Contact: Denise Holden ex 7338

e-mail: [email protected]

1. Summary and Purpose

1.1. The purpose of this report is to alert Members to proposals from the NHS to vary or develop health services provided to people living in the area of the Committee.

1.2. Proposals that are considered to be substantial in nature will be subject to formal consultation. The nature and scope of this consultation should be discussed with the Committee at the earliest opportunity.

1.3. The response of the Committee will take account of the criteria adopted by the Committee on 29 July 2003 with particular emphasis on the duties placed on the NHS by Section 11 of the Health and Social Care Act 2001.

1.4. The Report is presented to the Committee in 2 parts:

_ Items for information: these alert the Committee to forthcoming proposals from the NHS to vary or change services. This provides the Committee with and opportunity to determine if the proposal would be considered substantial and assess the need to establish a formal joint committee

_ Items for action: these set out the actions required by the Committee to respond to proposals from the NHS to substantially change or vary NHS services.

1.5. This report and recommendations provide members with an opportunity to influence and improve the delivery of health services in Hampshire and therefore support the delivery of Aim 5 (Improving Services) of the Corporate Strategy.

Items for Information

2. Mid and South West Hants Cluster: surgical services reconfiguration

2.1. The Committee has been apprised of the intention of the review the options for a reconfiguring surgical services across SUHT, WEHT, Lymington Hospital and Andover Hospital.

2.2. The lead individual for this work is Mark Hackett, Chief Executive of SUHT.

2.3. The most recent up-date provided by the Trust is attached at Appendix One.

2.4. The case of need, and the options for providing surgical services to this population needs to be established to allow members to determine if the changes are substantial.

3. Winchester and Eastleigh Health Care Trust: temporary closure of Endoscopy Services at Andover War Memorial Hospital

3.1. The Trust has confirmed that this service reopened.

3.2. Members of the Committee have been invited to visit Andover Hospital on 1 April.

4. Winchester and Eastleigh Healthcare NHS Trust/ Mid Hants PCT: Changes to Day Surgery and Rehabilitation Services

4.1. The Committee has been alerted to potential changes to the number of beds supporting the delivery of surgical services and rehabilitation services in the mid-Hants area.

4.2. Additional information on the proposals being put forward by this cluster are attached at Appendix Two and Appendix Two A.

4.3. Reprseatatives from the Trust will be attending the meeting on the 29 March to answer any additional questions from Members.

5. The Future of Health Services in Fareham and Gosport

5.1. The Committee has received confirmation from the Minister of State for Health that the request for referral of this matter to the Independent Reconfiguration Panel is currently under consideration.

6. South East Hampshire Capacity Plan

6.1. Hampshire and Isle of Wight SHA published a draft paper for the Board meeting in February attached at Appendix Three. This included a number of proposals that would have a significant impact on services provided in the area

6.2. The Chairman of the Committee, with the support of Portsmouth, Southampton and Isle of Wight OSCs has written to the Chairman of the SHA setting out deep concerns about the proposals included in the draft capacity map for the area. This is attached at Appendix Four.

Items Requiring Action

7. Blackwater Valley and Hart PCT: Modernising Health Services at Fleet Hospital

7.1. This consultation closes on the 31 March. The Committee has previously noted the focus of the proposal on maintaining services in the community as close to people homes as possible. No additional comments have been made by members.

7.2. A report of the outcomes of the consultation process and the PCTs response has been requested.

8. Maternity Services in South East Hampshire

8.1. The Joint Committee is now meeting regularly and considering evidence from a wide range of stakeholders.

8.2. Cllr Ray Ellis has been appointed Vice Chairman of this Committee

9. Framework for Assessing Substantial Change

9.1. The joint committee for Health Overview and Scrutiny in Hampshire and the Isle of Wight has endorsed the document approved by the Committee.

9.2. The SHA has indicated it wish to be a signatory to the document.

9.3. The draft framework has been shared widely with NHS senior staff and the Independent Reconfiguration Panel and local district councils

9.4. Comments received indicate broad support for the framework in its current format. Minor amendments will now be made to the paper and the final draft presented for members approval at the next meeting.

10. Eastleigh and Test Valley South/New Forest PCT: Temporary Closure of the Fenwick Hospital

10.1. The Committee has been advised that the Fenwick Hospital has been closed for a period of three months due to staffing pressures.

Recommendations

Items for Information

11. Mid and South West Hants Cluster: surgical services reconfiguration

11.1. The Committee is provided with details of the changes to be included in the proposals and the OSCs whose populations will be affected by the proposed changes.

11.2. The Committee initiates early action to establish a joint committee for the OSCs affected.

11.3. Individual members with an interest in serving on the Joint Committee contact the Chairman by the 15 April.

11.4. The Committee is provided with an up-date on progress at its next meeting.

11.5. The agreed framework for assessing substantial change informs the development of the proposals for reconfiguring surgical services

12. Winchester and Eastleigh Health Care NHS Trust: temporary closure of Endoscopy Services at Andover Hospital

12.1. The Committee notes that this service has now been reopened.

13. Winchester and Eastleigh Healthcare NHS Trust/ Mid Hants PCT: Changes to Day Surgery and Rehabilitation Services

13.1. The Committee has advises of the PCT of any additional issues that need to be considered as part of the development of these proposals and engagement with local people.

13.2. An up-date on progress is provided at the next meeting.

14. Future of Health Services in Fareham and Gosport

14.1. The Committee be apprised of further correspondence from the Secretary of State for Health, the response from the SDHA to the concerns raised about the capacity map and further action with regard to consultation on emergency services.

15. South East Hampshire Capacity Plan

15.1. Members are advised of the response of the SHA

Items for Action

16. Blackwater Valley and Hart PCT: Modernising Health Services at Fleet Hospital

16.1. The Committee responds to the PCT confirming the position as set out in 7.1 above.

16.2. The Committee is provided with details of the response of local stakeholders to the consultation process and the way in which this feedback informs the final decision of the Trust Board.

17. Maternity Services in South East Hampshire

17.1. Members continue to be apprised of the progress of the joint committee

18. Framework for Assessing Substantial Change

18.1. The Committee receives the final draft of the Framework at the next meeting.

19. Eastleigh and Test Valley South/New Forest PCT: Temporary Closure of the Fenwick Hospital

19.1. Members are advised of the position with regard to reopening the hospital at their next meeting

Section 100 D - Local Government Act 1972 - background papers

The following documents disclose facts or matters on which this report, or an important part of it, is based and has been relied upon to a material extent in the preparation of this report.

NB the list excludes:

1. Published works

2. Documents that disclose exempt or confidential information as defined in the Act.

File Location

None

Hampshire County Council Appendix One

Health Review Committee: 29 March 2005

Surgical Service Reconfiguration Up-Date (24 February 2005)

Plans to create a single surgical service across Southampton, Winchester, Lymington and Andover will affect fewer than five patients per hundred, says the doctor leading the project.

Consultant eye surgeon Rob Morris* says that outpatient, diagnostic and most day surgery work - which account for at least 95 per cent of secondary care - will still be provided close to people's homes wherever possible.

In a progress report to Trust Boards about general surgery and urology services, Rob said current thinking for planned inpatient care favours developing 'centres of excellence' in Southampton and Winchester. These would group together key staff and facilities to provide the best care for local people and make the best use of resources.

Under the most recent proposals being discussed, lower gastro-intestinal (GI) and laparoscopic upper GI services could be centralised in Winchester, at the Royal Hampshire County Hospital (RHCH) while inpatient urology, vascular and upper GI cancer services could be centralised in Southampton.

Work on options for breast/endocrine services will start once the results of a recent external review of services at Southampton have been considered.

Emergency admissions would continue at both Winchester and Southampton, although all poly-trauma (major accidents etc) would be treated at Southampton General Hospital.

One of the options being considered is whether the small number of patients per week who are operated on at Winchester out of hours could be treated in Southampton instead.

The emergency department at the Royal Hampshire County Hospital would still provide a 24 hour service, irrespective of changes to emergency surgery.

Rob Morris will continue to work with clinicians and other staff over the next few weeks to agree the way forward for general surgery and urology, and start developing similar proposals for ENT, orthopaedics and ophthalmology. These discussions also involve local patient and public representatives.

Final recommendations will be presented to the SUHT and WEHT Trust Boards in late Spring. After this, a formal consultation document will be presented to the public, Primary Care Trusts and hospital Trust Boards, thereby allowing further input into the decision-making process.

* Rob Morris works for both SUHT and WEHT. He has taken a six month secondment to be clinical project director for this project.

Hampshire County Council Appendix Two

Health Review Committee: 29 March 2005

Winchester and Eastleigh NHS Trust/ Mid Hants PCT: Changes to Day Surgery and Rehabilitation Services

Re: Service Changes within Mid Hampshire Partnership

Thank you for a very helpful phone discussion on how best the Partnership might work with the OSC regarding proposed service changes. I have e-mailed you a copy of the paper that both the PCT and WEHT Boards are considering in public session this week, but I am conscious that there may be a number of issues on which the OSC might require information that the paper does not cover in detail.

As I indicated when we spoke I would be very happy to come and discuss the proposals with the OSC members at the meeting that you have on Tuesday 29^th March; a number of my colleagues within the Partnership are similarly keen to explain in more detail what we are seeking to achieve through the proposed modernisation of services and would also be keen to join you at the meeting.

When we spoke you indicated the need to provide information and reassurance to the OSC members on the impact that the proposed changes might have on patients and the manner in which these have been assessed by the Partnership. You also indicated the need to clarify the relationship between these currently proposed changes, the project work currently taking place on the future configuration of services at AWMH, and the work taking place as part of Beyond Healthfit on the single surgical service. As your questions highlight, the environment within which healthcare is being provided is complex and changing. We would be very happy to elaborate more at the meeting, but I have set out below outline comments on these issues as a starting point for further discussion:

1. Impact on patients

Day Surgery

The Board paper signals the need to reconfigure services to respond both to changing clinical practice but also patient preference. The opening in July of the new day surgery unit in Winchester will mean that 1,700 surgical procedures that previously required an inpatient stay will now be undertaken as a day case.

Unfortunately the manner in which the procedures are coded, and the fact that some patients have more than one procedure within the same theatre session make it difficult to convert this into the number of patients who will benefit, but overall as a consequence of this unit opening 80% of surgery will be undertaken as day case (compared to the national target of 75%). In both local and national surveys patients have overwhelmingly indicated their preference for day case rather than in patient surgery.

At present a very small proportion of these procedures are carried out at AWMH; it is proposed that these will transfer to the new unit in Winchester, where patients will benefit from being in the new purpose built day theatre surroundings. The majority of surgery carried out at Andover is podiatric surgery and dental surgery - there are at present no plans to move this activity to Winchester.

The opening of the day surgery unit releases 12 in-patient beds within WEHT from July. In addition, over the next 12 months the Partnership will be reviewing those procedures currently undertaken under local anaesthetic that would be suitable for GPs with a special interest to carry out either in treatment rooms within their surgery or in the day unit at AWMH. One example of this on which we already have agreement is the transfer of approximately 250 vasectomies a year out of the hospital setting; these procedures will now be undertaken by trained local GPs in practices in Andover, Winchester and Bishops Waltham, making the service much more convenient for patients.

The Board paper signals two phases to the proposed service changes - an initial reduction in July of 34 beds, including the 12 surgical beds relating to the opening of the day surgery centre and a second phase on which more work is being undertaken. This second phase will include consideration of developments that allow less complex surgery to be carried out closer to patients' homes and without the need for a hospital stay. As we work through with local GPs and hospital clinicians the list of potential procedures that can transfer out of the hospital we will be mindful of the need to ensure fair access to services for patients across the catchment area of the PCT and WEHT.

Avoiding admission and reducing lengths of in-patient stay

The Partnership is committed to reducing the length of in-patient stay to the most clinically effective levels. For example, if we look at services in Salisbury, at any one time the hospital there has between 5 - 15 patients who are fit for discharge whose transfer of care is delayed for a variety of reasons; within WEHT this figure is currently around 40 - 50 patients. That represents 40 - 50 beds taken up at anyone time by people who are do not need to be in hospital. Improving systems to help patients move promptly into more appropriate care settings is both better for the patient but also means that we can release resources from these beds to fund other services.

This is only one example of ways in which we can make best use of our resources: the Department of Health have published evidence based guidance on 10 areas that all health communities should be addressing to improve efficiency and improve patient care. We will be working through these over the next 12 months, and in line with the national evidence, we expect to reduce the number of in-patient beds as these changes are implemented. No decision has been made at this stage about the location of the beds that will close, although it is anticipated that it will affect both the Andover and the Winchester sites. It is not intended that these changes will have a significant impact on patient flows since they largely relate to the greater efficiency of existing services.

2. Services at AWMH

Over the last few years there have been a number of pieces of work trying to identify the most effective configuration of services on the Andover War Memorial Site. As a consequence of the integration of the PCT and WEHT we have now been able to identify a single executive lead for this work (Peter Knight). A timetable has been drawn up to ensure active engagement of local patients, public and stakeholders in designing the best solution. We are expecting to undertake formal consultation on these changes as they emerge later in the summer.

The configuration of services at Andover is complex - there are many opportunities to change the model of care and to expand services: the purpose of the project that Peter Knight is leading is to determine the range and style of service that best fits local need now and in the future. Consideration will be given to issues such as:

_ The need to improve the outpatient facilities on site

_ Maximising use of the diagnostic facilities on site

_ Making best use of the day surgery facilities, including expanding the range of services undertaken by GPs on site

_ Re-providing the GP surgery

_ Developing a focus on rehabilitation so that more people receive intensive support to return home safely

_ Developing services for children and young people - a growing population in the Andover area

As indicated above, we expect in total to need 75 fewer beds across WEHT within the next 12 months, with the first 34 becoming surplus in July 2005. No decision has yet been made regarding the location of the first 34, but it is expected that the closure of 75 beds will affect both the Andover and the Winchester sites. The decision about the most sensible location for the first phase of bed reductions will be led by the need to maintain maximum efficiency amongst the remaining beds but will also take into account the profile of bed utilisation between Winchester and Andover residents. A commitment has been made to staff to finalise the plans within the next two weeks so that formal consultation on the criteria for staff reductions can commence with Union representatives.

In the event that the first phase of bed reductions does affect Andover, care will be taken to ensure that this does not undermine the wider development of the site.

3. Single Surgical Service

Beyond Healthfit includes a project to explore the potential to create a single delivery system for in-patient surgery across the catchments of SUHT and WEHT. This work has a separate programme of patient and public involvement that will include examination of the number of patients who may be affected if as anticipated some specialist surgery transfers from Southampton to Winchester and vice versa. It is not anticipated that this work will impact upon the provision of day surgical services, which as indicated above will account for 80% of surgical activity; all the organisations involved in the single surgical review are committed to maintaining day surgery provision in both Southampton and Winchester.

Please do let me know if there is any specific information that the OSC members would find helpful when we meet on 29^th March and I will work with colleagues to provide this either in advance if possible, or to follow. I hope that the meeting will provide the opportunity for an ongoing discussion with members on the programme of service change so that we can both respond to any concerns, but also develop the proposals in the best interest of local services and local patients.

We would like the first phase of service change to be implemented early in July 2005, possibly with the potential to make small scale changes in advance of this, but would like to work closely with you to achieve these challenging timescales.

Annexe A to Appendix Two

Mid Hampshire Primary Care Trust

Meeting: Board

Date: 22^nd & 23^rd March, 2005

Subject: Service Configuration in Mid Hampshire

Sponsor: Chris Evennett, Chief Executive

Author: Janet Rowse, Director of Strategy & Planning, MHPCT
Maureen Larkin, Director of Planning & Modernisation, WEHT

Purpose: To update the Board on the programme of service change set out in the attached paper

Decision Sought:

The Mid Hampshire PCT Board and the Winchester & Eastleigh Healthcare Trust Board are recommended to:

_ Approve the programme of service & bed changes

Key Messages:

_ New style services reflecting best clinical practice and patient preference.

_ The current model of care is unsustainable - no change is not an option

_ Modern community services mean more people can be cared for at home, which most patients prefer.

_ Keeping surgery local: 80% of elective surgery to be day case surgery with a new unit opening this year in Winchester.

_ Because we are moving away from an emphasis on bed based care, we need fewer beds.

_ High quality in-patient care will remain an important part of local services for those that need it.

_ Our focus is on providing the right care in the right setting at the right time.

Service Configuration in Mid Hampshire

1.0 Executive Summary

1.1 The Partnership between Mid Hampshire PCT and Winchester & Eastleigh Healthcare Trust was established in order to ensure that we make best use of our combined resources to the benefit of local people. This paper sets out the way in which local services need to develop if they are to remain fit for purpose and sustainable in the face of changing clinical practice and public expectation.

1.2 The way in which healthcare is now being provided is changing rapidly - more people want to be cared for at home, more procedures can now be undertaken as day stay in hospital or even as a simple procedure in out-patients or in the doctors surgery.

1.3 The Partnership is committed to ensuring high quality in-patient services are available for those who need them. In order to respond to the changing shape of healthcare however we need to unlock resource currently tied up in bed based services in order to develop community alternatives that better reflect the demands of modern healthcare. This is vital if services are to remain sustainable in the future.

1.4 There are three main issues affecting the way in which care is delivered:

_ The opening of new facilities which support different models of care. For example, the opening of the day treatment centre in Winchester to allow more day surgery and achieve shorter waiting times and expanded community facilities such as the Preventing Dependency Teams that provide intensive support and rehabilitation to people in their own homes.

_ Planned changes in clinical practice or changes in the way in which services are managed that reduce lengths of in-patient stay and make services more streamlined. For example changing systems to achieve separate ring fenced surgical beds so that planned surgery is not cancelled because of emergency medical admissions, or managing variation in the way patients are admitted to and discharged from hospital to ensure widespread best practice.

_ The development of alternative models of care in the community that reduce the need for hospital admissions. For example, specially trained GPs undertaking more surgery under local anaesthetic in their practices or providing more structured support to patients with chronic conditions such as asthma, diabetes, coronary heart disease and chronic obstructive pulmonary disease so that they are better able to manage their own care at home and have fewer unplanned admissions to hospital.

1.5 Winchester & Eastleigh Healthcare Trust (WEHT) has undertaken a detailed consideration of the first two bullet points above, and have identified that initially the current level of service can be provided with 34 fewer beds as a result of changing models of care. By systematically adopting national best practice we believe we can within the next 12 months reduce by a further 41 beds. This work is currently being further validated by an external review of bed requirements across Mid and South Hampshire.

1.6 This work is being taken forward in two phases: the first category of change above (the opening of new facilities) requires urgent action if resources are to be used to best effect. The new Treatment Centre, which is due to open in July 2005, will support the change from in-patient surgery to day surgery and will ensure the sustainability of local surgical services. Detailed modelling undertaken with clinicians, based on the conversion of in-patient to day case activity, has identified that we will need 12 fewer in-patient surgical beds to undertake the same level of activity

1.7 In addition, new community facilities such as the Preventing Dependency Teams are now fully staffed and offer 24-hour service. As a consequence of these developments it has been identified that from July 2005 we need 22 fewer medical beds in WEHT. No decision has yet been made on whether beds in Winchester or Andover will be affected by these changes. Within this first phase of change therefore we have identified that from July 2005 there will be 34 beds (12 surgical & 22 medical) that we no longer require in the light of the new more modern facilities that are opening. Some of these resources tied up in these facilities need to be released in order to fund the new style services.

1.8 The second phase of change (changing clinical practice & systems and developing community based alternatives to admission) requires further work to assess how best to change the model of care. There is the opportunity for a more detailed process of engagement with staff and public on these proposals to ensure that the full impact of these changes has been fully worked through. It is anticipated that these changes will be implemented later in the year.

1.9 Mid Hampshire PCT and WEHT together have an underlying recurrent deficit of £9.5m; we are required urgently to tackle the deficit and balance the books. The changes set out within this paper represent real opportunities to modernise the model of care creating a more flexible service better suited to patient needs and preferences, but they also have the potential to release funds to tackle the deficit. Where significant change in practice is required to release these funds we propose a longer period of engagement, however it is imperative that the first phase of changes, the closure of 34 beds within WEHT, are implemented at the same time as the new facilities become available if the underlying financial position is not to deteriorate further. This first phase is expected to contribute approximately £1m to the underlying recurrent deficit, with part year effect of approximately £825k in 2005/6.

Key Messages:

_ New style services reflecting best clinical practice and patient preference.

_ The current model of care is unsustainable - no change is not an option

_ Modern community services mean more people can be cared for at home, which most patients prefer.

_ Keeping surgery local: 80% of elective surgery to be day case surgery with a new unit opening this year in Winchester.

_ Because we are moving away from an emphasis on bed based care, we need fewer beds.

_ High quality in-patient care will remain an important part of local services for those that need it.

_ Our focus is on providing the right care in the right setting at the right time.

2.0 Background

2.1 In July 2000, after a period of public consultation, the Department of Health (DoH) published The NHS Plan - a plan for investment, a plan for reform. This document highlighted the changes already taking place in the way in which healthcare is being delivered and described a programme of reform across the whole of the NHS. The NHS Improvement Plan (DoH 2004) updated the implementation programme that the NHS needs to achieve. The delivery of health care within Mid Hampshire and WEHT has been developing in response to these changing demands, presenting real opportunities to improve patient experience of health and healthcare:

_ Surgery that used to require several days recovery in hospital is increasingly undertaken as day surgery. This is more acceptable and convenient for patients, more efficient for the hospital and helps to reduce the length of time that people wait for treatment.

_ Procedures that used to require attendance at hospital (e.g. vasectomies) are increasingly being undertaken in GP practice, again at greater convenience to the patients and at reduced cost.

_ People with long term chronic conditions increasingly want to be partners in their healthcare and have more control over their disease and its impact on their lives - as more effective early intervention and preventative services are developed there is less need for people with life long conditions to make frequent visits to hospital and less danger of people needing emergency admissions because their disease is better managed.

_ Community based health services have expanded and developed - they routinely care for people who would previously have needed to be admitted to hospital and provide intensive rehabilitation and support to maintain people at home or in the community wherever possible. Older people in particular benefit from these services and are saved the stress and disruption of hospital admission as well as the risk of infection that exists in all hospitals.

2.2 Local services need to develop to respond to these changing demands, with resources being released from beds to fund care in alternative settings. This is not an entirely new agenda, many such changes are already planned and either already available or are about to come into use, for example:

_ The PCT has invested nearly £1m in developing three 24-hour community based Preventing Dependency Teams including nursing, therapy, night sitting, and equipment. The teams are based in Andover, Winchester and the Meon Valley. They provide intensive multi-disciplinary support and rehabilitation to people in their own homes. These teams help people remain at home who would otherwise have been admitted and also ensure that people do not need to stay as long in hospital because there is specialist support available in the community.

_ The new contract for GPs and primary healthcare teams means real improvement in primary care with more and more people with long term chronic diseases receiving early interventions and proactive care thus reducing the chance that they will be admitted to hospital as an emergency.

_ The PCT is re-designing the way that all our community nursing services are organised so that they work more efficiently with the hospital based services ensuring that patients are well supported and either do not need to go into hospital or are able to come home again as soon as possible.

_ The new Day Treatment Centre is opening in Winchester in July 2005. £7m has been invested in the development of this unit which will allow more people to have day surgery and which increases the overall surgical capacity of the Trust, allowing more surgery to take place and reducing waiting times. This unit will ensure that 80% of surgery will in the future be undertaken locally as day surgery.

_ The Partnership is re-designing the way in which A&E services and admission procedures operate so that people quickly receive the right care in an appropriate setting.

2.3 The context within which these changes are taking place is challenging. Considerable additional funding has been received by the NHS in recent years as part of the implementation of the NHS Plan. Local people and the quality of local healthcare have benefited from this investment:

_ Waiting times for in patient and out patient treatment have fallen significantly

_ Waiting times in A&E have fallen

_ Waiting times to see a GP & primary care professionals have fallen

_ Additional investments in community services allow more people than ever to be cared for at home.

_ There have been significant improvements and expansion in services for people with heart disease and those with cancer.

Despite the many local achievements we are not complacent and we recognise that there are many more challenges to tackle.

2.4 Over time the cost of providing services and the number of people being treated has risen, resulting in the PCT and WEHT dealing with a £9.5m underlying recurrent deficit that we now need to address together. (In other words, we are now spending £9.5m a year more on healthcare than we receive funds). The number of patients referred for treatment by their GP has risen year on year, as has the number of people treated in hospital. Neither the growth in population nor the increasing age of the population fully explains this rate of growth.

3.0 Outline of proposed changes in service provision

3.1 Despite the many existing developments that are outlined above, we also know that there are inefficiencies in the way our combined services work that sometimes mean people stay in hospital longer than they need to: -there are delays in accessing diagnostic tests, ways of working that sometimes mean people stay in hospital when they could have gone home, procedures that other hospitals undertake as day surgery are undertaken as in-patient surgery, sometimes people who are ready for transfer out of hospital are delayed because they may be waiting for rehabilitation, or for assessment for a package of care at home, or even waiting for a place in the nursing home of their choice to become vacant.

3.2 We have a programme of work that will address each of these issues - improving our joint working with Social Services, implementing best practice from NHS organisations which have already successfully tackled these issues and making sure that our scarce resources are directed to those most in need.

3.3 When we have addressed all these issues, and when we are able to control demand for services by providing viable alternatives to admission, then the model of care will be radically different, with more care at home, and many existing in-patient surgical procedures being undertaken as day surgery. This will mean that we will require fewer hospital in-patient beds to treat the same number of patients.

3.4 Modelling exercises to help us estimate requisite bed numbers, based on best practice elsewhere, have already been undertaken within the Hospital and have been discussed in detail with clinical teams. Naturally they are concerned to ensure that services are available for those that need them, and we acknowledge that we must phase the reduction in beds in line with the development of alternative services and new models of care.

3.5 In conjunction with other NHS organisations within Mid and South Hampshire we are working with a team of specialist consultants who will verify the assumptions we have made and ensure that the changes we make are based on good evidence and best practice.

3.6 In-patient beds account for much of the most complex and expensive activity in a hospital. They represent a considerable investment of experience and expertise but also expense. It is therefore essential that we ensure these resources are directed to those who will benefit most; where clinical practice and other changes indicate that the beds may no longer be required we have to take prompt action in order to ensure that our scare resources are used to best effect. For this reason there are regular reviews and processes in place to implement national best practice to ensure effective use of the resource for the benefit of the whole community.

3.7 The bed review undertaken within WEHT recently aimed to determine the number of beds required from 2005-06 onwards. This work aimed to calculate the demand for beds from both emergency admissions and elective or planned admissions over the next few years. There are three factors influencing bed requirements:

_ The opening of new facilities which will support different models of care (paragraph 3.8)

_ Planned changes in clinical practice or to the way in which services are managed (paragraph 3.9)

_ Reductions in the number of patients who are referred to the hospital by developing alternative models of care in the community (paragraph 3.10)

The bed modelling exercise in WEHT took account of the first two bullet points above

3.8 The opening of new facilities which will support different models of care

3.8.1 Surveys and feedback from focus groups have shown that patients want treatment that is safe, efficient and effective, and which provides the least possible disruption to their lives. Day surgery gives this patient-focused care with repeated patient surveys demonstrating that the great majority of patients prefer to recover in their own homes rather than staying overnight in hospital.

3.8.2 Up until now a lack of dedicated day surgery facilities locally has prevented more surgery being undertaken as day case, however in July 2005 the new Treatment Centre opens in Winchester. This provides the Partnership with the opportunity to offer many more surgical procedures as day cases and ensures that this activity is retained locally. There may be minor changes in the type of surgery undertaken in Andover as a consequence, but by implementing national day case best practice we estimate around 1700 surgical procedures that would have involved an in-patient hospital stay can now be treated as a day case.

3.8.3 The new Treatment Centre will have a small number of overnight beds (initially this will be need to be between 5-10 beds) should a patient need to stay in hospital. By moving this many procedures from in-patient to day case less in-patient beds will be needed to treat the patients and therefore we have calculated that the surgical inpatient beds could reduce by 12. Joint work is taking place with neighbouring PCTs and with Southampton University Hospital Trust regarding the most effective way of organising in patient surgical services. This work is likely to result in some changes in the location of services; some may transfer from Southampton to Winchester and vice versa. This piece of work will have implications for Winchester which will be fully discussed when the outcomes of the study emerge; the Treatment Centre in Winchester however will become the focus for local day surgery. and is an important development that means the majority of surgery is undertaken locally.

3.8.4 Additional community resources, including extra nursing home beds are coming into use, building up from April. Our multi-disciplinary community teams are now at full strength and since the beginning of March have been operating 24 hours a day, and we expect to finish the re-organisation of community nursing and A&E by September this year. At any one time WEHT has a substantial number of patients whose discharge from hospital or transfer to other care setting has been delayed and therefore they remain in a hospital bed although they no longer need the level of care provided in a hospital setting. These additional community resources will help us tackle this issue.

3.8.5 In the light of these new surgical and community services we expect to be able to reduce by 34 beds in July 2005. Further reductions in bed usage will follow towards the end of the financial year, but these require different ways of working across primary and secondary care, and will therefore take a little longer to implement.

3.9 Planned changes in clinical practice or to the way in which services are managed

3.9.1 For the three years between 2001 and 2004 work was undertaken by the Modernisation Agency (DoH) to collate service changes that have been implemented nationally that have resulted in improved patient experience and patient satisfaction, saved clinician hours or hospital bed days and appointments in primary and secondary care.

3.9.2 Analysing this information has led to the identification of the 10 High Impact Changes for Service Improvement and Delivery. These changes are patient-centred - "seeing the service through the patient's eyes" and are evidence-based - drawing on the best available learning in how to make organisations work effectively. They have been field tested and evaluated in real life NHS settings and then developed and adapted to have the best chance of success.

3.9.3 WEHT has assessed the potential impact of implementing a number of these changes focussing on reducing length of hospital stay, managing the variation in patient admissions, admitting patients on the day of surgery rather than before and removing delays in the patient care pathway. If implemented fully and all of the bed gains can be realised then there is the potential to save a further 41 beds. These changes will take time to test and then implement - the development programme is still at an early stage - and therefore these additional bed reductions will be phased over the remainder of the year.

3.9.4 The bed modelling exercise also made provision for some spare capacity to be made available to meet the peaks in demand/additional activity, otherwise these admissions, which are often emergencies, simply displace elective or planned admissions, leading to cancellations, disruption and inconvenience to patients.

3.10 Reductions in the number of patients who are referred to the hospital by developing alternative models of care in the community

3.10.1 Community based health services have expanded and developed - they routinely care for people who would previously have needed to be admitted to hospital and provide intensive rehabilitation and support to maintain people at home or in the community wherever possible. Best practice from around the country is also being evaluated to establish the most effective services that reduce the number of patients who are referred to hospital. Work will also be undertaken with local GPs to identify alternative services that might be developed that would allow them to care for more patients in the community rather than referring to the hospital.

3.10.2 As possible models of care are identified a more detailed process of engagement with staff and public will be undertaken to ensure that the full impact of any proposed changes has been fully worked through. This will also include the impact of any changes on in-patient bed numbers.

4.0 Contribution of Service Changes to the Joint Recovery Plan

4.1 Since its establishment in April 2001, the allocation that the PCT receives from the Department of Health for the procurement of healthcare has increased, as has its expenditure on healthcare. Expenditure is driven by rising costs and increasing demand for services.

4.2 Since 2001 the number of patients referred for treatment by their GPs has risen year on year, as has the number of people treated in hospital. Neither the growth in population nor the increasing age of the population fully explains this rate of growth - much of it is driven by the need to reduce waiting times.

4.3 MHPCT has identified a number of particular financial risks that have made it increasingly difficult to live within available resources:

_ Rising demand for service - increasing GP referrals and admissions for unscheduled care

_ Rising expenditure on continuing NHS care and high cost out of county placements

_ Increasing cost of prescribing in primary care

_ Cost of implementing the new GMS contract and putting in place the out of hours services that GPs are no longer required to deliver

_ Reducing ability to negotiate on cost, volume or location of activity in line with new national funding mechanisms within the NHS (Payment By Results, National Tariff, Choice)

_ Increasing pay bill relating to the new NHS pay structures (Agenda for Change)

4.4 Winchester & Eastleigh Healthcare Trust have also identified specific pressures:

_ Rising costs linked to provision of more care

_ Meeting new regulations on junior doctor hours and European working time directives

_ Implementing the new Consultant Contract & Agenda for Change

_ Expenditure associated with the need to upgrade facilities and infrastructure (new buildings, IT etc)

4.5 As a result of these pressures, both organisations are spending more than their income; we have to act quickly together to address this. It is a statutory requirement that all organisations within the NHS operate within their available resources. Within Mid Hampshire we know that we will only receive minimal growth for the foreseeable future because the Department of Health have assessed that we are currently receiving more than our fair share of funding; we cannot therefore rely on receiving extra money to help with the problem. This makes is even more important that we make best use of our funding - making sure that it is not tied up in beds that are no longer needed.

4.6 Overall WEHT have estimated that a reduction of 75 beds would contribute £1.8m a year to the Joint Recovery Plan through reductions in pay and non pay costs; of this the first 34 beds would contribute £1050k a year, with part year effect of £825k in 2005/06.

5.0 Next Steps

_ Further detailed work is required to develop the implementation plan for bed closures planned for July, including work with staff and staff representatives and more detailed financial modelling of costs.

_ A broader development programme is being set up to implement the recommendations set out within the WEHT bed model - these need to be validated when the outcome of the external review of bed requirements is complete.

_ A programme of wider engagement is required to build understanding and ownership of the need for change, with specific focus on the second phase of the implementation.

6.0 Recommendation:

The Mid Hampshire PCT Board and the Winchester & Eastleigh Healthcare Trust Board are recommended to:

_ Approve the programme of service & bed changes

Hampshire County Council Appendix Three

Health Review Committee: 29 March 2005

PORTSMOUTH & SOUTH EAST HAMPSHIRE HEALTH ECONOMY CAPACITY MAP

PAPER FOR PCT BOARDS

1. This paper summarises work on developing a capacity map for Portsmouth & South East Hampshire. The work, undertaken by a group drawn from all the local NHS organisations (see list at Annex A) has brought together capital development plans for the health economy to test their fit in terms of physical capacity and affordability. In its completed form the capacity map will set out the health economy's strategy for the development of community hospitals. Boards are asked to note the position reached to date and further work planned to complete the capacity map.

Background

2. For many years strategy for provision of hospital services in Portsmouth and South East Hampshire has been based on major acute hospital services in Portsmouth supported by a network of community hospitals. This reflects the desire to provide locally accessible services, but also recognises that the volume of services required by the large catchment population of approaching 600,000 cannot be provided in a single acute hospital in Portsmouth.

3. When the strategy was first developed in the late 1980s it involved providing four purpose built community hospitals in Petersfield, Gosport, Havant and Fareham, rationalising small scale hospital provision then existing on nine hospital sites. Portsmouth City currently has no community hospital facilities and as part of the PFI plans it was decided to develop a community hospital, probably on the St Mary's Hospital site, which would bring together equivalent services for Portsmouth City residents which are currently located in various locations around the site.

4. In the early 1990s new community hospitals in Petersfield and Gosport were developed, replacing five smaller local hospitals. But community hospital provision for Havant and Fareham continues to be in old buildings whose condition and fitness for purpose are steadily deteriorating. The physical environment for elderly mental health (EMH) services at St James's Hospital, serving Portsmouth City and East Hampshire, is also unsatisfactory and constrains the options for care provision.

5. Acute hospital redevelopment in Portsmouth will be completed in mid 2008, when the PFI scheme on the Queen Alexandra Hospital site is commissioned. In line with the overall strategy outlined above, the size and functional content of the redeveloped hospital are designed to be complemented by a range of services in the community. The Full Business Case for the redevelopment set out the assumptions around activity transfers to community settings and the associated physical capacity requirements:

· A&E and Minor Injury Units (70,000 attendances in total)

· inpatients: pre/post acute care in general medicine, elderly med, general and stroke rehab (240 beds)

· day care: some surgery; elderly assessment/treatment/rehab (55 places)

· outpatients and supporting diagnostics, including endoscopy (116,000 atts).

6. The NHS organisations recently signed contracts for an Independent Sector Treatment Centre (ISTC) on the St Mary's site. The ISTC will be operational from late 2005 and will provide day surgery, diagnostics and minor injuries services together with a walk-in centre. The contract provides for diagnostics to be provided by the private sector provider, Mercury, from the new community hospital in Havant by 2008.

Current plans for community hospital development

7. The PFI assumptions have been a key driver in the development of current plans for community hospitals, together with the need to address the deteriorating condition of existing small community hospitals and to reprovide EMH services in more appropriate facilities and locations. The functional content of the plans is summarised at Annex B. Key components are

· Oak Park Community Hospital at Havant: completion of original community hospital network (replacing two cottage hospitals), provision complementary to PFI, independent sector provision of diagnostics and reprovision of EMH services from St James's Hospital

· Gosport War Memorial Hospital: additional community hospital provision associated with the closure of Haslar, including provision complementary to PFI

· Fareham Community Hospital at Coldeast: completion of original network (replacing one existing community hospital, a maternity home and outpatient clinics) and provision complementary to PFI

· community hospital for Portsmouth City on part of the St Mary's site vacated by Portsmouth Hospitals Trust when the PFI is complete: provision complementary to PFI (with ISTC on the same site)

· EMH facility for Portsmouth City: reprovision of existing services.

8. The timescale for all components is linked to the expected completion date for the PFI. In order to support a smooth transfer of services when the redevelopment is complete, and to meet ISTC commitments, it has been assumed that Oak Park and the additional provision at Gosport War Memorial should be available by summer 2008. There are advantages in both cost and service terms of completing Portsmouth City EMH facility to the same timetable so as to avoid in separating provision for East Hampshire and Portsmouth City patients until new facilities are available for both. Fareham Community Hospital would be operational by the end of 2008/09. Work on converting retained buildings at St Mary's Hospital to form Portsmouth Community Hospital would start when the buildings are vacated in summer 2008 and is expected to take about two to three years to complete.

Assessing physical capacity requirements

9. At the start of its work, the capacity map group mapped existing physical capacity and plans for 2008 and beyond. Estimates of future capacity were based on plans for the PFI and those outlined above, and also took account of planned moves to nursing home provision for continuing care. The results of this exercise for inpatient beds and day case spaces are shown at Annex C. Overall, planned and existing capacity is similar with inpatient beds showing a slight decrease while day case spaces increase.

10. A key issue highlighted by the mapping exercise was that the total number of inpatient beds planned across the health economy is some 150 less than planned in the PFI Full Business Case. The main reason for this is that PCTs, anticipating changes in the patient pathway and the impact of measures to reduce unscheduled care admissions, are planning for a total of 90 pre- and post-acute beds instead of the 240 originally envisaged.

11. In order to test the robustness of the plans, Portsmouth Hospitals Trust and the three PCTs commissioned a review of expected future bed requirements across the health economy. The review was based on analysis of data collected in a November 2003 bed census across all hospital locations. Patients were assessed to determine their need for care in an acute or community hospital bed and, where appropriate, to identify where else care could have been provided and the constraints on such provision.

12. The review concluded that around 200 people currently in hospital beds could be more appropriately cared for in non-hospital environments: either at home, in a nursing home or in a residential care home. Provided that this shift of care can be achieved by putting community services in place and streamlining processes to allow earlier discharge, planned physical capacity is in overall balance with expected future requirements.

13. The plans for future physical capacity were also checked for consistency with activity assumptions underpinning the annual capacity planning round and organisations' Local Delivery Plans (LDPs). A key target in the next round of LDPs is a 5% reduction in emergency bed days by 2008. While overall inpatient bed numbers are stable in the locality plans, bed days will fall as occupancy is reduced from present levels above 90% to 85% as recommended in the National Beds Inquiry. This reduction is needed to maintain the 4-hour A&E target; to support action to reduce MRSA infection rates (which are linked to high occupancy) and to provide capacity for patient choice and growth in elective activity. The capacity plans are therefore consistent with the emergency bed days target. The community hospital developments will also contribute to achievement of the 18 week wait target through improving access to diagnostics.

Affordability

14. The work described above provides a robust assessment of the plans for community hospital provision in terms of physical capacity and service performance, including the reduction in post-acute beds compared with plans in the PFI Full Business Case. The parallel assessment of affordability demonstrated a potential funding gap of £3m across the health economy if the community hospital developments came on stream in 2008 as anticipated. Although this represents only 0.36% of the three PCTs' combined allocations, it depends on achieving the challenging financial recovery plans that they have put in place. The capacity map group therefore decided to undertake a review of alternative options for the scope and timing of developments.

15. It should be noted that continuing uncertainties around the introduction of the national Payment by Results policy mean that it is very difficult to assess the financial impact of proposed developments. In particular it is unclear how service providers are expected to absorb increases in infrastructure costs associated with moving to new premises within the national tariff. This creates the potential for conflict between Payment by Results and policies promoting local delivery of services, which has been flagged up at both local and national level but not yet resolved.

16. The capacity map group looked at a spectrum of options, starting from `do nothing' and successively adding elements of the proposed developments. Service constraints and interdependencies and were explored to identify options for phasing that would make sense in clinical and financial terms. After initial review three options were selected for detailed assessment:

· Option 1: implementation of community hospital plans as currently proposed

· Option 2: `do minimum'

· Option 3: phased implementation.

17. The options were assessed in terms of their financial implications and across a range of non-financial dimensions: clinical model, strategic fit, access, quality of environment, public aspirations and recruitment and retention.

Option 1

18. This option would see the plans set out in paragraph 7 implemented to the current timetable. Local services currently at Royal Hospital Haslar would transfer to Gosport War Memorial Hospital in summer 2008 when the redeveloped Queen Alexandra Hospital is ready. Oak Park Community Hospital and the Portsmouth City EMH facility would be operational from summer 2008, Fareham Community Hospital by the end of 2008/09. The services making up Portsmouth Community Hospital, currently provided at various locations on the St Mary's Hospital site, would be consolidated in the retained buildings on site as these are converted from their current use.

19. The community hospital development plans involve a combination of LIFT schemes and NHS capital. The capital cost for Option 1 is estimated at £23m, mainly for conversion of buildings at St Mary's Hospital. Revenue costs would be £10m higher than current services, although some of this investment is unavoidable.

20. In non-financial terms this option delivers the desired clinical model and strategic fit, improves access and the quality of the environment and meets public aspirations particularly in relation to community hospitals for Havant and Fareham. Recruitment and retention problems are expected to ease as a result of improved environments and a more suitable model of care for EMH services.

Option 2

21. The first alternative explored was to scale back development plans to the minimum considered essential to ensure continuity of patient care. Some services must be reprovided when Haslar closes but existing community hospitals and other facilities due to be replaced would be maintained with necessary investment. The activity detailed in paragraph 5, which is assumed to transfer to community settings, cannot be accommodated in the redeveloped Queen Alexandra Hospital so in this option it would be provided at St Mary's with some increase in the size of the retained estate.

22. The capacity map group considered leaving services on the St Mary's Hospital site in their current locations, in order to avoid converting the retained buildings. However, this would delay disposal of the site with the loss of capital receipts and savings in capital charges which have been factored into the PFI, and after financial assessment this variant was discarded.

23. The components of the `do minimum' option are therefore:

· changes at Gosport War Memorial Hospital to accommodate the Haslar Accident Treatment Centre (including relocation of a health centre)

· retained buildings at St Mary's Hospital converted to accommodate:

· services intended for Portsmouth Community Hospital (moved from various locations around the St Mary's site)

· outpatients and diagnostics intended for Oak Park Community Hospital, Fareham Community Hospital and Gosport War Memorial Hospital

· post-acute beds intended for Oak Park and Fareham Community Hospitals (requiring retention of an additional building on site)

· younger person's rehabilitation currently provided at Haslar

· retention of community hospitals in Havant, Emsworth and Fareham; Blackbrook Birth Centre; and EMH services at St James's Hospital

· development of an EMH facility for both Portsmouth City and East Hampshire by 2010/11: existing buildings could not be maintained beyond 2013.

24. Option 2 requires significant capital investment to keep buildings that were expected to be replaced in service, and to convert a larger area at St Mary's. This is estimated as £29m in total. Revenue costs for this option are around £6m more than current services.

25. This is an extreme option which would have serious consequences. Aside from the long-standing public expectation of a community hospital for Havant, East Hampshire PCT would incur penalties under the ISTC contract if diagnostics facilities are not available at Oak Park by 2008. The failure to deliver any large schemes under LIFT could give rise to the payment of abortive bid costs to the private sector consortium if sufficient smaller schemes are not completed. In addition, Fareham & Gosport PCT Board recently resolved to build Fareham Community Hospital to improve access to services for local residents. Under Option 2, this would not be delivered and access would deteriorate for Fareham and Gosport residents as services transferred from Haslar to St Mary's. Community hospital services for Portsmouth City would be brought together relatively quickly but without a separate identity as other services would remain on site.

26. The `do minimum' option perpetuates an emphasis on hospitalisation, runs counter to the health economy's strategy for reducing admissions and fails to deliver the clinical model needed to complement the PFI. The condition of buildings would inevitably continue to degrade and recruitment and retention problems would persist.

Option 3

27. The capacity map group has therefore explored a third option, that of phasing implementation of planned developments. As well as potentially improving affordability this would address constraints in the capacity of both the NHS and the construction sector to deliver such a large building programme (including the PFI) by 2008. In developing this option the group has explored the way that services could be grouped into phases to maintain service coherence and avoid nugatory costs.

28. Bearing in mind contractual commitments, service interdependencies and physical constraints, the elements that could in theory be phased are

· Fareham Community Hospital: operational date could be deferred to April 2010

· Oak Park Community Hospital/Portsmouth City EMH facility: potential to defer East Hampshire post-acute and EMH beds moving to Oak Park, and Portsmouth City EMH beds moving to a purpose-built facility. Oak Park Phase 1 comprising diagnostics (for the ISTC contract), outpatients, minor injuries, day assessment/ treatment units and reprovision of beds from the two cottage hospitals would be operational from summer 2008. Phase 2 would have to be completed by 2013 as EMH facilities are unsustainable beyond this point.

29. Two phasing sub-options were therefore explored:

· Option 3a: Fareham Community Hospital only (to 2010)

· Option 3b: Fareham Community Hospital (to 2010); Oak Park post-acute and EMH beds and Portsmouth City EMH facility (to 2011/12).

30. In Option 3b post-acute beds for East Hampshire and outpatients, diagnostics and post-acute beds for Fareham residents would be accommodated on the St Mary's Hospital site in the interim. This would require an extension to the retained estate as for Option 2. In Option 3a, only Fareham services would remain and these could be accommodated within current plans.

31. In financial terms, compared with Option 1, Option 3a reduces the revenue requirement in 2009/10 by £2.5m and Option 3b by £3.5m. As these are short term deferrals, the revenue impact by 2013/14 is broadly the same as in Option 1.

32. Option 3a would deliver most of the non-financial benefits of Option 1, albeit to slightly longer timescales in some cases. Delays would not compromise delivery of the desired clinical model and strategic fit. Public aspirations would be met, and improvements in the quality of the physical environment would be achieved within a reasonable period. The main disadvantage is that access to services for Fareham residents would be more difficult during the interim period. However, the current timetable for Fareham Community Hospital is considered ambitious and, based on experience with Oak Park, an April 2010 operational date may be more realistic.

33. Option 3b would have more impact in non-financial terms. Delays in improving the clinical model and physical environment for EMH are a particular concern. Recruitment and retention problems could be expected to increase. Achieving changes in the model of care for post-acute patients would be significantly more difficult. This option has not yet been tested in design terms and requires further work to assess feasibility.

Discussion

34. Key messages from the assessment of options are that

· all options require significant capital investment, with higher levels of investment required for Option 2 because of the need to keep old buildings in use. Conversion of buildings at St Mary's could be considered for PFI but is unlikely to be attractive to potential private sector partners. The availability of NHS capital is therefore a potential constraint under any option

· if revenue costs associated with Option 2 are regarded as reflecting unavoidable investment in services, the net revenue requirement to deliver the planned developments is £4m per year. The bulk of this would be required in 2008/09 for Option 1 but under Option 3 it would be spread over four years. The investment represents a very small proportion of total revenue although a higher proportion of expected growth funding

· in non-financial terms Option 2 is significantly worse than Options 1 and 3, scoring badly on all dimensions of the assessment. It is inconsistent with recent decisions on the ISTC and the future of services for Fareham and Gosport. Option 3b scores lower than Option 3a for a marginal and temporary cost saving.

35. As noted above, a major question-mark remains around the impact of Payment by Results. This is a significant issue for East Hampshire PCT and Portsmouth Hospitals Trust as providers of acute and elderly services respectively, and needs further investigation although the lack of clarity at national level is an impediment. The overall financial picture for the health economy is also unclear pending notification of allocations and ongoing discussions on the LDP.

36. The capacity map is therefore being kept under review and will be revisited in March when other elements of the picture are clearer. At this stage the health economy expects to be able to take a view on the options outlined here and if necessary consider the scope for further delays in order to achieve financial balance. In the meantime, design work on Oak Park Community Hospital will test the physical feasibility of phasing as outlined in the Option 3 variant.

Portsmouth & South East Hampshire Capacity Map Group, January 2005

Hampshire County Council Appendix Four

Health Review Committee: 29 March 2005

South East Hampshire capacity Map: Letter from the Chairman

As I indicated during the SHA Board Meeting, we have very many concerns about the cost cutting options outlined in the paper on the Capacity Map. This paper is essentially a breakdown of existing stock and costs and not what we would regard as a capacity map. We would make the following points:

1. It reneges on the PCT proposals on which consultation has only recently concluded. These detailed proposals for community hospitals at both Gosport and Fareham, with firm dates for the completion. Indeed we are pursuing discussions about PCT proposals for facilities at the Fareham hospital, which we consider should be similar to those proposed for Gosport, particularly as the population of Fareham, (without taking in the proximity to Eastleigh and the Winchester part of Whitley), is considerably larger. The Gosport War Memorial Hospital site is not easily reached from Fareham, especially at peak rush hour times, car parking is not easy and we do not regard it as a suitable base for a minor injuries A & E for the Fareham population. These Community Hospitals need to be established now, but the time frame for this to occur is reducing rapidly. It is naïve in the extreme, in my view, to be pursuing this line now and even more naive as the Capacity Map group paper says at paragraph 32 to believe that under option 3a" Public aspirations will be met". Equally the public simply will not believe that project timetables are simply an issue and priorities. It will be seen as promises broken.

2. Some proposals in this paper cut across the on current maternity strategy consultations for this area.

3. There is no real information on current or future population health needs or with regard to patient flows.

4. There is no proposal for engagement with the local population on these proposals. These proposed service changes are substantial and would require both Section7 and Section11 consultation. These are not theoretical exercises as the population "out there" do require efficient health services as soon as possible.

5. We are concerned that with the implementation of the PFIs, the LIFT projects, and the Mercury Treatment Centre the NHS provision for this area will be effectively mortgaged to the private sector. We were alarmed by the statement in the paper with regard to the QA PFI assumptions " but did not include any financial assessment or details of the proposed bed numbers". The provision of local health facilities is absolutely essential to our population and there must be sufficient funding to provide it. We feel that an earlier estimate of the effects of the various developmental projects on the total health economy of the area should have been made.

6. The choice agenda to some extent implies that an excess of capacity will be required, if the agenda is to be meaningful. There is little evidence to show that this will be the case, indeed at the same SHA meeting a later paper indicated that the capacity for cancer patients would be about 5% less than required even after the modernisation of the Queen Alexander Hospital.

7. The plan assumes that the current NHS long stay provision will be eliminated. If this is to be so, in view of the demographic data, which points to an increasing older population, then very firm plans for the provision of continuing care provision must be made. This is complicated by the difficulty in recruitment of front line social workers, affordable housing and other factors.

8. Is the PbR deficit of £4.5M a one off or a recurring feature?

9. We would oppose any delay in the implementation of the "spokes". My comment in 1 above are apposite.

10. Our preferred option would be option one, which has been the subject of consultation and for which time is a real burden of public expectation . Also we would not favour any delay in implementation, as the need for these facilities has been well established over many years and the population needs action and not words. We are amazed that the paper refers to the need for "further work planned to complete the capacity map" we would have assumed that all of this work would have been completed prior to the PFI proposal and the Fareham & Gosport PCT consultation. It does reinforce our view that the health needs of S. E. Hampshire should be considered as a whole and not as isolated development. For instance the ISTC at St. Mary's Hospital was not factored into the first proposals from the PCT.

11. The decrease in beds "of some 120 less than planned in the full PFI business case" is we feel is not supported by any proper analysis of future needs of an increasingly ageing population but purely by assumptions relating to more home care.

12. In paragraph 17 it is stated that the options were assessed in terms of " .....access, quality of environment, public aspirations, recruitment and retention" For whom was the access assessed and whose public aspirations were considered?

13. We have serious doubts, based on experience with other PFI projects, that the QA Hospital will be completed by 2008 and within budget.

In summary, I am unclear of the status of this work and, indeed, when the Capacity Map report will be published although you seem to be expecting a recommendation to the next Board meeting. My own view is that the options will give serious cause for concern to the Health Review Committee and the Hampshire, Southampton, Portsmouth and Isle of Wight Health Scrutiny Joint Committee, I believe they will regard options 2 and 3 as matters of substantial change to health service provision and subject to the consultation processes as detailed in Sections 7 and 11 of the Act. I really believe that further informed discussion is required before the Board decision is taken.

I hope that you consider these comments to be helpful, and of assistance to the SHA Board when they next consider the paper or any development of it..