Agenda Item 6

HAMPSHIRE COUNTY COUNCIL

Report

1. Summary and Purpose

1.1. This report provides Members with information about the issues brought to the attention of the Committee and the response to these referrals. It sets out the inquiries received, the source of this inquiry and any action taken. Where appropriate comments have been included and copies of briefings or other information attached.

1.2. The approach adopted provides the route through which Local Involvement Networks (LINks) and other partner organisations (Hampshire district councils, NHS organisations, voluntary and independent sector providers and organisations that are representative of social care service users and carers) can raise issues with the Committee.

1.3. Where inquiries raised with the Committee are already subject to monitoring or other performance management activities the action taken will be focused on the local resolution of inquiries through appropriate sign-posting to the agency best placed to respond.

1.4. Where an issue cannot be satisfactorily resolved between the parties concerned then the Committee can consider options for further action.

1.5. New issues raised with the Committee, and those that are subject to on-going reporting are set out in Table One of this report.

1.6. The recommendations included in this report support the Corporate Strategy aim of maximising wellbeing through the overview and scrutiny of health services in the Hampshire County Council area.

Table One: Inquiries Received and Action Taken

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.

Appendix One:

RAPID APPRAISAL REVIEW OF FUTURE INVESTMENTS

ACTIONS TAKEN IN THE LIGHT OF RECENT FUNDING MESSAGES TO THE NHS

1. BACKGROUND

1.1. This paper has been drafted for consideration by the Hampshire Health Overview and Scrutiny Committee in September 2009. The paper details the process that has been pursued to rapidly assess the impact of reduced funding forecasts facing the NHS in Hampshire and sets out the proposals that will be considered by the NHS Hampshire Board at its meeting on 24 September 2009.

1.2. It is proposed that the outcome of the Board's discussion is reported to the HOSC at its meeting on 29 September 2009.

1.3. It is becoming clear that the future funding/growth levels for the NHS are likely to be much reduced from those that were previously anticipated and those that formed the basis of all PCT's strategic plans which were produced in 2008. Funding levels for 2009/10 and 2010/11 were announced last year but there is as yet no view for the levels in the next 1 or 2 spending rounds other than they are likely to be much reduced in line with equivalent approaches for other elements of the public sector.

1.4. Arising from the early receipt of this message (given at the video conference for Chief Executives from the NHS Chief Executive on 20^th May 2009) the Board agreed that we should review all investments and a series of criteria/questions were agreed at the July meeting.

2. RAPID APPRAISAL CRITERIA

2.1. The rapid appraisal process has considered a range of significant planned developments across Hampshire against five key questions, in order to determine whether each should continue unchecked or whether we need to do more work in partnership with local people to ensure we can deliver a sustainable model of care.

2.2. The five key questions, agreed at the July 2009 Board meeting, are re-stated below:

a) Are the revenue consequences of the proposed development financially significant when balanced against a £1.8bn operating budget? [It is proposed that this will be schemes with a recurrent revenue cost of over £500,000 per annum.]

If schemes are over £0.5m, it is proposed that they should be subject to pause and review, unless supported by one of the following criteria.

b) Has the development already commenced? [This can either be the actual construction of capital developments; the employment of staff; or signing of legally binding contracts for service developments.]

If a scheme has already started and there would be significant additional cost or penalty incurred without benefit as a consequence of pausing, it should continue.

c) If the scheme does not progress would it rapidly result in greater cost being incurred by the NHS in order to accommodate services or clients in alternative accommodation?

If the scheme can be demonstrated as being the most cost-effective solution for supporting services or clients, with the consequence of pausing being greater unavoidable cost, it should progress.

d) Does a critical decision need to be made on the development within the next 12 months? [This will include approval of final business case or stage 2 submission for capital developments; or the tendering of services for service schemes.]

If planning for the scheme can be delayed without incurring cost as a consequence of the delay, then a review should take place.

e) Is the development of the scheme a national requirement?

If the scheme is being supported by national ring-fenced capital or revenue that cannot be deployed for alternative use; or it is a requirement of a regulator or national policy, it should progress.

3. FUTURE FUNDING INTENTIONS

3.1. The Operating Plan investment and funding assumptions for the next three years are tabulated below:

3.2. The Executive Committee has reviewed the plans for the commitment of resources within the financial plans of the PCT and has come to the identified conclusions:

3.3. The following programmes are nationally-funded but require us to pick up costs in future years and therefore need to be reviewed now:

4. IMPACT

4.1. The net impact is that we propose to reconsider the following:

· Oak Park - the South East capacity map review and the review of use of current local facilities means this will not meet the Value for Money and affordability challenge in the business case for investment (see Appendix A for more detail on the appraisal process for Oak Park Community Hospital).

· Vascular screening - the current model does not appear to be cost effective and this could be a great opportunity to provide an innovative technological solution.

· IAPT - although this is nationally funded there is no clinical evidence of this being effective and it would not be the priority for the mental health clinical lead (ref Stuart Ward).

4.2. We propose to review in detail the following schemes with a view to reducing the net investment required. If a business case cannot be made that improves quality, outcomes and value for money then we will not proceed.

· Stroke - Alex Berry/David Balfour

· End of Life Care - Alex Berry

· NICE guidance - based on evidence of clinical and cost effectiveness - Christine Jackson

· Obesity interventions - based on evidence collected by the pilots - Christine Jackson

· Estates - depreciation impact - Inger Hebden

· IM&T - business cases to demonstrate benefit - Jenny Nash

4.3. We propose to continue with the following programmes as per our plan:

· Dental

· Bowel Screening

· Campus re-provision

· Chlamydia screening

· Breast screening

· Cervical screening

· Children's services

5. CONCLUSION

5.1. The NHS Hampshire Board has been is asked to:

· note the conclusions of the rapid appraisal review of future investments

· confirm the proposed position for the individual service developments, as set out above

5.2. The outcome of the Board's considerations will be reported to the HOSC at its meeting.

Appendix A

DELIVERING HEALTH SERVICES FOR THE

POPULATION OF HAVANT AND SOUTH EAST HAMPSHIRE

24 September 2009

1. INTRODUCTION

1.1 This paper sets out the reasons for the review of Oak Park Community Hospital (OPCH) plans, background to the project, information on the original plan, process and outcome of the review, conclusions and recommendations for taking plans forward to meet the needs of residents in the Havant and parts of East Hampshire area.

2. RAPID REVIEW OF OAK PARK COMMUNITY HOSPITAL PLANS

2.1 NHS Hampshire (part of Hampshire Primary Care Trust), as with every large organisation is affected by the global economic crisis and must formulate robust plans to mitigate any adverse impact on its service delivery. NHS Hampshire has undertaken a review of all current developments to test affordability and ensure best value for money in the light of this significantly changed financial environment.

2.2 With the above in mind a rapid appraisal process was undertaken on all current developments by NHS Hampshire. All work on the OPCH development has been suspended pending this process.

2.3 NHS Hampshire, together with other NHS organisations in the South East Hampshire area, has been modelling the impact of new facilities on budgets for a number of years. We have been working on the basis that facilities are affordable to the local health economy on the basis of best, realistic and worst case funding scenarios.

2.4 It became clear at the end of May, that future funding growth levels would be lower than anticipated. At that time, the project was entering a stage where legal and financial advisors would be instructed by both the local NHS and the building supply chain. The PCT recognised that plans could change as funding is likely to be much reduced in line with equivalent approaches for other elements of the public sector and decided to suspend all work on the new hospital in order to minimise costs. An estimated cost of £800k in fees would have been spent in June and July if this decision had not been taken quickly.

2.5 The PCT Board agreed that we should review all investments and a series of criteria/questions were agreed at the July meeting. This confirmed that plans for OPCH would be reviewed.

2.6 This paper is reviewing the estates solution that has been proposed for the provision of services in Havant and South East Hampshire. This review does not seek to challenge the need to provide these services but rather seeks to explore whether there are feasible, more affordable alternatives to providing the new building.

3. BACKGROUND

Population Needs

3.1 The catchment population for OPCH includes all of the Borough of Havant, and elements of East Hampshire District and Winchester City Councils. Population projections to 2026 show an increase of between 2-3% for Havant Borough and less than 1% for East Hampshire. The Winchester City Council area includes significant new housing development in a major development area, West of Waterlooville. When completed, this could result in an additional 7- 8000 residents in the West of Waterlooville.

3.2 Overall the catchment population for the area is currently 171,000 and is projected to rise by 9,000 to 180,000 in 2026. This would lead to a need for additional primary care in the area and plans are already in place to provide additional GP surgery capacity in the West of Waterlooville and Cowplain to meet this need.

3.3 There are areas of deprivation in Havant which are amongst the most deprived in Hampshire and within the worst 20% nationally, as shown by the 2007 Indices of Deprivation.

Key Strategies and Drivers for Change

3.4 A number of key strategies and documents need to be considered when reviewing potential solutions for Havant and SE Hampshire:

· SE Hampshire Capacity Plan

· Strategic Services Development Plan (SSDP)

· Estate Strategy

· Healthy Horizons

· Drivers for Change

The Capacity Map

3.5 The proposed configuration of services which led to the design of a new hospital for Havant was developed through the `capacity mapping' exercise. This exercise was undertaken in 2005-2006 by the three local PCTs (2 of which are now merged into NHS Hampshire) and Portsmouth Hospitals Trust.

3.6 The Capacity Map was approved by the PCT Board in April 2006 and noted by the Strategic Health Authority Board in May 2006. The review was based on a detailed clinical analysis and took account of clinical pathways, changes in technology, lengths of stay, and the effect of the development of enhanced community rehabilitation teams.

3.7 The Capacity Map, and the infrastructure framework defined in it, also reflected the vision for new generation community hospitals in the White Paper, Our Health, Our Care, Our Say.

3.8 The Capacity Plans were reviewed in June 2008. This review confirmed the number of beds and theatres required for SE Hampshire and confirmed support for community hospital development. It demonstrated that there would be sufficient acute beds at Queen Alexandra Hospital (QAH) and a small surplus of beds in paediatrics, maternity and across other areas.

3.9 A key element of the Capacity Map is the new acute QAH (opened 15^th June 2009). The interdependence between the QAH and the planned community hospitals underpinned much of the proposed provision for Havant through a model of care designed to prevent admissions and visits to the acute facilities. This is to be achieved by offering comprehensive assessment facilities, supported with care packages in the community, either following a short period of assessment as a community hospital inpatient, or following assessment on a day or outpatient basis.

3.10 The capacity map assumed that 30% of outpatients would be provided in community settings.

Strategic Services Development Plan (SSDP)

3.11 A Community Hospital in Havant was a component of the first SSDP where it was included as a potential Tranche 1 scheme. The second SSDP re-affirmed the requirement for a community hospital in Havant and was approved by the PCT Board in April 2006.

3.12 The latest SSDP also includes OPCH, however the main focus of this revision is on potential future schemes beyond those currently under development.

Estate Strategy

3.13 HPCT updated its Estate Strategy in March 2009. This strategy summarised the plans for the Trusts estate over the next 5 years. OPCH was included within this planning and the proposed development meets many of the objectives of the strategy:

· Supports the framework for development of community facilities

· Improves patient healthcare experience

· Improves patient access to services

· Ensures estate is high quality and fit for purpose

· Improves functionality of estate

· The rationalisation of the estate

· The elimination of backlog maintenance

· In addition, it provides a carbon efficient building

Healthy Horizons

3.14 In November 2008 HPCT published Healthy Horizons, this document considered the challenges that HPCT will face in the coming years and outlined its proposals for dealing with these. The challenges identified were:

· Dealing with the effects of an ageing population

· Helping people make healthier lifestyle choices and reducing health inequalities across Hampshire

· Improving the pathway of care for patients

· Making more efficient use of resources

· Improving quality, focusing effort on the three key areas of patient safety, patient experience and clinical outcomes.

· Improving the way we engage with patients and the public

· Developing stronger partnerships

3.15 Any proposed estates solution will need to take account of the above documents to ensure that a coordinated approach is being taken to the development

3.16 These documents are available on the NHS Hampshire website.

Drivers for Change

3.17 The drivers for change for the reconfiguration of services have remained broadly unchanged for a number of years, these are:

· Drive to co-locate services - `one-stop shop'

· Provision of care close to home

· The freeing up of space in existing primary Care facilities

· To tackle existing health inequalities

· To improve the condition of existing accommodation

· To ensure that the clinical functionality of existing accommodation is of a high standard

· To provide care accessible to patients

· To allow new models of care to be implemented

· To rationalise the Trust estate;

o to make best use of existing estate

o to close Havant War Memorial Hospital (HWMH) and Emsworth Victoria Cottage Hospital (EVCH)

o to replace Havant Health Centre (HHC) in 9 years time (end of useful life)

· National policy :

o Our Health, Our Care, Our Say' a New Direction for Community Services'.

o `Our Health, our care, our community'.

o `Our NHS our future'

4. THE PLAN FOR OAK PARK COMMUNITY HOSPITAL

4.1 Local health service plans have envisaged a community hospital in Havant since the late 1980s as part of a network of community hospitals across SE Hampshire, complementary to and supporting the provision of acute services based at the redeveloped QAH.

4.2 The OPCH development is intended to facilitate the development of local services, in modern, fit for purpose facilities and to rationalise the existing hospital provision in Havant and East Hampshire. The hospital would accommodate existing services from sites in Havant and Emsworth and in addition, a broad range of outpatient services would be relocated from Portsmouth Hospitals as well as Older People's Mental Health inpatient services from St. James Hospital (SJH), Portsmouth. The hospital is planned to treat an estimated 25,000 outpatients each year.

4.3 The hospital would replace old accommodation at EVCH and HWMH, both of which would then close, and also release space at St James Hospital, in Portsmouth and Havant Health Centre.

4.4 The key objective for Havant services is to bring together a range of healthcare professionals from a range of existing acute and community sites, and also primary care staff located across South East Hampshire, to support and enhance the delivery of care services. The development of these services would:

· Improve patient access to a high standard of health care close to their homes

· Provide rapid access to diagnosis with a one-stop consultation and diagnostic service

· Provide a pleasing environment for patients, visitors and staff

· Enhance the integration of acute and community services to promote greater coordination and continuity of care with multi-professional clinics and assessments

· Provide opportunity for greater integration in the future

· Improve and allow seamless referrals between departments

4.5 The following clinical services are included in the plans:

· 25 Inpatient Beds - intermediate care

· Therapies Unit - clinical outpatient area covering physiotherapy, speech and language therapy and occupational therapy

· Minor Injuries Service - transfer from HWMH

· Outpatient Service

· Diagnostics (film X-ray, ECHO and ultrasound)

· Assessment, Treatment and Rehabilitation Centre (ATRC)

· 24 Older Persons Mental Health Beds

· Podiatry

· Endoscopy

· External hard standing for a mobile diagnostic imaging facility

4.6 Planning approval was granted for OPCH, after lengthy pre and post application discussions with Havant Borough Council and Hampshire County Council, and has involved significant input from clinical staff working in the area. Construction was due to commence in 2009 with completion and opening of the new hospital 2 years later (2011).

5. RAPID REVIEW PROCESS

5.1 NHS Hampshire's response to the challenge set by the financial outlook is underway and includes:

· ensuring that every possible efficiency and cost control is exercised in back office and procurement functions;

· redesigning pathways of care to deliver quality improvement and increased sustainability;

· working with local people to determine the priorities for future service provision;

· determining which treatments or services may be of a lower priority

5.2 With the above in mind NHS Hampshire Board (in their July Board meeting) have initiated a rapid appraisal process for each of its significant investment proposals across the entire organisation and taken steps to ensure that these do not incur unnecessary development costs and are still viable given revised income and expenditure projections.

5.3 The rapid appraisal process considered five key questions in order to determine which developments should continue unchecked and which should be subject to additional assessment (in partnership with stakeholders) to ensure that only financially sustainable developments are taken forwards.

5.4 The five key questions asked by the Trust Board were:

a. Are the revenue consequences of the proposed development financially significant when balanced against a £1.8bn operating budget? (Schemes with a recurrent revenue cost of over £500,000 per annum)

b. Has the development already commenced? (The actual construction phase; the employment of staff; or signing of legally binding contracts for service developments)

c. If the scheme does not progress would it rapidly result in greater cost being incurred by the NHS in order to accommodate services or clients in alternative accommodation?

d. Does a critical decision need to be made on the development within the next 12 months? (Including approval of final business case or stage 2 submissions for capital developments; or the tendering of services for service schemes).

e. Is the development of the scheme a national requirement? (Supported by national ring-fenced capital or revenue that cannot be deployed for alternative use; or it is a requirement of a regulator or national policy, it should progress).

5.5 The proposed OPCH was assessed against the above criteria and put on hold as it has recurrent revenue costs of over £500K and has yet to commence construction.

Work undertaken so far

5.6 As part of the OPCH review a number of work streams and structures have been put in place:

· A reporting structure has been put in place to drive and resolve the review; a pan NHS Steering Group has been set up: The Oak Park Review Steering Group

· Key stakeholder involvement has commenced including informal discussions and two workshops held in September

· Negotiations to optimise the existing OPCH solution took place

· The review of alternative estate options including a high level cost review has begun

Reporting Structure

5.7 To ensure clear and effective governance a reporting structure has been put in place to monitor and manage the review process of the Oak Park project as well as those other developments placed on hold. The Oak Park Review Steering Group ultimately reports to the Whole System Programme Board and PCT Board.

Input from Key Stakeholders

5.8 NHS Hampshire has been keen to explore all potential solutions and to keep key stakeholders fully informed and involved with the review process.

Informal discussions

5.9 Discussions have taken place with key stakeholders including the South East Hampshire Strategic Partnering Board, local Councillors and clinical leaders.

5.10 The key messages coming out of this are:

· Local residents are extremely disappointed that the hospital plans have been put on hold and may not come to fruition;

· Concern that Havant residents may not be able access services locally when they have a high level of need compared to other parts of Hampshire;

· A quick decision is required on whether the hospital is affordable or not, we want to know one way or another;

· Emsworth residents are concerned that beds were closed in Emsworth and are now provided in Havant and this was predicated on the future plans for a new hospital in Havant;

· If the hospital is not provided, the current providers of in-patient care would need time to review the service model across the South East. This includes both older people's mental health and intermediate care in-patient services;

· The Havant Civic Village development may offer opportunities for co-location of services, clinical administration in particular, as it includes Hampshire County Council and the voluntary sector staff;

· If, as part of the solution, Oak Park Children's Centre is used to provide more services, the needs of children and staff who work with children are included in the plans;

· Havant Health Centre needs to be replaced in 9 years time and land should be retained by the PCT at the Oak Park site for this purpose

Workshop

5.11 To ensure that the key stakeholders could be involved at any early stage, stakeholder workshops were held on the 3^rd of September. The workshops facilitated the following:

· To bring key stakeholders up to date with the position regarding the Oak Park Community Hospital review

· To enable them to share ideas for alternative solutions for the delivery of these services

· To set criteria for evaluating feasible options

5.12 The workshop participants included a broad cross-section of local interested parties. In total 93 people from a number of interested organisations were invited. Of the 93 invitees, 59 representatives attended.

5.13 The workshop consisted of a presentation by the NHS Hampshire Director of Capital Planning, the distribution of information packs and a facilitated `café' style discussion in which participants were asked to consider how and where the services could be delivered, facilitated by the Head of Service Redesign.

5.14 A range of suggestions for future service delivery were identified by the participants.

5.15 In order to ensure that the option appraisal reflected the issues and concerns of the stakeholders, participants were asked to develop generic and service specific criteria against which the various options would be scored. The stakeholders were asked to denote which criteria they felt were the most important, the criteria have been weighted accordingly to ensure that the criteria that the stakeholders felt was of the most importance is given the greatest priority.

5.16 The NHS Hampshire Team carefully considered the long list and distilled this into feasible options which reflect the ideas generated by the stakeholders. These options were added to the original plan for a new hospital and a `do-minimum' which is required as a baseline to score all the other options.

5.17 These options were discussed with the Oak Park Review Steering Group and PCT Executive Team. It was agreed that there are feasible options for providing the services that are needed, that would be more affordable than the plans for a new hospital.

Petitions

5.18 Following the suspension of work on OPCH, whilst the review was being carried out, a number of petitions were signed by local residents. These were presented to NHS Hampshire Chief Executive at the Cabinet Meeting of the Havant Borough Council on 9^th September 2009. 2852 signatures were received as follows:

Negotiations on Oak Park Community Hospital costs

5.19 Negotiations to optimise the existing OPCH solution took place and reductions in the costs of the original scheme have been secured. This reduced the affordability gap to circa £3m per year.

Review of alternative estate options

5.20 A detailed review of space utilisation was undertaken at Oak Park Children's Centre. This illustrated that there is spare clinical capacity. In addition, clinical administration space could be minimised, at the centre and at Havant Health Centre, by moving administration services to nearby offices. This would free up space to provide the ambulatory services (out-patients, diagnostics, assessment, treatment & rehabilitation) originally planned for the new hospital.

5.21 This would not accommodate in-patient services and various options were suggested to re-provide these services but more work would be required on this. The project team and providers of these services will need sufficient time to review the model of care with patients and staff, before recommending option(s).

6. CONCLUSION

6.1 The main driver for a review of the new hospital is the change in the economic climate. The review of plans for a new hospital at the Oak Park site in Havant has been undertaken rapidly and included key stakeholder involvement at an event on 3^rd September 2009. This highlights concerns about future service provision in the Havant area.

6.2 The review process has led to renewed discussions across the health system, about the potential to provide services in the Havant locality, for Havant and East Hampshire residents. The workshops generated a number of positive ideas and these will be explored with the local community. There are feasible options that could provide services for local residents, more affordably than the original plans for a new hospital. This would also lead to better utilisation of existing space in NHS facilities in Havant.

6.3 The costs for the new hospital building have been reduced by the supply chain; however the affordability gap of approximately £3m per year for 25 years still remains. The £3m gap, when combined with the savings which will have to be made to fund the increasing health needs of our population, means that the Oak Park Community Hospital plan is unaffordable.

6.4 The speed of the review necessitates further development of the alternative options for the future and this will provide an opportunity for wider involvement of staff, patients and local residents in shaping plans to meet patient's needs.

6.5 There are different options available for the ambulatory care service elements, which could be provided in Havant more quickly than the hospital would have been delivered, but options around the provision of part or whole of the previously planned in-patient services will take longer to develop. The two different elements could be divided into separate projects so that they are progressed as quickly as possible. This could result in faster improvements to services in Havant than if they remain as a single project. There are also opportunities to co-locate services in Havant Health Centre, Oak Park Children's Centre and with partners e.g. Havant Civic Village.

6.6 In order to progress any of the options, there needs to be commitment from all the participating organisations and whole system's leadership. This system is in place.

7. RECOMMENDATIONS

7.1 The NHS Hampshire Board is to be asked at its meeting on 24 September 2009 to approve the

following recommendations:

· The plans for the previously anticipated new hospital should be discontinued;

· A new programme to be commenced, led by the PCT and involving key local stakeholders, to assess the provision of health services for Havant and East Hampshire residents;

· The project should be divided into two separate work streams: ambulatory care services and in-patient services, so that they can proceed as quickly as possible. This will ensure that services which can be delivered easily are not delayed unnecessarily;

· Existing facilities, which are in good condition, should be fully utilised for providing clinical services;

· Clinical administration to be re-provided, as far as possible, in dedicated offices in Havant in order to maximise any existing clinical space for patients;

· Continue to work across whole system in SE Hampshire to gain commitment to a solution that meets the needs of local residents and provides best value for the local NHS

7.2 A report of the outcome of the Board meeting will be presented to the Health Overview and

Scrutiny Committee at its meeting in September 2009.

Appendix Two

Appendix Three: Briefing Paper regarding the Minor Injury Unit at Havant War Memorial Hospital

1. Introduction

1.1 This paper provides an update on the Minor Injuries service at Havant War Memorial Hospital (HWMH).

1.2 The strategy in South East Hampshire has been to take a whole systems approach to planning for health services. This has led to a hub and spoke model with Queen Alexandra Hospital (QAH) being the hub and the community hospitals the spokes, supported by health centres and GP surgeries. For maternity services, the main unit is at QAH together with a co-located nurse led birth centre and stand alone nurse led birth centres in Petersfield and Gosport. Minor Injury Units (MIU) have followed a similar configuration with the main Accident & Emergency (A&E) unit being provided at QAH, Cosham, plus additional MIU's at Gosport War Memorial Hospital (GWMH) and at Petersfield Community Hospital (PCH).

2. Minor Injury Unit, Havant War Memorial Hospital - pre-closure

2.1 Pre-Closure Position

2.2 Until December 2008, a small nurse led MIU service operated at Havant War Memorial Hospital: Monday - Friday, 8 am - 8 pm. The hospital is situated in a residential area with no direct public transport links. The room that was used to treat patients, is located in the middle of the inpatient area. The MIU has no dedicated staff and the service was provided by nursing staff working on the inpatient ward. In addition, there was no dedicated medical cover. Medical advice/support was provided, on an ad hoc basis, by local GPs with responsibility for the inpatients. Patients would either report to reception or ring the door bell out of hours. A nurse would then leave the inpatient ward and take the patient to the treatment room for assessment/treatment. There are no diagnostic facilities available at the hospital. The following conditions could be treated:

· cuts and grazes

· sprains and strains

· bites and stings

· infected wounds

· minor eye infections

· minor burns

2.3 Historically activity has been extremely low with approximately 100 attendances per year. Prior to December 2008, the service had already been subject to intermittent closures due to issues relating to staffing levels or when there was a viral or D&V outbreak on the inpatient ward. Any patient presenting with a condition not listed above or requiring more major intervention would be redirected to the Treatment Centre at St. Mary's Hospital or the A&E Department at QAH.

3. Current Position

3.1 The MIU at HWMH closed in the first instance because of staff vacancies and staff sickness. Subsequently an internal review was instigated. This review identified staffing levels, staff competencies, the absence of medical cover, lack of diagnostics, the physical environment, location of the hospital and the management of children, as key areas of concern.

3.2 The MIU has now been closed since December 2008 and remains closed for the above reasons. Since the MIU was closed there have been no patients presenting at the hospital wanting or needing treatment for a minor injury.

4. Staff Competency

4.1 There are currently no national agreed standards or benchmarks for minor injury nurses but guidance from the DoH Reforming Emergency and Unscheduled Care (2007) and the GMS contract Guidance on Minor Injury Services (2004) was applied when reviewing the service at HWMH.

4.2 All nurses in MIU should be qualified, trained and competent, in line with their professional accountability, through the Nursing and Midwifery Council and their Scope of Professional Practice (2004). National guidance states that patients should receive triage by an appropriately trained individual on arrival at MIU. There are currently no dedicated or suitably qualified nurses at HWMH available during the opening hours of the MIU. Any of the current nursing staff undertaking this role would be in breach of their Scope of Professional Practice.

4.3 An autonomous nurse practitioner should be available at all times during the unit's opening hours. In order to attend to patients with a minor injury presenting at HWMH, staff would need to leave their inpatients without sufficient care.

4.4 HWMH primarily provides a `step-down' in-patient service for patients who have been transferred from secondary care and this is the main focus for nurses currently working at HWMH. The nursing skills and knowledge needed for this level of care are very different to that required by patients attending with a minor injury. Nurses on the ward do not have the appropriate skills to undertake the following, all of which are needed to safely run an MIU:

· venepuncture

· IV drug administration

· advanced life support

· a full medical history and relevant clinical examination

· documentation in accordance with NMC recording keeping guidance

· treatment of an injury using evidence based techniques

· referral to another agency and follow up where necessary

· assess/treat children

4.5 Staff should be regularly using their skills and knowledge to maintain their competency, but due to the small numbers of patients presenting at the MIU, these are not maintainable.

5. Medical Cover

5.1 There is no dedicated medical cover for the MIU available at HWMH. If medical input is required the patient is redirected to either their own GP, the Treatment Centre at St. Mary's Hospital or to the A&E Department at QAH.

6. Location

6.1 HWMH is isolated in the middle of a residential area which is not easily accessible to the public.

6.2 The clinical area, used to assess/treat patients attending the MIU, is not compliant with current health and safety regulations or Infection Control Guidance (2005). In addition, the clinical area does not comply with Essence of Care (2004) resulting in the privacy and dignity of inpatients being compromised.

7. Diagnostics

7.1 Access to diagnostics, with suitably trained staff to request and interpret x-rays is required in MIU's, to enable patients to be treated promptly and appropriately. This is not available at HWMH and therefore means a delay in the patient obtaining treatment.

8. Children

8.1 In accordance with recommendations from the Royal College of Paediatrics and Child Health, Children's Attendance at a Minor Injury/Illness Service, February 2002, an MIU that sees children should be integrally linked to the main A&E Department and the secondary care provider for paediatrics, in order to maintain staff competencies and working practices. Staff should be appropriately skilled to manage illness/injury in children. There should be a separate area within the MIU dedicated to the assessment/treatment of children. Staff should be skilled in child protection procedures in accordance with the Health Care Commission Standard C2. The current staff at HWMH do not have these skills.

8.2 In July 2009, services for children transferred from St. Mary's Hospital, Portsmouth to QAH in Cosham. QAH provides a designated paediatric area, staffed by appropriately skilled nurses.

9. Internal Review Conclusion

9.1 The review concluded that the issues of medical cover, diagnostic facilities, staff competencies, the inappropriate environment and risk to inpatient privacy and dignity could not be addressed without major investment. In addition, the low number of patients presenting at the MIU means that, even if staff were to be appropriately skilled, they would be unable to maintain the necessary clinical skills required to ensure the service is safe and of a high quality. To enable existing staff to be skilled to the level required in a MIU would take a minimum of one year.

10. Other Minor Injury Services in the Area

10.1 St. Mary's Hospital, Portsmouth

10.2 A nurse led walk in treatment centre open 8 am - 10 pm, 7 days a week. Specifically trained nurses able to treat minor injuries and illness i.e. cuts, bruises, strains and sprains, stomach upsets, coughs and colds.

10.3 Petersfield Community Hospital

10.4 A nurse led MIU open 8 am - 8 pm, 7 days a week. Medical cover is provided by a Duty Doctor and the OOH Service. Treatment is available for cuts/grazes, sprains, broken bones/fractures, bites/stings, infected wounds, minor head injuries and eye infections. Access to diagnostics is available Monday - Friday, 9 - 12.30 pm. There is a separate area for children. Staff have the appropriate skills and competency to provide the service. Approximately 8,400 patients seen per year.

10.5 Gosport War Memorial Hospital

10.6 The MIU is a nurse led satellite unit of the main A&E Department at QAH staffed by Emergency Nurse Practitioners. It is open 8 am - 9 pm, 7 days week. Staff rotate between the emergency department at QAH and the MIU thereby maintaining professional competency and development. Dedicated medical cover is provided by telephone access to the main emergency department at QAH. Diagnostics are available on site and staff have referral rights to speciality clinics at QAH. Both adults and children are seen. Treatment available for minor injuries to foot, ankle, knee and hip, hand wrist, elbow and shoulder; minor head injuries, minor eye injuries and complaints, lacerations, minor burns, bites/stings, wound infections. There is a separate area for children. The unit is staffed to see 20,000 patients per year.

10.7 Queen Alexandra Hospital

10.8 The main A&E department treats all major and minor injuries and operates a 24 hour service. Patients are seen by both medical and nursing staff who are Emergency Nurse Practitioners and experienced A&E nurses. Approximately 110,000 patients are seen per year and minor injuries accounts for approximately 75% of this.

11. Primary Care

11.1 GPs in Havant provide a primary care level response to anyone having an accident or emergency in their area. This would include assessment, advice, simple dressings or onward referral if required. The OOH Service provides assessment/advice and management of minor injuries via the normal telephone route.

12. Community Pharmacists

12.1 Pharmacists are qualified experts who can give confidential advice on common minor illnesses like coughs and colds, headaches, skin complaints, stomach upsets or cystitis, as well as advice on prescribed medication and over the counter medicines and emergency contraception.

13. Dental Services

13.1 Urgent dental advice/treatment is provided by a patient's own dentist. For those patients not registered with a dentist then the Dental Helpline Service can access services. The Dental Helpline Service is available 7 days a week, 8.30am - 9.30 pm by calling 0845 050 8345.

14. NHS Direct

14.1 NHS Direct provides expert health advice and information via qualified nurses. The service is available 24 hours a day, 365 days a year, online at www.nhsdirect.nhs.uk by using the self help guide or sending an enquiry and on the telephone by calling 0845 4647.

Appendix Four:

Appendix Five: Draft response to HCC Health and Well Being Strategy

`Healthier Hampshire': HOSC response to consultation

Thank you for providing us with the opportunity to comment on the Health and Wellbeing Strategy. Overall the document was clear, easy to read and refreshingly short. We would endorse the importance of the need to work with partners to deliver the areas of focus outlined. It is important to recognise however that there must be engagement with the communities that are being targeted, whether this be geographic (e.g. Gosport) or thematic (e.g. older people). It was not clear from the strategy how the involvement of these populations would be achieved.

In terms of the specific areas of focus the importance of independence for all is clear, however there may be a benefit in acknowledging that public sector services have a duty to the most vulnerable in our society. Although you make reference to some groups, such as older people, it is important to recognise the needs of a range of vulnerable groups, such as children with special needs. Our work in this area is suggesting that not all partners are prioritising the needs of these populations in the same way. It may also be useful to draw out those areas, such as care at the end of life, where interagency collaboration is essential if the needs of patients and their carers are to be met, particularly with regard to the interface between health and social services. Although great strides have been made in building stronger working relationships across sectors we are aware that some issues, such as access to funding for continuing care remain an issue for some. The ambitions set out in the Hampshire Sustainable Community Strategy do include this commitment and this needs to be fully reflected in the areas of focus.

Clarity about responsibility for delivering the strategy is key and we welcome the role of the Partnership Board in this respect. It would be useful to look at how the work and targets set by the Board complement other indicators of performance, such as the LAA targets. We are also mindful that the public sector is facing significant financial challenges over the next 12- 36 months. Although the aspirations in the strategy are right in theory, tighter financial constraints could skew service delivery away from communities and into acute service settings. How would the Board intend to address this tendency to ensure that the strategy is carried forward in the difficult times ahead?

Our final point relates to the way in which the Board would intend satisfying members and the public that the strategy is being delivered and making a difference to the people of Hampshire. Reporting back to elected members is particularly important, whether that be by locality, District or through Hampshire wide forums, such as the HOSC.

I do hope you find our comments helpful. Please do contact me should you require any additional clarification of the points we have made.