We’ve included some frequently asked questions and themes from our engagement events around Building a sustainable future for the Friarage which we will continue to add to over the course of our engagement period from early October to 20 December 2017.
Are you planning to close the Friarage?
This public engagement is absolutely not about closing the hospital. The Friarage is an essential part of our Trust and will continue to play an important role in providing hospital services to local people.
Both ourselves as providers of hospital and some community services and NHS Hambleton, Richmondshire and Whitby Clinical Commissioning Group (CCG), who are responsible for planning and buying healthcare for the local population are committed to making sure that the Friarage has a long term future. This can be seen by the investment in the hospital in recent years.
Is this a public Consultation?
This is not a consultation at this stage. It is engagement to seek people’s views about the challenges we face. At the end of this engagement process, should we need to develop any proposals for a change in services, these would be subject to a formal process of consultation which would last for three months.
This is in line with legal duties around involvement and consultation in relation to health services.
What is the engagement about?
This conversation with our staff, the public and our local partner organisations is about what we need to do to continue to provide safe and sustainable emergency care services to people living within the Friarage catchment area.
Changes are happening in the NHS around the country mainly because of population changes, medical advances and increasing national standards which are aimed at giving seriously ill and injured people the best chances of survival and a good recovery.
At the Friarage we need to adapt to meet those challenges but we have some added difficulties around recruitment which make it even more difficult to continue to sustain some of our emergency services.
During the engagement we also want to talk about what opportunities there are at the Friarage going forward.
Can you tell us more about these challenges and the services they affect?
Our concerns are about how we provide the services for people who come to the hospital for emergency care. There are three main areas:
- 24/7 anaesthetic cover- in particular, providing a doctor to stay in the hospital overnight
- Critical care – the care provided for patients who are very seriously ill
Related to these areas is acute medicine, which is the care of patients who are very unwell when they come into hospital and need to be admitted and treated. We have less of a problem in acute medicine but all of these services are dependent on one another.
There are many reasons why we have come under increasing pressure in providing these services over a number of years including:
- A national shortage of anaesthetists – this makes recruitment very difficult especially in small hospitals like the Friarage
- National clinical standards around 24/7 care – aimed at making sure patients get the best chance of survival and a good recovery when they are very ill
- Changing rules about the hours a doctor can work and about the training of doctors
- More doctors choosing to specialise in particular services rather than be generalists
- Medical advances – which are greatly improving patients chances of surviving serious illnesses but need high levels of expertise that can’t be provided in every hospital
Against all of these challenges we also have to meet changing population needs. This includes an increasing number of older people who are sometimes living for many years with one or more long term conditions, such as diabetes, heart and lung diseases.
The main priority for the Trust is to make sure the services we deliver are safe, meet national clinical standards and can be sustained in the long term.
Can you tell us more about the emergency care services you have concerns about?
Our biggest problem is making sure that we have a resident anaesthetist (a doctor available in the hospital overnight). This cover was previously provided by trainee doctors but since we are no longer allowed to have trainees covering the overnight period at the Friarage Hospital, we have had to rely on locum doctors (temporary doctors).
This role is needed on the hospital site to allow emergency services to remain there and is supported by a consultant anaesthetist on call from home.
We need a team of seven doctors to provide this rota and currently have five vacancies that are filled by locum doctors. This is more expensive than employing permanent doctors and is not sustainable in the long term. On average our anaesthetists see three emergency patients a week in the overnight period (from 6pm to 8am).
We need a team of eight consultant anaesthetists to provide 24/7 cover (which includes the overnight anaesthetics on call rota), Previously four of these consultants provided specialist intensivist knowledge and covered the critical care unit during the day. Only two of the four are still in post.
This specialist knowledge is required daily to support the unit, so additional support is currently being provided by consultants from the James Cook site, which also has anaesthetic and intensivist vacancies. This increases pressures on the James Cook site which needs to cover a greater number of rotas across a range of specialities (i.e. trauma, consultant led maternity and paediatrics).
Despite extensive efforts to recruit, we have only managed to attract one new anaesthetist to cover the Friarage Hospital critical care unit and most vacancies are being filled by locum doctors.
We also have recruitment difficulties in A&E and again are relying on locum doctors. To provide a 24/7 rota we need seven A&E doctors. Four are permanent and we are using locum doctors to fill the other three posts.
This makes sure there is a doctor available in the department 24/7, supported by an emergency medicine consultant on site from 8am to 6pm, Monday to Friday, and available by phone outside these hours.
The number of patients attending A&E at the Friarage Hospital has reduced to around 60 a day. This is because medical advances and national policy mean seriously ill patients now go direct to a specialist centre and there are also more services in the community for people who become unwell.
The department sees on average four patients an hour between 8am and 8pm and on average one patient an hour from 8pm to 8am. Three-quarters of those attending A&E have minor injuries and minor illnesses.
What is the role of an anaesthetist?
Anaesthetists are specialist doctors who are responsible for providing anaesthesia to patients for operations and procedures. In addition, they have a range of practice which extends beyond anaesthesia for surgery for example providing pain management and intensive care to poorly patients, which is the type of support that is provided to the Friarage Hospital overnight. That’s why it’s so important we have enough doctors to be able to do this.
Why is it so hard to recruit doctors to the Friarage?
There is a national shortage of doctors in some specialties and sometimes doctors choose to work in large hospitals where they can develop their skills and be part of bigger teams. The Friarage is one of the smallest general hospitals in the country.
Our problem with recruitment is made worse because for the last year we have not been allowed to have anaesthetic trainees covering the overnight period at the Friarage Hospital and we have had to rely on locum doctors (temporary doctors).
Is it not just about trying harder to recruit doctors to work at the Friarage?
We have ongoing efforts to recruit doctors to work in emergency care services at the Friarage, including in this country and overseas. We use online recruitment sites and professional publications which are widely read by doctors, such as the British Medical Journal. We also attend recruitment fairs and conferences to promote our hospitals.
All of these efforts will continue and, in addition, we are looking at doing an international campaign where we specifically target countries which have more available anaesthetists.
This includes placing job adverts in Holland, Australia and New Zealand as well as headhunting in other countries such as Italy, Spain and Greece. Doctors who work at the Friarage have also worked hard to promote the hospital as a good place to work.
Have you adopted a Trust-wide approach to staffing in these key areas? Can medical rotas at James Cook be altered to ensure adequate cover at the Friarage? Is it true consultants at James Cook are reluctant to provide cover at the Friarage?
Where it is feasible to do so, a Trust wide approach to staffing is undertaken.
Consultant anaesthetists from James Cook are already providing support to the Friarage rota over and above the work they currently undertake. There are vacancies at both hospital sites which means that between them, the current staff are covering a high number of gaps in the rotas.
For the resident anaesthetist and the A&E doctor rotas at the Friarage, trainee doctors from the James Cook site are unable to provide support as the hospital is not a recognised training site for either specialty. The only option is trying to recruit substantive middle grade doctors (doctors who have either taken a year out of training or have yet to decide whether they want to continue to consultant level) or locum doctors.
A further complexity to the current problem is that anaesthetists from James Cook do not support the critical care unit as intensivists (i.e. consultants who specialise in critical care medicine).
This is because at the Friarage, the smaller critical care unit has always been staffed by anaesthetists who maintained their critical care medicine skills. However, due to further specialisation over the years, consultants now either specialise in critical care medicine or anaesthesia. There are fewer doctors who still undertake the dual role.
Can you adopt a more flexible approach to staffing that recognises the needs of a rural hospital? Are there alternative working models that might help?
The Trust has commissioned an independent review from the Royal College of Anaesthetists to explore whether there are other workforce models that could support the Friarage to maintain its critical care unit and anaesthetics role overnight.
A&E have started work on developing a more flexible model to the front of house emergency services and a pilot scheme started in March looking at how different roles( GP, paramedic, nurse practitioner) could work together in a more integrated way and the team have also commissioned an independent review for the Royal College of Emergency Medicine.
Much of the focus has been on recruiting consultants but can you use the skills of other staff, for example, specialist trained nurses?
A number of areas across the Trust have trained and recruited specialist trained nurses and the Trust is committed to continue in supporting these roles. At the Friarage Hospital for example, the ambulatory care unit is ran by an integrated team of GP hospitalists and specialist nurses, overseen by a consultant.
However, the critical roles such as the overnight doctor for anaesthetics cannot be an advanced specialist nurse practitioner as there has to be a doctor on site to provide support in case of an emergency.
Why can’t more patients be sent from The James Cook University Hospital to the Friarage Hospital?
Patients who need emergency care must go to the hospital that provides the level of care that they need. The James Cook is a very large hospital with a major trauma centre and specialist heart and stroke services. If a patient needed emergency care and lived nearer to James Cook, they would go directly there to receive the care they needed.
However, for planned care (in the NHS we call this elective care), patients can choose which hospital they go to and if they wished, they could go to the Friarage.
If you do make changes to some of the emergency care services at the Friarage, would James Cook be able to cope with extra patients going there?
First of all, there are no proposals at this stage – we are having a conversation about how we can work with staff, the public and local organisations to find a way of providing safe and sustainable emergency care services at the Friarage in the long term.
However, if we reached a stage of making proposals for change, capacity at James Cook and other parts of the health and care system, including ambulances, would need to be considered very carefully.
We are committed to providing as many services as we can at the Friarage, as long as they are safe and sustainable and we already know that James Cook does not have the capacity to take all of the emergency care from the Friarage. That is why this period of engagement is really important so that we can all work together on the best arrangements for the future if we cannot overcome the workforce challenges.
Some people feel that the Friarage does not have a strong voice within the Trust. Is this true?
We have heard this said and would like to reassure people that we have put steps in place to make sure that the Friarage is represented at the most senior levels within the Trust. We have introduced a management team structure at the Friarage, led by the Medical Director for Urgent and Emergency Care, Adrian Clements, who is also part of the Executive Team on the Board of Directors.
As part of this structure, we have created a number of new roles (Clinical Director, Service Manager and a Matron post) within the hospital to support the continuing development of the Friarage Hospital.
Has the Trust made up its mind already about future arrangements for emergency care services at the Friarage?
No we haven’t – we are very keen to hear from as many people as possible during this period of engagement. We hope that feedback received during this period of engagement will help us to shape a way forward.
Is this just about money?
This is absolutely not about money. This engagement is driven by the need to make sure that the services we provide are safe and sustainable in the long term and that we provide the right support to the doctors and other staff who work at the Friarage.
How can you say it is not about money when you need to make further savings of over £30million this financial year?
All NHS organisations are required to make efficiency savings year on year and for South Tees Hospitals, the target is £30m. This is about making the best use of the money available to us, so delivering services more efficiently and improving productivity. It is not about taking money away from clinical services.
What are you going to do next?
Between now and 20 December 2017 our conversation with staff, the public and our local partner organisations will continue. We are keen to make sure that everyone fully understands the staffing issues and other challenges that we are facing and that we can work together on how we might address these going forward.
All of the comments we receive will be included in an engagement report which the Trust will then consider. We will also share this report widely and make it available on our website.
We hope that the feedback will give us a better understanding of what is really important to people when they need to use emergency care services and also about how we can make sure that we provide these services in such a way that they are safe and sustainable long into the future.
It is important to stress that we could not make any major changes to the way services are provided without carrying our formal public consultation (unless there were any immediate safety concerns).
So, following this period of engagement if we do develop some proposals which would involve changes to services, there would need to be a three month period of public consultation. Such a period of consultation would need to provide many opportunities, including public events, for local people to make their views known.
We would work very closely with the local CCG and any proposals for service change would also be subject to a very comprehensive assurance process by NHS England. As part any process, we would also need to consult with North Yorkshire County Council’s Overview and Scrutiny Committee.
How can people make their views known?
Between 4 October and 20 December, we are holding a series of engagement events where patients, patient representatives, members of the public and local partner organisations can find out more about the challenges the Trust is facing and help us develop a long term plan for the Friarage. We are also carrying out engagement with our staff.
There is relatively poor public transport between the Dales, Northallerton and Middlesbrough, surely this adds to the case for keeping the services in the Friarage? Distance and transport are major concerns for people?
We know that transport is a big issue particularly given the rurality of the Hambleton and Richmondshire area. As such it is one of the important issues that we would need to take into consideration.
If you know that distance and transport are such big issues, why did you get rid of the shuttle bus which was put in place after changes to children’s and maternity services at the Friarage?
Hambleton, Richmondshire and Whitby Clinical Commissioning Group (CCG) discontinued the shuttle bus service between the Friarage and James Cook at the end of June 2016. The service started in October 2014 as a pilot to support users affected by changes to children’s and maternity services, although it was also made available to users of other services and staff.
Like many other NHS organisations, the CCG was asked to make savings for 2016/2017 so that it could deliver a balanced financial position, which they are statutorily required to do. The shuttle bus service was not running to full capacity, nor was it serving a significant number of people affected by the changes to children’s and maternity services. Therefore, the CCG decided that the £90,000 cost to run the shuttle bus would be better used.
Does the uncertainty about future services at the Friarage not hamper the Trust’s efforts to recruit?
The Trust and the CCG are committed to maintaining the Friarage hospital and have stressed that it will continue to play an important role in the provision of hospital services. The recruitment difficulties are affecting other hospitals around the country due to the national shortage of doctors in some specialties.
We hope that by developing a long term plan, which this engagement will help us with, it will be easier to recruit and retain doctors and other healthcare professionals.
The new MRI scanner which opened in April, along with other planned service developments such as The Sir Robert Ogden Macmillan Centre, show our long term commitment to delivering clinically safe and sustainable services at the Friarage for the people of Hambleton, Richmondshire, Whitby and the surrounding area.
There are plans to build an additional 1,000 new homes in Northallerton and hundreds at Catterick Garrison. These people will, potentially use the Friarage Hospital. Are you taking this into consideration?
Yes, all new developments will be needed to take into consideration.
Ambulance response times are a big concern for people living in rural areas, particularly if they are potentially going to have to travel even further for their care?
We understand people’s concerns about ambulance response times and the potential impact on patients. This would be an important piece of any work going forward.
Where does patient choice fit into this?
For emergency care patients need to go to the hospital that delivers the level of care they require to give them the best chances of survival and a good recovery. For planned care, patients will continue to have a choice over where to access their care.
However, it is very important to remember that emergency care represents a small proportion of healthcare. The vast majority of people already receive all of their healthcare out of hospital, in the community and increasingly in their own homes.
If you are asking for our views about future arrangements for emergency care services at the Friarage Hospital, have you taken into consideration the discussions that have been taking place as part of the Better Health Programme? People in Darlington have expressed concerns that they might lose their A&E department and some people in Richmondshire use that hospital too.
There have been discussions by the Better Health Programme about potential future arrangements for Darlington Memorial Hospital, The James Cook University Hospital and the University Hospital of North Tees. These have been taking place against a background of challenges including increasing national standards and some serious recruitment difficulties.
It is important to stress that no proposals have been made about any of these hospital services.
The discussions now taking place about the Friarage Hospital are part of a programme of engagement to seek views on how safe and sustainable emergency care services can be provided in the long term. Similarly, the discussions about other hospitals in south Durham and Teesside were engagement.
This type of engagement helps to understand what is important to people about services so that organisations can shape plans for the future.
No major changes to any of these hospitals could be made without proposals being developed which would then be subject to a formal process of public consultation, lasting three months and carried out in line with legislation and national guidance.
Proposals would also be subject to a very thorough assurance process carried out by NHS England which includes understanding the impact of any proposed change on patients, staff, and on other hospitals and healthcare services.
What is happening with the Better Health Programme/Sustainability and Transformation Partnership?
There have been recent discussions, which have been covered in the media, about closer working arrangements for sustainability and transformation partnerships.
Across the North East, organisations have always sought to work collaboratively where this benefits patients and supports local services. And now NHS leaders are looking at ways to coordinate any necessary changes, while making sure that plans are implemented working with local partners and reflecting the needs of individual communities. No decisions have been taken at this stage and discussions are continuing.
Why did the Duchess of Kent Military Hospital close?
The Duchess of Kent Military Hospital (DKMH Catterick), which opened in October 1976 at a cost of £3million, was closed in July 1999 after a nationwide defence review of the Army Medical Services, although a psychiatric unit remained open which provided 20 inpatient beds and an outpatient department.
Following a further review by the Ministry of Defence (MOD) in 2001, the psychiatric unit also closed with psychiatric care for military personnel being provided by Priory Clinics.
The Trust did continue to run a number of orthopaedic clinics and children’s outpatient clinics at the Duchess of Kent Hospital but these were relocated in 2014/2015. Orthopaedic clinics are now held at the Friary and Friarage hospitals while paediatric outpatient clinics moved to Catterick Village, Leyburn and Colburn. The Duchess of Kent Barracks closed on 1 March 2015
What will the two mental health wards at the Friarage be used for in the future?
The mental health wards will be used for the purpose of delivering health care as part of the longer-term strategy and vision for the Friarage Hospital
Can the Friarage guarantee that no other services will be cut once the overnight A&E service is resolved? People feel that they are having a lot of services cut from the Friarage – maternity, mental health and now A&E?
The discussions now taking place about the Friarage Hospital are part of a programme of engagement to seek views on how safe and sustainable emergency care services can be provided in the long term. No major changes to any services could be made without proposals being developed which would then be subject to a formal process of public consultation, lasting three months and carried out in line with legislation and national guidance.
Proposals would also be subject to a very thorough assurance process carried out by NHS England which includes understanding the impact of any proposed change on patients, staff, and on other hospitals and healthcare services.
Given the issues of sustainability identified, is the Trust satisfied that the sufficient level of infrastructure is in place to support the extensive level of house building taking place in Colburn/Catterick Garrison right now? Richmondshire District Council are currently waving through every application for house building with no apparent knowledge of these issues.
The Trust has met with Richmondshire District Council as part of the engagement process and all of the data/comments received have been shared with Hambleton, Richmondshire and Whitby CCG to help inform a draft consultation document. We have been assured that concerns raised about the extensive level of house building taking place will be raised with the local authorities.