IRP recommendation to the Minister of State for Well being on the Dorset Medical Companies Evaluation (accessible model)


1. Letter to the Minister of State for Well being

Chris Skidmore MP

Minister of State for Well being

39 Victoria Road

London

SW1H 0EU

30 August 2019

Thanks for forwarding copies of the referral letters and supporting documentation from Councillor Invoice Pipe and Councillor Peter Shorland, Chair and Vice-Chair respectively, Dorset Well being Scrutiny Committee (HSC). NHS England and NHS Enchancment (South West) accomplished the Unbiased Reconfiguration Panel (IRP) info template. An inventory of all of the paperwork obtained is at Appendix One. The IRP has undertaken an evaluation in accordance with our agreed protocol for dealing with contested proposals for the reconfiguration of NHS providers.

In contemplating any proposal for a considerable growth or variation to well being providers, the Native Authority (Public Well being and Wellbeing Boards and Well being Scrutiny) Rules 2013 require NHS our bodies and native authorities to fulfil sure necessities earlier than a report back to the Secretary of State could also be made. The IRP offers the recommendation beneath on the idea that the Division of Well being and Social Care is happy the referral meets the necessities of the laws.

The Panel considers every referral on its deserves and concludes that, with additional motion domestically, the proposals ought to proceed.

2. Background

Dorset is a largely rural county on the south coast of England with a inhabitants of simply over 770,000, projected to develop to over 800,000 by 2023. Primary inhabitants centres embrace Bournemouth (195,000), Poole (151,000), Weymouth and Portland (66,000), Christchurch (50,000) and Purbeck (47,000). Elsewhere some 102,000 individuals stay within the west of the county, 89,000 within the east and 71,000 within the north. Total, the resident inhabitants enjoys comparatively good well being although with variations in life expectancy of 5 to 6 years between these in essentially the most prosperous and disadvantaged areas. The age profile is older than the England common with round 17 per cent of the inhabitants over 70 and rising.

Acute well being care is offered by Royal Bournemouth & Christchurch Hospital Basis Belief, Poole Hospital NHS Basis Belief (roughly eight miles aside) and Dorset County Hospital Basis Belief in Dorchester. Dorset HealthCare College NHS Basis Belief offers group, psychological well being and different providers. Ambulance providers are offered by South Western Ambulance Service NHS Basis Belief (SWASFT). Many providers are commissioned by NHS Dorset Medical Commissioning Group (CCG) alongside NHS England who fee specialised providers and first care.

In March 2014, following a interval of public engagement, NHS Dorset CCG determined to provoke a scientific providers evaluate (CSR). Its objective was to contemplate how well being and care providers might be improved throughout Dorset by addressing difficulties with staffing, the wants of a rising aged inhabitants with more and more advanced situations, variations in high quality of care and a worsening monetary place. The CSR was formally launched in October 2014 and over the next months clinicians, the general public, sufferers and others from companion organisations had been concerned in working teams to design scientific fashions, advise about engagement and session, and supply assurance round finance.

In January 2015, the CCG printed info setting out the necessity to change. To facilitate goal differentiation between the accessible choices, six analysis standards had been recognized:

  • the standard of care and affected person security
  • entry to providers (journey)
  • price and affordability
  • the influence on employees (workforce)
  • whether or not the adjustments can be delivered throughout the required timescale (deliverability)
  • different components similar to analysis and training

A spread of proposals had been drawn up across the following themes:

  • care nearer to house – locality hubs with or with out group hospital beds
  • maternity and paediatric providers – making a pan-Dorset service (doubtlessly linked to providers in Somerset)
  • acute care – networked service incorporating a significant emergency hospital and a significant deliberate hospital within the east of Dorset together with a single emergency and deliberate hospital within the west of the county
  • psychological well being providers – wanting on the acute care pathway

Throughout March 2015, the Wessex Medical Senate was engaged to see evaluate rising scientific design and a Affected person and Public Engagement Group made suggestions on session rules. Stage one assurance was obtained from NHS England in April 2015.

Dorset HSC had first been made conscious of the intention to launch the CSR by a briefing paper offered to a gathering on 10 September 2014. An extra briefing paper was offered to the HSC in November 2014. On 22 Could 2015, the HSC obtained a report updating members on progress with the CSR. The Committee was requested to appoint members for a joint well being scrutiny committee (JHSC) to be convened with Bournemouth Borough Council, Borough of Poole and Hampshire County Council to scrutinise the CSR and reply to a proper session.

The JHSC first convened on 20 July 2015 when it was agreed that every constituent physique would retain its personal proper of referral. The assembly was supplied with context for the CSR and heard broad proposals. Additionally in July 2015, the Wessex Medical Senate submitted its report making 16 suggestions that had been subsequently integrated right into a pre-consultation enterprise case.

A collection of engagement conferences with the Dorset Affiliation of Parish and City Councils started in September 2015. The HSC obtained briefing updates on progress at conferences on 8 September and 16 November 2015.

The JHSC assembly on 2 December 2015 obtained a revised timetable for the CSR. Members famous issues about workforce and transport.

In March and April 2016, the Wessex Medical Senate carried out a evaluate of additional work carried out and made suggestions for areas of growth. 9 locality primarily based Built-in Group Companies engagement occasions had been held between March and April 2016. A evaluate of the CSR by the Royal Faculty of Paediatrics and Baby Well being in April 2016 made a lot of suggestions.

In June 2016, the JHSC obtained an replace on progress, a gathering with NHS England concluded that the CSR might be partially assured topic to Nationwide Funding Committee approval and Built-in Group Companies Roadshows had been held in 27 areas.

Casual conferences between NHS officers and the JHSC had been held on 14 July and 10 August 2016 to supply a top level view of pre-consultation engagement on proposals for built-in group providers and proposals for public session.

The Dorset Sustainability and Transformation Plan was launched in October 2016 constructing on the work of the CSR and outlining how the NHS five-year ahead plan can be delivered. The JHSC obtained a report on proposals to go ahead to NHS England for Stage two assurance and public session. Stage two assurance was confirmed in November 2016 following completion of labor required by the NHSE Funding Committee and the CSR pre-consultation enterprise case was printed.

The CSR public session, ‘Enhancing Dorset’s healthcare’, started on 1 December 2016 working till 28 February 2017. Two choices, having emerged from the scientific working teams and subjected to the agreed analysis standards, had been put ahead in respect of acute hospital providers. Choice A noticed Poole Hospital as the main emergency hospital with Royal Bournemouth Hospital as the main deliberate care hospital and Dorset County Hospital as a deliberate and emergency care hospital. Beneath Choice B, Poole Hospital can be a deliberate care hospital with Royal Bournemouth Hospital as the main emergency care hospital and Dorset County Hospital as a deliberate and emergency care hospital. Two choices had been proposed for maternity and paediatric providers. Choice A would see two centres – on the main emergency hospital within the east of Dorset and an built-in service throughout Dorset County Hospital and Yeovil District hospital for residents within the west of the county. Choice B would see a single specialist centre on the web site for the main emergency hospital within the east of Dorset.

Proposals for built-in group providers aimed to assist extra individuals locally as an alternative choice to main hospitals, enhance the vary of outpatient and remedy providers locally, create joined-up groups of well being and social care employees, transfer in direction of seven day providers accessible for longer hours, enhance using group hospitals as group hubs and assist the psychological well being acute pathway evaluate working alongside the CSR.

A workshop was held on 20 February 2017 for Dorset HSC members to contemplate questions within the formal session in preparation for a JHSC assembly on 23 February 2017. Issues had been raised about finance, workforce capability, potential lack of beds in group hospitals and using beds in care houses. On acute providers, issues had been expressed about ambulance response instances and the validity of journey time evaluation. On maternity and paediatrics, HSC members opposed the lack of providers in west Dorset however supported the proposal for an built-in service with Yeovil and Dorset County Hospital.

A collective response from the JHSC was submitted on 3 March 2017. It urged the NHS to take account of the issues raised because it developed the proposals and sought reassurance on two key points:

  • that full and detailed monetary modelling will probably be undertaken with all key companion businesses, notably the Native Authorities, to make sure that the price of proposals has been adequately established and that they’re inexpensive and achievable for all companions
  • that maternity and paediatric providers will probably be maintained to serve the west Dorset space, in recognition of the real issues that some Members have concerning journey instances, ought to consultant-led maternity and paediatric providers be primarily based in Bournemouth in future

Session responses had been independently analysed by Opinion Analysis Companies and high quality assured by the Session Institute. A report of the findings was printed in Could 2017. Extra work to deal with the issues raised was undertaken throughout Could and August 2017 together with work on emergency and non-emergency journey instances, equality influence assessments and scientific danger assurance. In July 2017, SWASFT printed a report ‘Modelling the potential influence on the emergency ambulance service’. It recognized a small web enhance in requirement for emergency ambulance useful resource and really helpful additional work to refine each the exercise modelling and the evaluate of scientific danger. Dorset County Council’s evaluate of non-emergency transport concluded that CSR journey instances had been inside acceptable parameters. NHS England present affirmation of capital assist – later confirmed at £147 million.

At a casual assembly of the HSC on 1 August 2017 CCG representatives offered findings from consultations into the 2 critiques (CSR and the psychological well being acute care pathway) forward of a JHSC assembly on 3 August 2017. The JHSC wrote to the CCG on 29 August 2017 highlighting areas for consideration and it was agreed these can be taken into consideration on the CCG Governing Physique assembly on 20 September 2017.

The CCG printed its decision-making enterprise case in September 2017 forward of a CCG Governing Physique decision-making assembly on 20 September 2017. In all, 23 suggestions had been authorised together with these about acute hospital providers (Choice B), maternity and paediatrics (Choice A) and commissioning built-in group providers nearer to house, delivered by built-in group groups and area people hubs to ship higher care.

A gathering of the HSC on 13 November 2017 obtained an replace report on the CCG’s response to the JHSC’s suggestions. The HSC resolved to refer the proposals to the Secretary of State topic to the end result of a gathering of the JHSC on 12 December 2017, convened in response to issues raised by the HSC. At its assembly, the JHSC obtained shows from representatives of the CCG and native NHS suppliers. The JHSC voted to not assist the HSC choice to refer, proposing as an alternative that detailed scrutiny of emergency ambulance providers be undertaken. The HSC met on 20 December 2017 and heard proof from CCG representatives outlining the rationale for the choices made. The Committee resolved to not refer however to proceed the scrutiny of ambulance providers and emergency transport.

On 8 March 2018, following an replace report back to the HSC, the Committee determined to ascertain a process and end group to evaluate current and new proof and decide standards for making a referral in future. The HSC Process and End Group met on 1 Could 2018 and agreed to adjourn till the end result of a judicial evaluate introduced by an area resident was recognized. The HSC met on 15 June 2018 and determined that the Process and End Group ought to recommence its work. The Process and End Group met on 4 July 2018 to scope its remit and invite audio system to a gathering on 22 August 2018. Subsequently, 19 questions had been submitted to native NHS our bodies for dialogue at a gathering on 18 September 2018 wherein the Group, having heard additional proof, resolved to suggest to the HSC to not make a referral to the Secretary of State however to proceed scrutinising the CSR and ambulance efficiency by the JHSC. The Process and End Group’s advice was reported to the HSC at a gathering on 17 October 2018. The HSC voted by a majority of six to 4 to submit a referral on two particular ‘components’:

  • concern that the journey instances by South West Ambulance Service NHS Basis Belief haven’t been satisfactorily scrutinised and that the proof wants additional investigation to the present declare that these journey instances is not going to trigger lack of life
  • concern that there isn’t a native different to the lack of group hospitals given Dorset’s demographic with its ageing inhabitants and the way that service will probably be delivered

The HSC wrote to the Secretary of State on 5 November 2018 to refer the matter.

A movement for the Borough of Poole Well being and Social Care Overview and Scrutiny Committee to refer the matter was defeated in December 2018. The Committee as an alternative wrote to the Secretary of State on 4 January 2019 to assist the referral made by Dorset HSC.

On 1 April 2019, following native authorities re-organisation, the 9 councils that beforehand existed in Dorset had been abolished and two new unitary councils – Dorset Council and Bournemouth, Christchurch & Poole Council – had been created. Each of the brand new councils include areas that shaped a part of the earlier Dorset County Council and each, due to this fact, retain an curiosity on this referral.

An utility to the Courtroom of Attraction to contemplate permission to attraction the earlier judicial evaluate was heard on 24 July 2019. The Courtroom’s judgment was handed down on 7 August 2019. The appellant was refused permission to attraction on all grounds.

3. Foundation for referral

The HSC’s letter of 5 November 2018 states:

The choice to make a referral was made on 17 October 2018 in respect of Part 23 of the Native Authority (Public Well being, Well being and Wellbeing Board and Well being Scrutiny) Rules 2013, Part (9) (c) – that Dorset considers ‘that the proposal wouldn’t be within the curiosity of the well being service in its space’.

4.
IRP view

With regard to the referral by the Dorset HSC, the Panel notes that:

  • the CSR has been the topic of detailed well being scrutiny by an appropriately shaped joint well being scrutiny committee that determined to not refer
  • the CCG individually and extensively responded to Dorset HSC earlier than (towards the advice of its personal Process and End Group) the HSC determined to refer – greater than a yr after the CCG’s selections
  • this referral offers additional proof in assist of reviewing present scrutiny steering
  • the 2 ‘components’ of the CSR which can be the topic of this referral had been each coated by the unique judicial evaluate, the judgment of which was upheld by the Courtroom of Attraction
  • emergency ambulance provision underneath the proposals has been topic to a lot evaluation and debate about the advantages of taking sufferers to the suitable location for care over the potential of added journey time
  • the present sample for group providers isn’t match for objective – the case for care nearer to house and for built-in community-based providers is broadly supported by these offering the providers however a explanation for concern to the native inhabitants

5. Recommendation

The Panel considers every referral on its deserves and concludes that, with additional motion domestically, the proposals ought to proceed.

5.1 Scrutiny

The IRP has commented beforehand on the method for establishing and working joint well being scrutiny committees. On this case, a joint well being scrutiny committee was established by Dorset, Bournemouth, Poole and Hampshire Councils because the well being physique to be consulted on issues referring to the planning, provision and operation of the well being providers within the space underneath the Native Authority (Public Well being, Well being and Wellbeing Boards and Well being Scrutiny) Rules 2013. The JHSC is the suitable and solely scrutiny physique with which the CCG should seek the advice of on any proposals developed in respect of the Medical Companies Evaluation. Additionally it is the one physique that the NHS is required to supply info to in these circumstances. The NHS on this occasion made extra efforts to have interaction with the constituent scrutiny committees individually however finally nonetheless discovered that its selections had been the topic of referral to the Secretary of State by a type of constituent committees, specifically Dorset HSC.

Each the JHSC and Dorset HSC resolved to not refer the proposals in December 2017 while committing to undertake additional joint scrutiny of ambulance providers and transport preparations associated to the adjustments. Within the Panel’s view, the HSC’s subsequent change in place and referral in October 2018 can’t be defined by the proof offered. They, with their joint scrutiny companions, had did not do the additional scrutiny relating on to one of many two particular points raised. The NHS engaged totally with the HSC’s personal Process and End Group, offering additional and new info in response to the questions raised by different events, resulting in a advice to not refer. The primary court docket judgment was additionally accessible, offering info and evaluation of the problems resulting in a transparent judgment in favour of the NHS.

The HSC has at all times acknowledged the case for change and agreed that the referral can be on two particular grounds and never on the whole lot of the 23 selections agreed by the CCG on 20 September 2017. The Panel is anxious that after 4 years of scrutiny, the HSC was both unable or unwilling to articulate a transparent view on the NHS’s proposals or certainly put ahead options. As a consequence, priceless effort and time has been diverted from implementing and bettering providers.

Whereas a number of the occasions recorded within the background above are undoubtedly distinctive to the Dorset CSR, this case offers additional proof for reviewing the aim and processes for scrutiny of well being providers. When revising its current steering on well being scrutiny the Division might want to contemplate the necessity for a evaluate of the efficiency of joint committees to make sure that they’re working as initially meant. Revisions to steering may additionally make clearer {that a} referral relies upon upon scrutiny taking a view on proposals and making purposeful effort to resolve variations of view with the native NHS.

5.2 Proposals not within the pursuits of the well being service

The Panel notes that the 2 ‘components’ of the CSR which the HSC selected to focus on in its referral had been coated in some element by each the unique judicial evaluate and by the Courtroom of Attraction and the context offered by these proceedings is actually distinctive within the IRP’s expertise of advising on well being service change. Nevertheless, referral to the Secretary of State and judicial evaluate are totally separate processes and the Panel has at all times been clear that it doesn’t advise on issues which can be for attorneys and the courts however reasonably considers every case on its deserves, consistent with our basic phrases of reference.

Emergency ambulance providers provision and efficiency are integral to those proposals and the potential influence of elevated journey time on outcomes for some instances has been the topic of a lot evaluation, evaluate and debate. From a respectably sized survey pattern which confirmed most sufferers will expertise shorter journey instances or no change, concern has been centered on the chance that for a really small proportion of instances (round 0.6 per cent) prolonged journey might current a danger. Having thought-about all of the proof offered to it fastidiously, together with the retrospective scientific case evaluate, the Panel was not persuaded by the assertion that worse outcomes would seemingly consequence from the longer emergency ambulance journey time.

Additional, one of many central functions of the proposals is to enhance the standard of care as soon as a affected person has been delivered to hospital. The Panel recognises that the advantages of sufferers being taken to the suitable place for the proper care has but to be totally appreciated by the general public who, understandably, see the potential of added journey time to the place of care as a possible danger issue. That is to underestimate the standard of care that may these days be offered by paramedic ambulance crews in stabilising and treating sufferers earlier than transferring them on to one of the best location for the following stage of their care and skilled administration.

Offering any well being service, however particularly those who concern pressing and emergency care, entails scientific dangers that have to be monitored and managed. Because the proposed adjustments to providers are launched incrementally over the following 5 years, open dialogue with events in regards to the points to be addressed will contribute to constructing confidence.

The case for care nearer to house and imaginative and prescient for built-in community-based providers is effectively developed and has been broadly supported. The present sample of providers isn’t match for objective by way of staffing, services and geographical distribution. That is acknowledged by those that work in them and so they have been instrumental in creating and designing the brand new mannequin and associated proposals.

The Panel agree that the ambition, mannequin and method are essential for the long run and the CCG’s proposals supply a robust platform to each resolve present points and meet future wants. Nevertheless, latterly the message about what is meant and the way it is going to be delivered appears to have been misplaced. Sufferers and the general public fairly wish to know what their native providers are and that their wants will proceed to be met by these proposals. There’s a clear narrative to be instructed in regards to the end result of session, incremental adjustments to providers and new funding, together with an total enhance in mattress capability. The IRP understands that translating excessive degree proposals into detailed adjustments on the bottom takes time and is topic to variation and iteration. Partaking the 2 lately shaped native authorities as companions chargeable for social care and the customers of native providers will probably be essential to creating progress.

6. Conclusion

These proposals have been developed over a protracted time period and command the arrogance of native clinicians who’ve been main their growth. The method is complete and adjustments to providers will probably be incremental and thoroughly thought-about with any new dangers recognized and mitigated. The Panel considers that the proposals are within the curiosity of native well being providers, will enhance outcomes and that the 5 assessments have been met.

All events should have interaction constructively sooner or later growth of well being providers. That there stay points and issues of native concern is to be anticipated however there is a chance now to inject new vigour into progressing the proposals to the following section of implementation.

That section ought to contain higher co-production between events than has hitherto been evident, not least in figuring out one of the best methods of explaining to native individuals the rationale behind the adjustments and the way they will affect the event of providers. These events ought to embrace all arms of the NHS, native authorities for the world in its new guise in addition to native Healthwatch and public and affected person teams. On this regard, the Panel was struck, regardless of their evident curiosity, by the obvious lack of involvement up to now of the Dorset Defend the NHS Residents Group within the growth of proposals. Regardless of the causes behind this, it’s to be hoped {that a} extra constructive relationship will be constructed going ahead.

Your predecessor, in his commissioning letter, requested the Panel to contemplate the potential relevance of the event of an ‘A&E Native mannequin’ as referred to within the NHS Lengthy Time period Plan. NHS England and NHS Enchancment suggested the Panel that, throughout the pressing and emergency transformation programme, work is underway on what could be a viable mannequin between the usual pressing therapy centre and a standard district basic hospital A&E. The work is seeking to construct on what’s already being thought-about in entrance line providers, bringing scientific experience and design collectively to discover choices. Little doubt, the NHS domestically will want to preserve abreast of developments on this sphere as new pondering emerges nationally.

Yours sincerely,
Lord Ribeiro CBE
Chairman, IRP

7. Appendix One – listing of paperwork obtained

7.1 Dorset HSC

  1. Referral letter to Secretary of State from councillors Invoice Pipe and Peter Shorland, Chair and Vice-Chair, Dorset HSC, 5 November 2019

Attachments:

  1. Referral doc

  2. Appendix 1 – Hyperlinks to agenda papers and minutes for Dorset HSC, Joint HOSC and Process and End Group

  3. Appendix 2 – Response of Joint HOSC to the session

  4. Appendix 3 – Letter from Joint HOSC in response to outcomes of consultations on CSR and MH ACP

  5. Appendix 4 – letter from CCG in response to letter from Joint HOSC, 29 August 2018

  6. Appendix 5 – Proof offered to Dorset HSC Process and End Group by invited representatives, 22 August 2018

  7. Appendix 6 – CCG and Trusts responses to 19 questions submitted by T&FG

  8. Appendix 7 – Letter to Chief Officer, NHS Dorset CCG re intention to refer, 23 October 2018

7.2 NHS

  1. IRP template for offering evaluation info with embedded paperwork

Attachments:

  1. Dorset Medical Companies Senate Council Report

  2. Pre-Session Enterprise Case (PCBC)

  3. PCBC appendix A

  4. PCBC appendices B, C, D, I, N, O

  5. PCBC appendix E

  6. PCBC appendix F

  7. PCBC appendix G

  8. PCBC appendix H

  9. PCBC appendix J

  10. PCBC appendix Ok

  11. PCBC appendix L

  12. PCBC appendix M

  13. PCBC appendix P

  14. PCBC appendix Q

  15. Medical Companies Evaluation (CSR) Session Doc

  16. Session Institute Doc re good observe

  17. Session Institute Doc re finest observe

  18. ORS Doc on session findings

  19. ORS report of findings

  20. ORS abstract report of findings

  21. CSR Resolution Making Enterprise Case (DMBC)

  22. CSR DMBC appendices

  23. NHS England letter of stage one assurance

  24. Dorset CSR Gateway report

  25. NHS England letter approving development to session

  26. CCG Governing Physique (GB) approval to proceed to session

  27. GB choice to delay continuing to session

  28. GB approval of acute hospital web site particular session choices, 18 Could 2016

  29. GB approval of group web site particular session choices, 20 July 2016

  30. GB approval of really helpful CSR choices, 20 September 2017

  31. GB particular minutes, 20 September 2017

  32. Judicial Evaluation judgment (full)

  33. Judicial Evaluation judgment (abstract)

  34. Debby Flemming witness assertion

  35. Affected person Advantages PBC lite v4

  36. South West Ambulance Service Basis Belief (SWAST) report, September 2017

  37. SWAST Medical Threat Evaluation Final result, December 2018

  38. SWAST Medical Threat Evaluation Knowledge, December 2018

  39. Stroke Transformation Plan FBC, 2019

  40. Group Beds knowledge, August 2019

7.3 Different proof

  1. Letter to Dorset HSC from Richard Drax, MP for South Dorset, 16 October 2018

  2. Borough of Poole letter to Secretary of State for Well being and Social Care, 4 January 2019

  3. Borough of Poole appendix A – Way forward for Poole Hospital presentation

  4. Borough of Poole appendix B – Public questions and responses by native NHS companions

  5. Borough of Poole appendix C – abstract of supplementary questions and responses

  6. Borough of Poole POSC minutes of particular assembly, 17 December 2017

  7. Hinsull v Dorset CCG judgment

  8. Hunsull v Dorset CCG abstract

  9. Hinsull permission to attraction

  10. Capsticks attraction end result letter to CCG, 24 July 2019

  11. Hinsull order

  12. Hunsull judgment for Hand Down

  13. Defend Dorset NHS Residents Group (DDNHS) submission to IRP, 5 August 2019

  14. Overlaying emails to submission to IRP from DDNHS, 15 November 2018

  15. Referral letter, 5 November 2018

  16. DDNHS Index and appendices to submission

  17. DDNHS Our Case

  18. DDNHS CCG cumbers at potential hurt

  19. DDNHS seemingly fatalities from SWAST report

  20. DDNHS Poole A&E Freedom of Info request

  21. DDNHS Poole Maternity Freedom of Info request

  22. DDNHS Royal Bournemouth hospital Freedom of Info request

  23. DDNHS Atmosphere Company re Hyperlink Street

  24. DDNHS CCG presentation to Poole Council, 29 November 2017

  25. DDNHS Langton Freedom of Info request pt1

  26. DDNHS Langton Freedom of Info request pt2

  27. DDNHS A&E guide of affected person security

  28. DDNHS group hospital beds

  29. DDNHS Why the CCG plan will fail

  30. DDNHS letter to Secretary of State, 27 November 2018

  31. DDNHS Poole A&E Freedom of Info request pt1

  32. DDNHS CCG numbers at potential hurt

  33. DDNHS letter, 11 January 2019

  34. DDNHS extra info, 24 August 2019

  35. Paperwork offered by Gerald Rigler (GMR)

  36. GMR A338 hospital entry

  37. GMR request to MP

  38. Philip Jordan (PJ) e-mail to Secretary of State, 8 January 2019

  39. PJ communication to assist CCG selections, 20 September 2017

  40. PJ questions for CCG Board assembly, 20 September 2017

  41. PJ Referral letter from Dorset HSC to Secretary of State, 5 November 2018

  42. PJ referral to Secretary of state from Dorset HSC, November 2018

  43. PJ appendices 1 to five referral to Secretary of State from Dorset HSC, November 2018

  44. PJ appendix 6 referral to Secretary of State from Dorset HSC, November 2018

  45. PJ appendix 7 referral to Secretary of State from Dorset HSC, November 2018

  46. PJ Conclusion to be learn with 30 August 2017 communication, 12 September 2017

  47. PJ Governing Physique public questions, 21 January 2015

  48. PJ Doc 4 specification, 18 Could 2015

  49. PJ draft notes re assembly, 17 August 2017

  50. PJ Web page 7 of 8 Must Change

  51. PJ Please postpone CSR selections, 20 September 2017

  52. PJ DHC journey survey



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