Meeting documents

PH/15/27

Health and Wellbeing Scrutiny Committee

10 November 2015

Safe and effective care within our budget: consultation

REPORT TO:	Devon Health and Wellbeing Scrutiny Committee
DATE:	10 November 2015
PRESENTED BY:	Alison Diamond, Chief Executive or Chris Bowman, Clinical Director, Community Services

1. Executive Summary

1.1. The Northern Devon Healthcare Trust provided a briefing to Devon Health and Wellbeing Scrutiny Committee on the Trust's 'Safe and effective care within the budget' consultation on 14 September 2014.

1.2. Members seeking to recap on the background can find the previous papers here.

1.3. The consultation ran from 18 August until 29 September and this paper presents the highlights, outcomes and key findings of the consultation.

1.4. The consultation was in response to the 2015/16 budget settlement between NEW Devon Clinical Commissioning Group and the Northern Devon Healthcare Trust which resulted in an 11 million gap in funding, 5 million of which was allocated to the community services budget.

1.5. The Trust and CCG initially embarked on the consultation jointly, however, the CCG withdrew on 8 August citing that their pace differed from the Trust's (more detail follows in the report).

1.6. The consultation asked stakeholders and the public to help the Trust decide the best location for these beds from the four community hospitals in Northern Devon. We asked the public to express their rationale in relation to the agreed decision-making criteria to a decision which considered health inequalities and distribution of provision could be made.

1.7. On 6 October 2015 the Northern Devon Healthcare Trust Board received the consultation outcome report which can be found here. Several members of the public were in attendance to hear the Board discuss the outcome of the consultation.

1.8. Having fully considered the responses to the consultation as well as the additional feedback from stakeholders, the Trust Board made the decision to locate the community hospital inpatient beds at Holsworthy and South Molton. The rationale for this decision is contained in section 8 of this report.

1.9. Following the first briefing on the 14 September, the Scrutiny Committee voted a resolution asking the Trust to halt its consultation and the Chairman of the Committee, Councillor Richard Westlake, wrote to the Trust on 16 September to this effect. The Trust's response to this request can be found in the supporting documents which are attached to this report. In summary, the Trust acknowledged the sentiment behind the motion, arising as it did from the fact that this was a difficult, emotive consultation. The Trust also provided reassurance that the consultation was robust and pointed out that the Scrutiny Committee made its resolution in full recognition that it was not in the Committee's terms of reference to require it to halt the consultation.

2. The context

2.1. There is a national policy to encourage more care to be provided out of hospital. Please see the NHS England Five Year Forward View for more detail on this strategy.

2.2. There is growing national and local evidence which demonstrates that you can provide more person-centred and effective care when you support people's recovery, health and wellbeing in their own homes rather than hospital. This is not a new direction of travel for the Northern Devon Healthcare Trust.

2.3. On any one day, the Trust supports 7000 patients to live in their own home across North and East Devon, compared to treating 600 patients in its hospitals.

2.4. The Trust's modelling of health outcomes in places where beds have been reduced (Torrington and Ilfracombe in North; Moretonhampstead, Crediton, Ottery and Axminster in East) confirms that this out of hospital model of care is safe, appropriate and high quality for the majority of patients.

2.5. The annual Acuity Audits carried out by Public Health Devon consistently show that (on the day of the audit ) between 30-45% of people do not need to be in a community hospital bed.

2.6. The Devon-wide System Resilience Group (SRG), made up of NHS providers and commissioners, has analysed the data and patient flows following the bed closures and support the out of hospital model of care and particularly the increased effectiveness of rapid response to the patient at home within two hours as compared to inpatient beds.

2.7. We know that patients want to get home as soon as is safely possible and we also know that people would choose to be treated at home where possible rather than in a hospital setting.

2.8. The model of seeing more patients in their own home is more cost effective because the Trust can care for more patients with the same resource. By closing one inpatient unit and investing in out of hospital services, the Trust will save an average of 700,000 per hospital site (full year effect).

2.9. The Trust has concerns over the resilience of community hospitals during a national nursing shortage and the Government's cap on agency spending exacerbates this. It is more difficult to recruit nurses to community hospitals across Devon, as opposed to community nursing posts, which are much easier to fill.

2.10. Devon is a financially-challenged health economy and whilst the Trust's first priority is to always provide high quality and compassionate care, it has to do so within the available budget.

2.11. This year's budget was only agreed with commissioners in month three of the financial year. The speed of the consultation was therefore dictated by the need to implement any service change safely before winter.

3. The consultation process

3.1. The consultation launched on 18 August 2015 and ran for 6 weeks until 29 September 2015.

The Trust consulted on how to transform its services to continue delivering high quality care within its budget. The Trust did not enter into the consultation with a preferred option.

3.2. There were three phases to the engagement and consultation:

Phase 1	Staff engagement	June 2015
	Stakeholder pre-engagement/discussion of key issues
Phase 2	Key stakeholder meetings Agree and weight decision-making criteria Score each hospital/town against the criteria Agree options for public consultation	6 and 10 August
Phase 3	Public consultation	18 Aug to 29 Sept
	Consultation with staff, clinicians, GPs
Phase 4	Board decision	6 October
Phase 5	Implementation	Oct/Nov

Phase 1: pre-engagement staff roadshows to discuss the context and the challenges with our staff and stakeholder roadshows to brief stakeholders on the context and out of hospital model of care

Phase 2: pre-consultation stakeholder meetings. Meeting 1 to agree the most important decision-making criteria. Meeting 2 to score and weight the decision-making criteria before applying these scores/weights to the consultation options. In this way stakeholders influenced the format and number of options witin the consultation.

Phase 3: public consultation, including consultation with staff, clinicians and GPs

A full description of the outcomes of the pre-engagement is contained within the consultation outcome report, which is attached.

3.3. The consultation contained three options:

Option A: community inpatient beds located at two community hospitals

Option B: community inpatient beds located at NDDH

Option C: community inpatient beds located at NDDH and a community hospital

3.4. A total of 24 engagement events were held, 21 of which were formal public consultation meetings, spread across Northern Devon in Barnstaple, Bideford, Hatherleigh, Holsworthy, Ilfracombe, Lynton and South Molton. The aim of these events was to allow in-depth, open and transparent discussion of the consultation options. Over 1000 people attended these meetings.

3.5. All questions and answers from the meetings can be found here: http://www.northdevonhealth.nhs.uk/consultnorth/how-to-get-involved/

3.6. The consultation and response mechanisms were promoted through a range of communication channels to give local people and organisations the opportunity to comment:

Three thousand consultation documents and posters were distributed widely amongst the community, with copies available at the hospital receptions, GP surgeries, libraries, town halls, parish halls and on request

Information about the consultation and online means of responding were accessible from the home page of the Northern Devon Healthcare Trust website www.northdevonhealth.nhs.uk

There was extensive media coverage in most editions of the local weekly newspapers North Devon Journal and North Devon Gazette and Advertiser

Social media: twitter and Facebook were used to promote the consultation

Personal telephone calls, letters and emails to key stakeholders i.e. all county, district and town councillors, parish clerks, MPs and GPs to encourage participation in the consultation

An online message board was maintained to allow people to post questions and get responses outside of the weekly meetings

4. Consultation Response

A total of 593 response forms were received, 396 of which were on paper and 201 online. 71 were from staff members and 496 from the public. The Trust received 52 letters and emails, all of which were answered within the consultation timeframe.

The preferred option from the public was Option A (two community sites), with the preferred combination Holsworthy and South Molton.

The least preferred option was Option B (NDDH)

58% people said that they understand home-based care but many had concerns about the availability of long-term social care.

An analysis of the feedback forms for each consultation question can be found in the consultation outcome report, attached.

5. Key themes from the public consultation

5.1. The following emerged as key themes from the public responses to the consultation:

Expressions of the value people placed in their local community hospital and personal examples of the excellent care received in community hospitals

Worry about lack of provision of long-term social care, including the difficulty in finding care home beds. The Trust encountered confusion over long-term social and continuing health care with short-term NHS-funded care, which was the subject of this consultation.

Concern over the distance to be travelled to NDDH and other community hospitals

Concern that there are not enough beds in the overall system to deal with periods of surge

Examples of house-building programmes leading to population increases

5.2. These following themes were reflected in the feedback from stakeholders:

5.2.1. Criticism of the consultation process, particularly concern over speed

It is understandable that there were strong reactions to the content of the consultation. However, the Trust maintains that the consultation was not flawed in terms of process and none of the stakeholders put forward a reason why it was flawed.

The Trust used Cabinet Office guidelines on standards of public consultation and incorporated the key recommendations on timing, materials and frameworks.

5.2.2. Concern over perceived lack of support of the consultation from the CCG

NEW Devon CCG's withdrawal from this consultation caused disquiet amongst the community and appears to be the key reason that people felt the process might be flawed.

The Trust is being very open and clear in response that whilst it would have preferred the CCG to support the consultation, it respected their decision to keep the consultations separate. The Trust provided the following consistent response to these concerns:

- The CCG wrote to us saying it supported NDHT's right to consult on ending the year in financial balance.

- We are tasked with delivering safe and effective care within our budget every financial year; the CCG has a longer-term timeline for its strategy and this accounts for the differing timescales as the reason why the processes separated.

- Any decision we make is reversible, so as not to prejudice the outcome of Care Closer to Home

5.2.3. Concern over the ability of an already stretched health system to cope during the winter.

The Trust believes that offering more care out of hospital will help with system resilience during the winter. Last winter, in East Devon, the Trust invested additional winter resources into increasing the number of community hospital beds, and into enhancing out of hospital services such as the rapid response team. When evaluating the effectiveness of these services, it was agreed that the out of hospital community services provided both better value for money and excellent care.

6. GP involvement in the consultation

6.1. During the consultation we convened two meetings with GPs and Practice Managers in North Devon. The GPs raised many constructive comments and we recorded their issues and circulated them via letter within a few days of the meeting. We confirmed that the issues they raised would be incorporated into the consultation.

Following this meeting, the Trust received a list of questions from GPs and also a number of letters from GP practices.

6.2. A further meeting was held with GPs on 29 September, 2015 where the proposals of the consultation were debated with GPs who expressed a desire to be involved in the development of metrics for the ongoing monitoring of the community services where beds are removed from a community hospital.

It was agreed that these meetings should happen more regularly so there is sound debate amongst the clinical community in North Devon about important issues in future.

7. Engagement with Trust clinicians

7.1. The Trust was very open in encouraging staff to attend the public meetings, join in the discussions and contribute their views. Their attendance at the public meetings always enhanced the debate and helped the public understand some of the complexity of the challenges we are facing.

7.2. We recorded the themes from the staff feedback in the consultation outcome report. Like members of the public and stakeholders, some of the clinicians wanted assurance about the alternative model of care and the level of investment needed to make this a safe level of care for patients. There was widespread support for the direction of travel of delivering more care out of hospital.

7.3. They requested assurance about the impact on NDDH and the current issues of discharging patients with complex social issues from NDDH. They also expressed additional concerns over the resilience of NDDH during the winter months and concerns over workforce pressures.

7.4. At the request of the stakeholders, the Trust clinicians were also asked to perform the same scoring and weighting exercise of the decision-making criteria to arrive at a preferred option. (For the result please see 8.5 below.)

8. Decision-making process

8.1. The Trust Board structured the consultation to allow a robust and transparent decision-making process, which used local knowledge and experience of accessing healthcare. This was viewed as far more constructive feedback than relying on quantity of responses from particular towns or number of signatures on a petition.

8.2. By using decision-making criteria the Board was careful not to establish a process which simply asked for the public to state the popularity of their local hospital. This would have resulted in a divisive consultation.

Instead, the consultation asked the public, stakeholders and our staff to use a set of decision-making criteria, developed with stakeholders, to record their choice of option.

In addition, there were a number of other 'essential criteria' which were not consulted upon because these are the statutory clinical or national standards to which all NHS providers are required to achieve:

- Statutory duty to operate within financial budgets, with increasing pressure on successful providers (NDHT included) from the Department of Health to increase its surplus

- Provide services which are clinically safe and high quality

8.3. The inclusion of Ilfracombe within the consultation

Ilfracombe was included in the consultation by stakeholder request.

The Trust's Estates team estimated that it would cost between 1.5 million and 2.5 million to refurbish or extend the facilities at Ilfracombe and this work would take at least two years.

No new suggestions put forward which would overcome the lack of finance and deliver the work in this current financial year.

In the final consultation outcome report Ilfracombe was therefore not considered a viable option.

8.4. The inclusion of the North Devon District Hospital (NDDH) option within the consultation

The option of putting all "community" beds at NDDH was put forward by the Trust's operations team as it was seen as having benefits with regards to the patient pathway and access to diagnostic services. However, this was viewed as the least favourite option by public, stakeholders and clinicians.

In the final consultation outcome report the operations team confirmed that there had been insufficient progress with regards to working practices and patient flow at NDDH and so this option was also not considered viable.

8.5. Preferred options

The preferred options which came out of the consultation were as follows:

Public: Option A: Holsworthy and South Molton

Stakeholder: Option A: Holsworthy and South Molton

Trust clinicians: Option A: Bideford and South Molton

Both the Trust's executive board and its senior clinicians carried out a risk assessment of these options. The pros and cons of each option were discussed in detail and can be found in the consultation outcome report (pages 50-56).

The recommended option which was put to the Board was Option A: Holsworthy and South Molton.

9. The decision

A Trust Board meeting was held on the 6 October 2015. The presentation to the Board can be found in the supporting documents to this report. The Trust Board was taken through the consultation process and the decision-making process which had led to the preferred option: community inpatient beds to remain at Holsworthy and South Molton.

9.1. The Board unanimously accepted the recommended option Option A, two community hospital sites and the preferred configuration Holsworthy and South Molton.

9.2. It is evident that the public influenced the Board decision. The rationale behind the decision was as follows, which clearly reflect the feedback received from the public during the consultation:

Bideford has the most challenging nurse staffing picture and has a reliance on agency nurses whereas Holsworthy has the most stable staffing for nurses

Both Holsworthy and South Molton serve large, dispersed communities

The rural isolation of Holsworthy has a significant impact on transport to and from NDDH and other hospitals

Both Holsworthy and South Molton have modern facilities

9.3. This means that the community inpatient beds on Willow Ward at Bideford will close and inpatient beds at Ilfracome will remain closed (they have been closed since September 2014). The stroke services at Bideford (Elizabeth Ward) are unaffected by this decision.

9.4. It is important to note two caveats to this decision:

1. The Board was informed that the implementation of this decision must be reconciled with the direction of travel of the Success Regime.

2. To address some of the concerns raised by Trust clinicians and GPs, the Trust Board also agreed to consider how it would measure the quality and performance of home-facing services. It was agreed that the Trust will work with GPs, clinical colleagues and wider stakeholders to develop KPIs to measure on a regular basis to demonstrate that the services are performing as expected.

10. Quality Impact Assessment

The Northern Devon Healthcare Trust prepared a full QIA of the consultation options for the Clinical Commissioning Group. This was presented to Scrutiny on 14 September 2015.

11. Implementation plans

Implementation plans for the closure of Willow Ward at Bideford are underway. It is expected that all patients will be discharged or transferred from Willow Ward by Friday 13 November. Individual meetings with staff have been held and plans are underway to redeploy staff into other units where possible. This is an ongoing process.

12. Supporting documents

The following documents are attached to this report

6 October 2015 consultation outcome report

Presentation delivered to Trust Board on 6 October 2015

Letter to Councillor Richard Westlake following his letter dated 16 September 2015

Other information is available at www.northdevonhealth.nhs.uk/consultnorth