Governing Body Report

Transcription

1 Governing Body Report Date 28 April 2016 Report title Author(s) Report purpose (for consultation, approval and information) Executive Summary Key Recommendations and Actions Requested Which other committees has this been to? Corporate Impact Assessment What, if any, are the financial implications? What, if any, are the QIPP implications? What, if any, are the legal implications? Reconfiguration of Community Services Simon Tapley, Ray Chalmers Approval This paper sets out the current position in relation to the proposed reconfiguration of community services; highlights a number of matters for consideration and sets out the consultation timetable That the Governing Body notes the content of the report, considers the issues highlighted and decides whether to proceed, subject to NHS England, to consultation stage Community Services Transformation Group Yes Yes Yes Quality and Equality Impact Assessment Are there any Quality or Equalities (including inequalities) implications of this report? (Please specify) Yes Have you carried out an initial Quality and Equality Impact Assessment (Y/N) and is it attached? (Y/N) yes If not, why not? Report September

2 Reconfiguration of Community Services Background Governing Body has been updated regularly on the progress of the engagement process via Clinical Services Transformation Group and directly. Our focus has been to find a sustainable way to deliver responsive, quality health and social care; to provide services closer to or in people s homes; to avoid unnecessary hospital admission; to ensure the availability of intermediate care; and above all to develop a clinically and financially viable model that meets the current and future needs of our population. The work done by the CCG since the major 2013 engagement and as summarised below means that the proposals set out in this document meet the four government tests for service reconfiguration: Strong public and patient engagement. Consistency with current and prospective need for patient choice. Clear, clinical evidence base. Support for proposals from commissioners. Subject to Governing Body agreement, NHS England will determine whether the proposals can go to consultation. Why change? The CCG and the health and social care community generally is under immense financial pressure. In addition to the rising cost of some treatments, the CCG has been advised that it currently receives more money than the national funding formula judges it should. We therefore need to manage our budgets to bring ourselves back into alignment. In reconfiguring services, we need therefore not only to take account of quality and safety issues but also the need to improve value for money and contribute to this funding gap by finding different and more effective ways of meeting the needs of our population. We also need to meet the increasing demand for specialist services, be able to look after an increasing number of older people as well as more people with several long term conditions, Given the pressures facing the health and social care community, change is inevitable and maintaining the status quo is not an option. In changing services, additional factors we need to take into account are the: Requirements of the national NHS Five Year Forward view and the NHS mandate Different needs of our rural and urban communities National safe staffing levels Desirability of closer joint working of health and social care as well as the voluntary sector Importance of aligning physical and mental health services Increasing effectiveness of preventative and self care approaches 1

3 Pressure on acute beds hospital beds and desire to improve community based out of hospital services Pressure on Accident and Emergency and the subsequent need for more effective minor injuries units Proposed Model of care The diagram below illustrates the model of care which has been the basis of recent engagement and which is proposed to form the basis of public consultation. It sees GPs, community health and social care teams and the voluntary sector working together to provide for the vast majority of people s health and wellbeing needs in each of the localities that make up the CCG and Trust population. To deliver this model of care, resources will be switched from bed based to community based care. Investment of 3.9m will be made in community services. Details are contained in the draft consultation document (appendix 1) and include the four key elements to delivering this care model locally locality clinical hubs, including community hospital beds and minor injuries units; local health and wellbeing centres; health and wellbeing teams and intermediate care provision. Clinical hubs: these are centres which will provide people with access to a range of medical, clinical and specialist services, within their local community. They will offer services such as outpatient appointments and specialist conditions clinics. Patients who currently access these specialist outpatient clinics travel from a wider geographical footprint to access them. They are mainly consultant led. These clinics are lower volume, which means they are attended by fewer people (less than 1000 attendances 2

4 a year). Some non-consultant led clinics such as audiology require more specialist facilities or equipment. Health and wellbeing centres: these are the locations from where a range of health and wellbeing services, provided by a number of organisations and agencies, are brought together. This will provide easy access in one place to a number of services which support the health and wellbeing of local people. Local Health and Wellbeing Teams will use these centres as a base from which to deliver services to the community. Within these centres, community clinics will be run. These would be attended by a higher volume of people (more than 1000 attendances a year) and which are mainly provided by professionals who are based locally and work across community sites. Health and wellbeing teams: these are made up of a number of organisations and agencies, working together to provide care and support services which meet a wide range of health and wellbeing needs of local people. This includes not just NHS and public services but also independent and voluntary sector providers. This team will oversee arrangements for intermediate care which is a range of integrated services, provided for a limited period of time, to people who need extra support and care following a period of ill-health. They are designed to help people recover more quickly following illness or injury, maximising their independence and resuming normal activities as soon as possible. They also support more timely discharge from hospital following an inpatient stay, and help to avoid unnecessary hospital admissions. Intermediate care services support people in their local communities, either at home or in another care setting. The model also includes a central co-ordinating point for information and signposting of local services so as to improve access to care. Proposed consultation changes In summary, the core changes proposed as a basis for consultation include: Increased investment in community based services to provide improved out of hospital services through a clinical hub in each locality and health and wellbeing centres within the main town areas Expansion of the private sector care home/intermediate care market Closure of four community hospitals - Asburton and Buckfastleigh, Bovey Tracey, Dartmouth and Paignton Reduction of MIUs by closing Ashburton (currently suspended), Brixham, Dartmouth, (currently suspended) Paignton. Three remaining MIUs Totnes, Newton Abbot and (in coastal) Dawlish would open 8 am to 8 pm, seven days a week and have diagnostics. The impact in each locality of these changes is summarised below. 3

5 Stakeholder engagement As the Governing Body is aware, during the last six months we have been engaging with stakeholder groups in Newton Abbot, Dartmouth, Ashburton/Buckfastleigh and Bovey Tracey about the significant challenges we face, the developing model of care and possible service configuration. Clinical Services Transformation Group has received regular updates on feedback from these meetings. In discussing the demographic and financial pressures, as well as the clinical case for change, there has been general agreement among most stakeholders, commissioners and providers that the future model of care should: Put greater focus on prevention and early intervention Ensure a seamless experience of care through partnership with statutory providers, independent and voluntary sector Make more flexible use of resources Establish a single point of access Manage increasing complexity in the community Care for people as close to home as possible Be sustainable in the future However, although many stakeholders criticise what they see as inadequate access to some out of hospital, community based services, the attachment to the current model of services is strong and in particular to community hospitals. In towns which have these, there are many people who do not want to see their hospital close. Some people would not, for example, accept the argument that fewer beds are required as a result of being able to provide services, traditionally associated with a community hospital, in people s homes or in another local community setting. Some people might accept the closure of beds if their hospital building became the base for health and social care services. Drafts of the proposals covered by this paper have in recent weeks been discussed with the stakeholder groups ahead of these proposals being finalised. Trust staff have also been briefed, as have MPs and other key stakeholders. Substantial engagement has also taken place with GP practices by both the Trust and the CCG. Devon Scrutiny Committee have received regular reports. A Scrutiny meeting schedules do not fit into the proposed timescale, members have been briefed or received written papers. Feedback at the most recent stakeholder meetings can be summarised as: Fear of not being able to cope with a reduced number of hospital beds, given current pressures on Torbay and other hospitals Scepticism that the private sector can provide the intermediate care capacity, especially in rural areas and a desire to know how this will be done Annoyance that the draft proposals contain insufficient details as to what services will be available locally and from where they will be delivered Concern that the proposals have not been fully thought through but are being rushed for financial reasons Unease that proposals to co-locate some services with GP practices have not yet been agreed 4

6 Desire to understand additional funding and staffing within community services, including understanding how many health and wellbeing coordinators are planned to be recruited Details of the actual values of community hospital buildings and whether any capital receipts will be used to meet local needs Concern over inadequate detail of mental health provision in health and wellbeing teams The lack of a transition timetable Support for more robust MIUs (eg from Ashburton) but a desire from others (eg The Bay) for an MIU to be maintained. Support for providing services as locally as possible and for investing in community services Governing Body will be aware that there has been considerable media coverage of the draft proposals discussed at recent engagement meetings and strong views expressed about retaining community hospitals. Local MPs have expressed a desire for more detail and petitions have been established to support local hospitals. While attention has focused on the hospitals, part of the reaction has focused on services as opposed to buildings and a desire to ensure they continue to be provided locally. Changes per locality The following tables summarise the changes in each of the four localities which are the subject of this reconfiguration. They indicate the clinics which will be delivered locally, in line with the 1,000 patient threshold set out above under the model of care. Moor to Sea What will be different? Dartmouth Hospital which provides 16 beds and Dartmouth Health Centre will close and is expected to be replaced by the new Health and Wellbeing Centre which will comprise colocated GP and health and wellbeing services. Plans are being developed for the new premises to be located at the site of Riverview Care Home. Totnes Hospital provides 19 beds which will reduce in line with safer staffing ratios to 16 beds. The MIU facility which is open between 8am and 9pm seven days a week will be open between 8am and 8pm seven days a week reflecting the times of greatest demand and is consistent with the opening times planned for the MIU in Dawlish and Newton Abbot. It will provide radiology services. Ashburton and Buckfastleigh Community Hospital which provides 10 beds will close under these proposals. This reflects the need to meet safer staffing ratios with a minimum of 16 beds which cannot be accommodated in this facility. A new health and Wellbeing Centre is being proposed as part of a co-located service within existing GP premises and will accommodate locally delivered services that are viable to serve the needs of the community. 5

7 What could services look like and where will they be? New Clinical Hub in Totnes (Currently Totnes Hospital) MIU with x-ray New long term conditions clinic Community outpatients Community beds (16 beds) Rehabilitation Gym Pharmacy Health and wellbeing team Health and Wellbeing Centre in Dartmouth (Plans are being developed to co-locate with Dartmouth Medical Practice in new premises). Community clinics Rehabilitation Gym Pharmacy Enhanced primary care MIU services Health and wellbeing team Health and Wellbeing Centre in Ashburton or Buckfastleigh (options are being explored to co-locate with GP s in either of the local towns). Community clinics (where facilities allow) Health and wellbeing team Newton Abbot What will be different? The Community will have access to a greater range of services and an enhanced intermediate care team as part of the Health and Wellbeing team. Newton Abbot Hospital will expand its bed based care services from 20 medical beds to 45 medical beds (plus 15 stroke) and provide a new clinical hub offering community clinics and rehabilitation services. The MIU facility which is open between 8am and 10pm 7 days a week will be open between 8am and 8pm seven days a week, reflecting the times of greatest demand and is consistent with the opening times planned for the MIU in Dawlish and Totnes. Radiology services will be available during the opening times of the MIU service. 6

8 What could services look like and where will they be? Clinical Hub in Newton Abbot (Currently Newton Abbot Hospital) MIU with x-ray New long term conditions clinic Community outpatients Community beds (45 beds) Rehabilitation Gym Pharmacy Health and wellbeing team Paignton and Brixham What will be different? Paignton Community Hospital currently provides 28 beds, an MIU facility and outpatient clinics. Midvale clinic provides community clinics and Church Street provides office accommodation to care staff who work in the community. The three sites will close under the proposals contained in this document Services will be provided in the new Health and Wellbeing Centre planned to be developed in Paignton as part of providing fit for purpose accommodation for local GP Services, and we hope to co-locate the most frequently used community services in this new facility. Brixham Hospital will become a clinical hub offering a range of services including flexible use of community beds. The MIU facility will not be available at the hospital. Patients will have the option of visiting their local GP for MIU services or attending the MIU in Totnes or Newton Abbot. What could services look like and where will they be? New Clinical Hub in Brixham (Currently Brixham Hospital) Long term conditions clinic Specialist outpatients: Audiology, Cardiology, Dermatology, Ear, Nose and Throat, Endocrinology, General Medicine, General Surgery, Gynaecology, Neurology, Orthopaedics, Paediatrics, Rheumatology, Urology. Community beds Day centre Rehabilitation Gym Pharmacy Health and wellbeing team Health and Wellbeing Centre in Paignton (Planned to be developed in Paignton as part of providing fit for purpose accommodation for local GP Services) 7

9 Community clinics: MSK assessment and treatment (not gym based) Speech and Language Therapy, Podiatry, Orthoptist, Continence, anaesthetics. Pharmacy Radiology (if viable) Enhanced primary care MIU services Health and wellbeing team Torquay What will be different? The Community will have access to a greater range of services and an enhanced intermediate care team as part of the Health and Wellbeing team. Castle Circus Health Centre will continue to deliver community clinics and a range of health services and Torbay Hospital will continue to provide specialist services and acute care to the whole footprint. What could services look like and where will they be? Health and Wellbeing Team Pharmacy Health and wellbeing team Consultation If Governing Body approves these proposals, there is a gateway meeting with NHS England for them to be signed off as a basis for consultation. As indicated in the consultation draft, governing body is invited to approve a single option approach as the basis of consultation while inviting alternative suggestions from the public. We have asked Healthwatch Devon and Healthwatch Torbay to work together and provide an independent place for all information received through the consultation to be received, processed and analysed. Online responses will be made to a Healthwatch website, paper responses will be posted to Healthwatch offices and they will also provide trained note takers to record comments made at meetings. They will provide an independent written report on the feedback and outcome of the consultation for consideration by our governing body. As previously indicated, we plan to communicate engage with communities during the consultation by holding a series of public meetings, drop in sessions and responding positively to invitations to attend community group meetings. We intend to maximise the use of social media and hold tweet chats on different aspects of the consultation. 8

10 We will ensure that as much information as possible is made available and we shall deploy all channels available to us as part of our efforts to engage with as many people as possible. As indicated in the draft developing consultation document (attached) we are committed to producing more detailed information ahead of the consultation documents covering: The clinical case for change The financial case for change Bed definitions Locality specific population data Modelling paper patient flow past and future; numbers Estates Subject to the appropriate approvals, 12 week consultation is planned to start on 13 May and complete at midnight on 5 August. Issues for consideration There are several specific aspects of the proposals where governing body needs to reassure itself of the approach being taken and/or to indicate its preferred option. 1 Location of health and wellbeing centres: in most localities it is hoped that these will be co-located with GP practices in existing or new accommodation. Investigations and discussions are taking place to identify precise locations but we cannot at this stage be specific to any one set of premises. However, we are committed to ensuring that in each town, there will be a health and wellbeing centre or locality hub and that the relevant hospitals will not be closed for outpatient services until these centres are in place and operating. 2 Outpatient clinics: a range of clinics are currently located at community hospitals. Throughout our engagement discussions, we have indicated that those clinics which attract a sufficient volume of patients in each area, would continue to be provided in the local area. After reviewing attendances in all areas and as indicated above under the model of care, clinics in future would be provided where there is currently more than 1,000 attendances per year. This figure is judged to be sufficient to staff these clinics and to justify the cost of holding them in the location. Based on this threshold, the following configuration appears likely although this will be finalised should we proceed to consultation. The details in the table below require further validation Brixham Services That Would Stay (more than 1000) Physiotherapy Services with fewer than 1000 attendances in each local town likely to be provided from Locality Hub Audiology 9

11 Podiatry Cardiology Continence General Medicine General Surgery Gynaecology Orthopaedics Orthoptist Paediatrics SALT Dermatology Other Activity: Health visiting, Minor Ops, Specialist Dermatology, LLTS, Drug and Alcohol services, Healthy Lifestyles, Smoking cessation and Weight management, LTC, Flu clinic NB: Radiology activity not known Paignton Services That Would Stay Audiology Radiology Podiatry SALT General Surgery Physiotherapy Dartmouth Services That Would Stay Day Care Physiotherapy Podiatry Services with fewer than 1000 attendances in each local town likely to be provided from Locality Hub Continence Dermatology Endocrinology Orthoptist Paediatrics Anaesthetics Cardiology ENT General Medicine Gynaecology Neurology Nursing Episodes Orthopaedics Rhematology Urology Other Activity: Neuro use of gym, Drug and Alcohol, Ad hoc clinics for DPT Services with fewer than 1000 attendances in each local town likely to be provided from Locality Hub Continence GPwSI ENT SALT 10

12 Other Activity: GPwSI, Dartmouth Caring, LLTS, DAS, Health Visitors, OPMH, Heart Failure clinic, Private Osteopath Ashburton/Buckfastleigh Services That Would Stay Physiotherapy Podiatry Bovey Tracey Services That Would Stay Physiotherapy Services with fewer than 1000 attendances in each local town likely to be provided from Locality Hub Neurology Nursing Episodes SALT Services with fewer than 1000 attendances in each local town likely to be provided from Locality Hub SALT Podiatry 3 X-ray facilities: there is concern that under current draft proposals there will not be an MIU with diagnostic facilities within the Bay. While the proposed dispositions of MIUs meet population demand, there are currently 7,000 referrals from within the Bay via local GPs. Under the current proposals this demand would need to be accommodated within Torbay Hospital or the MIUs at Totnes or Newton Abbot. Any decision to provide this resource within the Bay would clearly add cost/reduce savings and given the shortage of radiography staff, would be challenging to provide. Governing Body needs to consider whether in the context of this volume, this should be revisited. 4 Intermediate care investment: there are three options which Governing Body needs to consider in how the proposed investment of 3,705,873 should be apportioned. Option 1: the current suggested allocation is based on current activity, predictions for future activity and ambulatory admissions e.g. Newton Abbot currently has a higher referral rate per 1000 population than the other South Devon areas, 43/1000 as opposed to 28/1000 for Moor to Sea and 25/1000 for Coastal. For this option, the calculation is based on a combination of rates for 65+ and 80+. Newton Abbot: 928, Moor to Sea: 439, Coastal: 458, P&B: 1,085, Torquay: 794, Option 2: based on 65+ population at cost of per head Newton Abbot: 816,922 11

13 Moor to Sea: 466,143 Coastal: 538,457 P&B: 1,052,231 Torquay: 832,290 Option 3: based on 80+ population per head Newton Abbot: 832,149 Moor to Sea: 433,145 Coastal: 561,269 P&B: 1,035,684 Torquay: 843, Expansion of intermediate care An integral part of this care model approach is to stimulate the care home/intermediate care market. Notwithstanding the partial role that community hospitals play in this area, it is clear that the current provision does not meet current let alone future need. Until there is certainty as to future demand, it is unlikely that the market will expand. It is therefore envisaged that an invitation to express interest will be issued to the private sector so as to facilitate discussions on how best to meet future needs and to explain the model of care and the investment strategy. Discussions have taken place with local authority colleagues and with some care home operators and an initiative is underway to identify the most appropriate model based on a mixture of spot and block purchasing arrangements. It is for example envisaged that procurement of block contracts will shortly be underway in Torbay. 6 Finance As referred to above and as governing body is of course fully aware, the demands on funds outstrip any new funding available and the CCG needs to make significant savings over each of the coming years. For 2016/17 we currently have a 16m shortfall. The proposals which form the basis of this consultation proposal were scheduled to save 1.8m towards filling this gap. However in response to issues raised in engagement meetings and elsewhere, additional provision has resulted in this sum falling to circa 1.4m. The Trust has confirmed that it owns all its community hospitals and that should any close and be disposed of, the capital receipt would be available for investment into its local health services. 7 Consultation communication If governing body approves these proposals as a basis for consultation and approves this timeline, details of public meetings will need to be promoted ahead of NHSE final sign off so as to give people at least four weeks notice of these events. The first meetings are provisionally scheduled for week beginning 23 May. 12

14 8 Consultation questions Draft questions are included in the attached consultation document and are set out below. The aim of these is to try and gain a broader perspective from our communities on the choices which the CCG face. The questions below need further working as well as language simplification but governing body is invited to comment on the approach Draft Questionnaire To cope with future demand for services, to improve the experience of patients and to capitalise on the advantages of modern medical approaches, changes need to be made to the way services are provided. The/ This document [ Into the Future? ] sets out the background and detail of the changes being proposed in this consultation. Choices need to be made on where we can best use our funding to benefit most people. Y N DN Q1 Do you recognise that the NHS should spend most of its resources where it can help most people? Q2 As we live longer: Should the NHS be supporting people to keep well and independent for as long as possible? Should the NHS help people do this by spending more of its budget on local, community based out of hospital services? If yes and such service improvements can only be funded by closing some hospital beds, do you still support spending more on community services? Please say why Q3 Should people only be admitted to hospital if they cannot be looked after as well or better in or close to their own homes? Please say why? Q4 Should the NHS keep people in hospital beds when they do not need nursing or medical care? Please say why? Q6 If you do not support switching funds from community hospitals to provide more local out-of-hospital services, do you accept that community services will not be improved? Please say why 13

15 Q7 What services do you think should be stopped to keep all community hospitals open? Can we give a list of possible examples? Q8 If out patient services and clinics currently provided in your local hospital were provided locally, in less costly, modern buildings would you support closing some community hospitals to fund them? Please say why Q9 Q10 If funds arising from the sale of any community hospital was reinvested into community health services based in that area, would you support the closure of the hospital? Please say why If you live in a town with a community hospital, are there any circumstances in which you would agree to its closure? Please say what these are 14

16 c fit QIPP / Finance 4 key tests Appendix 1 Copy of NHS England Effective Service Change: Stage II Assurance NHS England South West Effective Service Change: Stage II Assurance CCG: South Devon and Torbay Reconfiguration/Service Change: Community Services Name of Person Completing: Rebecca Foweraker Date: Apr-16 Criteria Key Tests Example Evidence CCG Statement Source of Evidence NHS England Review Support from GP commissioners will be essential Documented evidence of GP support Support for the new model of care from the CCG Governing body and GP clinical leads. Governing body minutes, CCN minutes, Locality Leads minutes, LCG meetings Arrangements for public and patient engagement, See communications and clinical Arrangements in place- engagement with the public and stakeholders has been SD & T CCG Engagement reports, Consultation plan and associated including local authorities should be further strengthened quality and activity sections below ongoing since documentation. Health Scrutiny papers Clarity about the clinical evidence base underpinning proposals Proposals take into account the need to develop and support patient choice The clinical case for change is based on national evidence and best practice. Patients will be offered a choice of first outpatient appointment as per the Choice Framework. For the foreseeable future, choice will be offered via the CCG's commissioned referral management centre Devon Referral Support Services (DRSS). An enhanced MIU service will offer people greater choices with regards urgent care. Clinical case for change- should be read alongside the ICO Full Business Case DRSS specification, ICO Full Business Case and care model Best Practice Checks Example Evidence CCG Statement Source of Evidence NHS England Review How does the proposal support commissioner and provider financial sustainability? This proposal is essential to the financial sustainability of our health community and makes best use of public money. ICO Full Business Case, CCG Operating plan (not available until June 2016), Sustainability and Transformation Plan (not available until June 2016) and model of care, Health Scrutiny papers Does the proposed change improve quality and reduce cost? How (e.g. reduced duplication, increased efficiency)? Business case (if available) or strategic outline case including worked through financial models The new model of care presents the opportunity for whole system change by realiging bed-based capacity within the system to community based services. ICO Full Business Case and care model, Sustainability and Transformation Plan (not available until June 2016) What are the savings in financial terms? What capacity is being taken out of the system and where? How, when and where is a saving made? Is it a cash releasing saving? Are the transitional costs (including non-recurrent revenue and capital) identified and properly accounted for? How will they be funded? Capital investment implications have been considered in terms of the viability, deliverability and sustainability of the proposal and the economic (value for money) impact Evidence of aligned financial, workforce and activity models Capital investment implications identified to NHS England Project Appraisal Unit for review Demonstrated through the ICO business case. Through the reconfiguration of beds and estates. Demonstrated through the ICO business case. Demonstrated through the ICO business case. A significant amount of work has been undertaken on the strategic estate across the community to match the required investment in new facilities with divestments of old and no longer required estate. Planning incorporates GP premises and new and innovative models of partnership working around shared estate. Our health and care community has a shared vision of one public estate. ICO Full Business Case and care model ICO Full Business Case and care model ICO Full Business Case and care model ICO Full Business Case and care model Strategic Estates Plan, ICO Full business case Finance links consistently to workforce and activity models Demonstrated through the ICO business case. ICO Full Business Case Best Practice Checks Example Evidence CCG Statement Source of Evidence NHS England Review Clear articulation of patient, quality and financial benefits Clinical case for change including risk analysis The clinical case for change has been developed which includes the creation of a new model of care based on the progression of existing good practice already operational in Torbay. As part of this work we have taken into account the views of patients and stakeholders from our initial round of engagement in 2013 and we have evaluated and articulated the the patient benefits that this progression will bring as well as the financial opportunities. ICO Full Business Case, clinical case for change Clinical case fits with national best practice Reference to national evidence base which could include NCD reports, NICE, Royal College or NHS Evidence. The clinical case of change references national best practice. ICO Full Business Case and clinical case for change

17 Clinical quality and strategic Fit with local H&WB strategy and aligned with local commissioning plans The new model of care is aligned to the CCG Operating Plan, Health and Wellbeing strategy and Sustainability and Transformation Plan. SD & T CCG Operating Plan, Health and Wellbeing Strategies- Devon County Council, Torbay Council, Better care Fund narrative, Sustainability and Transformation plan (not available until June 2016) Options appraisal (inc. consideration of a network approach, cooperation and collaboration with other sites and/or organisations) Options appraisal for network /collaborative / cooperative approach Five options have been considered and appraised. Macro-impact is properly considered Analysis of macro-impact The proposed new model of care will present new opportunities for economic regeneration in this area, such as the expansion of the personal care workforce, the stimulation of the care home market and building the resilience of the voluntary sector. Alignment with QIPP work streams Identify links to local strategic plan and QIPP work streams Aligned to CCG Operating Plan, Health and Wellbeing strategy and Sustainability and Transformation Plan. Configuration proposal paper and care model costings Sustainability and Transformation plan (not available until June 2016), System Resilience Group minutes SD & T CCG Operating Plan, Health and Wellbeing Strategies- Devon County Council, Torbay Council, Better care Fund narrative, Sustainability and Transformation plan (not available until June 2016) Full impact analysis across CCG / NHS England commissioned services and shared sign up of all parties to analysis Analysis of impact on CCG / NHS England commissioned services endorsed by relevant parties. A full impact analysis will not be complete until we have fully formed proposals.

18 Resilience Travel Workforce Activity Best Practice Checks Example Evidence CCG Statement Source of Evidence NHS England Review All relevant patient flows and capacity are properly Outputs of accurate modelling with The ICO have completed capacity modelling which has resulted in the care model ICO Full Business Case and care Model modelled, assumptions are clear and reasonable assumptions clearly stated and sensitivity analysis option 2cV2. What are the changes in bed numbers? Clear explanation of reduction in bed numbers The ICO have completed capacity modelling which has resulted in the care model option 2cV2. ICO Full Business Case, Care Model Activity and capacity modelling clearly linked to service change objectives Narrative explaining link between modelling and service change objectives Aligned financial, workforce and activity models Analysis of key risks and any mitigating actions The ICO have completed capacity modelling which has resulted in the care model option 2cV2 of 93 beds ICO Full Business Case, Care Model, National Intermediate Care Audit Activity links consistently to workforce and finance models The ICO have completed capacity modelling which has resulted in the care model option 2cV2 ICO Full Business Case, Care Model Modelling of significant activity, workforce and finance The ICO have completed capacity modelling which has resulted in the care model ICO Full Business Case, Care Model impacts on other locations / organisations option 2cV2 Best Practice Checks Example Evidence CCG Statement Source of Evidence NHS England Review Do you have a workforce plan -integrated with finance Supply high level workforce risks Integrated Workforce Strategy, Managing Staff Changes Policy and activity plans? and mitigating actions Are you making most effective use of your workforce for service delivery and is it compliant with all appropriate guidance? Consider the implications for future workforce Have staff been properly engaged in developing the proposed change? Statement of assurance including reference to all appropriate standards Changes to provider Learning Development Agreements Evidence of appropriate staff engagement The original ICO business case described the model of care and workforce including the shift from bed based care to the community. The integrated workorce strategy describes how the workforce is being developed to deliver the new care model. The Trusts annual plan provides details of numbers, changes and costs to the workforce and how this will be achieved and is fully implemented with financial and activity plans. Specific workfroce plans for the community hospital closures and move to community based servcies are being developed based on the existing startegy and the trusts linked policies and procedures. The workforce is being developed as detailed above and is compliant with appropriate guidance including "safe staffing" and is assured using a range of measures as reported to the Board. The workforce is being developed as described above and workforce plans are developed liaising with HEE and HEI's. This includes influencing and agreeing specific education and development to deliver the described workforce. Staff engagement has been taking place since late Staff understand and have indicated that they support the direction of travel. Further engagement events have been held with affected staff prior to stakeholder consultation. Stakeholder briefings have been sent to staff. Staff have been integral to developing the local community teams. ICO Full Business Case, Integrated Workforce Strategy, Intermediate Care staffing costs proposals ICO Full Business Case, Integrated Workforce Strategy ICO workforce engagement timetable and plan, staff consultation materials Best Practice Checks Example Evidence CCG Statement Source of Evidence NHS England Review Has the travel impact of proposed change been Travel impact assessment Travel times to MIUs, community hospitals and outpatient clinics as a consequence of MIU travel time spreadsheet and outpatients relocation mileage modelled for all key populations including analysis of the changes has mapped. Travel times and parking have been key issues raised as part available transport options, public transport schedules of the April 2016 engagement process. and availability / affordability of car parking? Best Practice Checks Example Evidence CCG Statement Source of Evidence NHS England Review How will the proposed change impact on the ability of Statement of assurance There would be no impact. Torbay Hospital and Newton Abbot Hospital are the Emergency Planning Resilience Record which is assured by other parts of the local health economy to plan for, and respond to, a major incident? primary patient receiving hospitals during a major incident; this arrangement would still exist. The planning for major incident response would still be managed by the dedicated ICO team already in place. NHS E. Has a business impact analysis been conducted for all impacted organisations and appropriate changes made to Business Continuity Plans? Evidence the proposed service change and the impact on resilience has been assessed at the Local Health Resilience Partnership (LHRP)Business impact analysis Business continuity analysis has taken place for all sites; there would be no significant change to those response action cards. Emergency Planning Resilience Record which is assured by other parts of NHS E. Has the Local Health Resilience Partnership assessed the impact on resilience? The South Devon and Torbay System Resilience Group is clearly sited on the proposals for the new model of care which will provide greater stability and resilience within the system and improve patient flow. ICO Full Business Case Best Practice Checks Example Evidence CCG Statement Source of Evidence NHS England Review

19 Ambulance services Have the implications for ambulance services Statement of ambulance service (emergency and PTS) been identified and impact assessed engagement and impact assessment and appropriate discussions been held with ambulance service providers? The ambulance service is a key partner in our care model plans and is represented within our partnership at the South Devon and Torbay SRG. The projected travel time impacts will be shared with PTS when our proposals are further formed. SRG minutes

20 Others IT TDA/ Monitor Equality Impact Comms and Engagement Best Practice Checks Example Evidence CCG Statement Source of Evidence NHS England Review Are there plans to appropriately and effectively engage and involve all stakeholders and fulfil commitments under s.14z2 and s.13q of the Health and Social Care Act? Consultation plan and draft consultation document Consultation timeline, plan and associated documentation produced. Consultation plan and associated documentation (to include: staff, patients, carers, the public, Healthwatch, GPs, media, local authority overview and scrutiny functions, Health and Wellbeing Boards, local authorities, MPs, other partners and organizations) Public / stakeholder involvement strategy Consultation timeline, plan and associated documentation produced. Consultation plan and associated documentation Communications plan including full stakeholder map with timelines, key messages, named clinical spokespersons, sample materials and plans to reach seldom heard groups Consultation timeline, plan and associated documentation produced. Consultation plan and associated documentation which includes a communications plan Best Practice Checks Example Evidence CCG Statement Source of Evidence NHS England Review There has been an appropriate assessment of the Completed EqIA and Action Plan An EQIA was completed within the original ICO business case. EQIA, Consultation plan and associated documentation impact of the proposed service change on relevant diverse groups? Has engagement taken place with any groups that may Yes, engagement with a wide range of stakeholders has been ongoing since EQIA, Consultation plan and associated documentation be affected? What action will be taken to eliminate any adverse Some issues have already been identified via engagement- travel times, risk of Engagement notes impacts identified? reducing the number of MIU's, parking- these will be considered and mitigated, where possible, on a locality by locality basis Best Practice Checks Example Evidence CCG Statement Source of Evidence NHS England Review Is proposal aligned with the TDA s / Monitor s approach Business case (if available) or strategic outline case The ICO business case has support from the TDA and monitor, both organisations are fully cognisant of the South Devon and Torbay vision for integrated care. ICO Full Business Case and care model Best Practice Checks Example Evidence CCG Statement Source of Evidence NHS England Review Does proposal make best use of technology? Evidence of a review of how technology may support the service change been undertaken Joined-up care and information sharing is central to the vision of patient centred care. Information technology is seen as a key enabler. ICO Full Business Case, Joined Up IT strategy Assessment of the impact on local informatics strategy & IT deployments Detail of any changes to local informatics strategy and deployment plan, inc. information flows and governance. Key risks are highlighted and mitigating actions identified Please see Joined Up IT strategy ICO Full Business Case, Joined Up IT strategy (inc. Annex G - Programme Deployment Plan) Are there likely to be any data migration costs? No Joined Up IT strategy (inc. Annex G - Programme Deployment Plan) Are there any implications for specialist or network technology/equipment contracts associated with the service? No Joined Up IT strategy (inc. Annex G - Programme Deployment Plan) Best Practice Checks Example Evidence CCG Statement Source of Evidence NHS England Review Consistent with rules for cooperation and competition (Monitor/OFT/CC) Assurance from commissioners The South Devon and Torbay Health Community, CCG, local authority and providers and voluntary sector, are committed to a vision of integration for our health and care community. We can demonstrate that the development of the Integrated Care Organisation is the best delivery vehicle for that aspiration. ICO Full Business Case, Sustainability and Transformation Plan Consideration given to the most effective use of estates Estates impact assessment Torbay and South Devon NHS FT have developed an Estates Strategy. Strategic Estates Plan

21 Appendix 2 Working Draft Consultation Document [This is a working draft with more content to be added and then the document reduced to a tighter length with plainer language. Summaries may also need to be produced.] Contents Introduction Thank you for your interest in the changes being proposed for community health services across South Devon and Torbay. We hope you will take part in this consultation by attending meetings being held in your communities, contributing to the debate and letting us know your views. This document sets out the reasons for proposing change and the improvements we hope to make. It includes dates and times of meetings, sets out the different ways you can contribute your views and explains how to make alternative suggestions. Our goal is to ensure that our health system can meet future needs, providing the best possible health and social care we can within the geographical, staffing and financial limitations in which we operate. Decisions made at the end of this consultation will impact on your NHS services for years to come so it is important that all parts of our communities get involved and we receive the widest possible range of views. Please help us by sharing this document with your friends and family, encouraging them to take part. Who we are South Devon and Torbay Clinical Commissioning Group is the organisation which represents all of the local GP practices and is the NHS body responsible for buying and developing services for the people of the area. We are working closely with Torbay and South Devon NHS Foundation Trust which provides services at Torbay Hospital and community health and social care services in the area, including community hospitals and minor injury units. Within South Devona andtorbay, we work in partnership with the local councils and GPs to jointly develop services. We operate through five localities, each led by local GPs: Coastal (Teignmouth and Dawlish), Moor to Sea (Ashburton, Buckfastleigh, Totnes and Dartmouth), Newton Abbot (includes Bovey Tracey and Chudleigh), Torquay, Paignton & Brixham. Our coastal locality is not part of this process as we consulted here in 2015 and improvements are currently being implemented. Facing up to the challenge Communities across South Devon and Torbay are rightly proud of their local health and social care services and their record of meeting the expectations of people who need our care and delivering improved health and wellbeing for our local population. The NHS in South Devon and Torbay provides care and treatment to a population of [286,000], including some three million [episodes of care] annually - a number forecast to rise significantly over the next decade. 1

22 Year on year the NHS looks after more people, provides more specialist support and works increasingly in partnership with social care and the voluntary sector. The NHS has kept up with growing demand by constantly responding to changing needs by redesigning how services are provided, developing new techniques and adopting new drugs and approaches. We can easily forget how much the NHS has changed over the years. It is not that long ago for example that lengthy hospital stays were required for treatment which now takes place routinely in a few hours and without a hospital admission. Delivering health services today is challenging because we have: Increasing numbers of older people, many with long-term and complex health conditions who need support to live independently Growing proportion of our younger people living in areas of deprivation, especially in Torbay but also in some rural areas A high use of urgent care services, especially A&E which means increasing pressure on A&E and urgent care services Flat or reducing finances, especially when health and social care resources are combined Changes to professional NHS standards which specify minimum safe staffing levels and volumes of activity for quality care Recruitment problems due to a shortage of doctors, nurses and other clinical staff in some services. Faced with such challenges, the NHS needs to continue to work differently, creating services designed to support people to live well at home and in their local communities. We want to make sure that at every stage of life, the NHS can provide the best possible care. That is why we have been looking at how best to meet the future needs of local people, in a way that blends the best of current practice with new and innovative ways of working. Locally and nationally, the NHS must do more with the funding it receives, responding to the increasing needs of our population; delivering services which reflect the different requirements of rural and urban areas; and deploying resources where they can have most impact and where patient demand is greatest. 2

23 To meet the scale of these challenges, change is inevitable, essential and clinically desirable. We need to change to ensure we are able to deliver the services that local people need and want in order to support them to live their lives to the full. Consulting on the future: [13 May to 5 August] For these 12 weeks, we are asking the people of South Devon and Torbay to comment on our proposals for change and to tell us how we can make best use of the public funding we receive to better meet the needs of local populations. This document sets out how we believe we can best support our different communities. It describes a model of care where hospital beds are always available when needed but where people are only admitted if they cannot be cared for safely at home or in their local community. It explains how we will invest in services to keep people out-of-hospital unless medically necessary, make sure they stay not a day longer than is good for them, and deliver more care in or closer to people s homes. It also focuses on doing more to stop people getting ill and supporting them to make the best choices to be as healthy as possible, and to work in partnership with people with complex needs to become experts by experience. The proposals outlined in this document are the ways which we believe we can better meet the health and care needs of local people. We have engaged extensively with local people and their representatives in forming these proposals, and we have used their priorities to inform the changes in this document, which we believe will improve care and are affordable. But we are open to alternative suggestions for redesigning affordable services that meet local needs and no decisions will be made until after we have heard the views of the people of South Devon and Torbay. Views expressed in this consultation will be independently reported by [Healthwatch] and reported to the governing body of the South Devon and Torbay Clinical Commissioning Group, ahead of it deciding what changes should be made. All options put forward during the consultation will be examined before a decision is made on the future shape of community services. Why consult now? In late 2013, South Devon and Torbay Clinical Commissioning Group (CCG) in partnership with our acute hospital, community health providers, Devon County Council and Torbay Council carried out extensive engagement about our community health and social care services. People told us that the most important things to them were: Accessible services convenient opening hours, transport and accessible buildings Better communication between clinician and patient, and between clinicians themselves Continuity of care to allow relationship-building with clinicians and carers Coordination of care including joined-up information systems Support to stay at home with a wide range of services and support. Last year s creation of the integrated care organisation (Torbay and South Devon NHS Foundation Trust (TSDFT) resulted in the majority of our health and care services - from district nursing, social work, community therapy, complex care and multi-agency teams to highly specialist acute care - being delivered by the one NHS Trust. The bringing together of these and other services in one organisation created a huge opportunity to develop new ways of working which can deliver what people told us they wanted in

24 Throughout the autumn and winter months the CCG, supported (SDFT, has engaged with groups across the area to discuss how best to deliver services which will meet the future needs of our local population. These engagement discussions involved a range of interests and expertise and looked at for example the predicted health needs of our population, whether hospital beds should be used to look after people who can no longer live on their own, how best to provide more care in the local community and the difficulties of attracting specialist staff to the area. Out of the 2013 engagement and these discussions, we have developed a model of care (see page?) which the NHS and social care believe will meet future need, can be delivered and is affordable. We are grateful for the contributions everyone who participated made. The European referendum We would not normally hold a consultation such as this during an election or a referendum. But the pressures on our health service mean that we cannot delay making decisions on how best to reshape them to meet future need. However Britain votes in the European Referendum, the issues outlined in this document and the proposals made would not change. We need to make decisions now, to ensure we have services that are fit for the future. Whether staying in or leaving the EU would result in more or less money for the NHS in future is not relevant to this consultation. The local decisions we need to make now remain the same. Why change? Deliver high quality care to an increasing number of people We want to continue to deliver high quality health and social care to all the communities in South Devon and Torbay and we need to ensure our services not only meet local people s needs now but in the future. Our existing structures and approaches will not cope with the forecast demand for services in the coming years as illustrated in the table below. If we are to provide the care to support people to live the healthiest lives we need to change the way we work. Number of patients with disease; known or not known to primary care [Check figures] Moor to Sea Newton Abbot Paignton & Brixham Torquay % % % % Coronary heart disease Chronic kidney disease People aged 65 and over predicted to have: Type 1 or Type 2 diabetes A longstanding health condition caused by a stroke Dementia

25 Depression Severe depression een services A longstanding health condition caused by bronchitis and emphysema A moderate or severe visual impairment A moderate or severe, or profound, hearing impairment Incre ase joint work ing betw We have an international reputation for our pioneering integrated care model in which adult social care and health services are delivered by local teams working in a joined up way. Our new integrated care organisation, launched in October, now brings Torbay Hospital and these local community-based health and social care services into a single provider Trust. We want to extend this integration to include a more joined up way of working with local voluntary and charitable organisations, and with our partners in other public services such as mental health and children s social care. Improve life expectancy In each of our localities, there are significant differences in life expectancy between our most deprived and least deprived areas; the numbers of people in the under 16 or over 85 age groups; and the number of emergency admissions. We want to strengthen our preventative and selfcare services to help tackle health inequalities and reduce the gaps in life expectancy, providing the best care we can to all sections of our communities. Life expectancy gap between most deprived and the least deprived in each locality area Newton Abbot 15.8 years Torquay 14.1 years Paignton & Brixham 10.3years Moor to Sea 5.7 years Keep more people out-of-hospital People should only be admitted to hospital when medically necessary. If people do not need specialist nursing or medical help, they are better supported out-of-hospital. Successive audits have shown that almost a third of beds in community hospitals are occupied by patients who were fit to leave if more community support had been available. We therefore want to invest more in community services so we are able to treat and support people in their own homes or in locally accessible services. This is also what people tell us they would prefer. We know that treating people in a hospital bed is not always the best approach. For example, the longer older people remain in hospital, the harder it is for them to regain their independence and return home; the more likely they are to be readmitted; and the more vulnerable they are to hospital-acquired infections. Evidence also suggests that some people recover much quicker if they are cared for nearer to or in their own homes, in a more normal environment rather than in a busy hospital and we want to invest in community services to be able to support more people to recover as quickly as possible. 5

26 But where people need to be admitted to hospital, we want to make sure that they receive the best quality and experience of care, that we have enough staff to look after them and that we meet national safety standards. This is challenging as it is increasingly difficult to attract staff to community hospitals. Better support people in the community We need to make sure that we strengthen our out-of-hospital services so that they can both help people to avoid the need to be admitted to hospital and respond swiftly should they experience deterioration in their health. This means investing in more community-based services so that they mirror the availability and reliability of hospital-based care. We need to ensure it is provided in the evenings, at weekends, 365 days a year, in winter or in summer, in urban and in rural areas. To do this, we need to switch funding from hospital to community-based care, so we can increase the range of local services and the times that they are available. We also want to make sure that people do not travel further than they need to for treatment and support. The more out-of-hospital services we can provide in or close to people s homes the better. Provide effective minor injuries units (MIUs) MIUs in South Devon and Torbay should see enough patients (7,000 per year) to make best use of highly skilled staff and to justify the cost of keeping them open consistently, seven days a week with x-rays on site. Staff in MIUs need to be able to see a wide range of patients so they can keep their skills up to date to deal with urgent but not life threatening conditions. Minor injury units are an important part of the urgent care services by treating people with things like minor burns, sprains and fractured bones. We want to improve the consistency of their opening times and access to diagnostics so people are more likely to go to them rather than A&E. Focus resources where they have most impact Public finances are under considerable pressure. These are intensified within the NHS by the rising cost of some treatments, the increasing demand for specialist services and the need to look after more people with a number of long term conditions. NHS costs traditionally rise faster than inflation putting further pressure on the CCG budget. In addition, the CCG currently receives more money than the national funding formula judges it should, and we need to manage our budgets to bring ourselves back into alignment with the formula over the next several years. Taking these factors into account, the demands on funds outstrip any new funding available and the CCG needs to make significant savings over each of the coming years. For 2016/17 we currently have a 16m shortfall. In reconfiguring services, we need to not only take account of quality and safety issues but also the need to improve value for money and contribute to this funding gap by finding different and more effective ways of meeting the increasing needs of our population. The proposals which form the basis of this consultation will contribute almost 2m towards filling this gap. 6

27 And by switching funding from bed-based to community-based care, we will be investing more of our resources in the local services most used by our communities. As the chart below illustrates, the largest volume of activity rests with GPs and community therapy and nursing. Make best use of our staff We want to make best use of our staff, providing good career opportunities and roles which attract people to work in local health and social care services. Nationally there is a shortage of doctors, nurses and other qualified staff. We already see the impact of this locally with MIUs in Dartmouth and Ashburton temporarily closed and beds temporarily relocated to Newton Abbot from Bovey Community Hospital. Many other services are under similar strain with difficulties in recruiting to community and hospital nursing posts, some medical and therapy specialties, and to specialist social work and social care. Our partners in residential and nursing care are also experiencing challenges in recruiting staff and in providing the range of specialist care needed, particularly long term care for people with some forms of dementia. Attracting GPs to the area is also difficult with many practices struggling to recruit. We need to design services that make the best use of the time, availability and skills of these staff. By bringing them together to work as integrated teams in partnership with the local voluntary sector, we will have the range of skills to better respond to the needs of the community they serve. Local bases will enable them to have more patient and client contact rather than using their time in travelling. Ensure our estates for fit for the future 7