Hampshire County Council Health Overview and Scrutiny Committee Item 6 27 September 2005 Proposals to Develop or Vary NHS Services Report of the Chief Executive

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. No further information has been provided on progress with this initiative.

3. The Future of Health Services in Fareham and Gosport

3.1. Further to the meeting with Peter Viggers on the 18 July the Chairman wrote again to Lord Warner asking that the Committees request was dealt with as a matter of urgency.

3.2. The content of the response from Lord Warner, received on 22 of August, is attached at Appendix One

3.3. The text of the follow-up letter from the Chairman is attached at Appendix Two.

4. South East Hampshire Capacity Plan

4.1. No further information has been received about the capacity plan.

4.2. The PFI contract for Queen Alexandra is not signed.

4.3. The revised capacity plan for South East Hampshire has yet to be considered by the SHA.

5. Acute Paediatric Services/Maternity Services Review

5.1. The SHA ran an event to feedback comments from key stakeholders on the 15 September.

5.2. Feedback from the review included comments from parents, young people and children as well as health professionals.

5.3. Headline recommendations from the Review included:

_ The need to retain local access to paediatric services on all current sites

_ The expansion and development of ambulatory and community nursing services around the clock

_ one\\\\\\\\\one inpatient unit for the whole of North and Mid-Hampshire

_ acute and community paediatric services at Winchester and Basingstoke to be managed by one Trust

5.4. The full report will be available shortly. Public consultation will proceed following discussions with HOSCs in H&IoW.

6. Changes to Wessex Cardiac Services

6.1. The paper attached at Appendix Three was sent to the Committee on 26 August with a closing date of the 31 August, following a request from the SUHT P&PIF. Officer feedback has been provided indicating the following

_ The agreed framework had not been followed

_ The timeframes for comment precluded HOSC member input

_ The lack of information about the extent to which P&PIFs and other key stakeholders had contributed to shaping the proposal in accordance with section 11 requirements.

_ The lack of information about the patients affected, or alternative services available

_ The implications of delaying patient information

6.2. Southampton City HOSC has raised similar concerns.

6.3. A response to these issues has yet to be received.

7. Changes to bed Modelling at Winchester and Eastleigh Health NHS Trust

7.1. The paper attached at Appendix Four highlights a number of changes to the configuration of beds at WEHT.

7.2. The Trust and P&PIF have confirmed that services to patients will not be affected and that action is in hand to make patients aware of the changes proposed.

7.3. Comment has been invited from Social Services. No concerns have been raised.

Items Requiring Action

8. Winchester and Eastleigh Healthcare NHS Trust/ Mid Hants PCT: Changes to Rehabilitation Services at Andover Hospital

8.1. Further to the presentation to the Committee at the last meeting the NHS has now launched formal consultation with the public and key stakeholders.

8.2. The consultation will run from the 15 August to 31 October. Copies of the consultation can be obtained through the Health Scrutiny Manager.

8.3. A number of issues have been raised that it is anticipated will be addressed prior to the close of consultation:

_ The support for the proposal by the relevant P&PIFs, service users and carers

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

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

_ The provision of dental, pathology and diagnostic services in support of the service model identified in the proposal

_ The type of day surgery to be undertaken

9. East Hampshire PCT: Changes to community service configuration in Emsworth and Havant

9.1. The PCT will be attending the meeting to provide the Committee with details of the outcome of the consultation and the way in which the views of local people have informed the development of a preferred option for moving forward.

9.2. Members will wish to test if the consultation process followed and preferred option address the following points:

_ the `fit' of this work with the proposals on the future of community services in East Hampshire and across Fareham and Gosport

_ if there has been reasonable opportunity for engagement with key stakeholders, including staff, GPs, P&PIFs, social services and district councils

_ Clarity regarding the impact on other services providers, including social services

_ The additional community services to be put in place to support people in their own homes

_ The future of the `Oak Park' proposals

10. Maternity Services in South East Hampshire

10.1. The response to the Joint Committee from the lead PCT is included at Appendix Five. Members will wish to note that, following the findings of the joint Committee, the local NHS has agreed to revisit the decision not to provide a stand alone birth centre on Portsea Island.

10.2. It is anticipated that the future configuration of maternity services in south east Hampshire will be subject to further review by the NHS. It is not clear how this local work will link with the strategic work being undertaken by the SHA.

10.3. Members of the joint committee met again on the 5 September to ask for further information about next steps. No firm timescales were provided but members were clear that the reopening of the birth centres at the Grange and Blackbrook should happen as soon as possible, regardless of any pending review of maternity services.

11. South West Alliance- Community Strategy Services for Older People

11.1. Interim comments on behalf of the Committee were made to the PCT in early August. The text of this correspondence, and the reply from the PCT, is attached at Appendices Six and Seven respectively.

11.2. The public consultation meetings to date have attracted a significant public profile, with additional meetings set up to enable local people unable to access the venues to share their views.

11.3. Major concerns have been expressed about the loss of community hospital beds and the intention to close community hospitals without working with communities to identify alternative uses for these facilities. The Committee has received an unprecedented volume of correspondence on this issue, which has included comment from former health professionals and managers.

11.4. In order to promote further engagement with the communities affected funding has been made available by the Chairman to support independent work with the communities affected. This will complement additional work being taken forward by the PCT and provide a further opportunity for local people to shape the options being considered. An outline of the project plan, and the areas to be covered, is included at Appendix Eight.

11.5. It is expected that the PCT will not make any decision on how to proceed until this work has been completed. It is anticipated that this feedback will be presented at a meeting on the 25 October after which the Committee will wish to make a formal response to the proposals.

11.6. Additional information has been requested with regard to:

_ Health needs assessment

_ The service model envisaged

_ The financial implications and business case

_ The content of the clinical services strategy for Lymington PFI

12. North Hampshire PCT: Changes to the Configuration of Services at Alton Community Hospital

12.1. The PCT is working with local people to remodel the services provided by the hospital to maintain the 24 beds and provide alternative support community and services to older people living in the area.

13. Southampton City PCT: Modernising Community Services

13.1. The issues raised with the PCT following the last meeting and their response, are attached at Appendices Nine and Ten respectively.

14. `Commissioning a Patient led NHS': Department of Health

14.1. The DoH has instructed SHA to submit proposals for reconfiguring local health services. The organisations affected include SHAs, PCTs and Ambulance Trusts. SHAs are required inform the DoH of the outcome of their review by the 15 October.

14.2. It is intended that public consultation on these changes will be complete by March 2006, with all reconfiguration undertaken by October 2006. It is likely that timeframes locally will be shorter than this.

14.3. The proposals also include an expectation that PCTs will cease to provide services. The has significant implications for community services and the staff who run them. The changes also represent a significant opportunity to align local authority and NHS services to support improvements in health and well being in our populations.

14.4. The draft response to the SHA on these proposals is attached at Appendix Eleven

15. Portsmouth City PCT: Changes to substance misuse services

15.1. This proposal, presented at the last meeting, has now been submitted to the Joint HOSC for H&IOW to determine if this is a substantial change to service provision.

16. Portsmouth City PCT: Changes to low secure services rehabilitation services

16.1. This proposal, presented at the last meeting, has now be presented to the Joint HOSC for H&IOW to determine if this is a substantial change to services.

Recommendations

Items for Information

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

17.1. The Committee is up-dated on progress with developing the surgical service proposal at its next meeting.

18. Future of Health Services in Fareham and Gosport

18.1. The Committee be apprised of the response from Lord Warner.

19. South East Hampshire Capacity Plan

19.1. Members are advised of the next draft of the capacity plan

20. Acute Paediatric services/maternity service review

20.1. Members are advised of the full review and consultation process developed to support this work.

21. Wessex Cardiac Services

21.1. Further information is provided with regard to

_ Clinical support for the proposals

_ PCT sign-up to the changes

_ Compliance with section 11 requirements

_ Impact on patients

_ Communications with patients and other health professionals

22. Changes to bed modelling at WEHT

22.1. Members note that these changes will not affect service delivery and are not therefore substantial

Items for Action

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

23.1. Members review the consultation and engagement process with input from the relevant P&PIFs, dist councils and other key stakeholders

23.2. Additional questions from Committee members are directed to WEHT through Denise Holden up to 24 October

24. East Hampshire PCT: changes to community service configuration in Emsworth and Havant

24.1. Members highlight any additional action to be taken by the PCT

24.2. Members consider

_ If the consultation process has been adequate

_ If the preferred option identified is in the interests of the community affected

25. Maternity Services in South East Hampshire

25.1. Members are advised of further action taken with regard to the planned review of maternity services.

25.2. Local PCTs and PHT is advised of the expectation of the Committee that, not withstanding the review, the birthing centres at the Grange and Blackbrook will be reopened at the earliest opportunity. Progress with this will be reported at the next meeting of the Committee.

26. South West Alliance Community Strategy

26.1. Additional questions and queries from members to the PCT will be directed through Denise Holden up to and including 25 October.

26.2. The PCT is invited to confirm that no decisions will be taken until the additional work, commissioned by the Committee, has been fed back and reported.

26.3. Outstanding information relating to the financial assumptions, care pathways and needs assessment is made available to the Committee. The Committee will also wish to be mindful of the potential impact of other policy developments on the pattern of community service provision.

26.4. The Committee is clear about the way in which the views of local people have been taken into account prior to any decision being made.

26.5. The links with this consultation, and that being conducted on the same patient group by Southampton City PCT is clearly set out by the PCT.

27. North Hampshire PCT: Changes to the Configuration of Services at Alton Community Hospital.

27.1. Members are advised of progress with developing the consultation document at the next meeting.

28. Southampton City PCT: Modernising Community Services

28.1. The Committee notes the further work required to deliver the section 11 requirements and provide clarity about services for people living in the ETVS PCT area.

29. `Commissioning a Patient-led NHS'

29.1. Members agree the draft attached at Appendix Eleven

30. Portsmouth City PCT: Changes to substance misuse services

30.1. Members are apprised of the views of the Joint H&IOW HOSC on the proposals.

31. Portsmouth City PCT: Changes to low secure rehabilitation services

31.1. Members are apprised of the views of the Joint H&IOW HOSCs on the proposals.

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

Appendix One

Configuration of Health Services in South East Hampshire

You wrote to the Secretary of State on 31 January 2005 requesting that the

decision taken by Fareham and Gosport Primary Care Trust on their provision

of community and primary care services be referred to the Independent

Reconfiguration Panel. She has asked me to deal with this matter and reply

to you.

In order to come to my decision I have reviewed the papers available

including the option appraisal and Primary Care Trust decision. I have also

met with your local MP, Peter Viggers and representatives of Gosport

Borough Council, as well as with representatives of the local NHS. This has

enabled me to fully understand the situation about which you are concerned.

This change comes at a time of un-precedented investment in the NHS.

Locally in South East Hampshire this has enabled the development of an

Independent Treatment Centre at the St Mary's site that will provide an

integrated Minor Injury Unit and Primary Care walk-in centre, a Day Surgery

Unit and Diagnostic facilities.

The day surgery services will be provided to patients living in Portsmouth City,

Fareham and Gosport and East Hants Primary Care Trusts as well as to

patients living in the rest of Hampshire who require a cataract operation. The

Independent Treatment Centre will also provide access to diagnostic

treatments which will result in patients being seen more quickly with a faster

turnaround of test results enabling more rapid diagnosis.

The Primary Care Trust has to ensure that high quality, cost effective primary

and community care services are delivered. As you acknowledged, this

consultation process has been thorough, it has examined the cost and

benefits of each option and involved the local stakeholders. The option

appraisal clearly supports the decision of the Primary Care Trust.

The decision made by Fareham and Gosport Primary Care Trust is in regards

to where primary and community services will be provided in Gosport. The

consultation and the decision were not about the wider provision of health

care across South East Hampshire and the needs of military personnel and so

your questions on these issues are outside the scope of the consultation and

decision.

The NHS has to ensure services are provided through times of change, the local NHS

are working with MoD to ensure that any facilities required are available.

Therefore, I support the decision of the Primary Care Trust and can see no

reason to ask them to reconsider their actions or to refer their decision to the

Independent Reconfiguration Panel for consideration and advice.

I am copying this letter to Peter Viggers MP and Mark Hoban MP.

Appendix Two

The configuration of health services in south east Hampshire: response to referral

I am writing with regard to your dilatory response to our Committee following our referral to you in January 2005. It is a sad reflection on the Government's commitment to putting patients at the heart of the NHS that, not only have you disregarded the views of the community in south east Hampshire, but you have also chosen to ignore the issues we raised with you about the interdependency of services in the area and the impact that other changes will have on the configuration of health care to the local population.

We were specific in our original letter, and the repeated reminders to your office, that we were deeply concerned that the involvement of the Ministry of Defence in south east Hampshire was material to the options presented by the PCT and that the scope for local action was constrained by decisions made by central Government. We set out 5 questions that we considered needed to be answered and the grounds for our views. Your reply did not address these points, nor did it include the courtesy of an explanation for the time it has taken you to respond to us. Your selective reference to the Independent Treatment Centre at St Mary's does not address the concerns we have raised and is contradictory to your assertion that the consultation was not about the wider provision of health services.

Our reasons for referring this matter to you related to the interests of the health service in the area, not to the consultation process. In so doing we asked simply that the impact of the changes be independently assessed; the reasons for making this request have not changed. We have clearly stated the issues that we felt were outstanding and outside the remit of the PCT to address.

I am therefore writing to ask for a detailed response to each of the points that we raised with you in our original letter. In line with other guidance I am also expecting that your reply will be with us in 28 days and would be grateful if you could confirm the standards for responding to correspondence that exist in the Department of Health.

Appendix Three

SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST

PUBLIC AND STAFF INFORMATION PAPER ON SERVICE REDESIGN TO SUPPORT FINANCIAL RECOVERY AND NEW WAYS OF WORKING

Wessex Cardiothoracic Unit

INTRODUCTION

The Wessex Cardiothoracic Unit provides all Cardiothoracic services for the district of Southampton (0.5million) and provides a specialist service for a much wider population (3-4million) across the South of England. The unit undertakes about 11,500 episodes per year many of these on extremely acute patients who require complicated procedures. On most well recognised acuity scoring systems the unit treats among the most complicated and challenging group of patients in the UK.

This paper is the start of the process by which we wish to inform staff, patients, the public and any other interested parties as to what changes to services are being proposed as a result of a review of the service taking into account the need to address the financial deficit whilst maintaining high quality care. Comments, ideas and concerns would be most welcome and should be forwarded to the details given at the end of the document.

BACKGROUND

The Cardiothoracic Directorate has a severe financial gap, in the region of £4 million for the 2005/06 financial year. This is made up of an approximately £2 million deficit brought forward from the previous financial year and a further £2 million savings plan for 2005/06.

Financial difficulties are a well recognised problem across the whole of Hampshire and Isle of Wight health economy and as such each organisation and hence department has been set a target to reduce its workforce by at least 5%.

From March 2005 new referral criteria were introduced that has reduced the number of admissions into the unit and has increased the number of empty beds.

Development of angiography and some angioplasty services elsewhere has decreased the demand on the cardiac day unit.

OBJECTIVES

In proposing ideas for service redesign, the following objectives were considered:

· To maintain core acute services and throughput

· To maintain patient safety during admission

· To maintain services for which SUHT receives income

· To maintain the quality of acute care delivery

· To maintain an acceptable level of quality

· To fully consider the impact of service redesign on patient access to services

It should be noted that the vast majority of in and out patients receiving treatment in the Wessex Cardiothoracic centre will not notice any change to the quality and timeliness of their treatment.

.PROPOSED SERVICE REDESIGN TO SUPPORT FINANCIAL RECOVERY AND NEW WAYS OF WORKING

Service Delivery

Reduce the Number of CCU Beds from 14 to 10: Traditionally referrals to the Coronary Care Unit are made by A&E and based on the possibility of the patient having a cardiac condition. This inevitably led to a number of patients being admitted to CCU who would benefit from the specialist expertise of a different specialist team. Since 1 March 2005 the Cardiologists, in collaboration with General Medicine have developed new referral criteria for admission to the Coronary Care Unit. This has reduced the number of admissions to CCU and has led to an increase in the number of empty beds. It is thus considered that with the reduction of 4 CCU beds, adequate bed provision will still be available for the higher risk acute coronary syndrome patients.

Amalgamate the Cardiac Day / Short Stay Units: Due to the development of angiography and some angioplasty services at many District General Hospitals, notably, Chichester (angio), Portsmouth (angioplasty), Bournemouth (angioplasty) and Salisbury (angio) this has decreased the demand in the use of the Cardiac Day Unit. Improved patient throughput and a reduction in the number of people waiting for cardiology procedures through the Regional Transfer Unit, has led to a small over capacity in ward beds. The Cardiothoracic Unit are looking at different options of amalgamating the Day and Short Stay Units to optimise throughput. It is anticipated the amalgamation will reduce the overall number of Cardiac Day Unit / Short Stay beds. Patients who would have been treated in the Day Unit will be treated in the same way and can still anticipate that their procedure will be undertaken as a day case.

Repatriate Consultant Cardiologists: SUHT Adult Consultant Cardiologists provide peripheral commitments at both Winchester and Lymington. The provision at Lymington is for an outpatient clinic 31 weeks per year, cover of a stress test list and a ward round. For Winchester, this is one clinic per month. SUHT are in discussions with New Forest PCT and Winchester with regards to the proposal to end these commitments and repatriate the Consultant Cardiologists to do further work at SUHT. If this proceeds all patients, both new and follow up who would have been seen within these clinics, can be redirected to SUHT for Lymington patients and either other consultants' clinics at Winchester or to SUHT for Winchester patients.

Staffing

In line with the health economy-wide target and in order to reduce costs, it is the intention to reduce staffing levels by 38.55 whole time equivalents (WTEs). The table below shows the split across the various staffing groups.

Staffing Group	Current (WTE)	Proposed (WTE)	Reduction (WTE)
Nursing	295.37	268.87	26.50
Admin and Clerical/Management	62.14	54.41	7.73
Other Clinical Staff	52.63	52.13	0.50
Medical	77.17	73.35	3.82
TOTAL	487.31	448.76	38.55

It is anticipated that at this reduced level of staffing, throughput and core services will be maintained. However, there will be reductions in some other services as follows:

i. Reduction in liaison/support for cardiac rhythm management (CRM) patients: Currently the CRM service has a dedicated specialist nurse who provides support and advice. The proposal is to remove this specialist post and for patients to receive their advice and support from ward nurses and the cardiac rhythm management medical team. This is how the service ran prior to the establishment of this post in 2004, however, it should be recognised that queries may not be responded to as quickly and a dedicated patient support line will no longer be able to be run.

ii Reduction in liaison/support for Adult Congenital Heart Disease (ACHD) patients:

Currently the ACHD service has 1.40WTE dedicated specialist nurses who provide support and advice. The proposal is to remove these specialist posts and for patients to receive their advice and support from ward nurses and the ACHD medical team. This is how the service ran prior to the establishment of these posts in 2003, however, it should be recognised that queries may not be responded to as quickly and a dedicated patient support line will no longer be able to be run.

iii Reduction in specialist nurse liaison/support in paediatric congenital heart disease: The proposal is to reduce the number of staff working in this area from 3.6 WTE to 2 WTE. A specialist service will still be available for patients and relatives, however we will streamline this process by providing a more Directorate focus and reducing the demand on the liaison nurses time through streamlining or reducing peripheral clinics.

iv Redesignation of specialist nurse led thrombolysis service for patients suffering acute MIs: Currently 8.00 WTE specialist nurses provide 24 hour cover for patients suspected of having an acute coronary syndrome (ACS) and they also deliver thrombolysis where appropriate. The proposal is to reduce the numbers to 6.00 WTE and focus the specialist nurses working hours on when the majority of ACS patients are admitted - during the daytime. At night patients admitted with an ACS, and requiring thrombolysis will still receive their treatment in a timely and high quality manner by other health professionals.

v Potentially longer timeframe in the reporting and sending of clinical patient information to other healthcare providers and patients: We are restructuring our admin and clerical staff to move the admissions and waiting list management to a central office. This will enable us to reduce costs and reduce the number of staff in the medical secretarial offices. It is hoped that there will be little impact on timescales of sending clinical patient information, however, some delays on occasions should be expected.

Non Pay (Consumables)

Although the Directorate is striving to purchase consumables and drugs in as economical a manner as possible, it is not anticipated that this will impact on the quality of care given to individual patients.

5. PATIENT AND PUBLIC INVOLVEMENT AND FEEDBACK

This paper is the start of our engagement and involvement process. Our formal consultees (the Overview and Scrutiny Committee(s) and Patient and Public Involvement Forum)) will be advising us on whether the proposed changes amount to a substantial change to service.

As part of our statutory duties under section 11 of the Health and Social care Act, there will be a period of engagement with service users, carers, partner organisations, key stakeholders and Statutory bodies. These will include but will not be restricted to:

Strategic Health Authorities

Primary Care Trusts

Shared Care Acute Trusts

Central South Cost Cardiac Network

British Heart Foundation

Wessex Children's Heart Circle

Patients GUCH Association

Wessex Cardiothoracic Unit Staff

Wessex Heartbeat

Users of the service and their carers

PPI Forums (will need to include all P&PIFs as patients not restricted to SUHT PPIF)

Overview and Scrutiny Committee (Southampton and Hampshire)

MPs

We would welcome feedback on the proposed service redesign to support financial recovery and new ways of working plan for the Wessex Cardiothoracic Unit. If you would like to send comments, ideas or concerns, please write to the address below or e mail: [email protected] by 31 August 2005.

Robert Burns

Clinical Service Manager

Wessex Cardiothoracic Centre

Mailpoint 46

Southampton University Hospitals NHS Trust

Tremona Road

Southampton

SO16 6YD

Glossary of Terms

Cardiothoracic - Relating to the heart and the chest

Angiogram - An X Ray image that looks at the blood vessels supplying the heart muscle

Angioplasty - A technique that uses metal jackets called stents to squash open narrowings in the blood vessels that supply the heart muscle to treat angina or heart attack.

Appendix Four

WINCHESTER AND EASTLEIGH HEALTHCARE

NHS TRUST

Bed Model Implementation, August 2005

Staff Information and Consultation Paper

The purpose of this paper is to explain how the Trust plans to reorganise inpatient services. This follows on from the staff information and consultation paper published in May 2005 which described the impact on wards and services following the opening the new Treatment Centre (TC). The Treatment Centre is now expected to open in mid September 2005.

As a result of ongoing initiatives the Trust intends to close 75 of its current inpatient beds, 43 in Medicine and 32 in Surgery.

Division	Current bed number at (May 2005)	Future bed number required	Reduction
Medicine and Elderly	288	245	43
Anaesthetics and Surgery	142	110	32
Total	430	355	75

Such a significant reduction in bed numbers will have an inevitable impact on staffing resources. However, as a consequence of the Trust's recent policy on limiting recruitment, we have many unfilled posts especially in the Medicine and Elderly Care Division. It is not anticipated that any compulsory redundancies will be needed.

This paper also explains the detail of changes to ward configurations, timescales and the process through which staff whose wards are affected by the changes will be supported.

Background

In December 2004 the Management Board agreed the `Changing Beds' paper which set out the number of beds that would be required by the Anaesthetics & Surgery and Medicine and Elderly Care Divisions following implementation of modernisation initiatives. The paper identified that by changing the way we deliver our services we can reduce the demand on inpatient beds. Modernisation initiatives now underway include:

· A shift from inpatient to day case and 23 hour stay surgery linked to the opening of the Treatment Centre.

· Implementation of the Modernisation Agency's `10 High Impact Changes' (HIC) such as reducing length of stay, reducing delayed discharges, admitting patients on the day of surgery, improving patient pathways and higher bed occupancy.

· Proposed service improvements, e.g. joint medical / surgical gastroenterology ward and surgical assessment beds.

SERVICES / WARDS - NATURE OF CHANGES

Table 1. Services/Departments Affected

Service/Ward Current Function	Nature of Change Future function	Impact on Staff
Wainwriht Ward 12 beds 5 day stay ward catering for short stay surgery	The transfer of ENT inpatient surgery and day case and short stay cases from Nightingale theatres to the TC will mean that Wainwright inpatient ward facilities will close when the Treatment Centre opens.	Staff associated with the services will transfer to the Treatment Centre when it opens in mid September 2005. Wainwright nurses who currently staff ENT outpatient clinics and do ENT pre-assessment will continue to cover these sessions as part of the wider Treatment Centre team.
Ophthalmology Surgery Day Surgery admission and recovery on Wainwright ward	Ophthalmology surgical sessions will continue to take place in Theatre 5 with the pre assessment and recovery taking place on the Eye bay on Wainwright Ward.	Staff currently associated with this service will continue to provide the service and be managed as part of the wider Treatment Centre team.
Orthopaedic Wards Bartlett 27 beds elective orthopaedic surgery Taunton 27 beds Trauma	Bartlett will reduce from 27 beds to 22 on 19th September 2005. 5 `swing' beds can be opened as and when required to support additional funded elective surgery. Taunton's beds will increase from 27 to 28 following the refurbishment of an office back into a single room.	The reduction in beds on Bartlett will result in a changed skill mix. Surplus staff will be redeployed into vacancies on Taunton Ward.
Kemp Welch Ward 28 beds General Surgery	Kemp Welch will become the joint medical and surgical Gastroenterology (GI) ward with 12 surgical and 16 medical beds from 19th September 2005. The new ward will be managed by the Anaesthetics & Surgery Division. Up to 16 medical patients will transfer from Victoria ward	As this is a major change in function the ward will require a new staffing profile. All staff from Kemp Welch and Victoria ward have had the opportunity to express an interest in working on the `new `ward as part of the process commenced in May. Staff who have expressed their interest to stay on New Kemp Welch will be advised as soon as possible.
Other Surgical Wards	Freshfield Ward will continue to admit Colorectal and Vascular surgery. St Cross will admit Urology and Breast Surgery	There will be no overall change in the staffing profile
Victoria Ward 31 beds General Medicine	Victoria will become a general medical ward and will reduce to 17 beds on 19th September 2005. Victoria Ward will however have the physical ability to `swing' open additional beds when required and agreed.	Staff have already had an opportunity to express their interest in moving to New Kemp Welch and will be advised as soon as possible.
Compton Ward 18 beds Rehab/Rheumatology	Compton ward will close with the loss of 18 beds by the end of September 2005	Staff will be redeployed within either Victoria Ward or the M&E Division
Twyford Ward Haematology/General Medicine	Twyford Ward will reduce from 27 to 25 beds by the end of September 2005	Vacant posts will be reviewed to reduce the impact on some posts.
Clarke Ward 20 beds Cardiology and General Medicine	Clarke ward will reduce from 20 to 18 beds by the 30th September	No reduction in staffing is anticipated
Butterfield Ward 28 beds for General and Respiratory Medicine	Following the refurbishment of Shawford Ward, Butterfield Ward will relocate to Shawford and reduce from 28 to 27 beds. This will enable the Trust to begin the closure of the temporary wards	A revised skill mix is anticipated.
Other Medical Wards	RDU, EMAU, Clifton and Mount Wards will not change their patient mix or size	No changes to the staff profile on these wards
Andover 52 inpatient beds for Rehabilitation	Pending the outcome of public consultation (which started on the 15th of August 2005 and will last until the 31st October 2005) proposal is to reduce the number of beds at Andover from 52 to 30	Vacancies at Andover are already causing service delivery difficulties.

CURRENT AND FUTURE STAFFING NEEDS

For Anaesthetic and Surgery

Following the transfer of staff to the Treatment Centre, the number of staff in post within the division is broadly consistent with the new bed model. Some issues of grade mix will need to be considered.

For Medicine and Elderly

The process of withholding vacancies means we are close to the staff numbers required for the new bed model.

For both Divisions the levels of staff required are based on the year 2004/05. Further work however is now underway with Kay Riley, Director of Nursing, leading a piece of work with the senior nurses to review the mix of skills for each ward, ensuring that historic staffing establishments are re-evaluated and new staff profiles are made up of staff with the right skills for the future. The outcome of this work may change future skills profiles.

STAFF APPOINTMENT AND REDEPLOYMENT PROCESS

The process of staff appointments to the Treatment Centre which began in May is now completed.

The further reconfiguration of services and reduction in bed capacity described in this paper creates a number of challenges for staff deployment.

The development of Kemp Welch as a GI ward, as noted above will require a different skill mix and has therefore been treated as a new development requiring a staff matching process. Appointments to "New Kemp Welch" is well underway and will be progressed further by publication of the new staffing structure. Existing staff who expressed an interest in the new ward will be notified of the outcome by their divisional manager.

The overall reduction in capacity will result in a number of staff becoming displaced from existing roles. In some cases this will happen as a direct consequence of ward closure or reduction in the number of beds, in others it will be necessary to adjust the skill mix on a ward to provide appropriate patient support. In all cases redeployment of staff will be handled sensitively and in consultation. However, the ultimate decision on where staff will be allocated will be taken by divisional management.

Where an initial surplus of staff or skills difference exists within a division every effort will be made to use resources cost effectively. This will require a high degree of flexibility and could involve the creation of "flexible staffing pools" to be used as an alternative to bank and agency. Temporary redeployments beyond traditional boundaries may also need to be considered until appropriate vacancies arise.

Full discussion with trade union and staff representatives on these and all other measures to avoid redundancies is ongoing.

NEXT STEPS

For Victoria and Kemp Welch Ward staff affected by the new joint Gastroenterology ward development, Divisional General Managers will write to staff with the ward structure and the process for matching staff to posts by 26^th August 2005.

Staff in other ward areas affected by these changes and identified for redeployment will be informed on a one to one basis by divisional management with HR support, no later than 19^th September 2005.

The process of formal staff consultation, which has been taking place over recent months, will continue with fortnightly meetings to monitor the process.

Any queries about this paper should be raised with your line manager in the first instance.

Many thanks

Kay Riley Vicki Fletcher

Acting CEO and Director of Nursing Director, Human Resources and Facilities

Appendix Five

A HEALTHY FUTURE FOR MOTHER AND BABIES

Thank you for your letter of 28 July, I am sorry to hear that you have cancelled the meeting of the Joint Committee scheduled for 4 August, but please find below our response to the report from the Joint Committee regarding the above consultation. The response is from the organisations involved - East Hampshire, Fareham and Gosport and Portsmouth City Primary Care Trusts (PCTs) and Portsmouth Hospitals NHS Trust.

We value the Joint Committee's response and the interest and involvement shown in the `A healthy future for mother and babies' consultation. Our response below is focussed on section 10, Conclusions and Recommendations.

We acknowledge the point made by the Committee. We are aware of other models of running birth centres but rejected these initially because we have not fully examined the Governance and risk issues associated with running these types of service. We are, however, planning to undertake further work examining other models in depth in the Autumn of this year and will be involving the Maternity Services Liaison Committee (MSLC) in this piece of work. We would be pleased to report on our conclusions to the OSC if the Committee would find this appropriate.

Throughout the consultation we were trying to take into account the needs of women in the whole of the district, not purely those living on Portsea Island. 50% of women using the Mary Rose Birth Centre are from the Portsmouth City PCT area of which 50% are from Portsea Island. The majority of the remaining 50% of users are from East Hampshire PCT area. The latest figures (2003) quoted on page 35, Appendix 5, of the Maternity Strategy show that 388 users were from the Portsmouth City PCT area, 267 from East Hampshire PCT area and 40 from Fareham and Gosport PCT area. Please also see `Who uses the Mary Rose Birth Centre now?' on pages 12 and 13 of the consultation document. We agree with the committee that there is a high deprivation in the City, at the same time acknowledging there are also significant areas of deprivation in the East Hampshire and Fareham and Gosport area.

We agree with your response that women should have access to a choice of maternity services that are as local as possible and indeed 25% of births in the district are out of hospital/home births, one of the highest in the country, which we believe is a good indication of the choice provided. We support your comment regarding a safe environment, which is, and will continue to be, one of our main priorities. Indeed, as you are fully aware, Portsmouth Hospitals NHS Trust recently had to close the Grange and Blackbrook Birth Centres temporarily because it could not provide safe levels of staffing across the six locations where birth is usually supported because of unusually high maternity leave and sick leave. (The six locations include home, Blackbrook, Blake, the Grange and Mary Rose Birth Centres, and the main obstetric unit).

Although the environment in the main obstetric unit was not part of the consultation brief we are pleased to advise the Joint Committee that throughout the design and planning of the unit we have had the active involvement of users who will continue to be part of this process.

The modelling, which took place to determine the number of beds was based on projected figures for population growth, as, outlined in section `Population growth and birth forecasts' on page 6 of the consultation document.

The costings for siting the options are covered on pages 15 and 16 of the consultation document under the headings of `The option of a stand-alone birth centre on Portsea Island' sub heading `How much would it cost?' (page 15) and `The option of a co-located birth centre at Queen Alexandra Hospital' sub heading `How much would it cost?' (page 16).

As the preferred option at the time of the consultation was providing a like for like unit it was not felt the need to overly state the clinical evidence because we already have a co-located option within the services provision currently, and are not suggesting that either option has a clinical superiority over the other. Both options allow for midwifery led care, however, one is closer to the main unit than the other.

We acknowledge that the stand-alone units of Blake, Blackbrook and the Grange have a lower transfer rate to the main obstetric unit at St Mary's Hospital than does the Mary Rose Birth Centre to the main obstetric unit, referred to under `Co-located or stand-alone unit: the issues' on page 12 of the consultation document. Portsmouth Hospitals is committed to undertaking a piece of work to shed further light on the differences between the transfer rate from the Mary Rose Birth Centre to the main obstetric unit and those of Blake, Blackbrook and the Grange. Please also see Appendix 5, page 34 of the Maternity Strategy.

We note the commendations of the Portsmouth, Hampshire and Isle of Wight Joint Health Overview and Scrutiny Committee. The decisions made by the Boards of the organisations involved in the consultation process are:

Portsmouth City PCT voted 6/5 in favour of a stand-alone birth centre on Portsea Island subject to the development of a business case.

Portsmouth Hospitals NHS Trust supported the decision made by the Board of Portsmouth City PCT.

East Hampshire and Fareham and Gosport Primary Care Trusts' (the two PCTs have combined their management arrangements and now make decisions jointly about the future shape and delivery of local health services as a `Cluster') Boards would wish to see a review of maternity services across the area currently served by Portsmouth Hospitals maternity and obstetric services, i.e. the areas served by East Hampshire, Fareham and Gosport and Portsmouth City PCTs. Such a review would allow the PCT to look at the disposition of maternity services across the whole patch, taking account of choice for mothers, but also the cost and logistics of different service options. It would be the wish of East Hampshire and Fareham and Gosport PCTs to conduct such a review in parallel with Portsmouth City PCT's development of a business case.

We will share with you our plans and timescales for moving forward around a full review of the services, after further discussions with the executive teams for the organisations of East Hampshire, Fareham and Gosport and Portsmouth City PCTs and Portsmouth Hospitals NHS Trust.

Appendix Six

Community Services Strategy: Interim Comments

Our members have now been able to consider the consultation document published on the 11 July and receive feedback from some of the public consultation meetings that the Alliance has held. In view of the strength of public views that have been expressed, and taking account of other developments that have been shared with us, we felt it would be timely to provide the Alliance with some interim comments, which may inform the next stages of the consultation process.

For ease of reference we have split our commentary into the two areas that we will be focusing as an Overview and Scrutiny Committee. Where appropriate we have also referred back to previous correspondence relating to the development of the strategy.

1. The Consultation Process. We are deeply concerned that communities across the New Forest areas have been alienated by the consultation that has taken place to date and that this has created little opportunity of a meaningful dialogue about the services that are needed. As presented the options have attracted significant public criticism, much of which has been focused on the threat of closures.

We have previously requested that the limited focus of the options under consideration be extended to look at the range of services that could be provided in both the community and the community hospitals sites. The document published by the Alliance does not do this, indeed the options presented focus on closure of beds with no scope for an informed for discussion about what would change and what could be retained in the different settings.

We are also concerned that there has been no assessment of the impact of the of the options presented on the viability of the different community hospital sites. Inevitably this has meant that, for many local people, the closure of rehabilitation beds has translated into the closure of community hospitals. The fact that community hospital beds are appropriately used for other purposes, such as orthopaedic rehabilitation or maternity services has not been presented clearly, reinforcing this perception.

We are aware of the financial pressures on local NHS services and the massive £27.5 million deficit that the New Forest PCT must plan to recover in 2005/06. We are also cognisant of the need to modernise health services and move away from traditional, bed-based models of care. The present discussion about the way forward for community services in the New Forest area is, in our view divisive not least because staff or local GPs have stated so publicly that they do not support the proposals.

We believe that the solutions must lie with the communities affected, each of which provides different opportunities to meet different needs. The discussion therefore needs to move away from that of confrontation to a more informed and constructive debate. The announcement of `Commissioning for a Patient led NHS', which has significant implications for PCTs and the services they provide, reinforces our view that there is a need for a different approach to the planning of these important services.

2. The interests of the health service in the area affected. We have previously raised a number of these points but they have yet to be fully addressed. We would therefore appreciate your further comment on the following:

2.1. The need for the strategy produced by the Alliance to cover the population served by the Alliance. The focus of the strategy remains on the New Forest. The `Modernising Community Services' strategy produced by Southampton City PCT makes reference to the population of Eastleigh but does not align with the document you are currently consulting on. You have already been copied into our response back to the Southampton City, but anomalies such as the suggested use of either Hythe or Romsey to meet the needs of Eastleigh patients are not helpful. Similarly we have shared with you proposals from Southampton University Hospitals Trust that refer to 14 orthopaedic rehabilitation beds to be created at Hythe Hospital. This does not give us any reassurance that NHS organisations are working systemically to find solutions to issues and reinforces the comments above about the need to pause, take stock and engage directly with the communities affected to find a way forward.

2.2. We still do not know what community services will be required to deliver the changes inferred. There is little information for example about the skill mix of the rapid response teams, how they quickly they could respond or whether they could provide night sitting or respite support or the contribution that they could make to preventing hospital admission

2.3. We still do not know what consideration has been given to reproviding services from an acute to a community setting. There must be scope for a range of different outpatient and diagnostic work to be appropriately and safely provided in this way. What work has been undertaken to look at patient flows to Southampton, Bournemouth and Salisbury with a view to providing care more locally.

2.4. We accept that most people would prefer to remain at home if possible. If admission is required however, most people would rather be admitted to a community hospital rather than an acute hospital. An increasing range of care can now be safely provided in this sort of setting. In some instances a bed may be required, in others care can be provided on a day case basis. We would like to see more work done to explore these possibilities in the context of the community hospitals and community services in the New Forest.

2.5. We have still not received information about the financial modelling that has taken place to demonstrate that the options outlined are affordable and sustainable, nor are we aware of any work that has taken place to explore how LIFT could support local developments. Given the current financial pressures on the New Forest PCT this is a major concern. The budgetary information presented at Appendix D is simply not sufficient particularly as this is suggesting that nearly 23% of the available funding would be directed to savings plans.

2.6. We remain concerned that the needs of the different communities affected, particularly in the Fordingbridge area, have not been properly assessed for the purposes of this consultation.

2.7. Beyond a brief reference there is no alignment of this work with other strategies, including the single surgical service strategy and the clinical service strategy for Lymington. Your previous response referred to the need for OOH services to link with the planned changes but this is not included in the consultation document.

2.8. We remain deeply concerned about the recruitment and retention of staff, particularly those at the front line and have been alarmed by suggestions that the posts of key staff such as district nurses and health visitors are under threat. Comments from the public meetings would also suggest that staff and other health professionals have not been able to contribute fully to the development of the proposal.

There are other comments that we may wish to raise with you, however these are so fundamental to the consultation process we felt that you needed to be apprised of our views at the earliest opportunity. We are keen to actively support discussions with local people about the way forward and are aware that change is inevitable. Should you decide that the focus of the consultation should be changed we would work with you and other stakeholders to achieve this.

Appendix Seven

Community Services Strategy: Interim Comments

Thank you for your letter of 2 August 2005 enclosing some interim comments which are of use to the Alliance in planning the next stages of the consultation process. I will also attempt to respond to some supplementary issues which you raised at our recent meeting with Dr Julian Lewis, MP.

1 The Consultation Process. I agree that some aspects of the public consultation meetings and press coverage to date militate against having a meaningful dialogue about the services that are needed. This is highly regrettable although I disagree with the implicit suggestion that this is a result of the way that the PCTs have presented the consultation. The PCTs have been at pains from the outset to open up a dialogue with the public about the services that are needed, but I believe it is also important for us to be honest and straightforward about the potential impact of the proposed service changes on particular facilities. Indeed, you have encouraged us to do so. It is inevitable, therefore, that the impact of these proposals on facilities has aroused considerable controversy, given the important place that the hospitals have held in the life of their communities. Again, it is regrettable that these concerns have tended to divert attention away from the service needs of patients. At all times, PCT staff have sought to raise the profile of these issues but have frequently been drowned out by vociferous and orchestrated opposition to facility closures. Whilst this is a necessary fact of life, I would hope that the Review Committee would share our desire to maintain a proper perspective on this.

We have responded to requests from communities who have wanted the format of a large public meeting and have so far conducted 8 of these meetings across the affected area. We have also had some feedback from both the PPI Forums and some individuals that have suggested a different approach. Our September meetings will therefore follow a different format and will be run as a series of sessions with smaller discussion groups that make it easier for everyone to have their say and to explore issues in more depth. I would also like to reassure you that we have been, in the interim, meeting with smaller groups and having helpful dialogues.

I do not understand your comments about the limited focus of the options under consideration. The consultation indeed examines a wide range of services needed by older people and I disagree that the options presented focus on the closure of beds. The options presented focus on meeting the needs of this patient group in a variety of settings. However, we also felt that it was important to be honest and direct about the impact that the service model will have on the requirement for in-patient beds in community settings.

Whilst it is true that some staff and GPs have expressed concern about the proposals, and it is right and proper for them to do so, you will also be aware that the Steering Group for the strategy has comprised local clinical staff and many of our staff are indeed extremely supportive of the proposals, as evidenced by the clinical input to every public meeting presentation.

Our service models are based on local needs assessment for each of the communities affected, based upon need. It is also important that the PCT takes full account of professional advice about clinical effectiveness, changes in clinical practice and the requirements of national service frameworks and guidance such as "Supporting People with Long Term Conditions". {Department of Health].

I wholeheartedly agree that the discussion needs to move away from that of confrontation to a more informed and constructive debate. This is indeed our earnest desire and indeed our experience, particularly beyond the forum of the large public meeting which is seldom conducive to such a debate. However, as mentioned above, we do accept the need to respond positively to the demand people have expressed for these large public meetings and I would contend that we have put an immense effort into meeting this demand. It would be nice to have that effort acknowledged at some point.

Publication of "Commissioning a Patient Led NHS" may indeed have profound implications. I would be interested to receive your views on how the approach to planning these important services will need to change. Nevertheless, at the present time, the PCT has a responsibility to plan, secure and deliver effective healthcare to our population and this is precisely what we intend to do. Whilst organisations change and policies come and go, it would be irresponsible for the PCT to abdicate its responsibilities in this area and leave it to someone else to sort out.

2 The interests of the health service in the area affected. I am sorry that you feel that issues you have raised previously have yet to be fully addressed. I and my team have gone to considerable lengths to ensure that we do respond fully and appropriately to the points you have raised.

2.1 I can assure you that we are working with Southampton City PCT on their proposals and will discuss with them the points that you raise. The focus of the strategy is indeed on both the New Forest and Test Valley South. The services in Eastleigh north were largely addressed last year through consultation on the reprovision of services from The Mount Hospital. As you correctly infer, more work needs to be done on the planning of services to the southern part of Eastleigh Borough.

2.2 Whilst we provided an outline service model in the consultation, we understand your requirements for more details and we aim to produce a detailed model by the end of August. We have been clear throughout about our desire to provide a 24-hour rapid response community service. We have certainly considered and continue to work on opportunities for re-providing services from acute to community settings.

2.3 We acknowledge that local people want and need access to out-patients and diagnostic services locally and we are currently exploring the options for improving access. Part of this work is, of course, entailed in the development of the clinical strategy for the new Lymington hospital.

2.4 We agree that step-up care, as it is sometimes called, can appropriately be provided in community hospitals, avoiding the need for emergency admission to a general hospital. Some aspects of this type of care are already in place. We welcome discussion about the potential for enhancing this aspect of care provision.

2.5 We note your point about requiring more detailed financial information. This will form part of our service model and indeed the development of the business case over the next few weeks.

2.6 I am not sure on what evidence you base your assertion that the PCT has not taken the needs of communities into account, particularly for Fordingbridge. This is not the case.

2.7 I can assure you that this strategy is aligned with other relevant areas of work. Our approach has been to produce a consultation document that is clear about the scope of the redesign being proposed and sufficiently discrete to enable a focussed and purposeful discussion.

2.8 We consider the recruitment and retention of staff to be one of our greatest priorities as an organisation. I can assure you that District Nurses are not being placed at risk of redundancy and indeed we are looking at how the service can be extended into new roles, further integrated with other aspects of primary care and, in particular, further extended to cover nights and weekends where appropriate.

Finally, I would reassure you that we have taken considerable steps to engage with staff, including:

· team brief

· community services strategy updates

· letters to staff

· all staff and GPs working with older people have been offered one-to- one meetings

· staff groups [eg District Nursing and Practice Managers]

· a workshop held on 11 July open to all community staff working with older people

I trust this addresses all the points you have raised and I thank you for your detailed letter. I would also thank you particularly for your offer of support around our consultation process and I know that colleagues are in discussion with your staff currently about how this may be taken forward.

You raised several points during our meeting on 10 August and I promised to respond.

a) You have heard a rumour that the new Lymington Hospital might become a private treatment centre. I can confirm that Lymington will be providing healthcare to the general public and funded by the NHS. We are currently exploring the best way of managing the hospital, including an option of asking independent sector providers to undertake this role.

b) You suggested there should be a `more systematic check' undertaken than the patient dependency survey referred to in the strategy document. I can confirm that this survey is only one (albeit important) factor we are taking into account, and that more recent analysis (at a detailed level) by Teamwork has reinforced these findings. We also regularly monitor bed occupancy, length of stay and other key information.

c) You observed that considerable sums of money have been raised by private subscription for the community hospitals. We respect this fact and will continue to work with the Leagues of Friends to find a mutually acceptable way forward.

Appendix Eight

Developing a Picture of Older People's Health & Wellbeing

in South West Hampshire

Project Summary

Background

NHS organisations in South West Hampshire are currently - through a series of public meetings - consulting with local people about proposals for the future of community services for older people.

Hampshire County Council has commissioned the Older People's Programme¹ to complement this work by organising and facilitating a series of local participative events in the communities affected by these proposals.

Purpose of this work

Our focus therefore is on drawing together and mapping local information from local people about their health and wellbeing; and the services and resources which contribute to this.

There are two broad aims for this work:

a) To build up a broad picture of health, wellbeing and independence for older people within communities across South West Hampshire;

b) To inform the planning of services for older people by the NHS, considering a wide range of perspectives, experiences and local knowledge from within these communities.

To achieve these aims, we are holding a number of meetings to which we are inviting a range of different people in the New Forest and Test Valley South areas. The purpose of these meetings is for participants to help us to explore how the whole spectrum of public, private and voluntary services in their local communities can best support, and enhance, the wellbeing and independence of older people.

How we plan to do this

There are two stages to this process, each bringing different, invited people together to discuss their communities' health needs and how these could be met.

Stage One

Stage One involves five local meetings - one in each of five different areas in South West Hampshire. These are each planned to last for approximately half a day. A range of local people who are able to reflect a wide variety of views and experiences across their communities are being invited to attend these meetings. Meetings will be conducted using a framework of common headings to undertake the following activities:-

· Exploring the current situation/picture of needs and services

· Capturing local knowledge and experience about local needs, preferences, patterns and populations

· Celebrating what works well

· Identifying what doesn't work well, including what's missing

· Agreeing what should be built upon, promoted and enhanced; including what's possible to develop/create locally

· Understanding the constraints and pressures present in local and wider communities - and how to work with them

· Agreeing the key messages, needs, aspirations, concerns to take to the large workshop in October

· Producing a local community storyboard that can act as a visual record of the meeting, which can be shared and built upon at the October event

· Exploring related, future consultation activities including the most effective and inclusive ways of reaching local communities about the outcome of this alternative process.

These meetings will be organised, facilitated and recorded by staff from the Older People's Programme. The five areas are set out below:-

Meeting 1 Heart of the Forest, covering:

- Brockenhurst & Forest South;

- Bramshaw, Copythorne & North Minstead;

- Lyndhurst;

- Ashurst, Copythorne South & Netley Marsh;

- Boldre & Sway

To be held on the 29^th of September from 3.30 until 7pm

Meeting 2 South Coast, covering:

- Milford

- Buckland

- Lymington Town

- Pennington

- Hordle

- Bashley

- Fernhill

- Milton

- Barton

- Becton

To be held on the 30^th of September 2005 from 10am until 1pm

Meeting 3 Western Forest, covering:

- Downlands & Forest

- Forest North West

- Ringwood North

- Ringwood South

- Ringwood East & Sopley

- Fordingbridge

- Bransgore & Burley

To be held on 3^rd of October from 3.00 to 6.30pm

Meeting 4 Southern Test Valley, covering:

- Nursling & Rownhams

- Chilworth

- Ampfield

- North Baddersley

- Melchet Park & Plaitford

- Braishfield

- Michelmersh

- Mottisfont

- Lockerley

- Sherfield English

- Wellow

- Romsey & Romsey Extra

- Awbridge

To be held on 13^th of October - time to be confirmed

Meeting 5 Waterside area, covering:

- Dibden & Hythe East

- Marchwood

- Hythe West & Langdown

- Butts Ash & Dibden Purlieu

- Furzedown & Hardley

- Fawley, Blackfield & Langley

- Holbury & North Blackfield

- Totton South

- Totton Central

- Totton East

- Totton North

- Totton West

To be held on the 18^th of October from 3.30 until 7pm

Stage Two

A large, one day workshop for all five communities to come together to share their Community Storyboards and focus on future opportunities and priorities for developing community services for older people will be held on Tuesday 25^th October, in Winchester. This event will be hosted by HOSC and facilitated by the Older People's Programme. Participants will also include senior managers from the PCTs, County and District Councils, voluntary organisations, and other organisations who have a cross cutting role or function across the New Forest and Southern Test Valley areas. The day will also be attended by the Director of Better Government for Older People to contribute the national vision of public services and improving older people's lives.

Participants from the five communities will come together at the beginning of this day to share their local information and views - drawing out common themes, issues, concerns and examples of what works well in supporting independence, wellbeing and quality of life for older people. The afternoon sessions will be used to focus on future opportunities and priorities for developing community services for older people.

A report outlining the outcomes from this process, including the detailed Storyboards from each community, will be produced by OPP, and fed into the PCT's decision-making processes for shaping the future of community services for older people.

Appendix Nine

Modernising Community Services

Thank you for your e-mail of 22 July, setting out the PCTs response to the additional questions we raised about the document that the PCT published on 24 June.

The Hampshire Health Overview and Scrutiny Committee has now had an opportunity to consider this document, your reply and the consultation document on community services for older people published by the South West Alliance on the 11 July. I am therefore writing to set out our concerns about the lack of information included in the document, with specific regard to:

· Section 11 engagement and involvement. As presented in the document this is not in keeping with the process described in `Strengthening Accountability'. We will be seeking the views of Eastleigh and Test Valley South Patient and Public Involvement Forum and Eastleigh District Council about the proposal, and will expect to see evidence that other key stakeholders, such as the voluntary sector and carers, have been fully involved in developing the proposal.

· What the changes will mean for the residents of Eastleigh and how the Alliance will be providing community services for this vulnerable population. We are particularly concerned with the suggestion that patients currently attending Moorgreen could be sent to Hythe, or indeed Romsey. This raises a number of issues relating to access and transport that have not been addressed.

· There are no alternative options are presented, nor is there a description of the care that will be provided to patients, beyond a very general reference to community services. The statement that it is up to the Alliance to decide how to provide the additional community services provided is alarming and does not provide us with any reassurance that there has been a thorough assessment of patient needs.

· The reference to patients going to Hythe also seems to be at variance with the consultation on community provision that the Alliance is conducting. We have stressed previously the need for there to be a strategic approach to commissioning services such as this across the health economy but can find no evidence that this approach is being managed by those responsible for commissioning services for older people across the south west cluster.

· The current consultation by the Alliance does not provide any additional information about what services will be provided for this population. The services affected, such as respite, inpatient and outpatient rehabilitation are vital if older people are to be supported to maintain their independence and live at home for as long as possible.

· No financial information has been presented to show that the change suggested is both affordable and sustainable.

· We are not clear that the additional nursing home capacity referred to is in fact present. A number of proposals currently being developed would seem to be making the same assumptions about the availability of the new places that are jointly funded.

· There is no information about the workforce modelling undertaken to ensure that staff could be recruited to the community posts envisaged

In short there was not sufficient information for the Committee to come to a view about the merits or otherwise of the proposal. Our members were particularly disappointed that the approach set out in the `Framework for Assessing Substantial Change', which was published earlier this year, did not appear to have informed the development of the proposal.

I would welcome your thoughts on how the issues outlined above can most constructively be addressed and accept that it may be for the South West Alliance to be taking further action on some points. I will be writing to John Richards separately.

Our members are acutely aware of the budgetary pressures facing the local NHS, and the need for there to be service change and modernisation. It would not however be in the interests of the those who may be affected by these changes for finances to drive this agenda, without regard to the impact this may have on the health and well being of older people living in our area. Effective working arrangements across organisational boundaries are essential if the service improvements suggested are to be delivered and the financial challenges addressed.

I would appreciate any comments you may have by 2 September so that I can advise our members on any additional action that we need to consider.

Appendix Ten

Thank you for your comments outlined in your letter of 1 ^St August 2005. I will attempt to answer your concerns below.

Section II

We have done much public consultation on our Clinical Blueprint and Primary Care Strategy both of which lay out a vision for more care in the community and an increase in the range and number of skills in community services.

Changes for Residents in Eastleigh & Test Valley

As stated previously there are a range of options for the E&TVS population and the Primary Care Trust are currently considering them.

· Inpatient beds at Royal South Hants

· Nursing home beds purchased locally for rehabilitation

· Beds at Hythe or Romsey (dependent on outcome of consultation)

· Intermediate Care and care packages at home

Description of Care

It is difficult to give a description of care as this is a very individual arrangement, but in general it will be more home nursing and care packages, and more hospital avoidance by proactive management of vulnerable patients.

Where admission is required care will follow the patient into hospital and pull the patient out as soon as they are fit therefore shortening length of stay and reducing bed usage.

· I did provide financial information on the cost of running present services and savings to be made.

· The additional nursing home capacity is present at Northlands (101 beds) in addition to the Hampshire Nursing Homes Project.

· The workforce modelling tool is one that has been previously in the area and we are currently working on this.

· Over £1 million pounds was invested in Intermediate Care last year and £400,000 has been put aside for increased investment this financial year.

· We are now working closely with SUHT, the Alliance and our Social Services colleagues to ensure co-ordination of these proposals and have attended meetings jointly where possible.

Appendix Eleven

`Commissioning for a Patient-led NHS': Configuration of Health Services in Hampshire

The proposals outlined in `Commissioning a Patient Led NHS' provide a significant opportunity to review health, community and social care provision across Hampshire and the Isle of Wight. Most importantly it allows for there to be local influence on the configuration of health and social services in order to achieve the greatest improvement for the populations that we serve. We are acutely aware of the challenges you face in addressing the financial deficits that this health economy has generated. We have already indicated our wish for there to be clear and consistent strategic leadership for the NHS in Hampshire and the Isle of Wight. It is of no satisfaction to note that our concerns about `refocusing leadership' have been realised. It is essential that all learn from this experience and move forward. We believe that `Commissioning a patient led NHS' provides this opportunity.

Leaving aside the current local issues, we are also mindful of the significance of the national agenda around the introduction of practice based commissioning (PBC) and payment by results (PbR) as well as the forthcoming White Paper on `Healthcare outside Hospital'. These drivers, when linked with the intention to introduce plurality to community services as PCTs concentrate on commissioning care, need to be carefully worked through to deliver maximum local benefit.

The time constraints for responding to the Department of Health are exceptionally tight and it may be helpful to take this work forward in two stages:

1) Focusing on the right configuration of health service organisations in our area, we would support better organisational alignment between the NHS and Local Government to simplify and concentrate partnership working as well as minimising overheads and bureaucracy, specifically:

· Reconfiguration of PCTs: The need for PCTs to be aligned with Local Authority Social Service Boundaries. We believe there are particular strengths to the notion of a single PCT aligned with us as a County Council. The current arrangements provide coterminosity with other Local Authorities in the area of the SHA and have brought advantages in terms of partnership working and joint arrangements for service provision. The move to the PCT clusters has not brought the benefits originally anticipated by the SHA and to perpetuate this model would be a missed opportunity. We are already progressing well with the arrangements for Local Area Agreements. A single PCT for Hampshire would add momentum to this direction of travel, providing a more consistent strategic context for health and increasing the scope for locally determined service delivery through joint working arrangements. An added benefit would be the increased commissioning leverage that this would bring, addressing a notable weakness in the current structure of the local NHS. As Foundation Hospitals become the norm in the acute sector, and contestability is introduced to community provision, this leverage will become increasingly important.

· Reconfiguration of SHAs: We do not support the proposition of coterminosity between SHAs and local government regional offices. If it is true that `form follows function' we would wish to propose a more radical proposition and suggest that SHAs would not be needed if PCTs were aligned with Local Authority boundaries as suggested above. Given that the Healthcare Commission, working with CSCI, will be undertaking a significant amount of local performance monitoring, and the role of Health Overview and Scrutiny in looking at health and health services, it would make sense for the performance monitoring role envisaged to be undertaken at this level, rather than attempting to create ad hoc intermediate structures that are expedient rather than functional. As PBC develops accountability will be with the communities served. The question of why performance manage the PCTs through another tier then needs to be considered.

If it is determined that SHAs are able to `add value' to the model we are suggesting then from a `health' perspective it is difficult to discern the rationale for linking with Thames Valley; current patient flows would suggest an alignment with Surry Sussex, or indeed Dorset and Wiltshire as being more appropriate. We do not support the suggested link with Thames Valley and would prefer that consideration be given to the Hampshire, Dorset, Wiltshire model.

2) Secondly we would wish to influence and contribute to more focused work with health at a local level. The proposals for a commissioner/provider split has significant implications for us as a County Council, particularly if the intended `plurality' of providers is to be achieved. There is scope for the County Council to look at extending and enhancing provider functions, or establishing new working arrangements with other service providers. Bearing in mind that this is a process that, despite the initial deadlines, will take place over a period of approximately 18 months (or 30 months with regard to changes to PCT provision), this really needs to be seen at the start of an ongoing debate. We believe that early consideration should be given to the following:

· PCB and Service Provision: we need to build on the partnership working that has already been acknowledged as working well in a number of areas. Our work around the local area agreements has shown how, within an overall strategic framework, local issues and priorities for action can be agreed and taken forward. As PbR is rolled out this local sensitivity will be essential if health services are to be commissioned according to need. In other instances it may be that combining some services will allow for better care provision to the communities served. Clearly this is a major issue for the NHS and Local Authorities. A useful starting point could be the development of joint values/principles that would underpin our approach to this aspect of the proposals, as well as our thinking about `Healthcare outside Hospitals'. There is scope for the County to take on the commissioning of some services, such as public health, using the LSPs and districts as the focal points for shaping local action. Equally it could be that the County works with the NHS to combines services to reduce the duplication of functions, the provision of emergency services (i.e. Ambulance and Fire) is one example of a different way of working that could bring benefits to all, the provision of services for older people is another.