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 public 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 Framework for assessing Substantial Change and Variation in Health Services agreed by the Hampshire, Isle of Wight, Portsmouth and Southampton Joint Committee in March 2005. This places particular emphasis duties imposed on the NHS by Section 11 of the Health and Social Care Act 2001.

1.4. This 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. Early feedback to SUHT from this Committee and Southampton Health Scrutiny Committee has reinforced the need for there following

_ Information about patient flows and how these will be affected by the changes proposed

_ All Overview and Scrutiny Committees affected to be alerted to the changes by SUHT

_ The need for the `Framework for Assessing Substantial change', agreed by Health Overview and Scrutiny Committees in Hampshire and the Isle of Wight to inform the development of the proposals

2.4. The most recent bulletin on changes to health services in south west Hampshire is attached at Appendix One.

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

3.1. 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.

3.2. Members of the Committee visited Andover War Memorial Hospital on 1 April. The tour of the hospital site included:

_ Day Unit

_ Minor injuries unit & X-Ray

_ Birthing Units

_ Rehabilitation Wards

_ Hospice

_ Out-patient unit & therapy services

_ medical records area

3.3. Members were given a brief presentation on progress with the review of services currently provided on the site and the options for future service development. Trust representatives emphasised that, as a result of the current review, some services may need to change as part of the modernisation programme. It was also confirmed that the hospital would continue to provide a range of services to local people in the future. This would include the birthing centre and hospice.

3.4. The options for service provision on the Andover War Memorial site would be subject to public consultation once the service review was complete.

3.5. With regard to the proposal put forward to close 22 rehabilitation beds the Chairman has asked for the following information to help the Committee ascertain if this would be a substantial change in services:

_ Where the beds will be closed

_ Whether this change was part of the original consultation about the provision of nursing homes

_ If the proposals is supported by the relevant P&PIFs, service users and carers

_ Whether the necessary infrastructure is in place to provide the level of support necessary in a community setting

_ If the Trust Board is satisfied that Section 11 responsibilities have been met

_ What monitoring procedures are in place to ensure that the service operates as expected

4. The Future of Health Services in Fareham and Gosport

4.1. The Chairman wrote to the Minister of State for Health in April expressing concern that the request from the Committee for referral to the Independent Reconfiguration Panel was still outstanding. This is attached at Appendix Two.

4.2. Since the election the Chairman has written to the new Secretary of State for Health asking that this matter be deal with as a matter of urgency.

4.3. The Committee has been alerted to work by East Hampshire/Fareham and Gosport PCT to a review of beds for older people. A copy of the review to date is available from Denise Holden.

4.4. The Chairman has highlighted that the Committee supports the action to provide timely services as locally as possible and prevent older people having to be admitted to hospital. The following additional information has been requested:

_ What is the `fit' of this work with the proposals on the future of community services in Fareham and Gosport

_ How will key stakeholders be engaged

_ How will staff be involved

_ What will the impact be on other services providers, including social services

_ What range of community services will be put in place to support people in their own homes

5. South East Hampshire Capacity Plan

5.1. The response from the SHA to the issues raised by the Committee was circulated at the last meeting. The Chairman replied to the SHA on the 5 April setting the continuing concerns of the Committee (see Appendix Three)

5.2. Specific points raised with the SHA related to:

_ Section 11 places a duty on the NHS to involve and consult at all stages in planning. This is not optional and, whatever the difficulties faced by the NHS, failure to respond to this duty could leave decisions made by Trust Boards open to challenge from any party that is adversely affected. If the capacity map includes recommendations for action that will have an impact on the way in which services are delivered Section 11 engagement will be included.

_ Although the recurring PbR deficit may not be unique to Portsmouth PFI, the financial position of the NHS in south east Hampshire does introduce specific challenges in managing this issue. The impact of this needs to be clearly understood by all parties as plans for reconfiguring services develop

5.3. Additional information has also been requested about the clinical audit work that has underpinned the suggested reduction in bed numbers.

6. New Forest PCT: Forthcoming service reconfigurations

6.1. New Forest PCT has signalled that the following services will be subject to consultation pending service reconfiguration

_ mid-wife led maternity services

_ Health Visitor services

_ Sexual Health services

Items Requiring Action

7. Maternity Services in South East Hampshire

7.1. The Joint Committee is anticipating that it will be able to finalise its views on the proposal in June.

7.2. The report will be presented to the Committee at its next meeting.

8. Eastleigh and Test Valley South/New Forest PCT: Temporary Closure of In-patient beds at the Fenwick Hospital

8.1. The Chairman was alerted to immediate action by the PCT to close inpatient beds at the Fenwick Hospital on the grounds of patient safety a t the end of January. At this time the PCT indicated that this closure would be for a period of three months.

8.2. The PCT has now confirmed that the beds would not be re-opening at the end of May as expected and the Chairman has written the Chief Executive of Eastleigh and Test Valley South PCT stating his concern that the Trust was now seeking to defer re-opening these beds pending the outcome of the consultation on the community hospital strategy.

8.3. The PCT has been reminded that this was not the case for temporary closure put forward by the Trust and shared with key stakeholders on the 28 January.

8.4. The following additional information has been requested in order that the Committee can review its response to the PCT:

_ The grounds on which any decision is made not to reinstate the beds at the Fenwick Hospital after the initial three month closure

_ Action taken by the Trust since January 2005 to seek to resolve the staffing issues that underpinned the closure

_ Confirmation of the support of local GPs for the decision of the Trust Board

_ Confirmation that key stakeholders, including the P&PIF, relevant district/parish councils and Leagues of Friends are aware of, and had an opportunity to comment on, the decision of the Trust Board

_ Action being taken to apprise local people of the actions of the Trust

8.5. The response from the Trust is attached at Appendix Four

9. South West Alliance- Community Hospital Strategy

9.1. The South West Alliance (comprising Eastleigh and Test Valley South PCT and New Forest PCT) has indicated that it will be consulting on a community services strategy in the summer.

9.2. The Chairman has written to the PCT highlighting key questions to be addressed by the strategy. This is attached at Appendix Five

9.3. Progress with developing options for community services in the Alliance is attached at Appendix Six

Recommendations

Items for Information

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

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

11.1. The Committee is advised of further developments taken for-ward with regard to

_ The redevelopment of Andover War Memorial Hospital

_ Changes to the configuration of Community services in mid- Hampshire

_ The response of WEHT to the issues raised by the Committee.

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

12. Future of Health Services in Fareham and Gosport

12.1. The Committee be apprised of further correspondence from the Secretary of State for Health.

12.2. The response of the PCT to the questions raised by the Chairman is shared with the Committee.

13. South East Hampshire Capacity Plan

13.1. Members are advised of the response of the SHA

14. New Forest PCT: pending service reconfiguration

14.1. Members are advised of arrangements for conducting consultation on mid- wife led maternity services, health visitor services and sexual health services

Items for Action

15. Maternity Services in South East Hampshire

15.1. Members receive a copy of the final report of the joint committee at their next meeting

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

16.1. Members confirm if the response of the PCT is satisfactory and agree any additional action required.

17. South West Alliance Community Strategy

17.1. Members receive the response of the PCT to the issues raised by the Chairman and are up-dated on progress with the development of options and the consultation process

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 Overview and Scrutiny Committee: 31 May 2005

Single Surgical System Project: March Update

1. Developing the Clinical Vision

Rob Morris presented the clinical vision for General Surgery and Urology to SUHT and WEHTs Trust Board in February 2005 and will update this and brief on the vision for Orthopaedics, ENT and Urology in March. In brief the proposed clinical model is:

Outpatient appointments and Day Cases will remain as close to patients homes as possible.

Elective, planned inpatient care will be delivered through two `centres of excellence' focused at the Southampton General and Royal County Hospital sites with each centre focusing on a different range of services.

Access to emergency, unplanned care, surgical care will continue on both sites, although again, some services may be focused onto one site (i.e.poly trauma and vascular surgery) and the clinical groups are currently considering options for caring for emergency patients out of hours.

The clinical vision will be finalised at the end of March and will form the basis of the proposed strategic framework for surgical services to be presented to Trust Boards in May 2005.

2. Recent Progress

· The Project Initiation Document has been finalised and a project timetable agreed.

· The Surgical Project Board met on the 9^th March. It was agreed the clinical vision for Surgery and Urology must be completed by the end of March and a further Board meeting has been arranged for the 24^th March.

· Andrew Hyslop from Sheephouse Consulting is supporting the financial and activity modelling for the project. Baseline information has been passed to him and he is undertaking the modelling. Teamwork Management Consultants are also beginning to work on an activity model.

· There has been an initial bid of £2m to the Strategic Health Authority for capital money to support enabling works and the purchase of equipment and instrumentation. This figure will be revised as the project progresses.

3. Public and Patient Involvement

The first PPI/Comms group has taken place with PPI Forum members from SUHT, WEHT and Mid Hants in attendance. It was agreed that an A4 `key facts' briefing sheet would be produced to share will all key partners and a summary of the project would be circulated to over 4,500 individuals and organisations through a local newsletter as well as to people who signed up to be members of the Foundation Trust.

A PPI/Comms plan has now been developed and the Surgical Project will link into the Local Delivery Agreement monthly newsletter.

Jane Hayward, Project Manager, March 2005

Hampshire County Council Appendix Two

Health Overview and Scrutiny Committee: 31 May 2005

Letter to the Minister of Health

Dear Minister

Configuration of Health Services in South East Hampshire: Delay in responding to Referral

I am writing further to your letter of the 23 February, which confirmed that you had received our request that plans for reconfiguring health services in south east Hampshire be referred to the Independent Reconfiguration Panel.

We have had no further communication from you and now, with the announcement of the general election, do not anticipate that we will receive a decision until the new government is formed.

Our original letter was sent to the Secretary of State for Health on the 31 January. The issues that we raised are of deep concern to local people and clarity about the way forward is urgently needed is NHS services are to be safeguarded for the future. The imminence of a general election may have made it expedient for you to delay your decision on this controversial issue, however this is not in the interests of health services in south east Hampshire and should not be politicised. Dr Reid visited the Queen Alexandra site earlier this week and will therefore be aware of the immense pressures that NHS staff across the area are striving to manage.

Local people need to be confident that the proposed reconfiguration of health services will be able to meet current and future health needs; if not alternative options need to be explored to ensure that public funding is used effectively. It is therefore deeply frustrating that our request for this matter to be referred to the Independent Reconfiguration Panel has not been dealt with in a timely manner. This needs to be addressed as a matter of urgency and I am therefore writing to ask, yet again, that our request is given the immediate attention that is required to ensure that the local people are able to access the health services that they need.

Hampshire County Council Appendix Three

Health Overview and Scrutiny Committee

South East Hampshire Capacity Plan: Letter to the SHA

Dear Jonathan

Thank you for arranging for Ms Spiller to respond to my letter of the 21 February. We did appreciate the detail that she included in her correspondence and the context in which she described the capacity plan.

I am writing back to you because, whilst not doubting her assurances, I and my colleagues remain concerned that the financial pressures facing the local health system are having an adverse impact on planning processes and in particular the capacity of NHS organisations to effectively discharge their responsibilities with regard to Section 11 and Section 7 of the Health and Social Care Act.

We are also of the view that, to make the case that the needs of the populations served by the PCTs would be factored in once business plans were being developed is perhaps not the most effective way of building the system change that HealthFit and Beyond Health Fit envisaged. We have previously made the point that the capacity plan originally outlined did not bring together the needs of the population served and the resources available to meet these needs. Whilst not doubting the intention of the SHA to have an overall framework to inform its understanding of service developments we cannot see how this can be achieved without reference to the needs of local people- or indeed the strategic context outlined in the HealthFit programmes. One option may be to be clearer about the status of the plan and the recommendations contained therein. As presently framed the recommendations put forward have the potential to impact on service delivery, but there has been no involvement or engagement with patients, the public or those that represent them.

The recent consultation on the future of health services in Fareham and Gosport gave a clear assurance that services at Queen Alexandra Hospital would be supported by appropriate community provision. The capacity plan paper put forward threatens this `hub and spoke model'. We have commented previously about the need for there to be an integrated approach to developing these services and have received repeated assurances from the SHA and the health community that this would happen. The paper to the February SHA Board does not support this position and, in our view, undermines the recent consultation undertaken by Fareham and Gosport PCT.

Rather than enter into an unhelpful exchange of correspondence with regard to the capacity plan I would appreciate confirmation that the Strategic Health Authority would support two particular points when considering subsequent drafts:

1. Section 11 places a duty on the NHS to involve and consult at all stages in planning. This is not optional and, whatever the difficulties faced by the NHS, failure to respond to this duty could leave decisions made by Trust Boards open to challenge from any party that is adversely affected. If the capacity map includes recommendations for action that will have an impact on the way in which services are delivered Section 11 engagement will be included.

2. Although the recurring PbR deficit may not be unique to Portsmouth PFI, the financial position of the NHS in south east Hampshire does introduce specific challenges in managing this issue. The impact of this needs to be clearly understood by all parties as plans for reconfiguring services develop.

I would also be grateful if a copy of the clinical audit referred to at point 11 will be sent to myself and Cllr Charlton to inform our understanding of the rationale for decreasing the planned bed numbers by 120.

We remain committed to working in partnership with the NHS and will endeavour to be as flexible as possible in responding to the challenges currently facing health services in Hampshire and the Isle of Wight, particularly with regard to the financial position. This does however require that the NHS is clear about our role and interest in service developments. I believe we have made considerable progress with this agenda locally, as evidenced by the joint consultation on assessing substantial change in health services.

The issues raised with regard to the capacity map for south east Hampshire do however underline the need for us to continue to work closely and your thoughts on any other action that we can take to collectively move forward would be very welcome.

Yours sincerely

Cllr Dr Raymond J Ellis C.Chem FRSC

County Councillor, Fareham South East

CC Cllr I Stephens, Cllr F Charlton, Cllr B Parnell

Hampshire County Council Appendix Four

Health Overview and Scrutiny Committee: 31 May 2005

New Forest PCT: Closure of Inpatient Beds at the Fenwick Hospital, Response to the Committee

Fenwick Inpatient Beds

Thank you for your letter requesting clarification of the situation with regard to the Fenwick beds. I hope the following covers the points you have raised:

1. The circumstances which led to the temporary closure of the beds have not changed or improved. In addition, the experience of the last few months has been that the changes have been to the benefit of patients, with occupancy levels substantially improved at the other hospitals and delayed transfers reduced. It therefore seems appropriate to defer making any further changes until the consultations on the Community Services Strategy and Clinical Strategy for the new Lymington Hospital are determined.

2. The ability to recruit staff and use agency nurses is linked to the financial position of the Alliance. The decision to close the beds was on the basis that improvements to the staffing situation could not be achieved without substantial investment. The position remains the same, and with the current financial position it is not possible to recruit more staff. As a direct consequence of the transfer of staff from the Fenwick the staffing levels have improved at other hospitals. The improved medical staffing at Hythe has also enabled the earlier transfer of patients from the acute sector.

3. Dr David Balfour is the Chairman of the Professional Executive Committee and a member of the Trust Board. He is also the senior partner in the local practice. Although disappointed that we are unable to re-open the facility, he supports the approach that the Community Services Strategy is the vehicle for the re-design of future healthcare and facilities.

The decision is also fully supported by Dr Peter Hockey, the Medical Director, who has chaired the Project Board for the development of the Community Services Strategy.

4. There has been active engagement with the PPI/PPI Forum and discussions, with the Parish Council; dialogue with the NFDC; discussions with the League of Friends, and an open meeting organised by the League of Friends for the Fenwick Hospital and Lyndhurst practice will be held on Monday 16 May 2005, which will be attended by the Chief Executive and Directors.

5. We are currently developing a framework for formal consultation with local people. A "Listening Exercise" is also well underway, and has continued during the purdah period. There has also been wide press coverage, with a statement and letter from the Chief Executive.

I hope this gives you the information you require to understand why a decision has been made to continue with the temporary closure.

Hampshire County Council Appendix Five

Health Overview and Scrutiny Committee: 31 May 2005

South West Alliance Community Strategy: HOSC comments on early draft

1. The document is presented as a strategy for the Alliance rather than individuals PCTs. The principle focus seems to be on reducing inappropriate admission to, and delayed discharge from, acute and community hospital beds with particular regard to the New Forest. How is it envisaged that this strategy will impact on the wider population served by the Alliance.

2. We are not clear what community services will be required to deliver the changes inferred and provide the level of support necessary to ensure that people are appropriately supported in the community.

3. There is reference in the options, and the case for change to a reduction in the in-patient beds provided in the community hospitals in the New Forest, no indication is given of where this reduction could take place or the impact that this may have on these facilities in terms of viability.

4. What are the catchment populations for each of the community hospitals and what range of in-patient, out-patient, rehabilitation diagnostic and other services are currently provided in each.

5. What are the reference costs for the services provided in the community hospitals and how do these compare to other similar facilities and services commissioned from the acute sector.

6. With regard to the siting of non-acute services what consideration has been given to the range of services, currently provided in an acute hospital setting that it might be possible to re-provide the community (e.g. dermatology, physiotherapy, dental, podiatry, diagnostics). This should include services commissioned from the Royal Bournemouth and Salisbury Hospital as well as Southampton General.

7. In terms of health needs assessment the focus remains on the elderly and very elderly population (40,000). Whilst this group may be significant users of services, it would be helpful to see the needs of others in the population considered, particularly those that are economically disadvantaged (estimates put the total population of the New Forest area at 170.0000).

8. Additionally the pressures of the high number of seasonal visitors need to be understood- services such as non emergency unscheduled care, minor injuries and OOH are particularly important in this respect. How have these pressures been factored into the proposal.

9. Comment is made about over performance in some areas but it is not clear if there is work taking place to test the appropriateness of those referrals that are generating this activity. Similarly patient flows to the other acute hospitals do not seem to have been evaluated to test if there are opportunities to provide care more locally.

10. Travel and transport needs do not seem to have been considered. Access has previously been identified as a particular problem for people living in the area.

11. Difficulties recruiting qualified staff are noted but there is no indication if it will be possible to recruit the community staff envisaged- this is identified as a high risk, high impact issue. How will this be addressed.

12. How will community services people with mental health problems (functional and organic) be dealt with in the context of the community strategy, this includes support to carers, respite and assessment services.

13. Given the financial pressures facing the Alliance what level of savings are anticipated as a result of the implementation of the proposals put forward by the Alliance Trust Boards. What proportion of this would be directed to developing new community services and what would be directed to reducing the financial deficit.

14. How long would it be before the Alliance saw the financial benefits of reduced admission to acute hospitals. The costs of admission to an acute hospital are significantly higher than for community beds- how has this been factored in the assessment of the need for community beds.

15. The options presented seem to be focused on admissions and are therefore rather limited in their scope. We would ask that these be extended to allow for there to be a wider debate about the range of services that could be provided both in a community setting and at current community hospital sites. This provides an opportunity to explore service redesign across the range of care commissioned by the PCT, rather than a more limited discussion about beds and support to older people. Importantly this would also provide an opportunity to factor in the direction of travel set by initiatives such as the single surgical delivery system and other locality-wide initiatives that will impact on the population of the Alliance.

16. The health needs of the population in the Fordingbridge area, and the associated links with other community services do not seem to have been considered. This community tends to look to Bournemouth and Salisbury rather than Southampton for acute services. Current inpatient services at Fordingbridge Hospital provide a valuable `step down' facility for this community on discharge from acute care.

17. As the proposals move to the next stage of development there will need to be an impact assessment has been undertaken of hard to reach or other vulnerable groups that will be affected by the proposals. We would appreciate further information about how the PCT intends to do this work.

18. It would be helpful to have further information on the Teamwork Audit methodology that has been used to predict needs for community beds. We would be particularly interested in additional information on the cohort of patients covered, including the percentage that were unplanned and those suffering from a long term condition. It would also be helpful to have additional information about the cause of delayed discharges and any mapping that has taken place to identify where bottlenecks exist.

19. Noting your comments about compliance with the guidance on safety and quality produced by the Healthcare Commission it would also be useful to have your evaluation of the areas where the current configuration of community hospitals would be considered non-compliant and further information regarding the service improvements that would be delivered as a result of the implementation of the options presented.

20. Given the emphasis on the Modernisations Agency's work on `10 High Impact Changes' we would be keen to hear how this advice is being used to inform the Alliance's work on the community strategy.

Hampshire County Council Appendix Six Health Overview and Scrutiny Committee: 31 May 2005

South West Alliance: Update on Progress with the Community Services Strategy

Community Services Strategy

Update for Trust Board Meeting Thursday 26 May 2005

1. Purpose

The purpose of this paper is to: -

· Update the Board on progress to date with the Community Services Strategy.

· Ask the Board to agree that the PCT Alliance can go out to formal consultation on the two options outlined below.

2. Background

A paper, outlining high level strategic options for community services for adults and older persons was presented to Trust Board in March 2005, and a mandate given to further develop this work. The paper was updated and presented to the Strategic Health Authority in April 2005. At this stage, 5 high level options were considered:

· Doing Nothing

· Developing community services to deliver better home based services

· A reduction in acute beds commissioned by the PCT alliance

· A reduction in the number of community hospital beds provided

· A fully community based service for non acute care.

The ETVS and NF Boards requested that the project team further develop and clarify these options.

3. Progress

Since April 2005 the Community Services Strategy Project Team has undertaken further work, included further information gathering, and a "listening exercise" involving staff, patients and the public. They have also attended a number of public meetings to ascertain the views of residents in both the New Forest and Eastleigh Test Valley South PCT areas and received a significant amount of feedback.

From this feedback the points of particular relevance are: -

· Options 2,3 and 4 were complementary and could be combined to develop a coherent pathway of community based services

· A need for greater linkages between the Community Services Strategy and the developing Clinical Strategy for Lymington Hospital PFI

· A need for clearer statements about what could and should be offered in a community hospital setting

· A need for clarity of what is health services provision and what is social service provision.

· Partner organisations find our services difficult to access and navigate

This document seeks to address these issues and outline in greater clarity the proposed range of options that will feature in the formal consultation document for the PCT Alliance.

4. Key issues

The Alliance wishes to provide an improved network of older people's services to support the Management of Long Term Conditions and enable older people to be cared for within their own homes, where it is safe and appropriate to do so.

Traditional models of providing care, particularly in the New Forest have been too focussed on bed based services. Current and emerging best practice, supported by the views of older persons, is that where clinically safe and appropriate, care at home is the better option.

The financial position of the Alliance and the organisation's statutory responsibility to achieve financial balance require the provision of services based on best practice. The largest area of financial deficit is in the commissioning budget, and both PCTs have been commissioning more emergency care from acute trusts than is affordable. This is largely due to the current configuration of services which does not proactively support the management of health care of people with long term conditions in their own homes to a sufficiently high standard to prevent their need for hospital admission. Patients, staff and partner organisations have highlighted that services are difficult to access, and cannot always respond quickly resulting in unnecessary hospital admissions.

Three key issues have shaped the strategy, and will shape the consultation document as listed below.

4.1 Total Bed Capacity and the Teamwork Audit

Current in-patient bed capacity within the Alliance is:-

Milford-on-Sea 19

Hythe (excluding Maternity) 17

Fenwick 20 (temporarily closed)

Romsey 20

Fordingbridge 31

Lymington 57

TOTAL 164

With the opening of the new 104-bed Lymington-New Forest Hospital (LNFH) in 2007, the total capacity within the Alliance would increase to 211 beds. There is no suggestion or belief within the local health economy that these beds are either required on clinical grounds or financially sustainable. It is therefore clear that a reduction in bed numbers is inevitable, and it is unlikely that these will occur in the newly opened LNFH. These bed reductions will by necessity therefore need to occur in community hospitals. Simply to get back to our current total bed capacity of 164, will mean the closure of 47 in-patient beds in Community Hospitals reducing the total number to 60. This figure is similar to the figure of 53 community beds suggested by the Teamwork Audit (detail below). Further reductions are almost certainly possible, as the temporary closure of the 20 Fenwick beds has enabled increased usage and efficiency of other community beds and domiciliary support teams.

In September 2004 a "Teamwork Audit" was undertaken across hospitals in South West Hampshire when 1375 patients were assessed. Of these, 1008 were in an acute hospital, 276 in a community hospital and the remainder in beds for the elderly mental ill. A validated tool was used to assess the need for acute inpatient care with an assessment of alternative ways of meeting needs for rehabilitation and non-acute services.

Key points from the study are:

· Only 64% of patients required in-patient hospital care

· Of patients in SUHT, 78 could be appropriately cared for in community hospitals and 166 could either be managed at home or an institutional setting such as a care home

· Of the 160 patients in a community hospital, only 16% of patients in Alliance Community Hospitals were in the appropriate setting, and the remaining 84% could be managed safely either at home or in a residential home.

· The New Forest commissions 30% of acute beds at SUHT. Therefore the share of patients who could be managed in community beds is 23.

· Eastleigh and Test Valley South PCT commission approximately 18% of acute beds at SUHT. Therefore the share of patients who could be managed in community beds is 14.

· The number of patients in the Alliance community hospitals who needed that level of care was 16

· On this basis alone there is a need for approximately 53 community hospital beds across the Alliance

The robust development of community based services to manage long term conditions, plus better management of delayed transfers of care across the Alliance and our commissioned acute beds would have a further significant impact on the number of beds we need to provide within community hospitals.

With all these factors being addressed and systems in place to ensure that:-

· Hospital beds are used only for those needing that level of care

· Patients with long term conditions are managed at home to prevent exacerbations

· In-patients do not experience delays in treatment, transfer of care or discharge

modelling suggest that the number of community hospital beds could be reduced to between 27 and 53 to meet the needs of the population.

4.2 The Development of the New Lymington Hospital

The New Lymington Hospital will have almost double the number of beds compared to the current Lymington Hospital (104 instead of the current 57), as well as double the capacity for outpatients, radiology, theatre and endoscopy. Additionally, the new hospital, is planned to be equipped with a CT scanner will be able to play a major role for rapid assessment and diagnosis of our population. This impacts upon our community services strategy in a number of ways.

Firstly, we will be able to assess, diagnose and treat more acutely ill patients, thus reducing the need to commission this capacity from other acute hospitals. Patients will benefit by being seen nearer to their homes.

Secondly, patient care will be delivered in a state of the art, modern health care facility designed with our populations needs in mind.

Thirdly, the above analysis in section 4.1 has already demonstrated that we have too many community hospital beds which are not used appropriately, and patients who do not have the level of clinical need to require a hospital setting occupy the majority of these beds. It is currently proposed that the new Lymington Hospital will be able to treat acute stroke, and that the post acute stroke rehabilitation beds, currently situated at Milford on Sea Hospital will transfer to Lymington Hospital.

4.3 Feedback from our staff and population

We have sought throughout this project to engage the views and input from our staff, the staff of our partner agencies and our population and have done this through a variety of mechanisms, from meetings, public fora, 1:1 interviews, questionnaires and membership on project meetings.

The feedback we have received has been largely both helpful and constructive. Analysis of 240 of the questionnaires we have received has advised us that our public would: -

· Overwhelmingly wish to receive community services in their own homes where possible, and made particular positive comments about the District Nursing Service.

· They would like, where possible to be able to use community hospital sites for outpatient appointments, diagnostic services (The X-ray services were particularly mentioned)

· In-patient beds were noted as less of a priority

Initial feedback from staff interviews has indicated a wish to work with partner organisations, such as social services and the ambulance service to provide a more "joined up" approach to care. Discussions and feedback from community staff has shown some enthusiasm for better co-ordinated management of long term conditions and the role of the new community matron in delivering this. Constraints in the current way of working have also been identified by some members of staff who have expressed that it is sometimes difficult to be able to provide the type of care they would wish to.

Feedback from our partner organisations has also helped inform the options. In particular, it has been noted that it is often difficult to access our services: - there is no single point of access for community services, and clinical staff in other settings do not have time to navigate the current system. Our services do not run cohesively out of office hours. It can be difficult too to access beds in our community hospitals because of staffing problems, or because staff do not always have the necessary clinical skills to manage particular health issues. There has been excellent feedback about areas where the system does work - for example, orthopaedic choice.

We have identified that a responsive and effective Single Point of Access facility will be pivotal in maximising the use of our facilities - both in-patient beds and community-based services.

The current configuration of services for adults and older people across the Alliance is not equitable for our population. Not all of our population have a community hospital in their locality which they can access. Therefore whilst understandably, localities are attached to their community hospitals, the Alliance needs to ensure all our population can access the appropriate health care services no matter where they live.

5. Definition of Options

From the feedback received, and the mandate from both Trust Boards and the Strategic Health Authority Board, this paper seeks to further define the options for consultation. Only 2 models will be provided for consultation offering clear pathways of care.

Option 1 has been excluded as it is not a realistic and viable option, as it perpetuates a model of care that is not part of our strategic vision to modernise health care within an affordable financial envelope. It is also clear that we must, in partnership with our acute colleagues work towards a reduction in the number of acute beds that we purchase.

Our listening exercise has suggested that Options 2,3 and 4 should be linked to describe clear pathways and models of care, with a further range of "sub options" that will clearly specify from which sites the pathways will be provided. Option 5 will remain the same.

Model 1

Provide a comprehensive network of expanded and strengthened community based services with a reduction in the number of community hospital beds.

This will mean drawing on, and expanding work already started with the development of Locality Teams, working closely with Rapid Response and Community Nursing to provide a comprehensive clinical service, based in the community with expertise in the management of long term conditions and case management. Closer links will be forged with Social Services, Hampshire Partnership Trust and Hampshire Ambulance Service, with development of care pathways. Much of this work has been started within the Alliance, and recent guidelines on the management of Long Term Conditions gives us a clear steer on how to take this work forward.

Proactive management in the community, coupled with clear pathways and guidance on ensuring patients are in the right care setting, at the right time, will mean a reduction in the number of community hospital beds that will be needed. The consultation paper should be clear on what this means across each site. Public feedback has shown a wish for locally based outpatient and diagnostic services, and where there are existing "centres of excellence" eg Orthopaedic Choice, at Hythe Hospital, these are shown to be effective and successful. The establishment of centres of excellence for Long Term Conditions will be considered in this framework.

Model 2

Move to a Community based service by closing all community hospital beds.

This option focuses on closing all community inpatient beds and providing services based purely within the community; either within patients own homes, or in other care settings such as nursing homes or sheltered housing with extra care. This model of care operates successfully in other parts of the country, and is similar to the style of service that will be provided in Eastleigh following the re-provision of the Mount Hospital. It will necessitate, as described above the cohesive development of community based teams.

6. Next Steps

The next stage of this process is to proceed to public consultation. It is currently anticipated that this will commence formally in July, and be co-ordinated with other key strategic issues for the Alliance, including the Clinical Strategy for the New Lymington Hospital and maternity Services.

AH 170505