Chris Best

South-East London Joint Health Overview and Scrutiny Committee

Formal Response to NHS England on the proposed reconfiguration of children’s cancer services

Authority



The South-East London Joint Health Overview and Scrutiny Committee (SEL JHOSC) is constituted in accordance with the Local Authority Public Health, Health & Wellbeing Boards and Health Scrutiny Regulations 2013 (the “Regulations”) and Department of Health Guidance to review and scrutinise any matter, including, when required, substantial reconfiguration proposals, relating to the planning, provision and operation of health services covering more than one Council area from within the South East London Integrated Care System (ICS). The South-East London ICS region consists of the London Boroughs of Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark.





The SEL JHOSC has agreed for its Chair and Vice Chair to send the Committee’s formal response to the proposed reconfiguration of children’s cancer services. Accordingly, we are writing to you in our respective capacities as the Chair and Vice-Chair of the SEL JHOSC outlining our views as below.

Background



In November 2021, a new service specification for children’s cancer PTCs (Principal Treatment Centre) and for paediatric oncology shared units was published. The key change in the new service specification was a requirement for each specialist children’s cancer PTC site to be on the same site as a paediatric intensive care unit for 0–15-year-olds. The current PTC serving children across Brighton and Hove, East Sussex, Kent, Medway, South London and most of Surrey is split across two sites- The Royal Marsden NHS Foundation Trust- Sutton site and St. George’s University Hospitals NHS Foundation Trust. The Royal Marsden does not have a paediatric intensive care unit or specialist children’s services (these services are located at St George’s), and the Committee were informed that there is no clinically or financially sustainable means to provide these services on the Sutton site. It was reported that to be compliant with the nationally agreed service specification, the way the services are currently being delivered needs to change, involving the relocation of services.



Since this service change and relocation of services affects multiple Council areas from within the South East London ICS, the SEL JHOSC was informed. In April 2023, the SEL JHOSC decided that this service change was a substantial variation and that they would like to be formally consulted on the proposed changes.



Following this decision, NHS England has continued to engage with SEL JHOSC on this service change proposal through formal meetings and informal briefings.



NHS England (London Region) worked with clinicians, parents, carers and other experts and undertook an options appraisal process, resulting in a short list of two location options-



· St George’s University Hospitals, the partner provider with The Royal Marsden of the current children’s cancer PTC; and

· Guys and St. Thomas’ NHS Foundation Trust’s Evelina children’s hospital, the largest specialist centre serving south London and the south east of England.



(With either option, services would cease at the Royal Marsden) Under both location options in the consultation, it was proposed that children’s conventional radiotherapy moves from The Royal Marsden to University College Hospital in Central London. Proton beam therapy is already provided at University College Hospital and bringing all radiotherapy services together in a larger centre would create opportunities to improve outcomes for children in the future (these proposals do not affect radiotherapy services for teenagers and young adults or adults provided at The Royal Marsden).



In June 2023, after undertaking further work to evaluate both options and based on the evidence provided, NHS England (London region) informed the SEL JHOSC that Evelina children’s hospital had emerged as the preferred option. However, it was also made clear that both options had scored highly and were viable. Therefore, the public consultation process would consult on both location options and a decision regarding the location of the future PTC would only be made after the conclusion of the consultation and after taking account of all other relevant factors.



The public consultation on this matter was launched on the 26th of September 2023 and closed at midnight on the 18th of December 2023. NHS England (London region) met with the SEL JHOSC members in November 2023 for a mid-point review of the consultation. Following this, a final report on the feedback received through the public consultation was presented at the formal SEL JHOSC meeting on the 1st of February 2024.



SEL JHOSC has considered all the evidence and information that it has received on this matter via formal meetings and informal briefings while formulating its formal response as set out below.



Formal response



We would like to thank NHS England officers for their active engagement with the SEL JHOSC. From December 2022 to February 2024, NHS England officers have utilised diverse communication channels, including regular email updates, informal briefings and formal meetings, to update the SEL JHOSC members. They have provided the Committee with comprehensive information and valuable insights that have helped the Committee formulate its formal response.In formulating this formal response, the SEL JHOSC has grouped its comments as follows- Travel and parking arrangements Accommodation and Other Incidental Costs



Workforce concerns Local support offer



Delivery timeline Public consultation feedback



Travel and parking arrangements







SEL JHOSC has consistently raised queries and voiced concerns about the impact of journey times on people required to travel to the two locations- Evelina hospital and St George’s hospital. During the mid-point review of the consultation, Members were informed that this concern was also emerging as a key theme through the public consultation.







In November 2023, NHS England officers informed the Committee that an independent travel analysis had looked at journey times and found that:







· For the vast majority of people in South East London, both Evelina children’s hospital and St George’s hospital were very similar or faster to get to by public transport compared to the Royal Marsden’s Sutton site.



· In terms of road transport, that for residents in most boroughs within South East London, a decrease in travel time would be seen for both St George's Hospital and the Evelina Children's Hospital compared to The Royal Marsden. However, residents of Bromley and Bexley would see an increase in travel time for driving on average for both potential future sites.



The Committee were also informed that to understand the impact on travel times of the proposal to move conventional radiotherapy services from The Royal Marsden to University College Hospital, an independent analysis was carried out. It compared travel times to The Royal Marsden and University College Hospital by car and by public transport for all children across the catchment area. This analysis found that University College Hospital would be faster to get to by public transport and slower by road than The Royal Marsden for most children in the catchment area.



SEL JHOSC had also previously expressed concerns about the existing parking facilities and parking arrangements at both proposed locations for the PTC and having dedicated parking for patients. However, it was noted that the interim Equality and Health Inequality Impact Assessment (EHIA) included a range of recommendations to support access to the future PTC; and that Evelina and St George's had both set out their commitment to the development of detailed plans to implement those recommendations. Both locations have expressed their desire to provide dedicated parking for patients of the centre.

While we note and welcome this commitment, we also note the comments made by the Medical Director of the Royal Marsden at our 1st February 2024 meeting regarding the inability to fully replicate what is in place currently at the Royal Marsden. Again, we note that it has been clear from consultation, that access and easy vehicle access is very important to people and work would be required to ensure access is as easy for people as possible.



At the mid-point review meeting in November 2023, NHS England officers reported there would be a range of measures to support people with improved travel options including:

· Help to plan journeys to hospital



· Financial support to help with travel costs (such as the ability to reclaim ULEZ charges and congestion charges, if applicable)



· Non-emergency transport services



· Space for families to stay



· Easy arrangements at the site including dedicated parking and drop-off

· Convenient appointment times

· More care closer to homes.



At our formal meeting on 1st February 2024, we raised further concerns regarding the associated costs of travel, which was noted to be a major concern emerging from the public consultation. From a South East London perspective, we have concerns about the cost implications on residents driving to a Central London location given not only the impact of ULEZ and Congestion Zone charges but also the future impact of toll charges due to be introduced for the use of both the Blackwall and Silvertown tunnels. We noted that NHS England will be ensuring that these considerations are factored into the ongoing travel costs analysis.



Members note that work on a travel cost analysis continues and that both potential locations for the future PTC have committed to setting up a Travel and Access working group. In terms of reimbursement, the Committee notes that there are such schemes already in place and that people receiving cancer services are highly likely to be eligible for these. We agree that people will need help to understand what is available and help in how to access those schemes.



The JHOSC has also sought assurances with regards to dedicated, non-emergency hospital transport and noted that this is a scheme that all hospitals have in place with associated eligibility criteria. We note that children being treated for cancer are more than likely to be eligible for such transport but would reiterate the importance of such arrangements for those who cannot drive or make use of public transport and for those in more remote areas.



Accommodation and other Incidental Costs Another key concern emerging from the public consultation, was that of accommodation for families whilst their Children are receiving treatment; the JHOSC has raised particular concerns about the potential cost implications, particularly if families need to find nearby hotels should they not be able to use accommodation nearby the chosen PTC location or should they require additional rooms, for example.



We noted that in both options, there is an already an option for families to stay while their child is receiving treatment in the same way the Royal Marsden does but recognise people had raised some more nuanced points during the consultation regarding location of that accommodation and the facilities available. We note that NHS England will be considering this as part of the implementation process.



We are also concerned about the impact of other incidental costs on families as Central London is an expensive place to be, and we have sought assurances that analysis is being done into these costs.



Workforce concerns



The SEL JHOSC has previously discussed that regardless of which site is chosen to be the future PTC, there will be significant implications for the staff currently based at Royal Marsden Hospital. The Committee has enquired how the impact on staff will be mitigated and about the plan for recruitment and retention at the new location.



NHS England officers have acknowledged that workforce issues are one of the more challenging aspects of the decision-making process. It has also been discussed that the largest staff group being impacted by the decision will be nurses.



The Committee are particularly concerned about the impact of travel and associated costs as well as car parking arrangements for staff. It was noted that there has been discontent among health professionals in recent times and the Committee have concerns about the impact on retention of staff including those with specialist skills and knowledge and the need to maintain the high excellence of care currently provided at the Royal Marsden.



Members have also noted that car parking for staff is also a concern as it is often difficult and expensive, as well as there often being a long wait time for permits to be issued; there are again concerns about the impact this could have on staff retention within the service.



The Committee has noted that there will be protections for staff transferred over to the new service particularly in terms of travel costs, for a period of time after a move. We also noted that there had been a lot of feedback from staff during the consultation about travel and access and that NHS England and the Hospitals involved are acutely aware of the potential impact. We also commented on the need for a wrap-around package of support for staff and the need to make sure they are looked after.



We were interested to note the comments from the Medical Director at The Royal Marsden who reported that a significant majority of their current paediatric staff either drive to work or live close enough to cycle or use a local bus and that a high proportion of staff currently working in the service at The Royal Marsden will not transfer due to personal, and lifestyle reasons/circumstances and would not commute into Central London. We noted that there is recognition from NHS England and the other hospitals involved that not all staff will want to transfer to the new service and therefore the chosen Hospital would need to plan work on any gaps in the workforce that exist. The Committee remains concerned about this and would welcome future updates on this process and mitigations identified.



Members of the Committee also expressed concern about potential competition for staff with other nearby hospitals and children’s hospitals such as Great Ormond Street, if the future location of the PTC is to be in Central London given the higher density of hospitals and thoughts on this in future would be welcomed.



There was some also concern from a Member of the Committee that within Guy’s and St Thomas’ NHS Foundation Trust, expertise in cancer is currently centred at Guy’s Hospital and not at the Evelina Children’s hospital itself, albeit that the Evelina is an excellent Children’s hospital. The Member also felt that quality of treatment is the priority and that St George’s Hospital and The Royal Marsden currently have a high level of expertise and good links with one another.



The Committee has sought assurance throughout, that the voice of Staff have been heard and will continue to be heard; SEL JHOSC Members have been informed that NHS England, through its consultation and engagement process, has continued to hear from staff about the things that are important to them and is continuing to work with NHS Trusts to encourage this process up to and after the point of a decision. NHS England officers have also assured Members that throughout the implementation phase there will be a dedicated focus on workforce.



Local support offer



PTCs work in partnership with Paediatric Oncology Shared Care Units (POSCUs). SEL JHOSC acknowledges and appreciates the vital role played by POSCUs in delivering care closer to children’s homes and providing responsive care to local communities.



The Committee also positively notes the fact that many children with cancer receive care in their homes from staff or 'outreach' services from the PTC, POSCU or staff from children's community nursing teams. SEL JHOSC understands and emphasises the importance of a good local support offer for children, their families and carers.



Previously, SEL JHOSC has enquired about having ‘local sites’ that children, families and carers could access in their communities, reducing the dependency on a central site for small needs. Paediatric cancer services require highly specialised care and fortunately, the number of children in need of these services is relatively low. Therefore, it has been discussed that while this limited demand is positive, it poses challenges for establishing satellite or local sites, as the lower numbers might result in underutilised facilities. Moreover, providing the safest and highest quality care for seriously ill children will be difficult at local centres.



The Committee notes that POSCUs are part of the service specification for Principal Treatment Centres published in November 2021 and that there are significant changes and investment planned to enhance the level of care that children can safely receive at home. It was noted that work on this should ensure that only the patients with the greatest need would need to go to the PTC for very specialised care. It was reported that both proposed options would meet that objective.

Delivery timeline



Previously, the SEL JHOSC has enquired whether both site providers- Evelina and St George’s, are adequately prepared to meet the 2.5-year implementation timeline of this service change. NHS England officers have reported that the level of preparedness is the same for both providers. However, unforeseen events like general elections and mayoral elections may introduce additional time constraints. Both site providers will also need to refurbish space in existing buildings, which will take time.



The Committee has been informed that both potential providers have shared their plans for transitioning the PTC over the 2.5-year period. Once a decision is made, the implementation phase will involve work with a number of stakeholders to do detailed implementation planning for the service change.



The SEL JHOSC wants to emphasise the importance of meeting this delivery timeline to minimise the impact on the current service for children and the need for a timely decision to minimise the level of uncertainty for staff and families.



Public consultation feedback



The Committee received the feedback from the public consultation for its 1st February 2024 meeting and noted that a copy of the full, published, independent report into the outcome of the public consultation was shared with the Committee alongside a summary of some of the key findings from the report.



The Committee noted some of the key headline feedback emerging from the report including some of the key themes raised by South East London respondents at its meeting on 1st February, the minutes for which will be published in due course. The Committee agree however that it was disappointing however that these documents were made available to Members so soon prior to the meeting, particularly given the level of detail, and would hope that such issues can be avoided in future.



The Committee agreed that the level of response to the consultation was positive, with over 2500 formal responses to the consultation in total; 16% of which were from the South East London ICB area, which was noted to roughly align with the proportion of people who currently use the service. Members noted that there had been good reach to both clinical and non-clinical staff affected at both The Royal Marsden and St George’s Hospital. We noted that there was a slight skew in the age of respondents from South East London, with most respondents being between the ages of 41-60 and recognised that while there was still a good proportion of responses from Children and Young People themselves, ideally more would have been welcomed.



Overall, we would like to thank NHS England officers for their thorough engagement process, and the level of community engagement during the consultation and we were pleased to note for example, that there was a high level of response from ethnic groups other than white from South East London.



Conclusion



The SEL JHOSC would again like to thank NHS England for their engagement with the Committee on these proposals; we hope that the comments and concerns we have raised in this response, will be carefully considered along with the other feedback raised by the Public and other stakeholders when making a decision.



The Committee’s conclusion was non-unanimous, however in terms of the two options presented, by significant majority and based on the evidence presented and considered, the Committee’s recommended/preferred option is for Guys and St. Thomas’ NHS Foundation Trust’s Evelina children’s hospital to be the future location of the Principal Treatment Centre.



The Committee look forward to hearing from you again in due course, about the decision made, any mitigations identified and reflections on the concerns raised and to hear about next steps.



The Committee trusts that the final decision made on the service change proposal will prioritise the well-being of children, families, and carers affected by it.







Yours sincerely,



Councillor Chris Best, Chair, SEL JHOSC



Councillor Christopher Taylor, Vice-Chair, SEL JHOSC