Agenda item

To consider the report of the Director of Transformation and Governance on proposals from the NHS or providers of health services to vary or develop health services in the area of the Committee.

Items for Monitoring

a)  Out of Area Beds and Divisional Bed Management System (Southern Health)  

b)  Spinal Surgery Service Implementation Update (University Hospital Southampton) 

c)  Beggarwood and Rooksdown Surgeries Update (NHS North Hampshire CCG)

d)  Orthopaedic Trauma Modernization Pilot (NHS Hampshire Hospitals Foundation Trust)

e)  Andover Hospital Minor Injuries Unit Update (NHS Hampshire Hospitals Foundation Trust)

Items for Monitoring

a) Out-of-Area Beds and Divisional Bed Management System (Southern Health)

Representatives from Southern Health provided an overview of one of their most significant organizational challenges - managing out of area beds.  Managing demand of inpatient services within capacity has led to moving patients out of county and into private care. 

Having a variety of inpatient facilities and in keeping with the reorganization, there are 4 divisions that are managed together.  More local ownership and a new approach has led to fewer patients in out-of-area beds, and more capacity is being created to address demand.

A crisis lounge will assist with demand and relocation of facilities to allow more accessibility to patients, including a new OPMH ward.  This will be a complicated series of moves but will allow for refurbishment and accommodating needs in a dementia-friendly environment.  While currently in the early stages of proposals and commissioning beds, eventually purchasing additional beds will no longer be necessary.

In response to questions, Members heard:

• Longer stays in Hampshire versus the national average are due to several reasons, including the limited range of community services available here.  There is a need to expand the variety of alternatives to inpatient admissions and the long-term plan highlights need to invest more in community mental health services and crisis management.  Longer stays have higher financial costs and are detrimental to patients but in the short-term people must be accommodated should they need impatient care.  Progress continues to be made in this area.
• Challenges with foreseeing volume of beds and past closures have led to purchasing beds to accommodate needs in the meantime.  With new leadership, there are now alternatives to admission, stepdown admissions, and a comprehensive plan for additional inpatient capacity.  Renting facilities as an alternative has significant challenges in staffing nurses and specialists.
• While prior planning is preferable to crisis management, new leadership must face current organizational challenges and work with commissioners to increase investment in mental health services with comprehensive crisis and inpatient care.  Colleagues in primary care can ensure that there are mental health workers to better support patients moving towards and model of care that focuses on prevention and wellbeing.
• Planned work in Tatchbury is continuing and will provide mental health support for children.  Other much needed units for disadvantaged residents will be completed in the next financial year.
• Long serving members of HASC have seen new models of care put into effect with removal of beds which are now being added back in for adequate capacity.  Scrutiny must challenge these assertions and are only worthwhile if lessons are learned.  The impact on distressed carers and families, as well as challenges for community teams with inadequate resources and insufficient accommodation are closely monitored and not being underestimated.  Funding is provided to allow for family contact and bonds to remain.  In-house care is always the preferred option and length of stay in external beds are limited as much as possible.
• While the cost of internal beds is approximately 50% that of private beds, the current contract is necessary to cover needs until accommodation can be provided in-house in Hampshire.  This is a short-term temporary solution and these beds will eventually be vacated and no longer necessary.
• In terms of monitoring care and sharing records for continuity of care, there have been challenges with not all providers using the same EMRs.  Care coordinators work to ensure that copies of paper records are taken from the private hospitals upon discharge and updated in the system.
• Private sector resources and forecasting are very different from the NHS model and are more adept and agile in terms of creating capacity and developing needs addressing through services with more funding available for projects.
• The divisional bed model may leave some patients in out of area care and there may be some loss of the ability to deploy patients.  These concerns are being managed through close scrutiny and daily review and analysis of data (including number of admissions, discharges, etc.) to ensure spare capacity at all times as best practice.  Significant improvements have been made with this model and 85% capacity is ideal to cope with unforeseen needs in demand and each division must have some local authority and ownership to attain this.  In time, with an increase in the number of beds and alternative services to inpatient care will allow for sufficient capacity.
• Prevention remains vital and collaboration with Public Health at the Hampshire County Council allowed for further resources to promote mental health wellbeing and prevent mental ill health in children and young people.
• Support is critical for patients with psychiatric issues disadvantaged families must be supported to allow them to visit their loved ones.  Effort is made to shorten the length of stay in out-of-area beds while travel costs are paid for and patients are often repatriated closer to families.
• Rough timescales for proposals to be implemented are as follows - the crisis lounge to be moved by Christmas to the Southampton location, the Abbey Ward will be more complicated and take several months, likely next year and also linked to Stephano Oliviery Unit as their relocations are interconnected.

RESOLVED:

That the Committee:

• Noted the update and current challenges as well as any recorded issues addressed and/or resolved
• Noted that the proposed changes are in the interest of the service users affected
• Requested an update for January 2020 to report back on changes implemented

b) Spinal Surgery Service Implementation Update (University Hospital Southampton)

A representative from University Hospital Southampton provided an update on the work in progress with spinal service from when the paper was first submitted two years ago.  In order to take on this service in its entirety from Portsmouth, other services were moved to be able to absorb this service fully in-house.  Only those needing surgery proceed to Southampton and it has been a successful pathway. 

In response to questions, Members heard: 

• Vascular services had previously moved from Portsmouth to Southampton following a request from The Royal College.   The spinal service relocation request came directly from Portsmouth.  Currently, the STP is looking into these transfers and some work will have to move to Portsmouth to accommodate these changes.  Diagnostics have been left in Winchester and physiotherapy also remains local and patients travel to Southampton only to see a surgeon.
• Recruiting spinal surgeons has been a challenge and ongoing effort.  In a year’s time, the hospital expects to have on staff experienced surgeons to cope with the waiting list to lessen wait times for surgery.
• The current wait times for orthopaedic surgery is between 18 weeks to a year and in addition to having adequate operating theatres, staffing remains one of the biggest challenges.  The multi-disciplinary surgery team is key and a new set of hiring routes and a robust workforce plan is in place to address staffing vacancies.

RESOLVED:

That the Committee:

• Noted the update on the implemented service transfer and any recorded issues addressed and/or resolved
• Requested a further update in March 2020 with regards to staffing and wait times

c) Beggarwood and Rooksdown Surgeries Update (NHS North Hampshire CCG)

Representatives from the CCG and North Hampshire Urgent Care provided an update about approximately 13.5 thousand patients were affected across 2 sites, when Cedar Medical’s contract came to an end.  Concerns were escalated by patients and the CQC due to deteriorating outcomes with commissioners intervening and contract withdrawn.

On 9 September, new providers started at Beggarwood and while there were issues, doors were opened and services continued to be provided.  Similarly, Rooksdown was taken on by another GP practice and absorbed as another branch.  Beggarwood was taken on by North Hampshire Urgent Care for 2 years and the practice continues to be supported by the CCG.

In consultation with the Beggarwood staff and patient participation group and listening to the needs of the population, the immediate concern is to stabilize the practice and ensure it is running safely, before considering what else can be implemented to support the patients.  All changes in service will be proceed in conjunction with the PPG.  The local Member is supportive of this course of action.

In response to questions, Members heard:

• Whilst they had some very stressful weeks, the support staff have remained and been greatly involved in the development of the practice.  Two locums have also stayed on and the first full time GP is permanently on staff with a second GP to be hired and positive responses to nurse practitioner advertisements.
• Population expansion and local community needs will feed directly into determining services provided from a list of preferences.  The diverse community with 90% working patients will determine the contracting of local services and mechanisms to commission what is needed, rather than a traditional GP model.  Bringing in services from the hospital and technology such as virtual teleconferencing etc. will be considered once the practice has been stabilized to ultimately be an exemplary, outstanding GP practice.

RESOLVED:

That the Committee:

Noted the update and current challenges as well as any recorded issues addressed and/or resolved

• Requested a further written update for January 2020

d) Orthopaedic Trauma Modernization Pilot (NHS Hampshire Hospitals Foundation Trust)

Representatives from the Hampshire Hospitals Foundation Trust and the West Hampshire CCG provided an overview of the Orthopaedic Trauma Modernization Project.  Wait times for orthopaedic surgery has been an issue without a straightforward solution.  There is significant evidence that immediate surgery is crucial for emergency situations and this can be done rapidly in Basingstoke while all planned work would be at the Winchester site.  This would allow for smoother winter operations and preventing cancellations at short term notice for patients with better urgent and planned care.  While some engagement has taken place, more would be valuable and feedback during the pilot will be useful and relevant.

In order to provide the highest quality and consistency of care and no wait times for surgery, there must be dedicated lists to improve outcomes and centralized multi-disciplinary teams to help patients reduce the length of stay and regain their health.  The managing trauma in Basingstoke recommendation came from Professor Tim Briggs, National Clinical Director for Improvements, to address mortality rates above the national average.  The aim is good results and safer, timely care with lower mortality rates and less complications.  Approximately 93 percent of patients will be unaffected by these changes and 3-4 people per day would benefit from them. 

The elective arthroplasty centre would be for knee and hip operations and developed in stages to become a centre of excellence.  Winter operation cancellations on short notice that occur due to people falling or simply being unwell and taking up beds would be reduced.  With trauma housed elsewhere, patients suffering significant impact and distress from living with a disability or pain can be protected from long wait times and 17 additional rehab beds would also be put into place.  While patients and families would have to travel to other sites, consultation has reinforced that better care is key and transport volunteers will be helping mitigate travel for carers and families.  Stroke and cardiac services have had similar changes and they have been well-received and effective. 

Some staff are anxious about the proposed changes and that they may cause personal and professional challenges.  Staff and patients, as well as acute providers, will continue to be supported.  In the future, elective arthroplasty services can be used by Southampton and Portsmouth for larger capacity.  Exploring this proposed service change would result in earlier operations with experienced specialist teams based on recommended change and other successful models which will help prevent cancellations and reduce wait times.  Less severe trauma or minor operations will see no change and they will continue to receive services same as before.

National teams work closely with acute hospitals and for effective care, these recommendations must match needs not only for current patients but engagement and learning must be tested with wider populations.  Understanding future needs - what works, what creates an impact is key.  Commissioners, providers, patients, and future patients should all be part of this discussion to ensure it is centralized and future proof.  Better patient care, shared skill sets, and a range of professionals on-hand is the direction of travel for the NHS in the broadest sense.  Resources have to be invested where they will go the furthest and have the most benefits.  Protected characteristics, disadvantaged people, and hard to reach groups will not be overlooked.  The engagement programme will be broad, deep, and detailed to understand the true impact and results will be reported back.  Stakeholders such as the ambulance service will also be engaged to ensure they can manage the new data, impact, and capacity.

In response to concerns noted on an anonymous letter that was received, Members heard:

• No resignations citing patient safety had been received but there has been a doctor preferring to move to a different service rather than location, and similar cases with some nurses.  Two staff members did leave due to geographical changes.
• Effective discharge plans and liaising with other departments and social care have been put into place with no issues to note.
• The public have been engaged in a number of conversations over the last 7 years, but there is a gap and more consultation to be completed.  Piloting in winter with parallel public engagement is key with responses based on experiencing the new arrangement.  Further work needs to be done and there is a joint HHFT/CCG engagement manager. 
• There are financial and staffing implications by nature, but this would be the investment for a long-term solution for better care, re-hab, and therapy in the right place.  Higher volume of operations will cost more but one 7-day team will eventually be more cost effective than duplicate teams. 

In response to questions, Members heard:

•  Portsmouth had been omitted from the map as a level 2 trauma centre, but that was an oversight.
• Patient safety, specialist input and way patients are looked after operations will all be key with a system where there is adequate staffing to run 7 days a week, as has been done in other areas.  While Winchester is bottom of the list for length of stay, the care is good, there is room to improve. 
• In 6 other national projects, there were anxieties prior to implementation, but positive feedback regarding improvement in service after.  Change does cost money and there will be new infrastructure, but better service with reduced length of stay and will not cost more in the long term.
• In the reconfiguration of services, other implemented centralized models and lessons learned had been considered that match Hampshire’s geography and needs.  The target is to cancel no operations.  The closest example from a clinical perspective is about 18 months ahead and will offer solid learning.
• The coming winter will be busier due to a hectic summer in the emergency department with surgeries having even been cancelled even in the summer creating longer waiting lists.  With a long waiting list, people can have 3-4 last minute cancellations and these individuals must be prioritized.
• Huge work is being taken on for sustainable changes to lower mortality.  The trust must wait a year in arrears for national comparison and believe the care is better, but infrastructure must be changed to sustain progress.  This is the absolute basis of why this change is being made with additional benefits.  Hospital acquired infection mortality is low for Hampshire.
• Cancellations are primarily due to bed issues, rather than staff issues and while multiple cancellations are challenging and patients struggle with pain, they do wait for their operations rather than do them privately.  Cancelled patients are put on a different list to be brought back in within the month.
• While there has been a 13% cut in falls prevention and it is key, the majority of the stress is people living longer but frailer.  People are encouraged to be mobile but that can lead to falls.  There are more fractured hips in Basingstoke than Winchester and these numbers need to be considered. 
• Data about falls prevention continues to be collected from patients and they are referred to classes, if they have not attended.
• The Public Health Budget does not quite match the complex long-term needs and required investment in prevention.  Understanding the financial implications and bolstering planned and unplanned services is critical.  For people with multiple health concerns, better, effective joined-up care plans need to be provided.
• The orthopaedic multi-disciplinary team have had informal and formal discussions and staff relocations were brought up in July.  Leadership is working to address concerns hospital wide and accommodate staff as much as possible.  Personal implications of the move are causing anxiety and those directly affected have been engaged.
• Hospital teams manage flow and planned discharge carefully with the hospital and ambulances to ensure people are receiving the best care in the right venue

Members noted that:

• This is an exciting prospect and if it has similar success to the centralization for stroke and cardiac care, it will make a significant difference in outcomes and waiting lists.  Accommodating accidents week-round is also critical and robust staffing must be in place for effective care. 
• Volunteer drivers and charitable organizations can also assist with travel.

RESOLVED:

That the Committee:

• Noted the update and current challenges as well as any recorded issues addressed and/or resolved
• Noted the proposed change is in the interest of the service users affected
• Requested a further update for March 2020 including an engagement update for staff and a comparison to the Cambridge implementation within the report

The Chairman called for a 10-minute recess.

e) Andover Hospital Minor Injuries Unit Update (NHS Hampshire Hospitals Foundation Trust)

A representative from the Hampshire Hospitals Foundation Trust provided a brief update on reduced hours implemented in June 2018 due to low occupancy.  An ambitious training programme has now been put into place and have attracted new trainees- currently there are 6 vacancies, expected to go down to 2.  Collaboration and   crossover training was undertaken with SCAS colleagues. 

There has been close monitoring of the effects and impact of closing early.  On occasion, the centre has closer earlier and people have been turned away 5 due to closing at 6.  Last year, a request was made to come up with a new model of care for meeting standards for urgent treatment centre.  A resources and finances proposal to meet expectations will be put together in October.  Minor injuries are continuing as per usual but may include illness care in the future.

In response to questions, Members heard: 

• Currently, patients are assessed only for minor injuries and the new service will have longer hours and people can then be seen for illnesses.  Hours will change to accommodate more homes and patients.  Current impediments include safely meeting needs within the budget provided current staff are trained to look after injuries, not illnesses.

RESOLVED:

That the Committee:

• Note the progress update and current challenges as well as any recorded issues addressed and/or resolved
• Request a further update for January 2020