in the next 5 years. Has this been considered?

Transport 37. Is there any transport provision for patients late at night who cannot afford taxis? 38. What about people that don’t have access to transport?

Access to GP services 39. What are you doing to make it easier for people to get a GP appointment? Other questions 40. If the NHS England requirement for a UCC is 12 hours, why not reduce to 12 hours rather than 14 hours? 41. Wouldn’t treating people in a calm and quiet environment at the QEII be better than sending people to an already busy A&E at Lister? 42. Have you any response to make to Dr John Lister’s comment that the Trust and CCG are stripping medical services out of this part of the county? 43. A&E centralised in Stevenage in the north of the county. Is this viable?

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Drop-ins and information stands

The CCG hosted 13 drop-in events in locations around east and north Hertfordshire, as well as two locations in the wider Hertfordshire area (St Albans and Wheathampstead). Two of these events took place at the offices of Hertfordshire County Council in Hatfield and Stevenage and were specifically for Council staff and official visitors. The other 11 drop-in events were for members of the public and other interested parties. In addition to the drop-ins, CCG staff manned public information stands on four occasions – two in the Asda supermarket in Hatfield and two in the Sainsbury’s supermarket in Welwyn Garden City.

As well as answering questions and giving out information, CCG staff members, when appropriate, made some brief anonymised notes about key points arising in the conversations and interactions they had with visitors and passers-by. The key themes and an approximation of how often they arose are presented below. It should be noted that these figures are drawn from the 123 sets of individual notes representing just a few of the many hundreds of interactions which took place at the various events. They are included to demonstrate the balance of opinion from these conversations, and should not be considered a robust, statistically valid representation of general public opinion.

Views on the proposal and local urgent care and out-of-hours services

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Concerns about the impacts of the proposed overnight closure

Alternative suggestions for actions the CCG could take

89 Opening hours at the Urgent Care Centre at the New QEII Hospital

Public engagement document 13 June - 4 September 2019 INTRODUCTION

NHS East and North Hertfordshire Clinical Commissioning Group (the CCG) is the organisation responsible for making sure that the 597,000 people in our area get the medical help, care and treatment that they need. This includes GP services, most planned hospital and community health services, mental health services and urgent and emergency care.

This document is about possible changes to the Urgent Care Centre for minor injuries and minor illnesses, which is one of the health services based at the New QEII Hospital in Welwyn Garden City.

Challenges facing the UCC in 2019

The national requirement is for Urgent Care Centres to be open for 12 hours a day or more.

The Urgent Care Centre is currently open 24 hrs a day, every day of the year. However, challenges facing NHS East and North Hertfordshire CCG as commissioners of local health services mean that:

• Due to recruitment difficulties, there is no doctor at the Urgent Care Centre after midnight. People who need to see a doctor between midnight and 8am are referred elsewhere (such as the Lister Hospital in Stevenage) or asked to call NHS 111.

• Despite a low number of users between 10pm and 6am, for safety reasons two highly-trained clinical staff must be on duty there at all times.

• Children cannot be seen at the Urgent Care Centre between midnight and 8am.

• X-rays are not available at the Urgent Care Centre after 11pm.

What do we know about the use of the Urgent Care Centre overnight?

Patient information gathered from people who do use the Urgent Care Centre overnight shows that:

• Less than one person an hour uses the Urgent Care Centre between 10pm and 6am.

• Two thirds of users have a minor illness and should be treated by a GP - but unfortunately there is no GP available there after midnight.

• 86% of users do not require any further tests, scans, medicine, or onward referral to another NHS service.

• There is some confusion about which services are currently available overnight at the UCC, leading to wasted journeys for some walk-in patients.

2 Public engagement: 13 June - 4 September 2019 Average number of attendances per hour in 2016-17

The majority of people who use the Urgent Care Centre visit during the daytime, or in the early evening.

The chart above shows the average number of attendances per hour at the Urgent Care Centre in 2016-17.

The CCG regularly promotes the Urgent Care Centre to local residents and the health advice service NHS 111 signposts callers to its services. However, as the chart shows, on average less than one visit per hour is made to the Urgent Care Centre between the hours of 10pm and 6am.

qeiiucc.enhertsccg.nhs.uk 3 Aims and principles regarding urgent and emergency care provision in the east and north Hertfordshire area

The CCG is considering making changes to the opening hours of the Urgent Care Centre at the New QEII Hospital to address the challenges we face, bearing in mind these principles:

• Urgent care and emergency health services should be high quality and reliable.

• Advice should be readily available and health services should be easy to use and understand.

• We should make the best use of clinically trained staff to treat as many patients as possible.

• Highly skilled staff should be available to care for patients who are very ill and facing life- threatening emergencies.

• A consistent range of services should be provided whenever the UCC is open to reduce confusion.

• The UCC should be open in excess of the government’s 12-hour minimum guidelines.

• The UCC should be open during the early evening when it is well used by patients.

WHAT IS BEING PROPOSED?

To address the challenges and achieve our aims we are considering closing the Urgent Care Centre at 10pm every night and re-opening at 8am each morning. What would happen if the Urgent Care Centre closed overnight?

• Out-of-hours GP services: Health advice and bookable GP appointments are already available at night in person, online or over the phone for those who need them by calling the free NHS 111 service or using NHS 111 online: www.111.nhs.uk

- Depending on where patients live, an appointment would either be offered at a local NHS 111 base in Welwyn Garden City, or elsewhere in the surrounding area. Visit www.hucweb.co.uk/contact/locations to see a list of primary care centres.

- People who are assessed as needing an urgent GP appointment who are too ill to travel can be visited by a GP at home.

4 Public engagement: 13 June - 4 September 2019 • Minor injuries services: Those patients who have a minor injury after 10pm and who can’t wait until the morning would have to be treated elsewhere. NHS 111 advisers would be able to refer them to the nearest suitable alternative treatment centre.

• Reassigning clinical staff: Closing the Urgent Care Centre at 10pm would mean that the highly skilled clinical staff who work there overnight could be redirected to work at our area’s Accident and Emergency service at the Lister Hospital instead – making better use of their expertise, and improving services for people who are very ill and face life-threatening emergencies.

Additional expert nursing staff called ‘advanced nurse practitioners’ are being recruited to join the team at the Urgent Care Centre, in order to undertake consultations and treatments that currently only GPs can carry out. This change should help to reduce waiting times and is in line with new national service specifications.

The rest of this document includes further information for you to consider before filling in our questionnaire. The questionnaire includes an opportunity for you to submit your own suggestions.

qeiiucc.enhertsccg.nhs.uk 5 Proposed changes

We are considering reducing the opening hours of the Urgent Care Centre at the New QEII Hospital. The details of the proposal are below, along with details of the current service.

PROPOSED CHANGES TO THE URGENT CARE CENTRE SERVICE Opening hours Clinical staff on duty

8am -10pm • GP • Advanced nurse practitioners The service would see patients who arrived • Emergency nurse practitioners before 10pm for up to two hours after closing • Nurses time, to allow time to treat them • Emergency medical technician

DETAILS OF THE CURRENT URGENT CARE CENTRE SERVICE

Clinical staff on duty Opening hours Daytime Overnight

• GPs • Emergency nurse practitioner • Emergency nurse practitioner Open 24 hours • Nurses • Nurses • Emergency medical technician

6 Public engagement: 13 June - 4 September 2019 Clinical roles and responsibilities at the Urgent Care Centre

GP: general practitioners- these will promote and monitor clinical care and oversee the governance of the service. They will be responsible for the training and monitoring of the primary care ANPs, in conjunction with Emergency Department matrons from the Lister Hospital. They will be responsible for the smooth running of the service, seeing patients where necessary and providing leadership for other staff members.

ANP: advanced nurse practitioner - these are very senior nurses who have undertaken further study at Masters level and use their expertise and experience to see and treat patients with a wide range of symptoms. They can also work alongside GPs to provide safe and effective care to patients presenting with a wider range of ailments.

ENP: emergency nurse practitioner - these are senior nurses who have undertaken advanced studies and are able to see treat and discharge patients who present with minor illnesses (for example: coughs, colds, ear infections, throat infections) or minor injuries dependent on their level of proficiency, this list is not exhaustive.

RGN (Band 5) nurse - registered general nurse who is qualified to undertake assessment, record observations, administer medication and perform basic nursing care to patients. They also provide education for patients to ensure they are seeking the best healthcare options.

EMT: emergency medical technician - qualified to undertake tasks that are given to them including plastering of limbs, closing of wounds and undertaking observations.

Why are these changes being proposed?

There are a number of issues facing NHS East and North Hertfordshire CCG as commissioners of local health services:

• Less than one person an hour on average uses the Urgent Care Centre between 10pm and 6am. This means that the highly skilled clinical staff who work there overnight spend very little time seeing patients.

• When people do go to the QEII UCC overnight, most of them want to see a GP urgently. Urgent GP appointments are available out-of-hours for local people who need them by calling NHS 111.

• East and North Hertfordshire NHS Trust (the hospital trust which runs the Urgent Care Centre), in common with health service organisations across the country, finds it very difficult to recruit and retain GPs to work in the Urgent Care Centre overnight. This means that people who go to the UCC because they need to see a doctor overnight are often referred elsewhere by the centre’s Emergency Nurse Practitioners or advised to call NHS 111.

qeiiucc.enhertsccg.nhs.uk 7 • The A&E service at the Lister Hospital is significantly busier overnight than the Urgent Care Centre. Due to recruitment challenges at the Lister Hospital, patients who have very serious health needs sometimes wait too long to be seen and treated. East and North Hertfordshire NHS Trust could make better use of their clinical staff if they were based at the Lister Hospital overnight rather than at the New QEII.

• To help address these issues, we are considering changing the opening hours of the Urgent Care Centre, which is currently open 24 hours a day, every day of the year. By reducing the opening hours of the Urgent Care Centre, the Trust could re-direct staff to our area’s Accident and Emergency service at the Lister Hospital overnight – making better use of staff skills and improving services for people who are very ill and face life-threatening emergencies. People who urgently need to be seen by a GP overnight could still see one by calling NHS 111.

How has the CCG developed this proposal?

In order to develop the proposal in this document, we have:

• Followed new NHS England national guidance on Urgent Treatment Centres and Emergency Care.* • Worked with East and North Hertfordshire NHS Trust to review staffing arrangements and waiting times for treatment at both the Urgent Care Centre and the Lister Hospital’s A&E. • Analysed information about when and why the Urgent Care Centre is used. • Had discussions with local politicians. • Worked with NHS England and neighbouring NHS organisations, including East of England Ambulance Service NHS Trust. • Taken advice from representatives of Hertfordshire County Council’s health scrutiny committee. • Talked to the patient representative organisation Healthwatch Hertfordshire. • Discussed key issues with local voluntary organisations. • Involved local GP groups and patient group representatives. • Carried out an Equality Impact Assessment on the proposal, to ensure that it does not discriminate against any groups with protected characteristics as defined by the Equality Act 2010.

Following this engagement process, we will review our initial impact assessment to consider any new information that people put forward.

* New national guidance has been introduced to rename Urgent Care Centres as Urgent Treatment Centres. The guidance also requires Urgent Treatment Centres across the country to offer a standard set of services which take the pressure off Accident and Emergency departments by dealing with most of the common ailments that people attend A&E for. The guidance requires Urgent Treatment Centres to be open for at least 12 hours a day.

8 Public engagement: 13 June - 4 September 2019 We know that the Urgent Care Centre in Welwyn Garden City is well used between 8am and 10pm. For this reason, we propose to exceed the national requirement and open for 14 hours a day (8am to 10pm), which is more than the minimum 12 hours required by NHS England.

Advantages of the proposal to close the UCC Disadvantages of this proposal at 10pm every night

• Clinical staff at the Urgent Care Centre • The very small number of patients who would be freed-up to work in A&E at the have minor injuries after 10pm would have Lister Hospital overnight, treating people to travel further to be seen if they needed with serious and life-threatening illnesses urgent treatment. and injuries. • Patients could no longer ‘drop in’ after • There would be a consistent range of 10pm and see a clinician. staff and services available to the public whenever the Urgent Care Centre is open. • The very small number of patients who attend the Urgent Care Centre overnight on • Children would be able to be seen foot would not have another local service whenever the Urgent Care Centre is open within walking distance. – rather than the current change in service overnight, providing clarity for the people who use these services.

• Opening hours would exceed new government requirements for minimum Urgent Treatment Centre opening hours.

• The UCC would remain open during the busy evening period.

qeiiucc.enhertsccg.nhs.uk 9 ABOUT THE URGENT CARE CENTRE

Currently open 24 hours a day, every day, the Urgent Care Centre at the New QEII Hospital sees patients with minor illnesses and injuries. It is staffed by:

• GPs • Emergency nurse practitioners and nurses • Receptionists • Administrators • Security personnel

The Urgent Care Centre sees around 118 people a day and offers a range of services, including x-ray.

Services at the Urgent Care Centre

East and North Hertfordshire NHS Trust is commissioned by the CCG to run the Urgent Care Centre at the New QEII Hospital in Welwyn Garden City and the Emergency Department (A&E) at the Lister Hospital in Stevenage. The Trust employs clinical staff at both locations.

Patients using the Urgent Care Centre can be x-rayed between 8am and 11pm, and have access to some tests and treatments. People who are seriously ill with life-threatening illnesses should call 999. They should not go to the Urgent Care Centre.

If very ill patients do arrive at the Urgent Care Centre, they are given emergency first aid if they need it and are redirected to an Emergency Department (A&E), in an ambulance if necessary.

10 Public engagement: 13 June - 4 September 2019 The Urgent Care Centre is very well used during the day by the local population, as well as people from the surrounding area. On an average day, approximately 118 people are seen at the Urgent Care Centre (based on 2016-17 figures), with most visiting between 8am and 10pm.

Please note 2016-17 attendance figures as supplied by East and North Hertfordshire NHS Trust are used throughout this document as this data is the most complete information available and broadly comparable to more recent data. A change in electronic record systems during 17-18 means that the accuracy of data for this year cannot be guaranteed.

What happens at the Urgent Care Centre overnight?

In order to staff the Urgent Care Centre safely, at least two members of clinical staff and a receptionist must be employed at all times, even when patient numbers are very low.

There is a national shortage of doctors and nurses which unfortunately affects NHS services across our area. A lack of appropriately skilled staff means that children cannot currently be seen between midnight and 8am at the Urgent Care Centre. The staff shortage also means that on a regular basis, adults with minor illnesses cannot be seen by a GP overnight and are redirected to the Lister Hospital or other appropriate service.

X-rays for patients with suspected fractures are available until 11pm.

If a child or adult urgently needs to be seen by a doctor overnight, an appointment can be made through the NHS 111 helpline team. NHS 111 advisers can also arrange for an ambulance to be sent if needed, or advise patients to attend A&E.

Who uses the Urgent Care Centre overnight?

A recent transport survey carried out by staff at the Urgent Care Centre shows that those people who do visit in the evening or overnight live in Welwyn Garden City or Hatfield. Almost all arrive by car with a minority arriving by taxi or on foot.

qeiiucc.enhertsccg.nhs.uk 11 GETTING HELP WHEN YOUR GP PRACTICE IS CLOSED

If you urgently need to see a GP or nurse when your surgery is closed, NHS 111 can book an appointment for you overnight, arrange a telephone consultation or visit from a GP or specialist nurse, or call an ambulance if you need one. Below is information about the range of local NHS services available when your GP practice is closed. These details may be useful when you give your views.

NHS 111

The local NHS 111 service now offers a wider range of services as part of an ‘integrated urgent care service’. This means that more people calling NHS 111 can now speak directly to a healthcare expert, such as a doctor, pharmacist, dentist or palliative care nurse, or be put in touch with a mental health professional.

If you urgently need to see a GP or nurse when your surgery is closed, NHS 111 can book an appointment for you overnight, arrange a telephone consultation or visit from a GP or specialist nurse, or call an ambulance if you need one.

Emergency GP appointments can take place at the patient’s own home if they are too ill to travel, at their Welwyn Garden City base, or at another base in the east and north Hertfordshire area, such as in Hertford or Bishop’s Stortford. NHS 111 can also arrange for an interpreter to talk to you in your first language, arrange for a British Sign Language interpreter to sign with you, or communicate with you through Typetalk or textphone by calling 18001 111.

12 Public engagement: 13 June - 4 September 2019 Appointments with NHS 111 GPs are always booked in advance. Each patient’s clinical needs are carefully assessed, following tried and tested questions. This makes the best use of each patient’s time, as well as GPs’ time. NHS 111 GPs spend some time each night travelling to patient’s homes, advising patients over the phone and seeing people who have booked appointments in local out- of-hours bases.

There are no proposals to change this service.

GP extended hours

We know that some people use urgent care services, such as the New QEII’s Urgent Care Centre, or even A&E, because they find it difficult to get a routine appointment with their GP or practice nurse at a time that fits in with their work or caring responsibilities.

To tackle this problem, we have worked with the GP practices in east and north Hertfordshire to put in place evening and weekend appointments which everyone can book into.

Extended hours appointments mean that it is now possible for all patients to book to see a GP or practice nurse from 8am-8pm on weekdays, from 8am-4pm on Saturdays and 8am-12pm on Sundays.

Improved X-ray availability at the Cheshunt Minor Injuries Unit

The Urgent Care Centre is used by people from a wide area, including people from Cheshunt. X-ray facilities at the Cheshunt Minor Injuries Unit are now open from 9am-6pm, seven days a week, which is a real improvement for people in the area. They no longer need to travel to the Urgent Care Centre in Welwyn Garden City or to services in Enfield between these times.

qeiiucc.enhertsccg.nhs.uk 13 NATIONAL CHANGES TO URGENT CARE

NHS England’s plans for urgent care services across the country

NHS England is standardising urgent care across the country, to make it easier for the public to understand the services on offer, and how to use them appropriately. As a result, a decision has been made that in future, centres offering services like those on offer at the New QEII Hospital will be called ‘Urgent Treatment Centres’, rather than Urgent Care Centres.

NHS England decided that people should be able to visit Urgent Treatment Centres that are open at least 12 hours a day, with access to tests like urine tests, heart tests (ECGs) and in some cases X-ray facilities. The Urgent Care Centre at the New QEII already offers all of these tests and we propose to open the Urgent Care Centre for 14 hours each day, exceeding this national requirement.

Similar Urgent Treatment Centres in Hertfordshire and in neighbouring counties are not open overnight.

URGENT TREATMENT CENTRE OPENING HOURS

Chase Farm Hospital, Enfield 8am – 9pm, every day

Hemel Hempstead Hospital 8am – 10pm, every day

Luton Town Centre Surgery and UTC 8am – 8pm, every day

Bedford Hospital South Wing 11am – 11pm, every day

NHS England has made it clear that as well as offering ‘walk-in’ services, people must be able to book appointments at Urgent Treatment Centres by ringing NHS 111. This is now the case at the New QEII, reducing uncertainty for patients about how long they will have to wait before they are treated.

Urgent Treatment Centres must work in conjunction with the ambulance service, NHS 111, local GPs, hospital A&E services and other organisations that provide health and care services.

You can find out more about NHS England’s plans by visiting www.england.nhs.uk and searching for ‘UTC standards’.

14 Public engagement: 13 June - 4 September 2019 WHAT HAPPENS NEXT?

We will be holding drop-in information events and public meetings across the area this summer, open to anyone who wants to find out more about this proposal and give their views, either in person or by filling in a questionnaire.

Your views, letters and questionnaire responses will be gathered and collated by an independent market research company, Opinion Research Services. Opinion Research Services will produce a report which will be presented to the Governing Body of East and North Hertfordshire CCG. This report will be made public on the CCG’s website.

A decision will be made by the Governing Body at a meeting held in public in Welwyn Garden City. Details of the decision-making timetable will be made available over the summer.

qeiiucc.enhertsccg.nhs.uk 15 If you have a question about any of the engagements or consultations we are running or would like any of the information in a different format (for example larger print, easy read or translated into a different language) then please call: 01707 685 397 or email: [email protected]

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Si vous souhaitez plus d’informations sur l’une de nos activités d’engagement ou si French vous souhaitez une traduction dans une autre langue, veuillez appeler le 01707 685 397 ou envoyer un courrier électronique à: [email protected]

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Bengali

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16 Public engagement: 13 June - 4 September 2019

CONFIDENTIAL WHEN COMPLETE Forms will be independently processed by Opinion Research Services (ORS)

Possible changes to opening hours at the New QEII Hospital Urgent Care Centre ENGAGEMENT QUESTIONNAIRE

NHS East and North Hertfordshire Clinical Commissioning Group (the CCG) want to hear your views about a proposed change to the opening hours at the Urgent Care Centre for minor injuries and minor illness, which is part of the New QEII Hospital in Welwyn Garden City. Please read the engagement document and/or go online to https://qeiiucc.enhertsccg.nhs.uk/ for further information. For a printed copy of the information or to ask questions about the engagement being run by the CCG, call 01707 685 140 or email: [email protected] To give your feedback, complete this questionnaire and return it FREEPOST to arrive by 4 September 2019 or complete the online questionnaire via the webpage above by the same date. NHS East and North Hertfordshire CCG has appointed ORS, an independent social research company, to manage the engagement and questionnaire responses and will faithfully report the outcomes. Information will only be used to inform this consultation and any personal information that could identify you will be kept in line with the NHS retention and disposal schedule and guidance, after any decisions have been finalised. Please visit https://www.england.nhs.uk/publication/corporate- records-retention-disposal-schedule-guidance for more details. The views of individual members of the public in a personal capacity will be anonymous. However, where feedback is from representatives of organisations or someone acting in an official capacity, it may be attributed to them. All the questions are optional, and all information you provide will be processed by ORS in accordance with the Data Protection Act and GDPR. Please visit www.ors.org.uk/privacy and/or https://www.enhertsccg.nhs.uk/privacy for more information.

The Urgent Care Centre for minor injuries and illness at the New QEII Hospital in Welwyn Garden City opened in May 2015. In the last 12 months, when have you used this service, if at all …? PLEASE TICK  ALL BOXES THAT APPLY For a family member For myself Never or someone I care for

During the daytime (Between 8am and 10pm)

Overnight (Between 10pm and 8am)

Challenges facing the Urgent Care Centre at the New QEII Hospital Please read the CCG’s engagement document for more information East and North Hertfordshire CCG is concerned about several challenges related to keeping the Urgent Care Centre (UCC) for minor injuries and illness open all the time at the New QEII Hospital:  There is a national shortage of doctors and nurses that affects NHS services across the country. This has an impact on the care that East and North Hertfordshire NHS Trust, the organisation which runs the Lister Hospital in Stevenage and the UCC in Welwyn Garden City, can deliver.  Because of recruitment difficulties, there is no GP at the Urgent Care Centre after midnight so patients who need to see a doctor are referred elsewhere.  The local Accident and Emergency service at the Lister Hospital treats more serious cases and faces significant ongoing staffing challenges.  Even though less than one person an hour uses the Urgent Care Centre between 10pm and 6am, two highly trained clinical staff must be on duty at all times.  From 11pm onwards, patients cannot be X-rayed at the Urgent Care Centre.  Between midnight and 8am, children cannot be treated at the Urgent Care Centre.

To what extent do you agree or disagree that East and North Hertfordshire CCG needs to make changes to respond to these challenges? PLEASE TICK  ONE BOX ONLY

Strongly Tend to Neither agree Tend to Strongly Don’t agree agree nor disagree disagree disagree know

Aims and principles regarding urgent care provision in the East and North Hertfordshire CCG area  Please read the CCG’s engagement document for more information

The CCG is considering making changes to the opening hours of the Urgent Care Centre at the New QEII Hospital to address the challenges above, bearing in mind these principles:  Urgent care and emergency health services should be high quality and reliable.  Advice should be readily available and health services should be easy to use and understand.  We should make the best use of clinically trained staff to treat as many patients as possible.  Highly skilled staff should be available to care for patients who are very ill and facing life- threatening emergencies.  A consistent range of services should be provided whenever the UCC is open to reduce confusion.  The UCC should be open in excess of the government’s 12-hour minimum guidelines.  The UCC should be open during the early evening when it is well used by patients.

To what extent do you agree or disagree that the principles identified by the CCG are appropriate? PLEASE TICK  ONE BOX ONLY Strongly Tend to Neither agree Tend to Strongly Don’t agree agree nor disagree disagree disagree know

Proposed changes to UCC opening hours at the New QEII Hospital Please read the CCG’s engagement document for more information

To address the challenges identified and achieve its aims, the CCG is proposing to close the Urgent Care Centre between 10pm and 8am each night. Under this proposed change:  The UCC would be open from 8am until 10pm every day, treating people of any age.  Patients arriving before 10pm would be seen and treated for up to two hours after closing time.  Additional highly skilled medical staff would be made available when the UCC is open.  Patients with minor injuries may have to travel further to receive medical treatment overnight.  Urgent GP appointments would still be available out-of-hours in the local area for people who need them, through calling NHS 111.  East and North Hertfordshire NHS Trust could relocate UCC staff to the Lister Hospital’s Accident and Emergency department in Stevenage overnight, where they could help more patients. To what extent do you agree or disagree with the proposal to reduce the New QEII Urgent Care Centre’s opening hours so that it is only open between 8am – 10pm each day? PLEASE TICK  ONE BOX ONLY Strongly Tend to Neither agree Tend to Strongly Don’t agree agree nor disagree disagree disagree know

If you disagree, please explain the reasons in the box below and continue on another sheet if necessary.

As a public body, NHS organisations have a duty to take into account the impact of their decisions on people with protected characteristics under the Equality Act 2010 (age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation), as well as the Human Rights Act 1998. Are there any groups protected under the Equality Act 2010 which you believe will be positively or negatively affected by the proposed changes? If so, what could be done to enhance the positive impacts or reduce any negative impacts? Please write below and continue on a separate sheet if necessary.

If you have any other comments or alternative suggestions on how the CCG should address the challenges caused by staff shortages, please write below and continue on a separate sheet if necessary.

Information About You

If you are responding on behalf of an ORGANISATION, which organisation do you represent? Please give us the name of the organisation and any specific group or department. Please also tell us who the organisation represents, what area the organisation covers and how you gathered the views of members. PLEASE ANSWER IN THE BOX BELOW AND CONTINUE ON A SEPARATE SHEET IF NECESSARY

If you are providing your own PERSONAL RESPONSE, please answer the questions below… The NHS has a duty to promote equality and wants to make sure all parts of the community are included in this engagement, but these questions are optional. All engagement responses will be taken fully into account when making decisions, regardless of whether you provide your details. Please provide your full postcode This will help us understand views in different areas.

PLEASE TICK  ONLY ONE BOX FOR EACH QUESTION What gender do you identify as? Do you have any dependent children aged Male Female under 18? Other (if you would like to, please say) Yes No

Prefer not to say Prefer not to say Are you currently pregnant or providing What was your age on your last birthday? maternity care for a new-born baby? Under 25 55 to 64 Yes 25 to 34 65 to 74 No 35 to 44 75 to 84 Prefer not to say 45 to 54 85 or over Do you look after, or give any help or support to Prefer not to say family members, friends, neighbours or others Do you consider yourself to have a disability? because of long-term physical or mental ill-health/ Yes disability or problems relating to old age? No Yes Prefer not to say No Prefer not to say How would you describe your ethnic origin? White Are you employed by the NHS? Mixed or multiple ethnic groups Yes Asian or Asian British No Black, African, Caribbean or Black British Prefer not to say Any other ethnic group Prefer not to say

THANK YOU FOR YOUR TIME Please return the questionnaire by 4th September 2019 to: Opinion Research Services  FREEPOST SS1018  PO Box 530  Swansea  SA1 1ZL

© Opinion Research Services TDUN01100000A57 Agenda Item No: 7

Date of Meeting: 24th October 2019

Governing Body Meeting in Public

Paper Title: Equality Impact Assessment

Decision or Approval Discussion Information

Report author: Nuala Milbourn, Assistant Director Communications and Engagement Report signed off by: Sheilagh Reavey, Director of Nursing and Quality

Executive Summary: This final equality impact assessment (EIA) takes account of the activities East and North Hertfordshire CCG (the CCG) has undertaken since the CCG’s proposal to close the Urgent Care Centre overnight between 10pm and 8am was put to the public in June 2019.

The initial EIA has been reviewed and updated with the information obtained during the subsequent 12 week public engagement process undertaken by the CCG.

An equality impact assessment is the process of assessing the impact of a proposal and its consequences for equality. There is a legal obligation to undertake EIAs to assess the impact of proposals on groups identified by the Equality Act 2010 (called protected characteristics). These groups are as follows:

Age Disability Gender reassignment Disability Marriage and civil partnership Pregnancy and maternity Race Religion and belief Sex Sexual orientation Carers* (this group is not identified by the Equality Act 2010 but is considered by the CCG to require particular consideration).

Equality analysis is a way of considering the effect of a proposed policy on different groups.

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This is to: • consider if there are any unintended consequences for some groups • considering what evidence there is to support the decision and identifying any gaps.

It involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of an organisation’s functions, contracts, policies or decisions.

East and North Hertfordshire CCG is subject to the general public sector equality duty required by Section 149 of the Equality Act 2010. This states that the CCG must “have due regard to the need to: 1. Eliminate discrimination, harassment, victimisation, and any other conduct prohibited by the Act 2. Advance equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it 3. Foster good relations between persons who share a relevant protected characteristic and persons who do not share it.”

This involves: • Removing or minimising disadvantages experienced by people due to their protected characteristics • Taking steps to meet the needs of people from protected groups where these are different from the needs of other people • Encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low.

Carrying out an equality impact assessment helps the CCG to make sure it has considered the needs of people with protected characteristics. This means it can:

• identify unintended consequences and mitigate them as far as possible • actively consider how the proposed change might support the advancement of equality and fostering of good relations.

Recommendations . To note to the members:

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Conflicts of Interest None. involved:

Conflict of Interest Definitions

The following table describes the sub-classifications of interests:

Type Description Financial Interests This is where an individual may get direct financial benefits from the consequences of a commissioning decision. Non-Financial This is where an individual may obtain a non-financial professional benefit Professional Interests from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. Non-Financial This is where an individual may benefit personally in ways which are not Personal Interests directly linked to their professional career and do not give rise to a direct financial benefit. Indirect Interests This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non- financial personal interest in a commissioning decision.

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Equality Analysis – Full Equality Impact Assessment This template is an adapted version of the NHS England Equality template which was published in September 2014 and is the current standard.

Version Date of Reason for review and updates Person reviewing review made

V0.1 November First draft Paul Curry, Equality 2018 and Diversity Lead,

East and North Hertfordshire CCG v.02 October Revised in the light of the CCG’s Paul Curry, Equality 2019 public engagement process. and Diversity Lead,

East and North Hertfordshire CCG

Proposal to change the opening hours of the Urgent Care Centre at the New QEII Hospital, Welwyn Garden City

About this document – the role of an equality impact assessment

This final equality impact assessment (EIA) takes account of the activities East and North Hertfordshire CCG (the CCG) has undertaken since the CCG’s proposal to close the Urgent Care Centre overnight between 10pm and 8am was put to the public in June 2019.

The initial EIA has been reviewed and updated with the information obtained during the subsequent 12 week public engagement process undertaken by the CCG.

An equality impact assessment is the process of assessing the impact of a proposal and its consequences for equality. There is a legal obligation to undertake EIAs to assess the impact of proposals on groups identified by the Equality Act 2010 (called protected characteristics). These groups are as follows:

Age Disability Gender reassignment Disability Marriage and civil partnership Pregnancy and maternity Race Religion and belief Sex Sexual orientation Carers* (this group is not identified by the Equality Act 2010 but is considered by the CCG to require particular consideration).

Equality analysis is a way of considering the effect of a proposed policy on different groups.

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This is to: • consider if there are any unintended consequences for some groups • considering what evidence there is to support the decision and identifying any gaps.

It involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of an organisation’s functions, contracts, policies or decisions.

East and North Hertfordshire CCG is subject to the general public sector equality duty required by Section 149 of the Equality Act 2010. This states that the CCG must “have due regard to the need to: 1. Eliminate discrimination, harassment, victimisation, and any other conduct prohibited by the Act 2. Advance equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it 3. Foster good relations between persons who share a relevant protected characteristic and persons who do not share it.”

This involves: • Removing or minimising disadvantages experienced by people due to their protected characteristics • Taking steps to meet the needs of people from protected groups where these are different from the needs of other people • Encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low.

Carrying out an equality impact assessment helps the CCG to make sure it has considered the needs of people with protected characteristics. This means it can: • identify unintended consequences and mitigate them as far as possible • actively consider how the proposed change might support the advancement of equality and fostering of good relations.

Introduction

The local context:

NHS East and North Hertfordshire Clinical Commissioning Group (the CCG) is the organisation responsible for making sure that the 597,000 people in our area get the medical help, care and treatment that they need. This includes GP services, most planned hospital and community health services, mental health services and urgent and emergency care.

The CCG commissioned the Urgent Care Centre (UCC) for minor injuries and minor illness at the New QEII Hospital. The service opened in 2015 and is very well used overall, with an average of 118 people attending the centre every 24 hours.

However, data collected locally and verified by the national body, NHS England, shows that the service is not well used overnight. Between 10pm and 8am, less than one person per hour on average uses the UCC.

Due to ongoing recruitment difficulties, there is currently no doctor at the Urgent Care Centre after midnight. People who need to see a doctor between midnight and 8am therefore cannot ‘drop in’ to see one as they do during the day.

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The UCC is staffed overnight by highly skilled nursing staff from East and North Hertfordshire NHS Trust, with a minimum of two clinical staff on duty at all times for patient and staff safety reasons. These staff treat an average of one patient each every two hours between 10pm and 8am. The same staff members would be expected to treat between 3-6 patients per hour each in an Accident and Emergency department, depending on the acuity of the needs of those patients.

The current staffing model means that children cannot be seen by the UCC’s nurses between midnight and 8am.

X-rays are not available at the Urgent Care Centre after 11pm. Patients with minor injuries requiring an X-ray after 11pm need to attend an alternative location, such as the Lister Hospital in Stevenage, or wait until services resume at 8am.

The change in services available during the day and overnight at the UCC is not always widely understood by people in the local area. This means that some patients attend the centre with a need that cannot be met at that time and have to be directed to an alternative service, such as NHS 111 or the Lister Hospital.

We know that some patients currently wait longer to be seen at the Lister Hospital A&E department than is ideal. For this reason, East and North Hertfordshire NHS Trust supports the principle of re-allocating its scarce nursing resource from the UCC to the Lister Hospital overnight to help to meet demand.

For the reasons outlined above, between June and September 2019, the CCG engaged with the public, stakeholders and NHS staff on a proposal to close the UCC between 10pm and 8am. Under this proposal, patients who arrived before 10pm would be treated before the Urgent Care Centre closed for the night.

The national context: improving urgent and emergency care is one of the top priorities of the NHS. There is a continued focus on the need to treat all patients with an urgent or emergency care need in a timely way, in a setting that is appropriate to their needs. Local pilot projects are also underway to test new national treatment standards for those with the most serious and life-threatening injuries.

Our CCG works very closely with social care, acute hospital, ambulance service and GP colleagues to meet this requirement, against a difficult background of increasing demand, an ageing population and recruitment challenges.

New national guidance has been introduced by NHS England which requires all centres like the UCC to offer a standard set of services and to open for at least 12 hours a day, taking into account local demand:

“Urgent treatment centres should be open for at least 12 hours a day, seven days a week, including bank holidays, to maximise their ability to receive streamed patients who would otherwise attend an A&E department. Typically this will be an 8-8 service, but commissioners will wish to tailor to local requirements based on locally determined demand.”

The aim of this national guidance is to make it easier for the public to understand the services on offer, and to use them appropriately.

As a result, a decision has been made that in future, urgent services like those on

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offer at the New QEII Hospital will be re-designated as ‘urgent treatment centres’ (UTCs), rather than Urgent Care Centres (UCCs).

NHS England has also decided that by December 2019, patients and the public will be able to visit UTCs that are open at least 12 hours a day, with access to tests like urine tests, heart tests (ECGs) and in some cases X-ray facilities.

NHS England has made it clear that as well as offering ‘walk-in’ services, people must be able to book appointments at UTCs through NHS 111. This should reduce uncertainty for patients about waiting times for treatment. The public engagement process The CCG’s public engagement focused on the following areas: 1. The reasons behind the proposed closure of the QEII UCC between 10pm and 8am 2. The staffing issues faced by East and North Hertfordshire NHS Trust and the need for the CCG to commission services that make the best use of the limited numbers of clinical staff in the area 3. The alternative urgent and emergency services available to the public in the local area. The evidence to support the rationale for engaging on these areas can be found in the public engagement document. The independent research company ORS was commissioned by the CCG to collate and analyse the findings of the engagement process. This report is included in the Governing Body papers where it can be viewed in full. As a result of the engagement process, two options have been brought forward for consideration by the Governing Body. Option 1 is to proceed to close the Urgent Care Centre in line with the proposal outlined in the engagement document. Option 2 is to keep the Urgent Care Centre at the New QEII Hospital open overnight until 31 March 2020 and implement a communications campaign to raise public awareness of the service and the wider urgent care and out-of-hours services available to the public. Any plan to retain the 24/7 opening hours at the UCC would need to demonstrate that the service remains viable, with sufficient, appropriate activity to justify the service remaining open through the night. The CCG will work with East and North Hertfordshire NHS Trust to quantify what levels of overnight activity represent a viable ongoing service. As such, patient activity numbers at the UCC would be reviewed at the end of March 2020 in order for the Governing Body to make a final decision on opening hours in April 2020.

What are the intended outcomes of this work?

Option 1

If the Governing Body decides to pursue Option 1, the CCG’s intended outcomes are as follows:

• A comprehensive publicity campaign will raise awareness of the services available in their local area, planned changes to the opening times at the

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UCC and overnight closure implementation date. This should result in more people becoming aware of the range of services available, reducing the number of avoidable attendances at the UCC and the Lister Hospital. • The UCC will close to new ‘walk-in’ patients at 10pm every night. Patients who have already registered at the UCC prior to 10pm will be treated before the UCC closes for the night. • The highly-qualified nursing staff who currently work at the UCC overnight will be re-allocated to work at the Lister Hospital’s Accident and Emergency department. It is intended that this staffing increase will have a positive impact on patient experience and outcomes in terms of waiting times at A&E. • Very senior nurses, called ‘advanced nurse practitioners’ will be recruited to increase the skill-mix of the staff who work at the UCC during opening hours. • The UCC will be officially re-designated as a UTC, in line with national guidance. • The services offered at the UCC will be the same throughout the hours during which it is open. Currently the availability of services varies depending on the time of day (e.g. X-ray closes at 11pm, children cannot be treated between midnight and 8am, there is no doctor available at the UCC to see patients who have ‘walked in’ after midnight). This consistency should improve public understanding of the services offered at the UCC.

Option 2

If the Governing Body decides to pursue Option 2, the intended outcomes are as follows:

• A comprehensive publicity campaign will raise awareness of the urgent, emergency and out-of-hours NHS services available in the local area, including those currently available at the 24/7 UCC. The CCG will seek to enlist the support of local stakeholders, such as local government representatives, to support this campaign. • The UCC will be officially re-designated as a UTC, in line with national guidance. • The CCG will work with East and North Hertfordshire NHS Trust to monitor attendance levels at the UCC until the end of March 2020. At this stage, a decision will be taken as to whether attendances have reached a level at which the continued overnight opening of the UCC can be justified.

How will these outcomes be achieved?

Following the Governing Body’s decision, either the Option 1 or Option 2 outcomes will be achieved in partnership with the CCG’s partner organisations – specifically East and North Hertfordshire Trust, (the operator of the UCC) Herts Urgent Care (the operator of Hertfordshire’s NHS 111 service) and local stakeholders.

The public awareness campaigns necessary to support either Option 1 or Option 2 will draw on the findings outlined in the engagement report. The ‘frequently asked questions’ document produced and regularly updated during the course of the public engagement process will be used to inform the CCG about services which residents find confusing or difficult to access. These questions and answers are hosted here on the CCG’s website: https://qeiiucc.enhertsccg.nhs.uk/faqs

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Who will be affected by this work?

Service users accessing the UCC

If the Governing Body decides to move to close the UCC overnight, people who want to access the services currently provided there between 10pm-8am will be affected.

Service users who need to see a doctor overnight will still be able to use NHS111 who will triage and, if required, offer the patient a telephone consultation with a clinician, an appointment at an out-of-hours base, a home visit, or will direct the patient to the emergency services if necessary. An out-of-hours GP base will continue to be located at the QEII Hospital. However patients who have a minor injury that requires treatment that cannot wait until the morning will need to travel to an Accident and Emergency department. Usage figures suggest that the number of patients that meet this criteria is very small.

If the decision is taken to close the UCC overnight, ENHT has committed to recruit very highly trained ‘Advanced Nurse Practitioners’ (ANPs) to add to the skill-mix of the staff working at the UCC during the day. ANPs are able to see and treat a wide range of patients, including patients who can currently only be seen at the UCC by a GP. This should help to reduce waiting times for patients who attend the UCC because they have a minor illness and cannot be treated by nursing staff. Detailed analysis has been undertaken to ensure that an ANP can treat the vast majority of patients currently seen by a GP. The national UTC guidelines require the unit to have GP leadership.

Service users accessing the Lister Hospital

If the Governing Body decides to pursue Option 1, it is expected that there will be a positive impact on service users attending the Lister Hospital Accident and Emergency department overnight as staffing levels will increase. This should result in an improved patient experience and outcomes as waiting times should reduce.

Staff

Depending on the outcome of the Governing Body meeting in October 2019, East and North Hertfordshire NHS Trust (ENHT) staff may be relocated to Lister A&E overnight. As the nursing staff currently rotate between both sites and are employed by ENHT who provide both services, it is not felt that this will pose a significant issue for this group. The Trust will need to engage with all affected staff (including administrative staff) to understand and explore any issues with them in the light of the Governing Body’s decision.

The Trust will also need to engage with the facilities management company who provide services at the New QEII Hospital to determine whether either option is likely to affect their staffing needs.

Partner organisations

Herts Urgent Care (HUC)

HUC is the organisation that operates the NHS 111 service in Hertfordshire. Both options before the Governing Body require a publicity campaign to increase awareness of urgent and out-of-hours services, including NHS 111. As a result, we can reasonably expect to see an increase in the number of calls to NHS111.

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This increase is in line with the CCG’s drive to increase public awareness of the range of NHS services accessible to patients online and over the phone, reducing unnecessary journeys by providing the assurance that patients need.

HUC operates the out-of-hours GP base located at the New QEII Hospital. The out- of-hours GP base will remain open as usual and will continue to be one of the locations where booked GP appointments, accessible through NHS 111, can take place. If the decision is made to close the UCC overnight, HUC employees staffing the out-of-hours base may be required to redirect any patients who are not aware of the change of opening hours at the UCC and have attended without a booked appointment.

There will need to be a clear process in place, agreed with HUC, to ensure patients who arrive at the UCC in error are re-directed appropriately and safely.

Evidence

What evidence have you considered?

In order to update this assessment, information has been drawn from a wide range of sources, including the comprehensive 12 week public engagement process:

Questionnaire As part of the engagement process, demographic data was collected with the permission of respondents to the CCG’s questionnaire. This has provided further insight into whether specific groups of protected characteristics who responded to the questionnaire view the impact of the CCG’s proposal in different ways. Responses have been analysed and incorporated into the Opinion Research Services report which forms part of the outcomes and recommendations report.

Responses relating to specific groups of protected characteristics are referenced in the relevant section below.

Focus groups During the engagement process, in order to provide thoughtful consideration of the CCG’s proposals by a representative sample of ‘ordinary’ members of the public, ORS recruited and facilitated two focus groups in August 2019. The purpose of these deliberative sessions was to allow ORS and NHS East and North Hertfordshire CCG to engage with, and listen to, members of the public about the proposed changes to the UCC and related issues - so that the participants would become more informed about the process, the case for change and the principles that form the basis of the proposal.

The focus groups were inclusive (encompassing a representative sample of the population of east and north Hertfordshire), not self-selecting (randomly recruited), relatively well-informed (following a presentation of the key issues and potential options by an expert CCG staff member with responsibility of urgent care services) and fairly conducted (through careful facilitation by ORS).

Concerns raised by focus group attendees about particular protected characteristics have also informed the relevant sections below.

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Age

The table below details the breakdown in ages of patients attending the UCC in 2016/17.

Age Band Total Child 0-1 927 Child 1-5 3,662 Child 5-16 7,365 Adult 16+ 32,200 Grand Total 44,154 Data source – 2016/17 enhanced trust-wide data set supplied by E&NHT

The information we hold about the age groups of people who use the Urgent Care Centre shows that children are frequent users of the UCC.

However, as children are currently not able to be seen between midnight and 8am at the UCC because there is no GP present, only those children who would have attended between 10pm and midnight would be affected if the decision is made to close the UCC at 10pm. If the proposal to close the UCC at 10pm goes ahead, patients of all ages will be able to be seen at the UCC during the time that it is open.

We will continue to work with agencies such as Hertfordshire County Council, family centres and schools to communicate to parents, carers and guardians the steps they need to take to access urgent medical help overnight for children. Children requiring a GP appointment out-of-hours will still be able to be seen at the UCC, as long as they have an appointment booked through the NHS 111 service.

The Welwyn Hatfield locality is home to the University of Hertfordshire. The vast majority of students will be registered with the university medical centre, but some, particularly those who may not be familiar with the area, may attend the UCC seeking urgent help. A national TV advertising campaign is due to launch in October 2019 promoting NHS 111 encouraging people to call the service or visit 111.nhs.uk, instead of worrying, self-diagnosing, or second-guessing what action to take with an urgent health problem. This campaign is targeted at those groups that NHS data show to be more frequent users of A&E departments, such as young adults. The CCG will reinforce this campaign with extensive local promotion of the Hertfordshire NHS 111 service.

We have carefully considered the number of concerns raised by individuals and stakeholders during the engagement period about how the proposal may affect older people, particularly with regard to those who do not have their own transport or who have limited mobility. Our attendance data shows that those aged 75 and upwards are the age group which uses the Urgent Care Centre the least. This could perhaps be because older people are more likely to seek help from the familiar surroundings of their GP practice or may be because older people are less likely to be able to

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navigate the healthcare system. “Less than half (46%) of the elderly population have the confidence they know how to access the health and care system.”[1] Because this older age group are already infrequent users of the service, we do not anticipate that any overnight closure would negatively impact on this cohort of patients.

Those aged 65 and over were the most common respondents to our engagement questionnaire (26% of all completed questionnaires). This age group was also the most supportive of the proposal to close the Urgent Care Centre overnight, with 52% in agreement.

Disability

Around 15,900 people in Welwyn Hatfield2 stated that they had a long-term health problem or disability that limited their day-to-day activities to some extent. This is around 14% of the borough’s population.

Latest estimates 3 suggest there are around 24,400 people in Hertfordshire who have a learning disability. The vast majority of these people are supported by Hertfordshire County Council’s Adult Disability Teams, who help service users with a learning disability to look after their health and access services.

The Urgent Care Centre does not routinely collect information about a patient’s disability when they attend to use the service, so there is no data available to show how many patients who use the UCC have a disability. There is no evidence that the overnight service is used more by those with a long term condition. Routine long term condition care is supported through primary care or specialist teams with the expert knowledge that the patient requires.

15% of those who responded during the engagement process declared they have a disability. Of those, 38% agreed with the proposal to close the UCC overnight and 61% disagreed. Concerns were raised in the engagement responses about the impact on people with disabilities who would have to travel further to access health services overnight and might not have access to a car or be able to afford to order a taxi.

However, should the Urgent Care Centre close overnight, it is not anticipated that this will affect those with a disability disproportionately more than other groups.

This is because: • access to a GP and urgent medical help will still be available at all times of the day or night by calling NHS 111 or using NHS 111 online. A textphone 111 service is also available for those with a hearing impediment. For those who are unable, due to their disability, to reach a local out-of-hours base to see a clinician, home visits by a GP are available • the recent transport survey carried out by staff at the Urgent Care Centre shows that those people who do visit in the evening or overnight live in Welwyn Garden City or Hatfield. Almost all arrive by car, with a minority arriving by taxi or on foot

[1] Khaldi, A (2013), A question of behaviours, cited by the NHS Confederation. 2 2011 census data (latest available figures) 3 https://www.poppi.org.uk and https://www.pansi.org.uk/

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• should the Governing Body agree to make changes to the opening hours, we will work with the Adult Disability Teams who provide help and support to those with a learning disability to ensure information about the change, plus information about the range of health services on offer, forms part of a person’s ‘purple folder’ in a suitable ‘easy read’ format. This information would also reference the impending change in name from a UCC to a UTC.

Gender reassignment (including transgender)

The Equality Act 2010 protects anyone proposing to undergo, anyone who is undergoing or has undergone a process for the purpose of reassigning the person's sex. It is therefore important this is clearly understood and followed within NHS services, for both patients and staff who are transgender.

There is no data available on the usage of the UCC overnight by transgender people but it is not anticipated that closing the UCC overnight would negatively impact a person on the basis of his / her / their gender.

Marriage and civil partnership

Because this provision within the Equality Act applies to employment matters only, this is not relevant to this EIA.

Pregnancy and maternity

Around 5,500 women give birth at our area’s maternity service at the Lister Hospital every year.

The Urgent Care Centre does not offer specific care for pregnancy-related concerns. Pregnant women who experience pregnancy-related health issues are advised to contact their maternity service for support. This information is provided in women’s patient-held notes and is reinforced by community midwives.

Therefore it is not anticipated that any overnight closure would negatively impact this group of patients.

It should be noted that less than 50% of those people who responded to the CCG’s questionnaire and declared that they were pregnant or providing maternity care agreed with the proposal to close the UCC between 10pm-8am.

Race

The available data for east and north Hertfordshire (2011) suggests that around 10% of the population are from a black or minority ethnic background. In Welwyn Hatfield this proportion increases to around 23%. 6

6 https://www.welhat.gov.uk/media/9345/Demographic-profile-of-Welwyn- Hatfield/pdf/Demographic_Profile_-_2018.pdf?m=636749457850500000

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92% of respondents to our engagement questionnaire defined their ethnicity as White British with 8% being from a black or minority ethnic (BME) background.

The majority of patients attending the unit are white British (72%) and this is comparable with the figure for the Welwyn Hatfield area (76%) and Hertfordshire as a whole (80.82%). 7

No evidence has been put forward to suggest that different options for opening hours will impact on ethnic groups in a way that is different from the population as a whole.

In 2011, 91.44% of Welwyn Hatfield residents had English as their main language. Approximately 1% of residents did not have English as a main language and could not speak English well. 0.13% of residents could not speak English at all. 8 The need to provide information about alternative services in different languages was raised during the engagement process. The requirement to re-name the service may impact on groups whose first language is not English.

Gypsy and traveller communities are known to sometimes encounter difficulties in registering with a GP surgery and therefore might be more likely to visit hospital- based services like A&E, urgent care centres or minor injuries units as a viable alternative. 10 There are 57 public and private pitches for the gypsy and traveller community in the borough of Welwyn Hatfield (2018).11 If the UCC were to close overnight the CCG will need, through the Hertfordshire Gypsy Service, to provide information on NHS 111 in an accessible format to ensure that this community is able to access urgent care for themselves and their family.

65% of non-white respondents to our questionnaire stated that they would not agree with the proposal to close the UCC between 10pm-8am.

The Urgent Care Centre has access to a telephone interpreting service to support consultations with patients who would find it difficult to communicate their health concerns in English. Patients can also access the Language Line service.

Dependent on the Governing Body’s decision, posters, leaflets and other communications materials will be provided and we will work with other local stakeholders to ensure that messages reach the appropriate audiences. Should there be a change in overnight provision, the CCG would look to provide signage at the UCC in the most commonly spoken languages, advising people to call NHS 111 when the service was closed. We would also work with community leaders to get this message widely circulated.

7 Data sources – 2016/17 enhanced trust-wide data set supplied by E&NHT and Office for National Statistics, 2011 Census data 8 https://www.welhat.gov.uk/media/9345/Demographic-profile-of-Welwyn- Hatfield/pdf/Demographic_Profile_-_2018.pdf?m=636749457850500000 10 http://eprints.brighton.ac.uk/8893/1/FFT_published_Report_.pdf 11 https://www.welhat.gov.uk/media/13613/EX76-WHBC-GTAA-2016-Updated-March- 2018/pdf/EX76__WHBC_GTAA_2016_Updated_March_2018.pdf?m=636622467670100000

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Religion or belief

There is no evidence to suggest that the issue of opening hours would impact on people differently according to their religious belief or non-belief.

Sex

The available data shows that there is a relatively even split between men and women accessing the services available at the UCC.

The table below details the breakdown between male, female and not specified.

Sex Total Male 21,268 Female 22,885 Not specified 1 Grand Total 44,154 Data source – 2016/17 enhanced trust-wide data set supplied by E&NHT

Public engagement questionnaire responses

A higher proportion of men than women strongly disagreed with the proposal to close the Urgent Care Centre between 10pm and 8am. However both men and women tended to disagree with the proposal to close the UCC between 10pm and 8am.

The UCC offers universal minor injury and minor illness services only. There are no maternity, well-man or well-woman services or clinics at the UCC that are specifically relevant to members of a particular protected characteristic.

Feedback from the public did not raise any specific issues relating to sex. Sexual orientation

It is not anticipated that this proposal would negatively impact on anyone on the basis of their sexual orientation. Services are accessible to all, regardless of their sexual orientation.

Feedback did not raise any specific issues relating to sexual orientation.

Other identified groups Carers

East and North Hertfordshire NHS Trust does not collect data on the number of carers who use the UCC.

Although carers are not included as one of the protected characteristics groups legislated for under the Equality Act, NHS East and North Hertfordshire CCG considers the impact of its policies and decisions on those who provide unpaid care for a family member or close friend and who define themselves as a ‘carer’.

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Public engagement questionnaire responses

65% of those respondents to our public engagement who identified themselves as having a caring role disagreed with the proposal to close the UCC between 10pm- 8am.

Carers who care for someone with a long term condition that requires inpatient, emergency or critical care are not currently seen at the QEII UCC, so the proposal to close the UCC overnight should not have a direct impact on the care that their friend or family member currently receives.

Carers of children who need to access health services overnight will be able to contact NHS 111 to get advice and a booked appointment, if necessary, regardless of whether the UCC closes overnight or not.

The current service at the QEII UTC does not see children between midnight and 8am, therefore if the proposal to close the service at 10pm overnight went ahead, the service would be reduced by a two hour period only.

Engagement and involvement

How have you engaged stakeholders with an interest in protected characteristics in gathering evidence or testing the evidence available?

As part of the engagement process we have:

• followed NHS England national guidance on Urgent and Emergency Care • analysed information about when and why the Urgent Care Centre is used • engaged with parish, district, town and county councillors • had discussions with local politicians • worked with NHS England and neighbouring NHS organisations • taken advice from representatives of Hertfordshire County Council’s health scrutiny committee • talked to the patient representative organisation Healthwatch Hertfordshire • discussed key issues with local voluntary organisations • engaged with organisations that represent groups with protected characteristics • involved local GPs and patient group representatives.

How have you engaged stakeholders in testing the policy or programme proposals?

To recap, the engagement period ran between 13 June and 4 September 2019. During this period, residents and other stakeholders were invited, and given opportunities, to provide feedback, including: • a questionnaire which was available online; paper questionnaires were widely circulated and available on request. An easy read version was also available

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• two deliberative focus groups with members of the public both held at the CCG’s office at Charter House, Welwyn Garden City • engagement activities hosted by or attended by CCG representatives including drop-in sessions around the area and meetings • answering queries raised during the process through social media sites. Residents, stakeholders and organisations were also able to provide their views by writing to the CCG or ORS, and a petition was submitted. The objective was that those who gave feedback and asked questions in the engagement period had their questions/ queries answered as fully as possible, to help them feel assured the information provided sufficiently covered these.

For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs:

Full details of the engagement activities undertaken are including in the independent report produced by Opinion Research Services which is included at Appendix 2 of the Governing Body report.

Summary of analysis

Considering the evidence and engagement activity you listed above, please summarise the impact of your work.

In summary, the majority of the Hertfordshire population who responded to the engagement process agreed with the principles set out in the engagement document and recognised the need for change. However, the majority of those who responded disagreed with the proposal to close the Urgent Care Centre between 10pm-8am.

Observations noted through the engagement process are as follows:

• respondents who live in the Welwyn Hatfield area are more likely to disagree with the proposal to close the UCC between 10pm and 8am • those who responded saying that they have used the service at the UCC overnight are more likely to disagree with the proposal to close the UCC between 10pm and 8am • there was a lack of understanding amongst some residents of the range of urgent, emergency and out-of-hours services available in the local area • people who responded often highlighted concerns on behalf of other groups, such as older people. These concerns were not reflected in the same way by members of those groups in their own responses • people who were involved in face-to-face conversations in meetings, drop-ins and through facilitated focus groups and therefore had the ability to ask questions and find out more about the proposals and the range of alternative services available are more likely than others to agree with the proposal to close the UCC overnight.

The findings of the engagement process will inform the communications campaign which will support either the implementation of Option 1 or Option 2.

Particular attention will be paid to the need to communicate with groups known as

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‘hard to reach’ or ‘hard to hear’. The effectiveness of face-to-face and social media conversations as a way to engage effectively with groups who are otherwise less likely to get involved with policy development at the CCG has been noted and will inform the communications campaign.

Now consider and detail below how the proposals could support the elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups (the General Duty of the Public Sector Equality Duty).

Eliminate discrimination, harassment and victimisation East and North Hertfordshire NHS Trust has a policy and procedures in place to eliminate discrimination, harassment and victimisation.

Advance equality of opportunity

The engagement process highlighted that concerns about travel and access to urgent care services were raised as an issue for a number of respondents, who considered that a number of protected characteristics could be disproportionately affected by the proposal (age, disability). The CCG is not responsible for patient transport of this kind. However the CCG can encourage and work with partner organisations to bring this issue to their attention, in an effort to bring about improvements in public/voluntary transport provision.

It is important to note that if the proposed overnight closure of the UCC goes ahead, it will still be possible for residents to access urgent overnight health advice and GP appointments in Welwyn Garden City via the NHS 111 service.

Promote good relations between groups

There will be continued engagement with staff, stakeholders and the public through the mechanisms detailed earlier in the document.

If the Governing Body pursues Option 1 then a staff engagement process will commence in line with East and North Hertfordshire NHS Trust’s HR procedures and guidance.

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Next steps

A concerted effort to raise awareness of local NHS services will take place regardless of the option chosen by the Governing Body. However, a decision to proceed with Option 1 will require a carefully designed communications and engagement approach to ensure information about service changes is accessible to all groups with protected characteristics.

Local stakeholders – such as the local MP, parish, town, district and county councillors will be asked to support the CCG to ensure that essential messages about NHS services are disseminated widely across the population.

This completed EIA will be published on the CCG’s website and shared at the Governing Body meeting in public on 24 October 2019.

Statement from the CCG’s Equality and Diversity Lead

Proposal to change the opening hours of the Urgent Care Centre at the New QEII Hospital, Welwyn Garden City

This equality impact assessment (EqIA) considers the two options being proposed. It provides significant and useful evidence from the public consultation that has taken place, including analysis by equality group where that information is available. It uses the evidence to identify potential impact.

It is worth nothing that there is a difference between a consulted group’s view on a proposal and the impact of that proposal on equality groups should it be implemented and decision makers should assure themselves that the impact identified and/or the assumptions made are reasonable.

Overall, it is likely that there is sufficient information in the EqIA to support decisions makers to be able to show Due Regard as required by the Equality Act 2010.

Paul Curry Equality and Diversity Lead 22 October 2019

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