1	The Committee endorses the reasons for reconfiguring ophthalmology including: - Clinical case for change and the potential for new services to improve patient care and experience. - The creation of the ‘Centre of Excellence’ diagnostic hub, one stop clinics, and measures to support staff recruitment and retention.
2	The Committee notes that the proposed choice of the Bexhill Hospital to consolidate ophthalmology services and recommends that mitigation measures are put in place to address the concerns about travel and access to this site.
3a	The Board recommends: A package of measures is put in place to mitigate the travel and access impacts of the proposals on patients, families, and carers, including: - the establishment of a Travel Liaison Officer post is essential. - the communication and clear messaging of advice and guidance on travel support options, including accessing financial support, including the ability to claim back travel costs following appointments etc. - the provision of information on the travel support available in referral letters via a separate leaflet or information sheet in an accessible format and links to the website. - the CCG and ESHT explore processes to ensure patients are asked about their travel and access needs at the point of referral or at an appropriate point in the patient pathway. - encourage providers to provide clear explanations of the eligibility criteria for Patient Transport Services. - increasing and maximising the number of on-site parking spaces at the Bexhill Hospital site. - actions to improve access via other transport alternatives (e.g. development of a shuttle bus service, volunteer transport services, community transport, taxi services, liaison with bus operators and the local authority etc.).
3b	The Board recommends: Ongoing monitoring of Did Not Attend (DNA) information is undertaken after implementation of the proposals to establish the reasons why patients do not attend appointments, and review the travel and access mitigations in the light of this information.
4	The Board recommends: - Patients are given a choice of hospital site for referral where appropriate. - Consideration is given to providing some specialist treatments at the Eastbourne DGH site in addition to Bexhill Hospital.
5	The Board recommends: - Detailed implementation plans are drawn up as soon as possible to facilitate the timely implementation of the proposals, once a decision is made. - The opportunity is taken to make early changes to services where this is possible.
6	The Board recommends: - Regular monitoring of staffing levels is undertaken post implementation to ensure the sustainability of the service. - Further staff recruitment and retention measures are developed.

Background

1. East Sussex Healthcare NHS Trust (ESHT) provides ophthalmology services for the residents of East Sussex. This includes adult and paediatric ophthalmology services provided at three main centres, which are the Conquest Hospital in Hastings, the Eastbourne District General Hospital (EDGH), and Bexhill Hospital.

2. Ophthalmology is a branch of medicine and surgery that provides diagnosis, treatment and prevention of conditions that affect the eye and visual system. Many eye conditions are age-related, making ophthalmology services more and more important as people get older. Ophthalmology services commonly include the diagnosis and treatment of Age-related Macular Degeneration (AMD), Cataracts and Glaucoma.

3. East Sussex has amongst the highest numbers of over 65-year olds and over 85-year olds in the country, and this is expected to grow further. This means that increasing numbers of people are needing to use ophthalmology services. The changing needs of the population, the changing nature of ophthalmology care and the associated challenges in providing ophthalmology services has made the redesign of ophthalmology a key priority for East Sussex NHS Clinical Commissioning Group (CCG), - which is the responsible organisation for service reconfigurations – and ESHT.[1]

4. The CCG and ESHT are proposing following changes to ophthalmology services provided by ESHT:

· to consolidate ophthalmology services at two hospital sites, Eastbourne District General Hospital and Bexhill Hospital;

· create one stop clinics at both hospitals and a diagnostic eye hub at Bexhill Hospital; and

· move outpatient appointments currently provided at the Conquest Hospital to Bexhill Hospital.

5. The CCG undertook a public consultation between 6^th December 2021 and 11^th March 2022 seeking views on the need to change the service, the proposed model of care, and the proposed location of ophthalmology services at Bexhill Hospital and EDGH.

6. In addition to its duties to engage with the public, the NHS is required under regulations to consult with the local health scrutiny committee(s) on any proposal that is deemed by the committee to be a substantial variation or development to existing services. As a result, representatives of the CCG and Trust attended the East Sussex Health Overview and Scrutiny Committee (HOSC) meeting on 2nd December 2021 to explain the proposed changes to ophthalmology services.

7. The HOSC agreed the proposals constituted a substantial variation to services requiring formal consultation with the Committee under health legislation. The HOSC established a Review Board to carry out a detailed review of the proposals and produce a report and recommendations on behalf of the Committee. The Review Board comprised Councillors Abul Azad, Colin Belsey, Christine Brett, and Christine Robinson and a community and voluntary sector representative, Geraldine Des Moulins. The Review Board elected Councillor Belsey as the Chair.

8. The Review Board carried out the majority of its review between March and June 2022. This report sets out the evidence the Board considered, along with its conclusions and recommendations.

1. The proposals for the future of ophthalmology

9. Ophthalmology is the branch of medicine and surgery that provides diagnosis, treatment and prevention of diseases of the eye and visual system. Medical ophthalmology involves diagnosis and management of disorders affecting a person’s vision. Surgical ophthalmology involves surgical procedures to correct or improve a person’s vision, for example, cataract surgery.

Department of ophthalmology

10. Ophthalmology services at East Sussex Healthcare NHS Trust (ESHT) are Consultant-led and provide services for children (paediatric) and adults across three hospital sites. Paediatric services are also provided from community sites across Hailsham, Crowborough and Seaford, and these will remain as this Pre-Consultation Business Case is focussed on the provision of specialist medical and surgical ophthalmology services across East Sussex Healthcare NHS Trust’s three main hospital sites, Eastbourne District General Hospital, Conquest and Bexhill.[2] The Trust also provides a Glaucoma Referral Refinement clinic, the purpose of which is to determine a patient’s risk of having glaucoma.[3]

11. East Sussex Healthcare Trust’s current ophthalmology service provision for adults and children is shown below[4]. This details the ophthalmology service as it currently exists.

12. The ophthalmology service is one of the most used outpatient services, as well as providing day case surgical procedures, and inpatient surgery. The table below[5] gives the activity levels for the service provided by ESHT from April 2019 to March 2020. It should be noted that March 2020 was impacted by the COVID-19 pandemic and Ophthalmology services were focused at the Bexhill site to ensure the Conquest and Eastbourne sites could be prioritised for acute services and COVID-19 infected patients.

13. Some East Sussex residents also receive ophthalmology care at other hospital trusts outside of the county.[6] For 2019/20, this was as follows:

Reason for changing the ophthalmology service

14. The East Sussex Clinical Commissioning Group (CCG) and East Sussex Healthcare Trust (ESHT) set out their concerns about the current service and why it needs to change (the case for change) in the PCBC document[7] which brings together local, regional and national requirements and drivers for change. These include:

· Quality - Healthcare systems are required to minimise the risk of significant harm, through delivering timely follow-up for patients with chronic conditions. The high and growing number of these cases within ophthalmology makes this a challenge.

· Service performance - Nationally, ophthalmology outpatient services are the most used of all outpatient services, with East Sussex Healthcare Trust seeing 18,075 new outpatients and 65,511 follow-up appointments in 2019-20. The Covid-19 pandemic has impacted heavily on ophthalmology provision and this, coupled with the very high levels of need for care, has led to the service no longer meeting national waiting time standards.

· Growing need - It is estimated that, over the next 20 years, the need for cataract services will rise by 50%, glaucoma cases by 44% and medical retina by 20%.

· IT / Digital - There would be a significant benefit to patients through ophthalmology services making the best possible use of modern digital technology, such as an Electronic Eyecare Referral System (EERS). Modern technology presents opportunities to improve patient pathways and better manage the growing need for ophthalmology services.

· Workforce - A census carried out by the Royal College of Ophthalmologists (RCOphth) in 2019 identifies gaps in recruitment for ophthalmologists and workforce planning, amid a predicted 40% increase in need over the next 20 years.

· Estates and equipment - Diagnosis and monitoring of ophthalmic patients is highly dependent on equipment. Much of the equipment currently used by the department across its three sites is old, which impedes the service’s ability to work efficiently and effectively. There are limitations of physical space in the current service configuration limiting the capacity of the service to meet the current and growing need of the local population which contributes to challenges in meeting service standards.

· The national Getting it Right First Time (GIRFT)2 programme reviewed the ophthalmology service in March 2018. It was recommended that ESHT:

o Review pre-assessment clinics and review/audit coding for complex cataracts to ensure the patient pathway for cataract surgery is optimised.

o Continue to develop health care professional (HCP) staff by training and developing all members of the multi-disciplinary team, whilst utilising competency frameworks to increase the number of non-consultant clinical staff.

o Look into using consultant-led and technician-provided virtual clinics for age-related macular degeneration (AMD) and glaucoma to improve refinement of treatment plans.

o Review coding practices to ensure accuracy, particularly around complex cataracts, corneal grafts, strabismus follow-ups and vitreo-retinal conditions.

o Continue to refer to the Royal College of Ophthalmologist’s “The Way Forward”3 document to identify options to help meet demand and the Common Competency Framework to support health care professional staff development.

15. The Review Board has also reviewed the recommendations from the Clinical Senate report on the proposals and the responses to them which have been included in the PCBC document. Amongst these recommendations the Clinical Senate makes clear that continuing with the current position, where a fragmented service is provided across three sites (i.e. the do nothing option), is not a sustainable option for the service going forward.[8]

Comments of the Board

16. The Board notes the reasons behind the proposals to change the model of care and transform the service in line with a number of local, regional, and national programmes and initiatives. It is clear that the ‘do nothing’ option would not be in the interests of patient care and would not address waiting times or workforce issues.

Proposed option for reconfiguring ophthalmology

17. Currently services are spread across three sites, and the proposal for the future is to locate ophthalmology services at two hospital sites, Eastbourne District General Hospital and Bexhill Hospital, supported by one stop clinics at both hospitals and a diagnostic eye hub at Bexhill Hospital. The introduction of one stop clinics and a diagnostic eye hub are aimed at ensuring faster diagnosis, reducing waiting times, reducing the number of appointments required for patients to attend and repeated tests. These are key quality improvements to the ophthalmology service identified in the proposals.

18. The selection of this option followed an options appraisal process that looked at the strengths and weaknesses of four options in total. More information on this process can be found in the Pre Consultation Business Case (PCBC). Under the proposals, the range of services provided at Eastbourne DGH will remain the same and will include the provision of a one stop clinic. The key changes under the proposals are that the outpatient services currently located at the Conquest Hospital will move to the Bexhill Hospital site. Day case procedures are currently provided at Bexhill Hospital rather than the Conquest Hospital, and any inpatient surgery requiring an overnight stay and emergency treatment in A&E will remain at the Conquest.

19. The Review Board heard that the proposed model provides the best opportunity to deliver high quality, safe and clinically sustainable services that also addresses the current challenges by bringing ophthalmology services together on two hospital sites. The benefits include:

· better patient experience;

· improved patient outcomes through streamlined outpatient pathways;

· a one stop service, including access to a multidisciplinary team; and

· providing sustainability of services for the future.

20. The Board questioned how the proposals will improve services. It heard evidence given by the CCG and ESHT that senior clinicians will have greater involvement in treatment plans and clinical decisions, and staff from different areas of ophthalmology would be able to work more closely together as one team enabling the service to meet national standards, guidelines and performance targets in the future. The new model will rationalise estates and equipment and align with the Sussex-wide ophthalmology Transformation Programme plan.

21. The Review Board heard evidence from a number of witnesses on the reasons for the proposed changes. This included the clinical lead for Ophthalmology, Mr Kash Qureshi, staff involved in providing the service and GP representatives in order to gain an understanding of the benefits for patients in terms of treatment, outcomes and patient experience.[9] The Board also considered evidence from Healthwatch East Sussex and submissions from the Friends of Bexhill Hospital, the Friends of Conquest Hospital and other stakeholders who responded to the HOSC Newsletter.[10]

Choice of site

22. The Board considered the reasons for the proposed location of the combined services at Bexhill Hospital and asked why Bexhill is the preferred site. The Board heard that if services stayed at the Conquest Hospital it would require an expansion of theatre space and would be more costly due to limited theatre capacity. The majority of procedures do not need to be on an acute site, so the clinical aspect of the service does not need to be at the Conquest Hospital. In addition, as the Bexhill site is a non acute site, services such as the treatment of macular degeneration were able to continue during the Covid pandemic.

23. Locating services at the Conquest was not the preferred option for a number of reasons. These included the position of the theatres which are located away from the outpatients department and the length of walk especially for elderly patients, which does not allow high patient throughput. The Conquest outpatients is not suitable for expansion to provide enhanced outpatient services needed.

24. The Board understands that the benefits of choosing the Bexhill site are that the Bexhill Hospital layout is better for patients, with the waiting areas next to the theatre, has room for expansion and allows increased patient flow. The proposals also allow for pre-assessment to be linked to the day case service as they can be done in the same location. Pre-assessment can take place on the same day as being seen, resulting in fewer appointments being needed and therefore fewer journeys for patients. This is not currently possible with the service spread across three sites and the proposals allow for a much more joined up service to be provided. This includes the creation of a multi-disciplinary team and enhanced provision of senior consultant advice and supervision.

Services at new facility

25. The Board heard that it is proposed to create a ‘Centre of Excellence’ at the Bexhill Hospital site which will include a diagnostic hub. These proposals include refurbished outpatients’ areas and the purchase of the latest diagnostic equipment. This will allow the provision of the most technologically advanced procedures and treatment for patients, which the board understands will lead to better patient care and outcomes.

26. The Board questioned the availability of funding for the transformation proposals. It was confirmed that the Trust has the necessary capital funding in place to implement the proposals and buy new equipment. The proposals will not require an expansion of the Bexhill hospital buildings but will mean other building users will be re-located to provide the expansion space for ophthalmology. A more detailed implementation plan for the proposals will be drawn up and included in the Decision Making Business Case (DMBC).[11]

Stated benefits to patients

27. The Board heard that under the proposed model patient waiting times will be shorter, with technician led diagnostic hubs meaning fewer appointments will be needed and decisions can be made more quickly. Patients will require fewer visits for diagnosis and treatment under the new model and will be seen in a timely way due to direct supervision by consultants. The new model will improve waiting times and crucially minimise risk of sight loss due to long waiting times for referrals. The new model will provide a one stop service with diagnostics and pre operation/procedure assessment taking place in one appointment. The new model will provide capacity for clinical staff to upskill and will provide sustainability of services for the future.

Stated benefits to staff

28. The Board was told that a ‘Centre of Excellence’ will be good for recruitment and retention and create an attractive environment for staff. Consolidation of the sites will make a more attractive proposition when recruiting as it provides the number and level of complex cases, coupled with the right level of supervision. Consolidation of services, using staff resources to their best potential, and working in a multidisciplinary team will provide opportunities for training (e.g. on laser techniques and injections) and provide efficiencies to cover staff sickness thereby avoiding the need to cancel appointments.

29. There will be no reduction of staff numbers and currently many of the ophthalmology staff work across all three sites. Under the proposals, members of staff currently working at the Conquest will transfer to Bexhill.

GPs Views

30. The Board heard that GPs are generally positive about the proposals from a service, diagnostic, and treatment perspective. Timely access to early diagnosis and assessment, and better access to qualified ophthalmological opinion are seen as a major benefits of the proposals. It is anticipated that individual patients will require fewer follow up appointments through the use of One Stop clinics and virtual clinics, which will benefit patient experience. GPs recognise the workforce pressures and the benefits of consolidation for recruitment and retention, and the training and development of non-medical roles, which can be upskilled. There is also an opportunity to upskill community services as part of the proposals. The new model to some extent has been tested during Covid-19 pandemic with Bexhill being used as a ‘cold site’.

31. The patient feedback from the pre engagement work is that people are generally happy to travel if they are receiving a senior opinion and if it involves fewer appointments. This is tempered by the issues with parking and travel at the Bexhill site. The Board heard that the overall view from GPs is the case for change is explained well. Under the new model the availability of a senior ophthalmologist is an important point which means clinical decisions can more easily be made in a single appointment. Virtual clinics are also an important element of the proposals which provides a variety of ways to access care and treatment. The proposals also provide opportunities to upskill community optometrists, who can deliver a wider range of care closer to home, which is complementary to this model.[12]

Views from Healthwatch

32. Healthwatch advised the Board that, in their view, the new model offers good quality services and an acknowledgement of the need for more space and modernisation. Healthwatch indicated that ESHT currently provides a good service, but it is overcrowded and needs more space. The challenges around recruitment are acknowledged with competition with London and hospitals within the M25 radius for suitably qualified ophthalmology staff. In this context it is important for ESHT and the CCG to provide up to date and efficient services to attract staff and to ensure a high quality of care for patients in East Sussex.

33. Healthwatch indicated that there are concerns about travel and access and there is a need to mitigate these concerns especially for people short of resources.

34. Healthwatch is supportive of the changes to ophthalmology services in East Sussex as set out in the PCBC. However, it is noted that the time taken to implement changes is sometimes slow and Healthwatch is keen to see the best quality of care being provided expeditiously for the benefit of patients in East Sussex.

Public consultation

35. A public consultation on the proposals for ophthalmology services was undertaken between 6 December 2021 and 11 March 2022, in which service users, members of the public, NHS staff members, organisations and other stakeholders were invited to give feedback on both the proposed model of care and locations for core ophthalmology services. The consultation and subsequent analysis were conducted by Opinion Research Services (ORS).

36. According to ORS, the consultation had 531 responses including 334 ophthalmology service users, 27 NHS ophthalmology staff members, 25 other NHS staff members, and 9 responses from 8 separate organisations. The consultation also included a number of focus groups and group discussions with services users, carers and ESHT ophthalmology staff; in-depth interviews and engagement with service users; workshops and in-depth interviews with stakeholder organisations; public meetings, listening events, staff forums and briefings, meetings with community groups, and ‘pop-up’ events in public spaces.

37. The public consultation outcomes included the following views on the need for change, the proposed model of care, and the proposed location of ophthalmology services:[13]

Views on the need for change – Overall, there was broad recognition for the need to make changes to address challenges and deliver improvement to ophthalmology services across the consultation feedback. There was high agreement from all stakeholder groups.

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Views on the proposed model of care - There was broad agreement across the consultation feedback on the model of care. However, there were some concerns expressed by those living closest to the Conquest Hospital.

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However, there were some evidence of concerns expressed by those living closest to the Conquest Hospital.

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Views on the proposed locations of services - There was majority agreement across the consultation feedback on the proposal to deliver ophthalmology services from Eastbourne DGH and Bexhill Hospital in future.

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However, a significant minority of respondents living closest to the Conquest Hospital (39%) disagreed with the proposed location.

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38. Among those consultation participants who agreed with the proposed model of care, it was commended for:

- Aiming to speed up the referral process and reduce waiting times;

- Centralising services on two sites and introducing the ‘one stop clinic’ model at both sites with a diagnostic hub at one site;

- Potentially creating a ‘centre of excellence’ in East Sussex with a high-quality service which could attract specialist clinicians.[14]

39. Across all consultation strands, the main reasons for disagreement with the proposed model of care centred around:

- Travel and access, including longer journey times and increased costs for people from Hastings and other areas of East Sussex used to traveling to Conquest Hospital for appointments; and

- Concerns with current road access and parking at, and public transport links to, the Bexhill Hospital site. [15]

40. The most commonly suggested mitigation measures to reduce travel and access impacts, if the changes did go ahead, were:

- Increasing and improving access to patient transport services, including addressing changes to eligibility criteria which were reported to have left large numbers of people without lifts;

- Recruiting more volunteer drivers and supporting ‘community bus services’;

- Introducing shuttle buses between East Sussex hospital sites and to and from local train stations;

- Working with local councils and public transport providers to improve public transport links to and from proposed sites;

- Providing financial support for service users who must use taxis to reach hospital;

- Introducing adequate and affordable/free parking (including additional disabled parking bays) at Bexhill Hospital and Eastbourne DGH; and

- Consult with Bexhill residents living close to the hospital who might be impacted by increased traffic and parking on residential streets. [16]

Comments of the Board

41. The Board found that the proposals for change are good, with patients being seen more quickly and having to make fewer visits. There is a convincing case that patient experience will be improved and there will be better outcomes. Getting the right processes in place for multidisciplinary teams needs to be done well, and this will be a key management responsibility in implementing the proposals. The Board notes the concerns about the time taken to implement changes in services which will benefit patients.

42. The ophthalmology consultants and staff are very supportive of the proposals to go ahead in order to be able to offer a sustainable, high quality and technically advanced service and to improve patient care and experience. Healthwatch and GP representatives considered the proposals would benefit patient care with reduced awaiting times, fewer appointments, and enhanced services, but were concerned about the inequity of access for some patients to the Bexhill Hospital site.

43. In summary, all witnesses were positive about the proposals for improvements in the service which will lead to a good quality service and increased patient care. The Board can see the potential problems with travel and access and any mitigating measures will need to be closely monitored. The Board notes there is a strength of feeling about travel and access to the Bexhill Hospital site, with a perception that it is difficult to get to via public transport and has limited parking.

Recommendation 1

The Committee endorses the reasons for reconfiguring ophthalmology including:

- Clinical case for change and the potential for new services to improve patient care and experience.

- The creation of the ‘Centre of Excellence’ diagnostic hub, one stop clinics, and measures to support staff recruitment and retention.

Recommendation 2

The Committee notes that the proposed choice of the Bexhill Hospital to consolidate ophthalmology services and recommends that mitigation measures are put in place to address the concerns about travel and access to this site.

2. Issues with the new service that should be addressed

44. During the course of its review, the Board identified several issues that the CCG and Trust should address. These are detailed below.

Access and travel

45. Access and travel are key issues at the Bexhill site. The Board heard from ESHT that patients will mostly travel by car or taxi to get to and from appointments. However, not everyone has family or friends who can help patients get to appointments and the situation regarding increased travel costs and affordability has changed since the PCBC was drawn up. Many people are on fixed incomes and there is a concern that those in deprived communities may not attend appointments due to these barriers.

46. It is acknowledged that the proposals may lead to patients needing to attend fewer appointments at the diagnostic hub at Bexhill. However, the difficulty of getting to this site, especially if you do not have access to a car or cannot afford a taxi, needs to be mitigated. The Board also heard concerns about the number of parking spaces available on site and the lack of frequent bus services.

47. Currently, Bexhill Hospital is served by two bus routes. Route 95 which runs 2 hourly between Bexhill and Battle via Bexhill Hospital and the Conquest. Route 98 runs hourly between Eastbourne, Bexhill and Hastings, and half hourly between Hastings and Bexhill. Neither route operates services on a Sunday. This compares with the Conquest Hospital which is served by a bus linking the hospital to the town centre and railway station approximately every 10 minutes, and Eastbourne DGH which is served by a bus linking the hospital to the town centre and railway station approximately every 5 minutes.[17]

48. These travel and access constraints will affect patients, families, and carers as well as the increased number of ophthalmology staff working at the site. With an estimated additional 18,750 outpatient visits per year[18] (taking into account the anticipated reduction in the number of appointments), there is a need to increase the amount of parking available on site for patients, people with disabilities, and staff.

49. The Board understands that a Travel and Access Group (TAG) has been established by ESHT to explore the deliverability and feasibility of a number of options to mitigate the travel and access issues at the Bexhill site. The outcomes from this work will be included in the Decision Making Business Case (DMBC) and may include:

· Creating a Travel Liaison Officer post to support patients and advise on the help that is available;

· Reviewing on-site parking provision, with a view to increasing the number of parking spaces. The Trust is confident it can fit any additional parking needed on site;

· Reviewing building and estates provision to ensure accessibility issues are addressed;

· Examining the potential of setting up a shuttle bus service;

· Looking at whether it is possible to increase work with volunteers and the voluntary sector;

· Examining how transport was used during the vaccination programme to see if there are any lessons learnt that could be used; and

· Exploring whether it would be possible to pay for taxis directly for those patients that are eligible to reclaim travel costs (e.g. through a contract with taxi firms).

50. The Board welcomes these proposals and supports the proposal to create a Travel Liaison Officer post that could help and support patients with their travel and access needs, and where patients could be referred to if they needed help with travel arrangements to get to an appointment.

51. From the evidence reviewed, it is unclear to the Board whether patients are routinely asked if they need help getting to an appointment and whether information on the support that is available for travel and access is consistently made available to patients at the point of referral or when appointment letters are sent out. The Board recommends that information on travel and access support is included with referral letters, and patients’ travel and access needs continue to be identified and recorded when referrals are made.

52. The Board also understands that at hospital sites where there is a cashier’s office it may be possible for patients to claim back travel costs on the same day as their appointment if they are eligible to do so. For people on limited incomes this would provide a faster way of reclaiming any travel costs, and the Board considers this option should be more widely publicised to those patients who may need financial help getting to appointments.

53. The Board is concerned that some patients may not attend appointments due to the difficulty of getting to the Bexhill Hospital site. The Board has reviewed Did Not Attend (DNA) data for the ophthalmology services provided at the Conquest and Bexhill Hospitals[19]. Anecdotally the most common reason for not attending an appointment during the period covered by the pandemic was the fear of catching Covid. There was no discernible difference in recent DNA rates due to an increase in the cost of travel or cost of living. However, the Board recommends that ongoing monitoring of DNA data is undertaken after implementation of the proposals to establish the reasons why patients do not attend appointments and review the travel and access mitigations in the light of this information.

Comments of the Board

54. The Board considers that a comprehensive package of measures needs to be introduced to mitigate the impact of the proposals on travel and access. It is clear that the existing support available needs to be publicised more widely, including the eligibility criteria for free Patient Transport Services. Asking about patient travel and access needs and offering information and support at the point of referral is also vital. The Board understands the clinical administration teams currently record any travel and access needs for existing patients and this should be continued and be included in all patients’ records.

55. The provision of information needs to be in accessible formats (including hard copies and large print) in a separate leaflet or information sheet for inclusion with referral letters. The Board considers that the eligibility criteria for Patient Transport Services needs to be clearly explained and more detailed clarification is required to make it easily understood. Examples should be given where a patients’ condition makes them eligible.

Recommendation 3

The Board recommends:

3a. A package of measures is put in place to mitigate the travel and access impacts of the proposals on patients, families, and carers, including but not limited to:

- the establishment of a Travel Liaison Officer post is essential.

- the communication and clear messaging of advice and guidance on travel support options, including accessing financial support, including the ability to claim back travel costs following appointments etc.

- the provision of information on the travel support available in referral letters via a separate leaflet or information sheet in an accessible format and links to the website.

- the CCG and ESHT explore processes to ensure patients are asked about their travel and access needs at the point of referral or at an appropriate point in the patient pathway.

- encourage providers to provide clear explanations of the eligibility criteria for Patient Transport Services.

- increasing and maximising the number of on-site parking spaces at the Bexhill Hospital site.

- actions to improve access via other transport alternatives (e.g. development of a shuttle bus service, volunteer transport services, community transport, taxi services, liaison with bus operators and the local authority etc.).

3b. Ongoing monitoring of Did Not Attend information is undertaken after implementation of the proposals to establish the reasons why patients do not attend appointments, and review the travel and access mitigations in the light of this information.

Patient choice and patient pathways

56. In reviewing patient flow information the Board could see that some patients, and in particular those in the west of the county around Seaford and Newhaven, were travelling quite long distances for appointments and treatment, rather than attending Brighton hospitals which are nearer. The Board examined whether patients had a choice of provider and where they go for appointments and treatment.

57. The Board heard that most outpatient appointments and diagnostic procedures can be accessed via any hospital site. However, some specialist treatments (e.g. eye injections) equipment and technicians are available only at certain hospitals (e.g. Bexhill Hospital). It was clarified that GPs will normally refer to the nearest provider and usually people would choose to travel to the nearest treatment centre. If there is a requirement for a specific treatment, there may not be a choice of provider. Referrals made by ESHT would normally be to ESHT provided services or tertiary centres where appropriate.

58. Although not part of the proposals, the Board asked whether specialist treatments such as regular injections for Age-related Macular Degeneration could be provided at Eastbourne DGH (e.g. via a weekly clinic) as well as Bexhill Hospital. This would lessen the amount of travel to the Bexhill site and improve patient experience as travelling to Eastbourne may be easier for a number of patients.

Comments of the Board

59. The Board considered that it would be beneficial for patients to be made aware of different patient pathways and where there is a choice of provider so that they can choose the hospital where they go for appointments and treatment. It was also noted that some services in future may increasingly be available from community-based opticians, which would also increase access to services.

Recommendation 4

The Board recommends:

- Patients are given a choice of hospital site for referral where appropriate.

- Consideration is given to providing some specialist treatments at the Eastbourne DGH site in addition to Bexhill Hospital.

Implementation timescales

60. The Board notes that one of the reasons for the proposed changes to the ophthalmology service is to reduce waiting times and allow the service to meet national waiting time standards. One of the concerns expressed by Healthwatch is how quickly the proposals can be implemented, in order to benefit patients as quickly as possible.

61. The Board heard that implementation of the proposals, if agreed, can take place relatively quickly. It may be possible to change some elements of the service, in advance of others, based on the experience gained during the Covid-19 pandemic. The Board heard that capital funding is in place to implement the proposals and agreement has been sought from Friends groups to relocate donated equipment if required. A detailed implementation plan will be included in the Decision Making Business Case, but it is estimated that given the lead times it may take 12 months to complete the necessary works.

Comments of the Board

62. The Board considers that implementing the proposals quickly once a decision is made will be key to achieving the anticipated benefits for patients, staff, and recruitment and retention. Therefore, any measures that can facilitate the timely implementation of the proposals should be taken where feasible.

Recommendation 5

The Board recommends:

- Detailed implementation plans are drawn up as soon as possible to facilitate the timely implementation of the proposals, once a decision is made.

- The opportunity is taken to make early changes to services where this is possible.

Staff recruitment and retention

63. The Board heard evidence of a number of measures to recruit and retain staff including innovative training contracts and providing assistance with relocation and training expenses. There is a rolling training programme with a pre-registration year being offered in a hospital setting which provides a training opportunity not commonly seen elsewhere. The transformation proposals also provide a basis to cross train and upskill existing staff.[20]

64. However, the Board is concerned about the impact on the sustainability of the service if the transformation fails to attract sufficient numbers of suitably qualified staff or provide the opportunities to cross train staff as envisaged. Therefore, the Board recommends that staff levels are closely monitored after the implementation of the changes to the service. If the proposals fail to attract the staff needed by the ophthalmology service, a package of additional staff recruitment and retention measures may need to be developed to tackle recruitment issues, in collaboration with system wide partners and the Sussex Integrated Care System (ICS).

Recommendation 6

The Board recommends:

- Regular monitoring of staffing levels is undertaken post implementation to ensure the sustainability of the service.

- Further staff recruitment and retention measures are developed.

Summary Comments

65. The Board has carefully considered the clinical case for change and the anticipated benefits for patients from the proposed service reconfiguration. The Board has also examined the proposed choice of the Bexhill Hospital site for the consolidation of some services serving the east of the county. The Board notes that the Bexhill site presents a number of challenges for travel and access to services based there. On balance, the Board considers that the proposed changes to the ophthalmology services in East Sussex are in the best interests of patients, but adequate mitigations must be put in place to address the travel and access issues that have been identified.

Appendix 1

Review Board meeting dates

The Review Board met on:

- 29^th March 2022 to agree its terms of reference and consider the CCG’s proposals.

- 22^nd April 2022 to examine in more detail the clinical case for change contained in the Pre consultation Business Case.

- 12^th May 2022 to examine patient flows, travel analysis and consider stakeholder views

- 25^th May 2022 to consider feedback form the Public Consultation and review ‘did not attend’ information.

- 14^th June 2022 to consider the draft report of the Review Board.

Witnesses

East Sussex Clinical Commissioning Group (CCG)

Jessica Britton, Executive Managing Director

Fiona Streeter, Associate Director of Commissioning and Partnerships

Dr Suneeta Kochhar, GP Clinical Lead representative

East Sussex Healthcare NHS Trust (ESHT)

Richard Milner, Director of Strategy

Michael Farrer, Strategic Transformation Manager

Ophthalmology Staff

Mr Kash Qureshi, Clinical Lead for Ophthalmology

Helen Peregrine, Head of Optometry

Sarah Bradbury

Sharon Ball

Jo Tucker

Healthwatch East Sussex

Alan Keys

East Sussex County Council (ESCC)

Neil Maguire, ESCC Transport Hub

List of documents considered by the Review Board

Documents provided to Review Board by the CCG and ESHT

Pre Consultation Business Case (PCBC) and appendices.

Travel Analysis Summary and Travel Study.

Patient flow data for the ophthalmology service.

Public Consultation summary and document

Public Consultation Feedback draft report (OCS). May 2022.

Did not Attend (DNA) information for the ophthalmology service.

Parking space capacity at Bexhill Hospital

Recommendations for South East Clinical Senate Review PCBC for Ophthalmology Services for East Sussex CCG

Witness Statements

Witness statements received from the following organisations and groups.

Friends of Bexhill Hospital

Friends of Conquest Hospital

Contact officer for this review:

Harvey Winder, Scrutiny and Policy Officer

Telephone: 01273 481796
E-mail: harvey.winder@eastsussex.gov.uk

East Sussex County Council
County Hall
St Anne's Crescent,
Lewes BN7 1UE

[5] Patient flow information provided at 12 May meeting.

[8] South East Clinical Senate Review PCBC for Ophthalmology Services for East Sussex CCG

[14] ORS Public Consultation feedback draft report May 2022

[16] ORS Public Consultation feedback draft report May 2022.