Devon Pre-Consultation Business Case

Transcription

1 Devon Pre-Consultation Business Case 21 September 2016

2 Contents 1 Executive summary Introduction Stakeholder engagement Context Case for change Responding to the case for change: this consultation and other changes Vision and models of care Impact of the new model of care Summary of financial analysis Progress in implementing the new model of care Community hospitals in Devon Development of options for location of community hospital beds in Eastern Devon Appraisal of shortlisted options Viable options for consultation Quality Assurance Implementation of the proposals Benefits framework Next steps Introduction Background The Success Regime Programme governance Purpose and scope of the Pre Consultation Business Case Stakeholder engagement Summary of stakeholder engagement strategy Principles for stakeholder engagement Identification of stakeholders Stakeholder engagement activities undertaken during pre-consultation Key themes of feedback Context Case for change The health and care needs of local people

3 5.2 Local people are living longer which means they need more care and treatment More local people are living with long-term conditions and their needs are complex Care needs to be more person-centred and co-ordinated especially for people with more than one long-term condition Equalities and inequalities analysis There are too many people in hospital beds who don t need to be there Space in community hospitals is not being well used There are also difficulties with recruiting and retaining staff Financial considerations Summary Vision and models of care Process for developing vision and models of care Principles Focus on population segments The model of care The role of hubs Examples of what is currently in place or underway Impact of the new model of care Outcomes and patient impact Finance Workforce Primary care provision Estates Other enablers Progress in implementing new models of care Northern Devon Western Devon Eastern Devon Community hospitals in Devon Background Estates requirements for community hospital beds Removal of unused beds Matching results achieved in North Devon Expert clinical opinion

4 9.2.4 Inpatient bed requirements with the new model of care Scope for further, future change Development of options for location of community hospital beds in Eastern Devon Process for option development Stakeholder engagement Developing the list of options to be evaluated Meets minimum size of 16 beds to deliver quality and efficiency No new build due to cost and timescales Make best use of PFI buildings Implement decisions from previous consultations Options Appraisal of shortlisted options Evaluation criteria Quality Patient access Access for carers Implementability Finance System impact Rating each option for each criterion Evaluation of options Access for carers Finance and implementability Ability to support whole system impact Overall evaluation Quality Assurance Four Tests (NHS England) Strong patient and public engagement Consistency with current and prospective patient choice Clear clinical evidence base Support for proposals from Commissioners Benefits framework Why a benefits framework is required Approach to defining benefits framework Expected benefits

5 13.4 How benefits will be realised and measured Implementation of the proposals Background to implementation Implementation plan Communications & engagement Governance Implementation risks and dependencies Measuring the impact of change Preparing for consultation Purpose of undertaking consultation Consultation methods Consultation materials External assurance of consultation plan Handling responses Website News and media Social media Consultation events Consultation plan Monitoring Next steps Summary of recommendations Approvals process Next steps Appendices Travel Model Detailed financial analysis Equalities Impact Assessment Quality Impact Assessment Endnotes

6 1 Executive summary 1.1 Introduction Over the last few years, organisations in Devon have been part of the Transforming Community Services programme of work. As part of this programme, Northern, Eastern and Western Devon s Clinical Commissioning Group (NEW Devon CCG) published Transforming Community Services Strategic Framework in October This framework set out a case for change, vision and care models for preventative and personalised support, people with complex health needs, urgent care in the community and specialty services in the community. Over the last 12 months, we have done further work to refresh the model of care and review progress in implementing the new model of care across NEW Devon. This included a re-fresh of the case for change. This work is being done as part of the Devon Success Regime. The Success Regime is a partnership of local health and care organisations working together to identify and solve the issues facing health and social care services across NEW Devon. Clinicians have led the programme throughout, working with wider stakeholders to develop these proposals. The work has also been supported by a Finance Working Group and Communications and Engagement Group. Consideration and understanding of the potential effects of our proposals on local people has been at the heart of our discussions. This pre consultation business case (PCBC) sets out the information necessary for NEW Devon CCG to make a decision as to whether to proceed to consultation on proposals for service change. 1.2 Stakeholder engagement We understand that patients, staff and the wider public care deeply about what happens to their local health and social care services and it is critical that they are fully engaged in developing proposals. Stakeholder engagement work has been on-going over the last three years as part of the Transforming Community Services programme and then as part of the Devon Success Regime. We have identified a wide range of stakeholders who should be involved in the development of our proposals. We have considered how to capture the full range of opinions in the development process and how to incorporate different experiences and learning from similar programmes. The key themes of the feedback were: There is a strong ambition for local people to be involved in discussing and informing potential future changes to health and social care services, across the relevant areas. Engagement events are often not attended by people from certain parts of certain local communities, who nonetheless may be affected by any potential changes to services. There is therefore a risk that their views will not be heard. This is addressed in the consultation through a range of ways for individuals to engage as well as plans for focus groups arranged via Healthwatch delivery partners in relation to groups with protected characteristics. The area covered by the programme does have varied geography, demography and services. Whilst this would be taken into account in implementation planning, the approach is to achieve an overall consistent core service offer and outcomes, wherever people live in Northern, Eastern and Western Devon. There needs to be an honest debate about issues such as finance, so that people feel the programme has engaged with them in an honest, open, and transparent way. Local services should not just be about providing care when a person falls ill, but should be about encouraging healthier living, so that ill health is prevented in the first place. 5

7 A number of specific, local issues may be raised by the programme and these are of concern to local communities. These include transport and travel times, the development of community hubs, and money raised by League of Friends organisations. This feedback was fully incorporated into our discussions and these proposals. 1.3 Context NEW Devon is located in the South West of England and covers a population of 883,000 people. This large geographical area (2,330 square miles) includes many smaller towns and villages and rural areas including the Dartmoor National Park. Health and social care spending on the residents of NEW Devon was 1.9bn in 2014/15. Health services in NEW Devon are commissioned on behalf of local people by Northern, Eastern and Western Devon Clinical Commissioning Group (NEW Devon CCG) and NHS England. NEW Devon CCG is the largest CCG in England, by the size of the local population. In 2014/15, in NEW Devon, there were around 5.5 million consultations at GP surgeries, 838,000 contacts with community staff, 190,000 attendances at A&E, 105,000 planned operations performed and 83,000 emergencies that required hospitalisation i. There is a complex range of organisations providing these health and social care services in NEW Devon. 1.4 Case for change A case for change was published as part of the Transforming Community Services Strategic Framework in October This has been updated as part of the work of the Success Regime in NEW Devon. The updated case for change was developed by local clinical and operational leaders across health and social care with involvement from the public and patients. They agree that local services are not keeping pace with the changing needs of local people and it is becoming increasingly difficult to make sure local people have access to consistently high quality care that is affordable and sustainable. This is because: People in NEW Devon are living longer, with increasingly more complex care needs that require more support from health and social care services. There are 280,000 local people, including 13,000 children, living with one or more long-term condition such as asthma, diabetes, hypertension, cancer and mental illness. Local health and social care organisations are facing a financial shortfall in 2015/16 of 122m (4% of funding), rising to 384m (14% of funding) in 2020/21 if nothing changes Although there have been some local successes in changing the way services are delivered, there are still many challenges facing local services: Care needs to be more person-centred and co-ordinated especially for people with more than one long-term health condition. There are also too many people in hospital beds who don t need to be there. Every day 500 people are in local acute hospitals and 100 are in community hospitals when they could be cared for at home. When people are ready to leave hospital, local services are often not ready to look after them, so they have to stay in hospital longer. Staying any longer than necessary in hospital causes harm to patients in reducing muscle function and diminishing the likelihood of returning to live independently at home as well as exposing them to risk of infection. It is also expensive the cost per bed day is and if the occupancy is low it means some of this money is being spent on unoccupied beds. 6

8 There is a lot of space in community hospitals that is not being used (up to half the space in some hospitals.) The pattern of the usage of community beds shows that while significant changes have been made in the north already, the East in particular has double the levels of community beds many of which are occupied by people who are medically fit to discharge. 1.5 Responding to the case for change: this consultation and other changes Advances in medicine, new technologies, innovative practices, increased knowledge and evidence about the way that care is provided tell us there is a way we can respond to the challenges set out in the case for change as well as achieving services that improve outcomes for people, make better use of resources and stand the test of time. Although services have continued to develop, they remain out of step with people s real needs. Add to that the severe financial pressure, the compelling evidence that the benefits of the right care in the right place far outweighs the harm that can be done with an outdated model that is over-reliant on beds and we know we need to act now. The focus of our attention is change not more. We need to target and make the best use of all of the resources (money and people) to achieve care at or closer to home where possible and to find increasingly co-ordinated and pro-active ways of working to provide safe care in the most appropriate way. Your Future Care is an important first step in the wider programme of change that is required to create services that provide the best care for people, and that are financially sustainable. We need to set the foundations now to unlock the resources needed to enable us to deliver a new integrated model of care for people across Devon which in turn will enable future changes to establish health and care services we can all be proud of and be pleased to receive support from. This is the clinical challenge that clinicians have been working on over the past four months. The delivery of care, particularly for the frail and elderly, is over-reliant on care in a hospital bed. The clinical evidence is clear that prolonged hospital stay increases long term physical and psychological dependence, and that addressing this model of care is a key priority. Bed audit and length of stay data point to a significant opportunity to transform care, by instituting a range of services (the new model of care ) that will: Identify all people who are frail or pre-frail, and therefore at risk of admission to hospital, put a care plan in place, owned by the individual, that outlines potential avenues for escalating care when it is required Provide a single point of access for when additional support is needed, connected to a comprehensive care at home service that supports people to remain at home rather than being admitted to hospital. Where hospital admission is unavoidable, coordinated discharge, connected to the same care at home service will ensure that hospital discharge is supported to occur as soon as it is clinically safe, with additional support at home including health and care workers delivering rehabilitation alongside traditional care. At scale, these services have the potential to allow the 600 people a day currently cared for in a hospital bed - but who do not require hospital care- to be supported at home, or where it is necessary and right for them, in a care home. One immediate consequence of implementing this model of care is a reduction in the requirement for community hospital beds, as much of the care delivered there could be delivered in people s homes. The generous provision of community beds in the Eastern locality of NEW Devon in particular reinforces the current pattern of care. Transferring resource from community bedded services into delivering home based care is the vital first step in implementing the new model. Bed reductions in the acute sector are expected to happen simultaneously but the first priority on acute sites is to reduce bed occupancy to a sustainable level, facilitating improvements in the timely delivery of both unplanned and planned care. 7

9 A reduction in the number of community beds in the Eastern locality will necessitate consolidation of the remaining beds onto a smaller number of sites. In the first instance community bed numbers in the Eastern locality will be aligned with those currently in use in the Northern locality, where components of the new model are already being developed and implemented reducing the requirement for community beds. Community bed numbers in the Western locality are already at the same level as in the Northern locality, and some elements of the new model are in place, but there is a significant opportunity to extend these and improve flow and performance. Therefore, the focus of this consultation is on reducing the number of sites with community beds in the East of Devon in the context of a developing an exciting new model of care. It is part of a wider engagement with the population of NEW Devon about changes needed to ensure the clinical and financial sustainability of services. This consultation forms part of a wider implementation of the requirements of the case for change, unlocking parts of the system and enabling the parallel changes within the acute sector. For patients, the main impact of the new model of care will be to enable them to live more independently with fewer occasions of being admitted to hospital and stays that are reduced in length to the absolute minimum required for medical reasons. Delays in discharge will be eliminated and a greater proportion of those who have been admitted to hospital will return to their full function. 1.6 Vision and models of care The overall vision of NEW Devon is: to provide care closer to home, away from acute hospitals wherever it is clinically safe to do so, and that the service is effective, efficient, and represents value for money. We will achieve this by making services easier to access where they cross acute and community service boundaries and provide greater levels of preventative care to help people selfmanage their conditions. We will standardise urgent care services so that they are easy to access and consistent, and increase the level of integration both within health care but also with social care providers. We are aware that communities can be wary of service change. We have, and will continue to engage with our communities and will ensure that their views are reflected in the design of services for the future This vision was expressed most recently in the consultation on Transforming Community Services. Local clinical experts have been meeting to refresh the vision and model of care developed as part of Transforming Community Services, particularly focussing on those patients who are likely to benefit most. Overall, the new models of care will focus on addressing the needs of those people who have greatest contact with the health and care service, including the frail and elderly, people with dementia, and people with chronic conditions (affecting both physical and mental health). A guiding set of principles has been established that include focussing on prevention, health and wellbeing, individual accountability and support; organising care around the needs of the individual; treating people in the lowest intensity setting possible and minimising the use of beds; and maintaining safe levels of staffing. 8

10 For these individuals in particular, we seek to make it possible for them to say: I have an improved quality of life and any health and/or support needs I have are identified quickly and addressed. I have information and advice that I can understand. I receive early help so that I can look after myself as much as possible. This means that any need for care in a hospital happens only when absolutely necessary and appropriate. I have a positive experience of care and support. I feel safe, and I am protected from avoidable harm. I am able to take positive risks because I am supported. I will have the correct care and support across health services so that I receive any diagnosis and treatment at the right time. Services will make reasonable adjustments to make sure that I get the help I need. I am helped to recover from episodes of ill health or injury in services that are as close to home as possible. I get the right amount of support to keep me as independent as possible. Within this context, clinicians have developed plans that will deliver more care at home, particularly for the frail and elderly and those with dementia, for whom admission to a hospital bed carries risk of physical and psychological deconditioning. 1.7 Impact of the new model of care For patients, the main impact of the new model of care will be to enable them to live more independently with fewer occasions of being admitted to hospital and stays that are reduced in length to the absolute minimum required for medical reasons. Delays in discharge will be eliminated and a greater proportion of those who have been admitted to hospital will return to their full function. The new model of care will also mean that there will be less requirement for bed-based care as care will be provided in lower intensity settings, particularly at home. This is likely to mean further consolidation and reduction in the number of beds across acute and community settings. This provides a significant opportunity to deliver care differently and to focus on prevention and wellbeing. Given the need for investment in staff who work in multidisciplinary teams, a reduction in the requirement for community beds and the need to make best use of scarce resources, and the local attachment to community hospitals, the concept of health and wellbeing hubs in the community has been developed to provide a wider range of enhanced services. The multidisciplinary community/primary care team form the back bone of the developing of health and wellbeing hubs. The primary focus of these teams is to support the person maintain their health and wellbeing. In some areas this can be enhanced to provide a wider range of services that may be located in a building/ community hospital. All of these will have the basis of maintaining people s independence. We want services and opportunities that improve the prospects for people in their lives and promotes every chance for individuals to be as independent as they can be. Our focus will be on recovery and will constantly promote opportunities for greater independence. By promoting independence for individuals in their own homes we will be giving people the opportunity to recover from the condition that led them to requiring help, or to better self-manage the condition they have. Our approach will start with what a person can do and in understanding the network of support that is already available to support and help someone, and build on that network. 9

11 m will be saved each and every year just as a result of reducing community bed usage in Eastern Devon, after providing for reinvestment in additional community services to support the new model of care. This is one key part and an enabler of a broader set of changes that include reduced hospital admissions and addressing the 500 unnecessary acute hospital beds being occupied which will deliver gross savings of m. Up to 28.5m will be reinvested in community services. This reinvestment will be used to improve care services, including the funding of 2.1k hours of care each day of care at home and 2.1k hours of care per day in co-located community sites. In addition, net savings of 42.8m p.a. will improve the financial sustainability of the local health economy. Most of the reinvestment in community services will be on staff who will move from their current roles to new roles within the new model of care. The new model of care will require the workforce to do different jobs in different locations we anticipate that people who are currently employed in delivering health and social care will continue do so albeit potentially in different roles and locations. We are confident that workforce can be transitioned effectively, due to high skill levels and high level of current vacancies in community hospitals. Where possible we hope the investment in extra community staff and therapists will minimise any extra workload for hard pressed General Practice teams where the workforce is struggling to cope with current and rising demand. We will look to work with the LMC and GP providers to assess and monitor any impact on GP teams (especially for time intensive domiciliary visits) and mitigate this through the planned reinvestment. There are a number of other enablers that need to be developed to support the delivery of the new model of care. These include: Leadership development: individuals, leaders and organisations will need support to deliver change on this scale. Time and investment will be needed to achieve this. Commissioning and contracting: to foster integration of care and provide care in new ways, innovative forms of payment and commissioning may need to be introduced. The potential benefits of new organisational forms will also be considered. IM&T: Investment in IT and infrastructure is very likely to be needed to support delivery of future care models. Central to this is the ability to have patient level datasets that support the identification of patients to focus our attention and support. Data that can be accessed by multidisciplinary teams that then support new forms of payment and reward. It should be noted that this investment is subject to accessing nationally available funding and is not a quick solution. New ways of working. Clinicians involved have emphasised the new model means providers and partners, staff and teams working together through a single co-ordinated approach to bringing benefits for patients and the population and to deliver efficiencies in the health and social care system. New ways of working will be a central enabler to success. 1.8 Summary of financial analysis NEW Devon health and social care organisations are facing a financial shortfall in 2015/16 of 122m (4% of funding), rising to 384m (14% of funding) in 2020/21 if nothing changes. Clinicians and executives from across NEW Devon have worked together to develop a set of opportunities captured in a strategic financial framework to deliver 399m in savings, including prevention ( 24m), excellent care ( 97m), productivity ( 278m) and configuration (no savings assumed). NEW Devon has agreed with NHS England and NHS Improvement that it will deliver 66m in 16/17 savings as part of the single control total for NEW Devon and will identify and agree 17/18 savings in the autumn. 10

12 NEW Devon is pursuing a set of transformational changes to deliver excellent care which will in total over 5 years yield 97m through reductions in admissions, reductions in acute beds, and reductions in community beds. A bed audit in October 2015 found more than 600 people in beds at any given time who were medically fit, with the majority of this opportunity sitting with acute hospitals and a significant number also in community. This Pre-Consultation Business Case is to support the CCG to undertake consultation about changes in community beds; in addition, work is underway to reduce acute beds and other service changes with further consultation planned for January Community bed net savings are 2.8m- 5.6m in net benefit per year based on the potential to reduce 71 beds in Eastern Devon at per bed day with 20-40% reinvestment; these figures are based on detailed costings of actual beds in Devon and conservative estimates of reinvestment requirements based on experience in Devon. This will bring the level of community bed provision in Eastern Devon down from 143 to 72 beds, representing a level that has already been achieved in Northern and Western Devon and has been endorsed by the clinical cabinet as being achievable. Northern Devon has spare capacity even at its current level of beds (32) which indicates that the new model of care is capable of driving even greater efficiency. It is important to note that, whilst the changes described in this PCBC deliver a relatively small level of savings in their own right, they do form a material building block in our wider plan, which will enable the transition from bed-based care to an improved out-of-hospital offer that significantly benefits patients. 1.9 Progress in implementing the new model of care Since the Transforming Community Services Strategic Framework was published in October 2014, changes have been implemented across NEW Devon. Northern Locality published and consulted on a document called Care Closer to Home in late This proposed the implementation of the new model care and a consequent reduction in the requirement for community hospital beds to 40 capacity. Northern Devon Healthcare NHS Trust then undertook a consultation in the summer of 2015 called Safe and Effective Care within a Budget which proposed the development of community health and social care teams to be a single point of co-ordination for people with complex needs and a reduction in community hospital facilities. This has been implemented and completed in FY 15/16 and has resulted in many benefits. The model now in operation in Northern Devon supports patients with: o a single point of contact for GPs, carers, patients and wider health and social care which navigates the system to get the right support in place o a rapid response capability to quickly respond to patients whose health is deteriorating. This proactive support has been shown to enable people to remain in their own homes when it is safe to do so. There has been closer working with the voluntary sector and mental health, and more integration between hospitals, community services and GPs. This has meant that: o patients are able to leave hospital more quickly o the enhanced community teams are able to offer patients support to avoid hospital admissions o with rapid response capability in place, the majority of people receive a visit from a multidisciplinary team within 2 hours. This support also avoids hospital admissions and has reduced the number of assessments needed so people do not have to tell their story multiple times. 11

13 o with more people treated in their homes, the number of community hospital beds across Northern Devon has halved and beds have been removed entirely from Torrington, Ilfracombe and Bideford. Western Locality published and consulted on a document called Your Health, Your Future, Your Say in late This document proposed the implementation of the new model of care and said that modelling would be done to determine the community hospital beds required. Eastern Locality published and consulted on a document called Pathways for the Future in This document recognised the need to provide more services for people at home and that this would lead to a reduction in the need for community hospital beds over time. Following consultation, it was decided that community hospital beds would be consolidated onto fewer sites without significant change in bed numbers. It was also agreed that bed numbers and inpatient units would be reduced over time as the new model of care was implemented. This experience shows that the proposed models of care can deliver significant improvements for patients including improved outcomes, improved access and a better patient experience Community hospitals in Devon There are currently 20 community hospitals in NEW Devon, and within Eastern Devon there are currently 12. Although all previously provided inpatient beds, this changed through the Transforming Community Services Programme with the result that 7 hospitals now provide inpatient care (Exeter, Exmouth, Sidmouth, Seaton, Honiton, Tiverton and Okehampton). On a temporary basis Ottery St Mary is currently providing stroke unit care which has enabled the flexibility to continue with its 3 community inpatient beds. The focus of this consultation is to establish people s views on the options for which community hospitals in Eastern Devon should continue to provide community beds. In addition to beds community hospitals provide a range of services including minor injury units, x-ray, surgical day-case units, therapies, outpatients co-located primary care, endoscopies and midwifery led units. These services are not included in this aspect of the consultation. In 2015 the capacity of beds described by the CCG was 158 (with potential to flex upwards to 163) in the East, 40 in the North and 72 in the west, with numbers that can also flex down in response to real demand. In the north for example the number actually in use has been flexed down since last year to 32. The data used in the analysis described throughout this document from this point forward is based on the number in use operationally- the flexed down position - to meet the existing demand. These numbers are presently 143 in the East, 32 in the North, and 72 in the West. In addition to this there are stroke rehabilitation beds in the community across NEW Devon. Although the latter figures appear in this document they are in the context of the overall position described in Of course the existing demand or use is only part of the picture. Where beds are occupied, many people are fit to leave (almost half of the patients in Eastern Devon). For almost half of these people, a lack of access to basic essential care, such as being bathed, is the reason they cannot go home. Being in hospital for long periods is often harmful, especially for the elderly, resulting in functional decline, increased risk of ending up in long term care and increased risk of infection. It is expensive with a cost of /bed day). It is also not what many patients or their carers want particularly the 7% of people who die in a community hospital, the majority of whom would prefer to be at home at this point in their lives. Clinicians have considered how many community hospital beds will be required to deliver the new model of care by looking at current bed use, benchmarking, delayed discharge and expert opinion. After reviewing all the evidence, local clinicians on the clinical cabinet have concluded that Eastern Devon require a maximum of 69 of the 143 beds they have currently (this is a reduction of 74 beds). Northern Devon are already implementing the new model of care and the number of community 12

14 hospital beds in use has changed from 52 to 32 since 2015 and Western Devon have 72 community medical inpatient beds that are in high demand due to the pressures on the acute beds at Derriford Hospital. There may therefore be further opportunities to reduce the capacity of community hospital beds in Western Devon and Northern Devon as the model of care becomes fully embedded. The current proposal will result in 2.8m - 5.6m of net savings per year and 1.4m - 1.9m of reinvestment into the new community model of care. As a first step, we want to consult on the location of community hospital beds in Eastern Devon as we believe there is an overwhelming case for change and immediate opportunities to improve care and efficiency. Consulting on community hospital beds first enables us to unlock a critical component of the system to transform the overall workforce supporting new models of care. The following community hospital sites are in scope of review: Seaton Sidmouth Exmouth Exeter Honiton Okehampton Tiverton Clinicians have been clear that change needs care and therefore have been developing a series of tests which will form a local gateway process. This builds on themes identified in the Transforming Community Services Programme, for example a similar Gateway process designed in Northern Devon, although several of these have already been included such as facilities and travel, in the options process that underpins the PCBC. The Gateway process will underpin the future implementation plan and will ensure that local clinicians have confidence in a safe implementation of new models of care and includes steps to measure the impact of the new models of care that will be in place across both Primary and Secondary care settings Development of options for location of community hospital beds in Eastern Devon Local clinicians have followed a process of considering all the possible options on the location of community hospital beds in Eastern Devon and gradually narrowing down this list to a preferred option. Clinicians used a number of hurdle criteria to reduce the list of all possible combinations of option to a manageable shortlist of options for detailed evaluation. These hurdle criteria are: Meets minimum size of 16 beds to deliver quality and efficiency No new build due to timescales and costs Make best use of PFI buildings Requirement to honour outstanding legally binding commitments As a consequence of the application of these hurdle criteria those sites already consulted upon (Axminster, Ottery St Mary and Crediton) were excluded from further consideration and Tiverton was established as a fixed point due to the high quality estate with PFI commitment and its large scale. This resulted in there being 15 options for further analysis as depicted in Figure 1-a. 13

15 Figure 1-a: 15 options for evaluation These options have been evaluated in more detail to produce a preferred option Appraisal of shortlisted options The evaluation of the options has been clinically led, with recommendations coming from the Clinical Cabinet and the Finance Working Group. Patient involvement has been ensured through: Representatives of the local Healthwatch organisations (Healthwatch Plymouth and Healthwatch Devon) being members of the Programme Delivery Executive Group, the Clinical Cabinet and New Models of Care Group. Representatives of the relevant local authorities being members of the Programme Delivery Executive Group, the Clinical Cabinet and New Models of Care Group. A Patient Public Engagement Committee is a sub-committee of NEW Devon Governing Body and provides assurance on engagement activities to the Governing Body. It has reviewed the consultation and engagement approach and has provided feedback to the governing body. The evaluation criteria build on the criteria used in previous public consultations in NEW Devon and have been agreed by the Clinical Cabinet and Finance Working Group. The evaluation criteria are: Quality: this criterion is extremely important and although there may be existing variations under the new model of care, quality will be improved for all patients. For this reason, clinicians agreed the offer will be no difference between options in terms of quality as the new model of care will be delivered across all sites. Patient access: access to services is very important but the new model of care will be delivered to the majority of people at home. Clinicians agreed that, as patients will be transported to and from services, there is no difference between the options in terms of patient access. Access for carers: people in community hospital beds are visited by carers, friends and relatives, many of whom will be elderly. Although the number of people affected by potential changes is small, the Clinical Cabinet agreed that access for carers does differentiate between options. 14

16 Finance: the saving due to the implementation of the new model of care ( 2.8m - 5.6m) will be the same across all options. However, the Finance Working Group agreed that there is a difference between the three potential 24 bed options in terms of ward reconfiguration costs Implementability: the required ward reconfiguration will take time to complete. The Finance Working Group agreed that there is a difference between the three potential 24 bed options in terms of time required for ward reconfiguration System impact: the current community hospital beds do not exist in isolation and are provided alongside other services. The Programme Delivery Executive Group agreed that system impact differentiates between options in terms of co-location with other services and flexibility of site. Application of these evaluation criteria resulted in Tiverton being agreed as the 32 bed site, in order to make best use of its large scale, high quality of care and PFI services, and two options remained viable for each of the 24 and 16 bed sites. Those options eliminated at this stage were those that either were not configured to accommodate the number of required beds, or they significantly impacted access for carers. Figure 1-b: Overall scoring of options using evaluation criteria 15

17 Option Summary 1. Seaton & Sidmouth Negative scores for both access for carers and whole system impact 2. Seaton & Honiton Neutral scores for both access for carers and whole systems impact 3. Seaton & Exmouth Preferred option to explore- positive score on whole systems impact and neutral score on access for carers 4. Seaton & Exeter Option to explore highly positive score for access for carers 5. Seaton & Okehampton Negative scores for both access for carers and whole system impact 6. Exmouth & Sidmouth Excluded by implementability and finance criteria 7. Exmouth & Honiton Excluded by implementability and finance criteria 8. Exmouth & Seaton Excluded by implementability and finance criteria 9. Exmouth & Exeter Excluded by implementability and finance criteria 10. Exmouth & Okehampton Excluded by implementability and finance criteria 11. Sidmouth & Exmouth Option to explore positive score on whole systems impact 12. Sidmouth & Honiton Neutral scores for both access for carers and whole systems impact 13. Sidmoth & Seaton Negative scores for both access for carers and whole system impact 14. Sidmouth & Exeter Option to explore highly positive score for access for carers 15. Sidmouth & Okehampton Neutral score for access for carers and negative score for whole system impact 1.13 Viable options for consultation There are four options which then emerge as being viable options for how community beds in Eastern Devon could be provided: 1) Seaton and Exmouth, 2) Sidmouth and Exmouth, 3) Seaton and Exeter, 4) Sidmouth and Exeter. There is a genuine choice about which of these is the best option for NEW Devon. However, by a small margin, the preferred option sees community hospital beds consolidated in Seaton and Exmouth as this combination optimises travel time and whole system impact. To reiterate, all four options are considered viable and a debate is welcome to determine the best option. In all cases, Tiverton will continue to be utilised as a fixed point due to the high quality estate, PFI commitment (it would cost 35m to exit the contract) and its large scale Quality Assurance This programme of work is going through a robust process of external review including a review of the proposed clinical model, a review of the finance modelling and a review of the readiness for consultation. These reviews will be carried out by NHS England, Academic Health Sciences Network (AHSN) and an independent evaluation post consultation. Planning, Assuring and Delivering Service Change for Patients from NHSE (updated in October 2015) reiterated earlier guidance that proposals for service change must demonstrate that they satisfy the four tests of service reconfiguration and are affordable in capital and revenue terms. 16

18 The government s four tests of service reconfiguration are: Strong public and patient engagement. Consistency with current and prospective need for patient choice. Clear, clinical evidence base. Support for proposals from commissioners. A summary of how this proposal meets the NHSE four tests is found in Figure 1-c. Figure 1-c: Assessment against NHSE four tests 1.15 Implementation of the proposals Where service reconfiguration is proposed, it is really important to take positive steps to make sure that the transition between the current model of care and the future model is planned and managed to make sure the best interests of patients and carers are maintained and gaps in care are not inadvertently created. As described in the previous consultation, when we are confident that this is in place, we will look to reduce the number of beds and/or inpatient units accordingly. We are now preparing for this next step and building in an approach that means bed closures will not take place until a Gateway process has confirmed clinical assurance that care with fewer beds and units is safe and of at least the same quality. Implementation of the new model care has already started in Northern Devon. We know that this implementation is leading to a number of improvements for patients. However, it will be crucially important to make sure that services are available to support the changes as they are implemented. Assuming the decision following consultation supports the proposal, it is envisaged that implementation of the changes in Eastern Devon will start as soon as the decision is made. Beginning in 2017 these will be completed as soon as possible in line with a gateway process to ensure the safety and stability of the new model. A formal local gateway process has been developed by clinicians and will be refined over the coming months, taking into account learnings from consultation and pre-engagement work. This process will be used by the wider system to assure itself that the transition to the new model of care is safe, takes account of workforce challenges and measures the impact of the changes across the system. Delivery of the requirements will be assessed by groups that include doctors, nurses, therapists and Healthwatch in their patient representative role to ensure that gaps in care are avoided. 17

19 The responsibility for implementation will lie with the NEW Devon CCG and resource has been committed to support this implementation as set out in the Appendix, to the value of 1.4m - 1.9m. NEW Devon CCG will drive the commissioning process required to implement the changes through contracts and benefit-focussed performance management Benefits framework The benefits framework allows us to quantify and monitor the successful delivery of benefits from the proposed changes, to patients, to staff and to the ways in which we run our services. The main benefits from the proposed changes to the model of care will be: Improved clinical outcomes for patients Improved experiences for patients and their carers Improved experiences for staff, due not only to improvements in patient care, but also improved team and multi-disciplinary working, improved integration across primary and secondary care, and increased opportunities to maintain and enhance skills Operating financially sustainable services. A pragmatic list of measurable performance indicators, focused on patient outcomes and patient experience, will be used to measure progress Next steps This pre consultation business case will be discussed by the NEW Devon CCG Governing Body on 28 th September 2016 and consultation is planned to commence on 7th October The consultation will be the opportunity to hear the views of the public and key stakeholders and the feedback from the consultation will be fully considered and taken into account, before any final decision is made. It is anticipated that a final decision will be made between January and March

20 2 Introduction 2.1 Background Over the last few years, organisations in Devon have been part of the Transforming Community Services programme of work. As part of this programme, NEW Devon CCG published the Transforming Community Services Strategic Framework in October Prior to adoption, there was an eight-week period of engagement with local people. This framework set out a case for change, vision and care models for: preventative and personalised support: community services designed to help people who are older, frail or otherwise have complex health needs to remain well, support them to recover and enable them to have choice and control of their own care through a new model and design of services. people with complex health needs: range of community hospital and community services to support people with complex health needs such as multiple long term conditions, frailty or disability with a new co-ordinated pathway design from pro-active care through crisis responses and to ongoing care. urgent care in the community: urgent minor injury and illness services to a new design that will achieve consistent, quality, resilient and networked urgent care in line with the requirements of the Keogh report 1. This new system design aims to listen to, see or treat people in the right setting. specialty services in the community: a range of specialist community services that support people who may be vulnerable and whose conditions or needs require more specialist input from professional in podiatry, bladder and bowel care, specialist nursing and others. Over the last 12 months, we have done further work to refresh the model of care and review progress in implementing the new model of care across NEW Devon. Details of progress made in implementing new models of care (especially in Northern Devon) are found in Section The Success Regime In mid-2015, commissioners and providers of health services in NEW Devon became part of the Success Regime, a national initiative to protect and promote services for patients in local health and care systems that are struggling with financial or quality problems, or sometimes both ii. In NEW Devon, this initiative is helping to solve local problems through short-term improvements in quality and finance, medium and long-term transformation of services and development of the local leadership to lead the challenging and necessary changes required. The Success Regime is a partnership of local health and care organisations including NEW Devon Clinical Commissioning Group, hospital trusts, social services, GP providers, mental health trusts, community trusts, private sector providers and the ambulance service. These organisations are working together to identify and solve the issues facing health and social care services across NEW Devon. Over the past nine months, clinical leaders and managers from these organisations, with patient and carers, have: Developed a case for change that has widespread support Looked at different types of health and social care issues to understand what care support is needed for different people Looked at the quality and safety of current services and identified where they could be improved

21 Identified 20 immediate ways in which the quality and delivery of services can be improved and selected 5 opportunities for accelerated implementation in 2016/17 Understood where there are financial pressures in the local health and social care system and why Identified and evaluated options for change. This programme of work is building on the work already completed as part of the Transforming Community Services programme and the work completed for this pre consultation business case has been done within the Success Regime programme. 2.3 Programme governance The work of the Success Regime is being overseen by a Programme Delivery Executive Group. This comprises the Chief Executives from across the system and Success Regime lead officers (including a clinical lead). For the purposes of this consultation, this Group makes recommendations to the NEW Devon CCG Governing Body, who make the final decisions on the issues covered by the consultation. Figure 2-a: Programme Governance Structure There are a number of groups working to the Programme Delivery Executive Group who are doing more detailed work as part of the development of these proposals, as shown in 2a. These include: Clinical Cabinet: comprised of senior clinical leaders from the Success Regime partners. The group provides senior leadership of clinical and care elements of the programme, leads the work of the Clinical Design Groups, ensures wider clinical engagement and leads implementation of plans. The Group is chaired by the Programme Medical Director. This group has been supported by a New Models of Care Group who have done the detailed work on the clinical model of care and development and evaluation of the options. Finance Working Group: comprised of the Directors of Finance from the Success Regime partners. The group provides senior leadership of financial elements of the programme, working alongside the Clinical Cabinet to develop a longlist of options for the future configuration of services and ensuring options are financially sustainable. This group is chaired by the Programme Finance Director. This group has been supported by Estates and operations task and finish sub group who have undertaken the detailed work car parking, capital and revenue implications, operational ease of use and whole system impact (flexibility of sites). 20

22 Communications and Engagement Group: comprised of the Heads of Communication and Engagement from the Success Regime partners. The group provides senior leadership of communications and engagement elements of the programme. This group is chaired by the Programme Head of Communications and Engagement. The Success Regime programme encompasses planning for change, consultation (if required) and implementation, as shown in Figure 2-b. Figure 2-b: Programme timeline Clinicians have led the programme throughout, working with wider stakeholder to develop these proposals. Consideration and understanding of the potential effect of our proposals on different people has been at the heart of their discussions. Further information on stakeholder engagement undertaken through this process of developing these proposals can be found in Section Purpose and scope of the Pre Consultation Business Case The focus of this consultation is on changes to community beds in Eastern Devon. Public consultation is typically necessary where significant service change is intended and the process of consultation and engagement is governed by Sections 14Z2 of the National Health Act 2006 (amended by the Health and Social Care Act 2012). The framework set out in the legislation has been expanded in guidance, Changing for the Better, High Quality for All NHS Next Stage Review and Planning, Assuring and Delivering Service Change for Patients, published by the Department of Health. The guidance mandates the need for a pre-consultation business case (PCBC). The PCBC is a technical and analytical document that sets out the information necessary for the Clinical Commissioning Group (CCG) to make a decision as to whether to proceed to consultation. It sets out in detail the process we have been through to identify our proposals for change, the final set of proposals and the implications of these proposals. It includes: Updates to the case for change, vision and service models since the Transforming Community Services Strategic Framework was published in October The benefits we expect to realise How we have considered the options available to us and evaluated them to a recommended option The proposals for service change we are recommending for consultation 21

23 What we believe the next steps are to enable the CCG to go to consultation and to support planning for implementation. The PCBC will be a published document but it is not intended to be the main mechanism through which we explain our proposals to the public. The consultation document is a public-facing document that sets out the proposals and their implications and asks specific questions to help us to test and refine these proposals. 22

24 3 Stakeholder engagement 3.1 Summary of stakeholder engagement strategy We have set out a clear stakeholder engagement strategy that is crucial to the successful delivery of our proposals. We understand that patients, staff and the wider public care deeply about what happens to their local health and social care services and it is critical that they are fully engaged in developing proposals. Stakeholder engagement work started at the beginning of the programme and built on work carried out over the last three years as part of the Transforming Community Services programme. We have carried out a systematic and wide-ranging programme of engagement based on an agreed set of principles, as shown in Figure 3-a, and an understanding of who our stakeholders are and how they are best engaged. Figure 3-a: Summary of stakeholder engagement strategy 3.2 Principles for stakeholder engagement Our engagement and communications work is underpinned by a number of principles: 1. We are committed to engaging as widely and deeply as possible, and will seek to ensure those who have attended our events continue to be engaged in our work. We will listen to them, and take account of their views. 2. Our clinical leaders will always talk to local communities to explain our changes as deeply, openly and frankly as they can. They will accommodate local views and contributions, wherever it appears that they will contribute to a better service. 23

25 3. We will put in place arrangements to review the impact of changes from a health inequality point of view. This will include targeted engagement, such as through focus groups or similar. 4. Engagement events will be held in a mix of areas chosen for their contrasting geography and demography, as well as supplemented by other work to ensure the full geographic and demographic diversity of the whole programme area (and any neighbouring areas it impacts on) is covered by representative events. 5. We will be open and transparent, and will continue to hold meetings in public venues wherever practicable and with an open invitation to the public to attend (recognising that on occasion some management of numbers may be necessary for health and safety reasons). 6. We will continue to make documents public, and respond promptly and openly to requests for information. We will also make our documents accessible, and write them in clear language. 7. The programme will make a careful note of specific, individual concerns raised and either pick them up with individuals or groups directly, or report back on action taken to resolve them at future events and in future reporting. 3.3 Identification of stakeholders The programme conducted a robust identification and prioritisation process that identified a wide range of stakeholders who should be involved in the development of our proposals. We considered how to capture the full range of opinions in the development process and how to incorporate different experiences and learning from similar programmes. As part of this process, the programme developed: An extensive stakeholder database drawing on both previous consultations and on stakeholder information already held by the local health and social care organisations. A stakeholder diary in which all external meetings with stakeholders were logged and communication tracked regularly. A meetings calendar in which all relevant stakeholder meetings were logged to ensure engagement with key stakeholders groups such that meetings were well attended and prepared for. 3.4 Stakeholder engagement activities undertaken during pre-consultation Over the past three years there has been extensive engagement and discussion with stakeholders about changes needed to deliver sustainable care. The Transforming Community Services Programme in the CCG was established in May 2013 to: Develop the strategy, principles, priorities and outcomes for future community services Achieve future provision arrangements for community services across the area The phases of this programme included: Initial co-production: Initial co-production to gain insights into the health needs of the population, views from engagement and information from national and local policy. This included a range of clinically led public engagement in each of northern, eastern and western localities as well as events involving system leaders to inform the strategy. Strategy development: The initial work contributed to the draft strategic framework, including principles, priorities and outcomes for community services which was published in May 2014 for a period of 8 weeks of comment prior to revision and finalisation of Integrated, personal and sustainable: Community Services for the 21st Century in September

26 Locality intentions: Three locality projects within the TCS Programme (Northern Care Closer to Home ; Eastern Pathways for the future ; and Western: Your health, your future, your say ) set out their local plans to deliver the strategy for consultation which commenced in September 2014 with decisions made for each locality by mid The strategy and locality intentions were built around 6 strategic priorities for community services developed in response to consultation and which were widely supported locally. These priorities are now expected to guide service delivery. Priority Help people to stay well Integrate care Personalise support Co-ordinate pathways Think carer think family Home as the first choice Service response Statutory services working in partnership together and with the voluntary sector and communities to help people to stay as well as possible for as long as possible Individuals and their families or carers experiencing consistently integrated and joined up care as a key outcome of services An increasingly flexible pattern of provision tailored to needs with greater choice and personalisation Knowledge that when a person accesses healthcare they will receive quality and co-ordinated pathways of care Carers seen as true partners in their key role with services and teams that recognise, identify and support carers in their role Delivery of reliable, safe and resilient models of care to help people remain at home or close to home, including through the use of appropriate technology To inform local stakeholders and communities about the Success Regime and the case for change in advance of formal consultation commencing and hear views a series of engagement events were held across NEW Devon between May and September Most recently, three half-day engagement events were held in key locations in the NEW Devon area on 18 May in Tiverton and Plymouth, and on 13 June in Barnstaple in association with two local HealthWatch organisations, HealthWatch Devon and HealthWatch Plymouth. A total of 265 people attended the events 107 in Tiverton, 83 in Plymouth, and 75 in Barnstaple. Many of those attending represented particular groups who work with the health and social care system, such as local authorities, voluntary groups, and charities. The meetings heard presentations about the case for change and the potential for development of new proposals, and then gathered feedback from attendees on the case for change, the vision, and the programme more broadly. The feedback was collected, analysed, and then reported back to all attendees, with commitments made according to each issue raised, which also then informed the consultation principles. Regular briefings were held with relevant local MPs, and with councillors. Meetings of the Overview and Scrutiny Committees and Health and Wellbeing Boards of the relevant councils were also attended, and briefings on the programme given. 25

27 Following the summer - a further series of events was held with key stakeholders from across Devon were particularly focused in the Eastern area of Devon: Friday 2 September Kenn Centre, Kennford, Exeter Thursday 8 September Beehive, Honiton Friday 9 September Ockment Centre, Okehampton All events were planned in association with Healthwatch, with key note speeches from Ruth Carnall or Angela Pedder and other speakers from across health and social care. Feedback was collated and fed into the programme team. Staff engagement has also been a priority. Senior and clinical leaders from local provider organisations are centrally engaged in this programme and a series of pre-consultation events for staff was held in September This is particularly important and workforce engagement will continue throughout the consultation period, and beyond to ensure the valuable knowledge and experience of staff contributes to the new model of care. 3.5 Key themes of feedback From the themes that emerged during pre-consultation engagement, the following conclusions were drawn. For each, an action was then reported which was taken forward by the programme. CONCLUSION FROM ENGAGEMENT Conclusion 01 There is a strong ambition for local people to be involved in discussing and informing potential future changes to health and social care services, across the relevant areas. This conclusion is evident not just from the number of comments made throughout the themes which underlined the level of interest in local health and social care services, but also more widely from the numbers that attended the events, the liveliness of the discussions at each table, and the time and energy attendees committed to each event, for the duration. The attendees, the communities they represent, and patients and the public more widely, deserve this to be recognised by the programme and deserve to be listened to carefully and thoughtfully as it progresses. COMMITMENT TO ACTION Action 01 The programme is committed to engaging as widely and deeply as possible, and will continue to invite all those who attended these events to be engaged in its work, will listen to them, and take account of their views. 26

28 CONCLUSION FROM ENGAGEMENT Conclusion 02 These engagement events are often not attended by people from certain parts of certain local communities, who nonetheless may be affected by any potential changes to services. There is therefore a risk that their views will not be heard. This conclusion is clear not just from comments directly made in this regard, but also from comments made about the I statements, in which attendees expressed concern that the statements only seemed to represent a few voices that were not completely representative of the full social and demographic profile of the NEW Devon area. There was therefore concern that certain specific communities, or pockets within certain communities, would be left out of engagement activity by the programme. Conclusion 03 The area covered by the programme is very different, geographically and demographically, from one locality to the next. The needs and services required by each local area therefore need to be different. The location of the events in Tiverton, Plymouth and Barnstaple in part emphasised this point, as attendees had come from a mix of rural and urban locations, and brought comments about this to their tables. Clearly the health and social care services needed in less populated rural areas are different to those needed in more densely populated urban areas, and this has specific impacts too, for example on transport (see also below). Conclusion 04 There needs to be an honest debate about issues such as finance, so that people feel the programme has engaged with them in an honest, open, and transparent way. This was not only acknowledged by presenters at the events as this issue came up, but was reinforced in feedback at the end and in the general tone and output of the events. This report itself is an example of how the programme intends not only to engage openly, but then be transparent about what it has found, what it is reporting back, and what it intends to do about it. COMMITMENT TO ACTION Action 02 The programme has carried out an equality impact assessment and will continue to analyse the impact of change throughout the process. Gaps in engagement for people with protected characteristics or protected characteristics identified in this way have been addressed in planning the consultation. Through work with Healthwatch there have been discussions on how best to connect with hear voices of people who may otherwise be hard to hear and a series of focus groups will now take place in the consultation. In more general terms the consultation plan is designed to be extensive to create maximum opportunities to engage the wider social and demographic profile. Action 03 Engagement events will be held in a mix of areas chosen for their contrasting geography and demography, as well as supplemented by focus group work as previously mentioned, to ensure the full geographic and demographic diversity of the whole programme area (and any neighbouring areas it impacts on) is covered by representative events. Action 04 The programme will be fully open, and transparent, and will hold meetings in public venues wherever practicable and with an open invitation to the public to attend (recognising that on occasion some management of numbers may be necessary for health and safety reasons). It will also make documents public, and respond promptly and openly to requests for information. On the specific question of finance, the programme will continue to make clear this is a key issue for the situation the local area finds itself in and that this in particular needs to be resolved. 27

29 CONCLUSION FROM ENGAGEMENT Conclusion 05 Local services should not just be about providing care when a person falls ill, but should be about encouraging healthier living, so that ill health is prevented in the first place. This has been a strong theme both of these events and of earlier engagement around the case for change. Local people understand that the NHS and social care services are not just there to pick up the pieces when they fall ill, but are there to encourage healthier lifestyles and healthier living too. Conclusion 06 A number of specific, local issues may be raised by the programme and these are of concern to local communities. These include transport and travel times, the development of community hubs, and money raised by League of Friends organisations. Inevitably a number of more specific, local issues were raised by attendees as is the nature of these events and these were noted by those gathering feedback. COMMITMENT TO ACTION Action 05 The programme will continue to emphasise that successful healthcare is about successful healthy living and successful prevention of ill health; especially through the working partnership it has with local authorities and other organisations with responsibility for local public health. Action 06 The programme will make a careful note of specific, individual concerns raised and either pick them up with individuals or groups directly, or report back on action taken to resolve them at future events and in future reporting. 28

30 4 Context NEW Devon is located in the South West of England and covers a population of 883,000 people iii. It includes the city of Plymouth (population c.250,000) in the west, the city of Exeter (population c.125,000) in the East and the large market town of Barnstaple (population c.24,000) in the north iv. This large geographical area (2,330 square miles) v includes many smaller towns and villages and rural areas including the Dartmoor National Park (369 square miles) vi. Health and social care spending on the residents of NEW Devon was 1.9bn in 2014/15. Health services in NEW Devon are commissioned on behalf of local people by Northern, Eastern and Western Devon Clinical Commissioning Group (NEW Devon CCG) and NHS England. NEW Devon CCG is the largest CCG in England, by the size of the local population vii. Since April 2015, health and social care services in Western Devon have been jointly commissioned by Plymouth City Council and NEW Devon CCG. Social care services in Northern and Eastern Devon are commissioned by Devon County Council. NHS England commissions specialist services such as major trauma, kidney transplants, eating disorders, plus primary care services whilst NEW Devon CCG commissions all other health services including mental health, hospital and community services (in partnership with Plymouth City Council in Western Devon). In 2014/15, in NEW Devon, there were around 5.5 million consultations at GP surgeries viii, 838,000 contacts with community staff, 190,000 attendances at A&E, 105,000 planned operations performed and 83,000 emergencies that required hospitalisation ix. As shown in Figure 4-a, there are a range of organisations providing health and social care services in a number of acute, community and mental health sites in NEW Devon. Figure 4-a: Main acute, community and mental health sites in NEW Devon 29

31 Health and care services are provided by a range of organisations: There are 121 GP practices, 130 dentist practices, 201 pharmacies, 112 opticians and many voluntary and community sector groups, which are all run independently and provide a range of primary care services x. The GP out-of-hours service is provided by Devon Doctors. There are two mental health providers which provide inpatient mental health facilities, community mental health teams, liaison psychiatry into hospitals and a range of specialist mental health services. There are three community providers which deliver a range of services including community hospital beds, stoke rehabilitation beds, urgent care, diagnostics, outpatients and minor surgery and community teams including community nurses, district nurses, health visitors and a range of therapists. There are also 20 community hospitals in NEW Devon. There are three hospital trusts providing acute hospital services including A&E, emergency and elective (planned) surgery, acute stroke services, consultant-led maternity services and inpatient children s services plus a range of specialist services. Ambulance services are provided by South Western Ambulance Service NHS Foundation Trust. 30

32 5 Case for change A case for change was published as part of the Transforming Community Services Strategic Framework in October This has now been updated as part of the development of this pre consultation business case. The updated case for change covers all aspects of health and social care in NEW Devon; this section of the pre consultation business case draws out those areas of particular relevance to these proposals. The case for change was developed by local clinical and operational leaders across health and social care with involvement from the public and patients. The key elements of the case for change relating to this pre consultation business case are set out below. Further detail is available in our full case for change, which was approved by the NEW Devon CCG Governing Body on 3 March 2016 and published as a standalone document which is available on our website at ( involved/get-involved---/community-services/changing-community-services-for-the-future-- document/101240). 5.1 The health and care needs of local people There are three distinct populations in NEW Devon xi. In Western Devon, people mainly live in and around the city of Plymouth and are relatively young (near the England average), more deprived and more urban than the people in the East and the North. The people in Eastern Devon are comparatively much older, more affluent and live in more rural locations. Eastern Devon has a higher proportion of very old people (aged 85+) than almost anywhere else in England. The people in Northern Devon are also comparatively old (although with a lower proportion of very old people than in the East) with pockets of deprivation, especially in Barnstaple. People in Northern Devon tend to live in more rural locations. These different sorts of people mean that there are different health needs and health outcomes across NEW Devon. Health outcomes are generally good in Northern and Eastern Devon although vaccination coverage is poor and infant mortality is high. In Western Devon, life expectancy is lower than the England average, mortality rates (number of deaths per thousand people) are high and smoking and alcohol consumption are higher than the England average xii. As shown in Figure 5-a, average deprivation levels across NEW Devon are lower than the national average; there are startling differences between areas. Western Devon (particularly Plymouth) has some of the most deprived populations in England, whereas Eastern Devon has none. For example, a person living in Ilfracombe is expected to die more than fifteen years earlier than a person living a twohour drive away in Newton Poppleford and Harpford. People living in poorer areas not only die xiii sooner, but spend more of their lives with disability an average total difference of 17 years xiv. 31

33 Figure 5-a: Deprivation levels in NEW Devon Many people in NEW Devon are generally healthy and only need health and social care occasionally. However, some groups of people need more care than others - this is common across England and is influenced by factors such as a person s age, underlying health and income. Consequently, around 40% of local people use almost 80% of health and social care in NEW Devon xv. Figure 5-b: Spend by population segment 32

34 Looking at local people in this way means that health and social care can be targeted at those who need it most, and that services can be designed for people with different needs. 5.2 Local people are living longer which means they need more care and treatment More than 1 in 5 people in NEW Devon is over 65, which is higher than the national average, and this will increase to be almost 1 in 4 people by 2021 xvi. The number of very elderly people is also high, with 3.1% people in NEW Devon over the age of 85 compared to 2.3% on average across England xvii. More of these older people live in Eastern Devon and fewer in Western Devon but all areas are seeing growth in the number of older people, in common with the rest of England. For local health and social services, an ageing population is hugely significant because older people are more likely to develop long term health needs such as diabetes, heart disease and breathing difficulties, and are more at risk of strokes, cancer and other health problems xviii which together means people tend to need more care and more treatment as they get older. In NEW Devon, almost 40% of health and social care expenditure is used for people aged over 70, even though they represent only 15% of the population. One third of the hospital beds in NEW Devon are occupied by someone over the age of 80 and two thirds of the people staying more than 10 days in hospital are over the age of 70 xix. There are also around 8,500 people in residential and nursing care homes in NEW Devon (half are aged over 85) xx. An ageing population also means increasing incidence of dementia: approximately 2% of the population in NEW Devon have dementia although only half of these have a formal diagnosis xxi. About 20% of emergency admissions to hospital have dementia and at least 2/5 of these are preventable with appropriate community support xxii. 30% of all patients in hospital beds have dementia. Given the number of people with dementia in NEW Devon, there is a real opportunity for local services to develop world class services to meet their needs. Older people also find it difficult to access services (especially if they have to travel long distances), are likely to be living with more than one long term health need and may also be carers for another older person in poor health. It is important local health and social care services need to prioritise high quality and accessible services for the older population. 5.3 More local people are living with long-term conditions and their needs are complex Although many people in NEW Devon are generally healthy, of the total population there are 280,000 people (including 13,000 children) with one or more long-term conditions and a person with a longterm condition as well as the impact on their lives; generates healthcare costs up to twice as much as a generally healthy person xxiii. A long-term condition is a health problem that is present for over a year. As shown in Figure 5-c, many local people have one or more long-term conditions with high levels of asthma, chronic obstructive pulmonary disorder (COPD), hyperthyroidism (metabolism), diabetes, chronic heart disease, atrial fibrillation (irregular heartbeat which can cause strokes) and hypertension (high blood pressure) xxiv. As may be expected, given the nature of the population, there are a high number of people in NEW Devon who have had a stroke over 1,800 in 2014/15 xxv. 33

35 Figure 5-c: Disease prevalence in NEW Devon As the population gets even older, more people are likely to have a long-term condition xxvi. This is a challenge for health and social care services because people with one or more long-term condition need high quality, consistent and integrated health and social care. Services are often not set up to provide this care they are set up to care for separate illnesses rather than deal with people s overall needs. People with a long-term condition are also likely to have a long term informal carer (such as a spouse or grown-up child) and these carers also need to be supported. Often people with one long-term condition can live with only a little support from health and social care services. People with more than one condition, or who have a long-term condition and then something else happens to them (such as having a fall), have more complex needs. Health and social care services need to be designed to respond to these needs. 5.4 Care needs to be more person-centred and co-ordinated especially for people with more than one long-term condition Although emergency admissions to hospital in NEW Devon are presently similar to other comparable populations, by population growth alone if nothing else changes, emergency admissions are projected to rise by 30% over the next five years. By 2021 there will be 37,000 more emergency admissions to local hospitals xxvii. Many of these admissions would be preventable through new ways of working and new models of care and we need to act now to make the change through a less reactive model which is better for patients and more sustainable too. Advances in technology mean that people are increasingly able to take responsibility for their own care. Information is much more available and technology means that treatments such as oxygen treatment, nutritional support (artificial feeding) and continuous glucose monitoring that used to require a hospital visit can now be done in the home. Assistive technology, from simple can openers to high tech equipment that monitors vital signs, will play a major role in the future, helping to support people to live independently and communicate with care staff. When people are involved in managing and deciding about their own care and treatment, the evidence tells us they have better outcomes, are 34

36 less likely to be hospitalised, tend to follow appropriate drug treatments and avoid over-treatment xxviii. This is particularly important for end of life care where, in NEW Devon, only 25% of local people die at home xxix whilst research shows that two thirds would like to do so xxx. People have said time and again that local services are disjointed and not focused clearly and exclusively on the person. This creates unnecessary duplication, fragmented services, poorer outcomes and exhausted carers. People have to report what has happened to them as a result of their long-term condition many times over. They also receive multiple home visits from different care staff, when often one should be enough. One aspect of Your future care is multi- skilling of staff and this would also have benefits in more co-ordinated care. It is also currently difficult to share clinical information between teams meaning people are being seen and treated by care professionals who do not know their medical history and care professionals become frustrated at not being able to flexibly provide the care that is required xxxi. Disjointed and reactive care is a particular issue for people living with a long-term condition. Moving constantly in and out of hospital means many are unable to lead normal lives. Around 1 in 3 of people are living with a long-term condition. It is known that people with one long term condition can often live with it with a little support but the current experience is that patients in NEW Devon report that they have not had enough support from local services to help them manage it xxxii. People find it hard to get the care they need when they need it, and this then has a knock-on effect on other services for example forcing them to go to hospital as the only other option available to them. Yet we know that positive and pro-active approaches to care could avoid or reduce these hospital stays and improve or maintain people s wellbeing and long term condition management. 5.5 Equalities and inequalities analysis Throughout the process and appraisal of options the CCG is having regard to its obligation under the NHS Act to reduce inequalities of access and outcomes. These issues are embedded within the evaluation criteria and form an important consideration for the CCG in making decisions on changing service provision. Under the Equality Act 2010 a public authority (and a person exercising public function) is subject to the Public Sector Equality Duty. At this early stage pre consultation an equalities and inequalities analysis was conducted to inform the proposals and ensure that appropriate consideration has been given to the impact of the options under consideration on protected characteristics and protected groups within the context of the Public Sector Equality Duty. It was determined that none of the evidence considered at this point identified differential or disproportionate impact on people or groups with protected characteristics in the scope of the Assessment. This means for all 15 options under consideration, none were identified as discriminating against vulnerable populations. If an agreed option for Eastern community bed reconfiguration is decided following consultation, the impact of the agreed option on protected characteristics or groups will be further tracked pre and post implementation, before wider change is rolled out across NEW Devon. 5.6 There are too many people in hospital beds who don t need to be there When people go to hospital in NEW Devon, they tend to stay in hospital for a long time and have difficulty getting out of hospital and back home. Every day 500 people are in local acute hospitals and 100 are in community hospitals when they could be cared for elsewhere xxxiii, as shown in Figure 5-d. Half of all people admitted to local acute hospitals stay longer than 10 days xxxiv and around one third of people are medically fit to leave hospital but can t xxxv. This is a particular issue for people over the age of 70 xxxvi. It is the same in the community and in mental health hospitals. Over half the people in NEW 35

37 Devon who are fit to leave the community hospital have been waiting to leave for at least four days xxxvii. Approximately 15% of all hospital beds are occupied by people with dementia who are medically well enough to leave the hospital. An estimated 36m is spent p.a. on admitting and keeping people with dementia in hospital when they don t need to be there. Figure 5-d: Number of people in hospital beds in NEW Devon who could be cared for elsewhere When people are ready to leave hospital, local services are often not ready to look after them, so they have to stay in hospital longer, as shown in Figure 5-e. 36

38 Figure 5-e: Reasons why people fit for discharge remain in hospital Some of the main causes of delay are people waiting for health care services in their homes, for a bed in a community hospital or for packages of social care xxxviii. Part of the reason people end up waiting for a bed in a community hospital is that the services are not structured in a way that enables people to go directly home. Add to that the fact that these services are often unable to accept transfers or set up care packages at weekends, so people who are medically fit are stuck in hospital. An estimated one third of the people experiencing delayed discharge also have dementia and care homes are often xxxix unable to accept people with dementia, especially at short notice. Delays in discharge contribute to a poor experience for local people especially at weekends and can have a lasting negative impact on independent living. It also represents poor value for money because hospital services are being used by people who are medically fit to leave the hospital. The longer people stay in hospital, the more likely they are to get complications. For example, one study has shown that every extra day in hospital reduces the muscle function of older people by 5% xl. It is also expensive it costs 250 per day xli to care for someone in an acute hospital bed and this money could be better used elsewhere. 5.7 Space in community hospitals is not being well used As shown in Figure 5-f, although the number of community hospital beds in NEW Devon has already been reduced as part of earlier programmes, there is still a lot of space in community hospitals that is not being used. In many community hospitals, up to half the bed spaces are not used, and, overall, one third of the total bed space is either under-used or empty xlii. 37

39 Figure 5-f: Capacity in community hospitals in NEW Devon (June 2016) This space could be used for something else, such as other services or community spaces. There is also an opportunity to consolidate some of this space and spend the money elsewhere. 5.8 There are also difficulties with recruiting and retaining staff The workforce in NEW Devon is getting older which is a problem because the NHS and social care lose trained and experienced workers when people retire. For example, 1 in 3 GPs xliii and 2 out of 5 nurses in practices, the community, mental health and social care are over the age of 50 xliv. As a result, the NHS and social care in NEW Devon is likely to face the retirement of many of its most experienced members of staff in the next five to ten years. This challenge needs to be urgently addressed by creating new roles and thinking about new ways of working. In addition, increased workloads in primary care which is already under pressure can lead to recruitment and retention problems. There are also high levels of vacancies, turnover and sickness amongst the workforce in NEW Devon. This is a problem because of the costs of recruiting and training new people, and covering vacancies with temporary staff. It is also a problem because of the pressure it puts on other staff to fill gaps and train new staff members, and the issues that arise from new members of staff who may not know local policies and processes. Sickness and turnover is particularly high for care workers and clinical support staff in NEW Devon with 1 in 5 leaving their job each year xlv. There are high vacancy rates for registered nurses in the community with 10% of posts vacant whilst a recent survey of GPs in the South West region of England revealed that 64% of GPs aged years intended to quit direct patient care within the next 5 years xlvi. 38

40 5.9 Financial considerations Although the Government s pledge to protect health budgets means they have fared better than some other areas of public spending, increases in health funding in the coming years are likely to be flat, in NEW Devon as much as anywhere else xlvii. In addition to this, the financial pressures caused by the increased burden of more ill health and the need to keep pace with new technology means that xlviii funding over and above inflation of 2.6% would be needed each year to deliver current services. Local health and social care organisations are therefore facing a financial shortfall in 2015/16 of 122m (4% of funding), rising to 384m (14% of funding) in 2020/21 if nothing changes xlix as shown in Figure 5-g. Figure 5-g: Financial challenge across NEW Devon to 2020/21 m 5.10 Summary The needs of local people are changing, the way in which health and social care is provided is changing and there are increasing financial pressures. It is tempting to argue simply that an injection of money would solve all the problems, but it would not. Even good services now will not be sustainable without change, and redesign is essential to maintain and improve clinical safety and quality, recruit and retain a sufficiently skilled and experienced workforce, and maintain patient/client satisfaction. Current ways of delivering care harm people and waste money - local health and social care services cannot continue to provide care as they do now and doing nothing is not an option. There is a growing and rapidly aging population with increasing frailty or complex needs There are pressures in relation to the money and the workforce There are projections of increased emergency admissions to hospital if no change is made There are already people in acute hospital waiting to move to a community hospital There are also people in all hospitals waiting for a package of social care There are people in hospital whose discharge home or to a nursing or care home is delayed There are beds that are empty as well as people who are in beds who don t need to be 39

41 Bedded hospital care will not provide an appropriate solution to address the above problems. In the pages that follow a future model that is less reliant on bedded care and designed to unlock these problems and enable resources to be better used is described. 40

42 6 Vision and models of care 6.1 Process for developing vision and models of care Local experts including hospital doctors, GPs, nurses, other clinical professionals and patient representatives have been meeting to refresh the model of care, in the first instance focussing on the model of care provided for the frail and elderly, which is currently over-reliant on care in a hospital bed. The clinical evidence is clear that prolonged hospital stay increases long term physical and psychological dependence, which is why addressing this model of care is a key priority. Their discussions have been informed by input at key meetings from members of HealthWatch and the relevant local authorities, and by a separate series of meetings set up by the Patient Public Engagement Committee. This work builds on the vision and care models described in the Transforming Community Services strategic framework. 6.2 Principles The vision set out in the Transforming Community Services Strategic Framework focussed on a series of commissioning principles. These principles have been built upon by local clinicians to generate a set of clinical design principles. These are being used to shape the services that will make up the new model of care, and also to understand where existing services are configured to deliver care in the way we would wish. 1. Have collective ownership of delivery as a system 2. Focus on prevention, physical and mental health and well-being, individual responsibility and support 3. Organise services around the needs of individual as identified in collaboration with them 4. Regard an inappropriate referral as well as an inappropriate place of care as a failure of the system 5. Strive to treat people in the lowest intensity setting, minimising the use of beds by eliminating periods of stay that add no value to the individual and gearing towards getting people home 6. Observe consistent standards across 7 days for emergency NHS care in hospital and community settings 7. Maintain a safe level of staffing in all care settings to ensure effective acute services 8. Make use of a flexible workforce working at as high a professional level as possible 9. Deliver services as locally as practicable within the constraints of quality and affordability 10. Live within our means to deliver financial balance 6.3 Focus on population segments The population of Devon is not uniform and the needs of different groups of population have been identified and examined. Two key segments addressed are the frail elderly and those living with dementia. These two groups are small groups overall but have high needs and consume significant resources. They are identified in Figure 6-a. 41

43 Figure 6-a: focus population segments In reviewing the care needs of these segments it was apparent that community bed usage was a key area for review. Current usage of these beds is shown in Figure 6-b. Figure 6-a For the frail and elderly, and particularly for those with dementia, it was felt that home based care was clinically more appropriate, less likely to result in long term dependence and should be the default option. The new model of care was developed to deliver on this aim. Typical patient profiles are provided in Figure 6-c & Figure 6-d. 42

44 Figure 6-b: Key users of community beds in current model of care Figure 6-c: Typical Frail / elderly patient 43

45 Figure 6-d: Typical frail / elderly with dementia patient 6.4 The model of care There are currently several issues to fix in the treatment and care of frail / elderly and those with dementia, outlined in Figure 6-e. Figure 6-e: Issues to fix in treatment and care of frail / elderly and those with dementia 44

46 We are developing a more fully integrated model of care that focuses on addressing the total health and social care needs of people and their families. We will intervene or provide support earlier, to prevent and/or delay ill health and to deal with it more responsively when illness does occur. This means making sure we also address the most significant wider determinants of health like social deprivation, loneliness and poor mental health. This includes working alongside the carers, voluntary organisations and other community organisations. The increased focus on prevention will be delivered through locality-based multi-agency teams who will have a specific role around prevention and wellbeing working with partners in the voluntary sector. Within this broader context one of our key aims is to reduce the dependence on bed based care as the default. For the elderly, particularly those with multiple conditions and/or dementia, admission to a bed results in deconditioning; the loss of physical and psychological reserve. This decline is difficult to reverse and increases long term dependence. The new model of care will be structured to ensure admission to a hospital bed can be avoided unless absolutely necessary and length of stay minimised to reduce the long term impact of hospitalisation. We have acted with a view to enabling patient choice in the model of care; the Transforming Community Services programme included a shift in emphasis to personalisation, choice and control and this area was discussed during the range of engagement in this programme. Patient choice has already increased with the drive towards Integrated Personalised Commissioning and Personal Health Budgets where the scope and uptake have increased and the role of personalisation remains central to future provision. In seeking to reduce unnecessary bed usage in the future, frail/elderly patients will: Be supported to maximise their independence and be as involved in decision making about themselves as they wish Be helped to access social networks, the voluntary sector and support to carers, to support health and well-being and also support carers in their roles Have an individual assigned to them who is responsible for coordinating their care both in and out of hospital. That person will be someone who is trusted, empathetic, well connected to the rest of health and care services and able to commit resources. They will work with the individual to develop an advance care plan to identify how to avoid hospitalisation and also to cover eventualities including death Have access to a rapid response team who can come to their home to assess and stabilise their condition avoiding the need to go to hospital in the first place or return, underpinned by a single point of access and access to single care records In the event of a hospital admission the individual will have a discharge plan developed on day one; by day two the individual will have a mobility assessment and plan for reablement to get home (with appropriate support) as soon as possible Where needed, modifications will be made to the home to permit the rapid return home This is supported by: A common offer of domiciliary care will be made available to those who need it Multi-disciplinary teams will work across all settings of care. The provision of this model of care envisions different settings: 45

47 To the maximum extent possible, support and care will be provided in the home either through someone visiting, communication by telephone or use of technology (including tele monitoring and telecare) Where it is not practical to deliver care at home, care will be provided in the community for a face to face interaction or access to therapy Only when necessary would patients travel to hospitals. Figure 6-f outlines proposed interventions to avoid hospital admissions, reduce LOS, optimise the discharge process and facilitate reablement for a typical elderly / frail patient. 46

48 47 Figure 6-f: New Model of Care- suggested interventions in hospital, out of hospital, at home for elderly / frail

49 A number of requirements to implement interventions have been identified, as outlined in Figure 6-g. Figure 6-g: Requirements to implement New Model of Care Three key interventions have been agreed to deliver key aspects of the new care model. These are: Comprehensive assessment. Identifying people who are frail or pre-frail, and therefore at risk of admission to hospital; put a care plan in place, owned by the individual, that outlines potential avenues for escalating care when it is required. Single point of access. When additional support is needed, a single point of access, connected to a comprehensive care at home service, will help to support people to remain at home with support, rather than being admitted to hospital. Rapid response (care at home). Where hospital admission is unavoidable, coordinated discharge, connected to the same care at home service will ensure that hospital discharge is supported to occur as soon as it is clinically safe, with additional support at home including health and care workers delivering rehabilitation alongside traditional care. Comprehensive Assessment The aim of assessment is to identify all people at risk (the frail and pre-frail), using tools such as the Devon predictive score or electronic frailty score, and ensure there is an agreed escalation plan in place. Assessment and planning should be supported by trained staff who may or may not be clinical, recognising that non-clinicians may obtain a more accurate picture of need Assessors will coordinate available sources of formal and more informal information including GP records, discussion with carers/family, and other agencies irrespective of sector 48

50 They would help connect with voluntary groups and work with social prescribing to ensure the frail and elderly were supported to remain well and retain their independence Assessments and plans would be reviewed after any major event such as change in circumstances or hospitalisation By basing assessors as part of a local community team serving a population of around they bring together the assessment of need and the coordination of the community activity that creates resilience Single Point of Access The single point of contact is required to make the accessing care at home as easy as care in a hospital It should be available 24/7 Referrals can be made by any care service including but not limited to domiciliary care teams, community nurses, GPs, paramedics, mental health teams, care homes and hospital services (ED, Rapid discharge teams, elderly medicine etc.) o Referral is a clinical conversation focussed on patient need. Referrals are received by a clinician (nurse, therapist, doctor) with: o core knowledge and specific training in triage, o access to the comprehensive assessment record. The service will determine the most appropriate first responder for the patient, and ensure this is timely and within 2 hours of referral. Once the referral is made they will assume responsibility for liaison with the patient and/or family Rapid Response (Care at Home) The rapid response multidisciplinary team will include: o Community nursing o Therapists o Health and Care assistants o Access to medical input o Prescribing appropriate to scope of practice o Mental health workers o Administration support o Domiciliary care workers While most care will be delivered in patients homes, the rapid response team will also support patients in residential and care homes The team will undertake an initial assessment of need and then institute a package of care at home including nursing, therapies, domiciliary support and night sitting Where care needs exceed the capability of the team they will escalate directly to the most appropriate level of care, including acute sector. 49

51 The team will ensure the patient s lead medical carer (usually their GP) is kept informed of progress, but the responsibility for care, including escalation to hospital based services as required, will remain with the team for up to 72 hours Care may be de-escalated sooner if no longer required The team will work alongside existing care providers to coordinate their input Where a package of care is already in place the team will support and build on this rather than substitute new care arrangements, so as to maintain continuity as far as possible The same team will support discharge from hospital as soon as this is clinically safe, accessed via the single point of contact. This will result in a managed transition between care settings. Home care workers (whether delivering health, personal or domiciliary care) will work with patients to achieve specific rehabilitation and reablement goals Work will continue over the coming months with a wide range of groups to develop the new services and ways of working that will provide safe, reliable care at home and make this rather than admission the default option. These groups will include the public, clinicians, local authority, and the voluntary and third sector. Through this work we will create greater clarity and confidence for patients and professionals that care will be readily accessible, resilient and organised around the needs of the community it serves. 6.5 The role of hubs Time and again health and social care professionals and the public have said that current care is fragmented, that services need to be joined up and where possible provided in, or near to, the places people live. In modern day healthcare, hospital is no longer the first choice for care. Instead services are increasingly focusing on helping people to stay as well as possible for as long as possible and independent in their own communities. Working in tandem with GP s and other primary care providers, social care, public health, mental health, community and voluntary services and communities themselves, the local healthcare system has the potential to design place based integrated prevention and care that will improve and maintain health, physical and emotional wellbeing and care within communities. We have described a hub as a focal point for modern day integrated care. It could be building based in an NHS or public service building such as a hospital or General Practice, or an alternative local building. Or the hub could be a network of professionals and communities working together on place based improvements. The core purpose is to: Positively contribute to improved outcomes at a place based level (public health, NHS, social care and locally defined outcomes). Reduce the need for people to travel to a large hospital by bringing a carefully planned mix of sustainable clinical services closer to home Ensure pro-active responses to people assessed as having higher level of health needs to help them remain as well as possible at home Offer a point of access to signpost people to preventive and pro-active care and a point of coordination for delivery of services 50

52 6.5.1 Examples of what is currently in place or underway In Leicester, the introduction of four community hubs have provided improved access of over 1700 additional appointments per week (details found in Figure 6-h): Additional GP and nurse appointments during evenings, weekends and bank holidays Appointment with a GP or an advanced nurse practitioner can be made by calling or walk-in to any of four hubs. The service has been arranged for Leicester City patients by three federations of Leicester City GP practices (Millennium Federation, Across Leicester Health and City Central), supported by NHS Leicester City Clinical Commissioning Group and NHS England. Figure 6-h: Community hubs in Leicester City Locally much of the early work has been building focused but as thinking develops the opportunities of place based networked hubs will also be taken into account. In East Devon project groups are in place in: Budleigh Salterton Crediton Moretonhampstead 51

53 These groups have a focus on the local health needs analysis from the JSNA, outputs from community engagement and knowledge of local services and circumstances to understand what will be required of each hub in the future. There have also been productive early discussions in Axminster. There is a strong focus on prevention and wellbeing, as well as integrating clinical, care and voluntary services with a social element to encourage communities to engage and stay well. Communities are playing a key role. The Woodbury, Exmouth and Budleigh area, the Community Board made up of stakeholder across health, social, voluntary, other statutory, private sector and members of the community have been meeting to discuss the local priorities. Similarly the parish council in Moretonhampstead and working group in Crediton are gaining a better understanding of community assets and how they can address local needs. In North Devon the Torrington hub is already established with a range of services including mental health and the voluntary sector, and a steering group is established through the town council to improve access to health and social care within Torrington and the further development of the Health and Wellbeing Hub. Similarly in Ilfracombe, which already hosts a number of clinics, development work is underway for the hub. For North and East a Hub Strategic Oversight Group which involves providers and stakeholders in the area has held meetings and workshops to advance hub development. In the West, particularly in Plymouth the driver is inequality, access and integration including linking the hub model with the development of at scale general practice. The council and CCG successfully partnered a bid to the Cabinet office to be part of the One Public Estate initiative which aims to join up developments around public sector land and property. Plans are now in development for taking this forward in the city to improve health outcomes. In the more rural aspects of the West the focus is more consistent with the North and East hub development. The benefit of the engagement on hubs that it makes the most of the capacity, innovation and passion ( renewable energy ) of local people for their own communities. Residents and front-line workers have a detailed understanding of the assets and needs of their areas. The partnership is not just with providers, it s a partnership with local people and local businesses, and it is co-designed and co-owned. If people are to be supported to take control over their own wellbeing, it has to be at the level they can connect with, which is often in the interactions they have in their own communities. 52

54 7 Impact of the new model of care 7.1 Outcomes and patient impact For patients, the main impact of the new model of care will be to enable them to live more independently with fewer occasions of being admitted to hospital and stays that are reduced in length to the absolute minimum required for medical reasons. Delays in discharge returning to their own beds will be eliminated. A greater proportion of those who have been admitted to hospital will return to full functioning. As the new model of care is developed with communities and local clinicians specific impacts and improvements in outcomes will be measured. These to be developed KPIs will form a fundamental part of the gateway process for implementation. They will include the national and local outcomes in line with the health and wellbeing strategy and CCG plans, as well as delivery in relation to the local system I statements, developed jointly for health and social care across what is now the STP area, which set out the experiences individuals should be able to expect when using health and care services. These are: I can plan my own care with people who work together to understand me and my family The team supporting me allow me control and bring services together for outcomes important to me I can get help at an early stage to avoid a crisis at a later time I tell my story once and I always know who is co-ordinating my care I have the information and the help I need to use it, to make decisions about my care and support I know what resources are available for my care and support and I can determine how they are used I receive high quality services that meet my needs, fit around my circumstances, and keep me safe I experience joined up and seamless care across organisational and team boundaries I can expect my services to be based on the best available evidence to achieve the best outcome I will take responsibility to stay well and independent as long as possible in my community There will also be specially identified Benefits Criteria and KPI s for the new model so that the impact of the change is clear and clinicians, patients, carers and the public can be assured the new model once introduced is meeting patient needs and achieving quality, efficient and value for money services. In the design of a new model of care the experience of North Devon (see Section 8.1) will be taken into account and an impact of a similar order of magnitude is expected. However the new model of care work will need to take into account local variances in need and environment, and therefore the Northern Devon experience is intended to be illustrative. 53

55 7.2 Finance NEW Devon health and social care organisations are facing a financial shortfall in 2015/16 of 122m (4% of funding), rising to 384m (14% of funding) in 2020/21 if nothing changes. Local clinicians and finance leads have worked together to understand the impact of the new model of care overall on activity and therefore on cost. Implementing the new model of care is forecast to deliver gross savings of m, mainly from reductions in length of stay in beds in acute and community hospitals, a reduction in emergency activity, a reduction in continuing care and promotion of excellent care initiatives in social care. The net savings from the new model of care will be 87.5m m. This is shown in Figure 7-a. Figure 7-a: Forecast to deliver savings Between 20.6 and 34.3m will be reinvested in community services and between 87.5 and 103.6m will contribute towards reducing the financial deficit ( 122m in 2015/16). Most of the reinvestment in community services (between 20.6 and 34.3m) will be on staff who will move from their current roles to new roles within the new model of care. More specifically, the financial impact of the changes in community beds in Eastern Devon will deliver gross savings of 4.7m - 7.0m, resulting in net savings of 2.8m- 5.6m based on the potential to reduce 71 beds in Eastern Devon at per bed day with 20-40% reinvestment ( 1.4m - 1.9m); these figures are based on detailed costings of actual beds in Devon and conservative estimates of reinvestment requirements based on experience in Devon. Clinicians working together in the New Model of Care group overseen by the Clinical Cabinet determined that there was an opportunity to reduce the number of community beds from 143 to 72 in Eastern Devon. This change will represent a shift to a level of beds per head that has already been achieved in Northern and Western Devon and has been endorsed by the clinical cabinet as being achievable. 54

56 The Finance Working Group (comprising FD s of the CCG and NHS Trusts and FTs) has identified that by making change: each bed reduced will bring savings of 65-99k per year in gross terms based on costs of per bed day and 90% utilisation (current occupancy rate is in excess of 90%) these figures are based on detailed costings of the affected beds in Eastern Devon; a reinvestment rate for the new model of 20-40% per bed reduced has been used as a conservative marker, noting North Devon s experience was that a reinvestment level of 15% was sufficient to safely deliver bed reductions. The current length of stay in community hospitals is approximately 30 days. In the new model of care the anticipated length of stay will be significantly reduced (circa 10 days) meaning that the remaining bed complement will accommodate much more patient activity. It is anticipated therefore that more patients can be treated in the new model, both in and out of hospital, for less money and with fewer beds. Timescales for the release of the savings and occurrence of costs relating to the reinvestment When community beds close, there is a simultaneous redeployment of the staff to their new environment, and any spare staff are redeployed to vacancies elsewhere, which then help to further cut agency costs. Local experience indicates that as soon as consultation is launched, it is very difficult to retain staff in community hospitals, and this forces the pace of the change. It is envisaged that the whole change that forms the subject of this consultation once decisions are made will happen over the Summer of 2017, so there will be a part year effect in 2017 and full year effect for all subsequent years. Transitional revenue costs for re-training, recruitment, relocation, redundancy The training requirements consist of: I. re-orientation of staff to work in their new environment and II. the change in culture that comes with the setting of care. Training is provided in-house through clinical trainers already within the organisation. Local staff turnover rates and current vacancy levels should provide sufficient opportunity to avoid any redundancy costs. Our New Model of Care is also enabling new ways of working that are building on the opportunities we already have and developing these further as they embed. Double running costs As described above, there will be no double running costs. Capital impact The New Model of Care is to provide most care in a patient s own home so that care provision does not require hospital space. Currently, many community staff provide home-based care and services, but come together for MDT meetings at GP practices or in other community premises and this will continue as a result of the change covered by the proposed changes. More detail on the financial impact can be found in Appendix Workforce We have a large and dedicated workforce delivering care to the people and patients of NEW Devon. They work hard to provide good care and high quality services. However, in order to deliver future transformation, significant changes in the workforce will be required. Changes to how and where care 55

57 is delivered will require additional staff and new roles, as well as requiring existing staff to work in different ways and potentially in different places. There will be particular emphasis on working together in an integrated way, building on the good practice which is already evident in parts of NEW Devon. There will be more seamless working across places of care with a focus on preventing admission to hospital, and supporting rapid discharge after appropriate periods of in-hospital care. More people will work in person in the home, remotely in the home (using technology to communicate with people) and in health and social care facilities outside the home. However, the focus will become more towards caring for people in their own homes. The overarching objective is to create a modern workforce fit for a 21 st century health and care system. A key point from previous consultations raised by members of the public, staff and scrutiny, has been how the workforce will be supported and engaged in delivering new models; how recruitment challenges will be addressed and how proposals and strategic plans will translate into reality for patients and the population. To make sure we get this right workforce experts from all of the organisations involved have been meeting to consider not only recruitment and retention of staff, but the learning, development and support that will be needed to create new opportunities for staff and quality services for patients. Their assessment is that there is sufficient staff to deliver the improvements proposed and there would be no need for compulsory redundancy. We have examined the following key workforce issues in preparing for this consultation (Figure 7-b). Figure 7-b: Key workforce issues examined The new model of care will require the workforce to do different jobs in different locations we anticipate that people who are currently employed in delivering health and social care will continue do so albeit potentially in different roles and locations. Latest estimates indicate a requirement for 50 staff to support the delivery of the new model of care at a scale sufficient to support the proposed community bed reductions in East Devon. 56

58 The focus now is on: The support, learning and development that will be needed to enable staff to take on new roles and new opportunities that deliver the model of care patients and their carers have told us time and again that they want. Ensuring that staff across all different organisations work together so that in the new model people experience: o Care that supports people to be as well and independent as possible and most importantly safe- and at home. o Services that are co-ordinated rather than disjointed and integrated across organisational boundaries for true continuity of care. We know we need to continue to concentrate on recruitment to more specialist roles such as physiotherapy, and we will do this. We also know Community based staff represent a reliable, quality and innovative workforce and we can be confident their skills will be needed in future. If following consultation, we proceed with our preferred option there will be particular workforce implications for across community sites. Employees who currently deliver bedded community care across the affected sites, who in the new model of care, will be redistributed to new roles. Some of those employees who currently deliver bedded care at sites where we propose beds would be removed could initially be used to fill the existing workforce gaps at bedded sites that will continue to deliver bedded care as well as undertaking other roles. The remaining employees will be used to deliver new roles in the community as well as addressing wider system churn and agency reduction targets. Figure 7-c details potential implications on employees. Figure 7-c: Workforce implications (WTEs) of proposed Eastern Devon community bed reconfiguration 57

59 Based on modelling of the Northern Devon model of care, a number of out of hospital options exist for redistributed workforce: 2 hour rapid response nursing Single point of access operator Reablement Therapists Domiciliary care Social care There will likely be a need for some degree of training/od for all affected employees; and targeted training for those undertaking new roles, based on developing core competencies to deliver the service. Over time it is envisaged that specific training will be developed to allow a single worker to meet more of a person s needs, creating flexibility within services and decreasing fragmentation for the patient as a single worker delivers care that might currently be delivered by 3 or 4. Workforce gaps following community and acute bed reconfiguration will be addressed through recruitment. It is envisaged that this may be particularly needed for therapists. If possible, the workforce transformation will offer personalised choice to those employees who will be affected by the change. It also goes without saying that Trade Unions will be involved throughout. A detailed workforce strategy will be developed to support the further implementation of the new model of care. This will include a more detailed analysis of the staff, roles, skills and training required. This strategy will form part of the final decision-making business case. We recognise that the successful implementation of the new model of care will not move pressure from one point in the system to another. We will work to ensure that existing pressures and new demands on existing workforce through new model of care are mitigated by actively redeploying workforce from bedded care to new model of care delivery. There has been engagement with staff in terms of the case for change and the potential transition from bedded to home based care. This has been done through face to face sessions and communications which began in February In addition, staff have been advised they will be notified of the options and preferred options via an ed letter from the CEO, before the CCG governing body papers are uploaded to the website on 21st September. Specific communication events are being conducted in advance of the launch of consultation. For example, the schedule of events for affected Northern Devon healthcare staff is shown below. Friday 16 th September Monday 19 th September Audience All staff Managers Unions Managers All staff Activity Send out staff express explaining consultation options will be available to staff from 3pm on Wed Ward manager meeting - introduce consultation Inaugural Devon Social Partnership forum meeting Clinical Services Meetings- introduce consultation Letter to staff telling them that the info will be posted and hard copies will be with all team leaders and phone lines will be open business partners at some community hospitals 58

60 Wednesday 21 st September Thursday 22 nd September Audience All staff Eastern staff All staff All staff Managers Affected staff in East Activity 2.45pm staff express about options and paper Eastern business managers to print off staff express and give to staff on community wards Phone line available 2pm to 5pm Ask CEO session Paper posted on CCG website from 4pm Northern HoDs meeting Managers welfare walkround together with Staff side reps Fri 23 rd September Eastern staff Exec briefings with RD&E 7.4 Primary care provision It is recognised across the system that there are real problems with workforce and workload affecting Primary care and specifically General Practice (In particular recruitment problems with Practice Nurses and GPs). In NEW Devon through the Resilience Assessment Toolkit that is being conducted in partnership with Devon LMC these pressures are being quantified and qualified into a baseline assessment against that will underpin a strategy for Primary Care which will be published in the autumn. This will address the quality and sustainability of General Practice including workforce and workload as required by the national planning guidance. We recognise the need to stabilise current provision and ensure continuity of service whilst preparing for the new models of care for the future. Contributing to the new models of care will support the quality and sustainability focus of the Primary Care Strategy. 7.5 Estates The new model of care will also mean that there will be less requirement for bed-based care as care will be provided in lower intensity settings and more locally. This is likely to mean further consolidation and reduction in the number of beds across acute and community settings. This provides a significant opportunity to deliver care differently and to focus on prevention and well-being. Given the need for this investment in staff who work in multidisciplinary teams, a reduction in the requirement for community beds, the need to make best use of scarce resources, and the local attachment to community hospitals, the concept of health and wellbeing hubs in the community has been developed to provide a wider range of enhanced services. A full review of the estate will be needed to ensure value for money is achieved in line with the Carter Review which will inform how we use the estate in the future. In the east the estate is due to come under the ownership of NHS Property Services from 1 st December The CCG is developing an estates strategy which will set out in detail the future use of the property portfolio. This includes which existing buildings will be developed into hubs in the future, which may be put to other uses, and which may be disposed of to provide funds for some redevelopment to ensure the future estate is fit for purpose. Early work has commenced to assess key aspects of the current estate such as the quality of buildings, their maintenance requirements and the utilisation of space. The emerging estate strategy will take account of the CCG's forthcoming Primary Care Strategy 59

61 as well as Lord Carter's report into the operational productivity of the NHS (February 2016) which includes recommendations on estates and facilities planning for NHS bodies. We will not be making any decisions on the future of buildings within the NEW Devon estate as part of the Your Future Care consultation and the strategy will conclude in Other enablers There are a number of other enablers that need to be developed to support the delivery of the new model of care. These include: Leadership development: individuals, leaders and organisations will need support to deliver change on this scale. Time and investment will be needed to develop the new ways of working, changes in behaviour and culture in order to ensure transformation can be implemented at pace and be sustainable. Commissioning and contracting: to foster integration of care and providing care in new ways, innovative forms of payment and commissioning may need to be introduced. The potential benefits of new organisational forms, for example accountable care organisations will also be considered. IM&T: Investment in IT and infrastructure is very likely to be needed to support delivery of future care models, in particular in creating integration between organisations. Combining patient level datasets to support the identification and focus on patients across multi-disciplinary teams is a key enabler to new models of care. This leads to a single care record, which allows health and care organisations to access one version of the truth and supports patient interaction with their own health and care information. It should be noted that this investment is subject to accessing nationally available funding and is not a quick solution New ways of working. Clinicians involved have emphasised the new model means providers and partners, staff and teams working together through a single co-ordinated approach to bringing benefits for patients and the population and to deliver efficiencies in the health and social care system. New ways of working will be a central enabler to success. The Devon health system is developing an estates strategy which will set out in detail the future use of the property portfolio. This includes which existing buildings will be developed into hubs in the future, which may be put to other uses, and which may be disposed of to provide funds for some redevelopment to ensure the future estate is fit for purpose. Early work has commenced to assess key aspects of the current estate such as the quality of buildings, their maintenance requirements and the utilisation of space. The emerging estate strategy will take account of the CCG's forthcoming Primary Care Strategy as well as Lord Carter's report into the operational productivity of the NHS (February 2016) which includes recommendations on estates and facilities planning for NHS bodies. We will not be making any decisions on the future of buildings within the NEW Devon estate as part of the Your Future Care consultation. Members of the public will have the opportunity to comment on the estate strategy at a later date. 60

62 8 Progress in implementing new models of care Since the Transforming Community Services Strategic Framework was published in October 2014, changes have been implemented across NEW Devon. 8.1 Northern Devon Northern Locality published and consulted on a document called Care Closer to Home between September and December This document was focussed on the delivery of the CCG strategic framework and proposed the implementation of the new model care. This meant greater focus on health promotion and ill health prevention, where more resources are shifted from traditionally acute services into modern, efficient community services. Detailed bed modelling was undertaken and a reduction in the requirement for community hospital beds to 40 identified. Northern Devon Hospital Trust (NDHT) then undertook a consultation in the summer of 2015 called Safe and Effective Care within a Budget which proposed the development of community health and social care teams to be a single point of co-ordination for people with complex needs and a reduction in community hospital facilities. This consultation was successfully concluded in October 2015 and implementation is underway As shown in Figure 8-a, this implementation is designed to deliver a new model of care which reduces the patient journey from 7-stages to 2-stages and is focussed on: Rapid health and social care assessment Single point of entry Time bound intervention Clear feedback and planning Single team solution An enablement model Incorporating voluntary sector Incorporating more formal mental health liaison Continuity of care between acute, community and primary care 61

63 Figure 8-a: Northern Devon model of care As a consequence of this transformation of services, there has thus far been: A reduction in the number of people staying for more than 14 days in hospital from 1,680 to 1,505 (10%) A reduction in volatility of the relative risk of readmission within 28 days of discharge over the previous 24 months, stabilising below the index of 100. A reduction in the number of assessments from an average of 4 to just 2 Variable pay prevalence at NDHT has gone from a weekly high of +350 shifts in October to 74 per week in Feb 2016 A reduction in the number of community medical inpatient beds from 74 to 40, and in actual fact flexed down further to 32 Figure 8-b illustrates the changes in community beds that have been made in three units in North Devon. In the period from 2013 to 2015, 52 community beds were closed or are no longer in use, reducing from 84 community medical beds to 32 community medical beds. 3.4 million per year has been saved through these closures with about 0.5m per year reinvested to provide 13 whole time equivalent staff working in the community, a 13% reinvestment rate. 62

64 Figure 8-b: Community beds in North Devon There was a concern that there might be an adverse impact on patients and the ability of the acute hospital to care for them as a consequence of the reductions in beds. However, data from North Devon has been used to demonstrate that the new model of care has not impacted local non-elective admissions, average length of stay or bed days and based on demand services have been operating at a flexed down level to 32 beds over the last year. Figure 8-c: Acute impacts of changes to Northern community model of care 63

65 8.2 Western Devon Western Locality published and consulted on a document called Your Health, Your Future, Your Say in late This document proposed the implementation of the new model of care with a focus on prevention of ill health, and the promotion of self-care and self-management of health conditions. The document asserted that community hospital beds are sometimes appropriate and that current facilities in Tavistock, Kingsbridge and Plymouth are in the right place. However, further modelling would be done to determine the community hospital beds required. 8.3 Eastern Devon Eastern Locality published a document called Pathways for the Future and undertook a consultation between September 2014 and February Pathways for the Future focussed on the delivery of the CCG strategic framework and recognised the need to provide more services for people at home and that this would lead to a reduction in the need for community hospital beds over time. Eastern Locality put forward a proposal that they would: commission inpatient units at a scale that guarantees clinical safety, efficiency and the flexibility to provide resilience and additional capacity during periods of increased demand. In the first instance, we plan to consolidate the existing number of beds, without significant or material change in bed numbers, into bigger units in the following towns. Tiverton Okehampton Whipton (Exeter) Exmouth Honiton Seaton Sidmouth We intend to use the flexibilities of the Better Care Fund to develop the capacity and capability of our community nursing, therapy and care teams over the next 12 months. This will allow patients who currently require community bed based care to be looked after at home or in other care settings. When we are confident that these services are in place we will reduce the number of beds and/or inpatient units accordingly. A decision on the number and location of hospital beds in Eastern Locality was made by the NEW Devon CCG Governing Body in July 2015, who voted unanimously to accept the locality proposal to consolidate beds on fewer sites as described in Pathways for the Future, closing beds permanently in Axminster, Ottery St Mary and Crediton reutilising these facilities for alternative services. As described in this document, the earlier consolidation of inpatient beds has already taken place, although for Ottery St Mary hospital we continue to operate an inpatient stroke rehabilitation unit and 3 inpatient beds on an interim basis. This earlier work in Eastern Locality made it clear that the consolidation of inpatient services was the first stage of reducing the levels of bed based community care in Eastern and that we would then look to harmonise the processes with those of the wider CCG. The Case for Change set out by the NEW Devon success regime steps up the pace, and further detailed analysis and review shows that in Northern and Western there is less reliance on beds and in Northern in particular the benefits of 64

66 earlier change are being demonstrated. A key message to the CCG during the Eastern consultation was the importance of integrated care as a basis for change. As a result of decisions recently made, a contract awarded has been made and this is designed to achieve integrated provision arrangement in Eastern. This pre-consultation business case is now focused on moving forward starting with harmonisation in North, East and West Devon through shifting from reliance on bed based care and building a model of care reduces overreliance on beds and is clinically and financially sustainable. 65

67 9 Community hospitals in Devon 9.1 Background There are currently 13 of the 20 community hospitals in NEW Devon providing medical beds, with 3 in West, 2 in North (Bideford has stroke rehab beds only) and 7 in East (8 including Ottery St Mary which has beds on an interim basis only) as shown in Figure 9-a. Figure 9-a: Community hospitals currently providing medical beds in NEW Devon Community hospitals provide a varied range of services by location including community hospital beds. Other services include minor injury units, x-ray, surgical day case units, therapies, outpatients colocated primary care, endoscopies and midwife led units. Different services are provided at each community hospital, as shown in Figure 9-b. This current pre-consultation business case and associated consultation does not address these other services but they are described below to show their wider role. 66

68 Figure 9-b: Description of community hospitals in NEW Devon Across these hospitals, there are 247 inpatient hospital beds which provide general medical care and 42 that provide stroke rehabilitation care. In Eastern Devon there are 143, 72 in Western and 32 in Northern community medical inpatient beds. As detailed in the case for change in Section 5, where beds are occupied many people are in fact fit to leave (almost half of the patients in Eastern Devon). For a quarter of the patients occupying beds in Eastern Devon, a lack of access to basic essential care such as being bathed is the reason they cannot go home. Being in hospital for long periods is often harmful, especially for the elderly, resulting in functional decline, increased risk of ending up in long term care and risk of infection. It is also expensive costing an average of 290 per day to keep someone in a community hospital in NEW Devon (cost ranged at /bed day). It is also not what patients or their carers want particularly the 7% of people in a community hospital who die there, the majority of whom would prefer to be at home when they die. 9.2 Estates requirements for community hospital beds Clinicians have considered how many community hospital beds will be required to deliver the new model of care. Four different methods were employed to consider the number of beds needed: 1. Removal of unused beds: to remove unutilised beds 2. Matching delivered results in North Devon: achieving a similar level of beds per head of population across NEW Devon. Delayed discharge was also reviewed to validate the benchmarking analysis. 3. Expert clinical opinion: input from clinicians to understand the scope for reduction. 4. Indicative Length of Stay reduction: Aiming to cap LOS for patients over 70 to 10 days subject to clinical needs Removal of unused beds There are currently many unused community beds in community hospitals across NEW Devon, with fewer than 50% of the available beds actually being used in some sites, and a total of 100 beds unused (and unstaffed) across the system. This is shown in Figure 9-c 67

69 Figure 9-c: Current utilisation of community hospital beds Matching results achieved in North Devon As explained in Section 8.1, Northern Devon has is implementing a new model of care that reduces the reliance on community beds and has delivered improved outcomes, patient experience and efficiency. The ratio of people to community hospital beds in Northern Devon is now 1.9 community hospital beds per 10,000 people. The current rate in Eastern Devon is more than double this. Applying the same ratio across NEW Devon to harmonise arrangements across the area in this next phase of development would suggest at this point in time 173 beds across NEW Devon and 69 in Eastern Devon a reduction of 74 beds. This is shown in Figure 9-d. In order to validate this reduction, the number of patients fit for discharge in community medical inpatient beds was also reviewed and this showed that almost half of the people in Eastern Devon were fit for discharge. If all those who were fit to leave were able to leave, this would result in a requirement for 79 fewer community hospital beds in Eastern Devon. This is similar to the reduction of 74 beds indicated by the benchmarking analysis. Section 10 explains how configuration considerations (i.e. that the most efficient and safe units should have a multiple of 8 beds) adjusts the new bed requirement figure in Eastern Devon up from 69 to 72, representing a reduction of 71 beds from the absolute total number of beds in Eastern Devon (in order to meet this operational and safety requirement). 68

70 Figure 9-d: Comparison of community medical inpatient beds across NEW Devon using benchmarking analysis Expert clinical opinion Clinicians have developed a detailed model of care which envisages care provided within the home except where intensive, specialist rehabilitation is required for those population groups who currently use the community beds most: frail elderly people (with or without dementia) and those at the end of life are better cared for at home. Clinicians have agreed that fewer community hospital beds are required in NEW Devon and that further implementation of the new model of care will support this Inpatient bed requirements with the new model of care After reviewing all the evidence, local clinicians have concluded that Eastern Devon requires a maximum of 69 of the 143 beds (this is a reduction of 74 beds). Northern Devon are already developing and implementing the new model of care and have reduced the number of community hospital beds in use from 52 to 32 since 2015 (and have experienced significant under-utilisation at one site as the model has been developed through 16/17). Western Devon currently has 72 community medical inpatient beds that are in high demand due to the pressures on the acute beds at Derriford Hospital. The system is in a rapid state of transition and there is growing confidence and evidence that materially lower bed numbers may be required. This is a start of a transition to a model of care that will continue to develop greater levels of independence and wellbeing for patients and there may be further opportunities in future to reduce the community hospital beds in NEW Devon as this model becomes embedded. Changing community beds and developing the new model will also provide the key to unlock change in the acute hospitals. Strong community services will support both avoidance of hospital admissions and reducing lengths of stay. 69

71 As a first and crucial step, we want to consult on the changes to community hospitals in Eastern Devon as we believe there is an overwhelming case for change and immediate opportunities to improve care and efficiency. This acts as the key enabler for releasing workforce and a new model of care across the whole system to be developed. This is part of a bigger picture of change and therefore as we continue to implement the new model of care, we expect further changes will important and where necessary and appropriate we will consult on these Scope for further, future change As described above this consultation is an important step along a journey to implement new models of care that deliver better outcomes for the community. 70

72 10 Development of options for location of community hospital beds in Eastern Devon 10.1 Process for option development Local clinicians have followed a process of considering all the possible options on the location of community hospital beds and gradually narrowing down this list to a preferred option. This is shown in Figure 10-a. Figure 10-a: Process for evaluating preferred option 10.2 Stakeholder engagement The options for consultation have been discussed with stakeholders in a number of ways: Representatives of the local HealthWatch organisations (HealthWatch Plymouth and HealthWatch Devon) being members of the Programme Delivery Executive Group, the Clinical Cabinet and New Models of Care Group. Representatives of the relevant local authorities being members of the Programme Delivery Executive Group, the Clinical Cabinet and New Models of Care Group. Representatives of the NEW Devon CCG s patient and public sub-committee being members of the Programme Delivery Executive Group, the Clinical Cabinet and New Models of Care Group Developing the list of options to be evaluated Clinicians used a number of hurdle criteria to reduce the list of all possible combinations of option to a manageable shortlist of options for detailed evaluation. These hurdle criteria are shown in Figure 10-b. Figure 10-b: hurdle criteria used to develop a shortlist of options Meets agreed minimum size of unit Make best use of PFI/LIFT services No new build due to cost and timescale Requirement to honour outstanding legally binding commitments 71

73 The most material consequence of these hurdle criteria is to establish Tiverton as a fixed point due to the high quality estate with PFI commitment and the hospital s large scale. The hurdle criteria rule out Ottery St Mary, Axminster, Crediton, Budleigh and Moretonhampstead which honours prior decisions made by the CCG Meets minimum size of 16 beds to deliver quality and efficiency Clinicians reviewed the minimum number of beds that are required in a unit for it to be clinically and financially viable. A minimum unit size of 16 was agreed, with all additional beds in multiples of 8, based on the following clinical constraints: 8:1 patient to staff ratio is required during the day 11:1 patient to staff ratio is required at night Never fewer than two registered professionals working at one time Finance leads reviewed the minimum number of beds that are required in a unit for it to be economically viable. A minimum unit size of 16 was agreed based on comparison of expected income per bed and the cost for each additional bed. The costs are stepped as each 8 patients require an additional member of staff (and that additional member of staff is required whether there is one more patient or eight more patients). The analysis in Figure 10-c shows that income exceeds costs at 11 beds but that 16 is the minimum financially viable number of beds. Figure 10-c: Most efficient number of community hospital beds The stepped cost means that the 72 community hospital beds that are required in Eastern Devon need to be delivered in multiples of 8. From a financial perspective, revenue maximization increases with size; with 16 beds being the minimum viable size, 24 being more economical, and 32 being stronger still. 72

74 No new build due to cost and timescales Clinicians have recommended that only the existing community hospital sites should be considered for future location of community hospital beds. New sites are not suitable due to the timescale required to find and develop any site. Equally, clinicians and finance leads have recommended that there should be no new build on existing sites given the timescales and costs, and given the existence of current community hospitals which are already not fully utilised. New buildings would not support a financially viable health system in NEW Devon in the future Make best use of PFI buildings Hospitals funded under the Private Finance Initiative (PFI) or Local Improvement Finance Trust (LIFT) have been built using funds secured via the private sector. In order to finance these significant capital costs, the local health service has entered into long term arrangements to rent back the property with private organisations who have borrowed the upfront costs. To exit these contracts is expensive. The high costs of contract termination and the generally high quality of the buildings mean it is prudent to make best use of PFI and LIFT premises. There is one hospital in Eastern Devon that is PFI-funded Tiverton Hospital built in 2004 with a contract that runs until 2034 with approximately 35m left on the contract. Clinicians and finance leads have recommended that 32 beds should continue to be used in all options, as best use of this space in the short to medium term Implement decisions from previous consultations There was a consultation on the provision of community hospital beds in Eastern Devon in The decision from this consultation was that community hospital beds would be consolidated, or concentrated, on fewer sites and closed inpatient provision in Axminster, Ottery St Mary and Crediton. It has been implemented, although on an interim basis in Ottery there is a stroke unit and a small number of medical beds in operation. Clinicians and finance leads recommended that this decision from previous consultations is maintained and therefore these Eastern beds will remain closed. 73

75 Figure 10-d: Geographic consequences of hurdle criteria The prior consultation recommended that Eastern community beds should be consolidated into seven sites at that point in time, whilst recognising further change may be required in the future. Subsequent detailed analysis as described in section 5 has identified that community beds could be further reduced to 72 beds across three sites Options A total of 72 community hospital beds are required in Eastern Devon and, if 32 are at Tiverton, 40 are required elsewhere. Given the constraints on minimum size of unit outlined in Section 10.3, this means that there must be one 24-bedded unit and one 16-bedded unit. This is shown in Figure 10-e. 74

76 Figure 10-e: Options for community hospital beds when PFI hospitals are fixed The application of these hurdle criteria resulted in 15 options for Eastern Devon (Figure 10-f). Figure 10-f: Options for Eastern Devon 75

77 11 Appraisal of shortlisted options 11.1 Evaluation criteria The evaluation of the options has been clinically led, with recommendations coming from the Clinical Cabinet and the Finance Working Group. The evaluation criteria build on the criteria used in previous public consultations in NEW Devon including Transforming Community Services, Pathway to the Future and Safe and Effective Care within a Budget. A final set of evaluation criteria was refined and agreed by the Programme Delivery Executive Group to be used as the basis for selecting the preferred option, as shown in Figure 11-a. Figure 11-a: Evaluation criteria It is important to understand that these evaluation criteria are useful only if they differentiate between different options. Evaluation criteria which are deemed to be non-differentiating have been considered and tested as part of the evaluation process, however the impact of these criteria do not differentiate between options, and therefore have not been used to compare the options. The nondifferentiating criteria are: Quality: the new care model will present a different operating model from the current procedures, with it defining new future quality levels regardless of the option selected Access for patients: this is deemed to be immaterial between options; the new model of care will see patients conveyed to community hospitals when they require bedded care Income and expenditure impact: This is immaterial as this is impacted by scale; as all options define a configuration of sites of the same size, this will be non-differentiating. 76

78 Quality The importance of clinical quality cannot be overestimated. The new model of care will improve quality and patient experience by reducing length of stay and the risk of deterioration (such as loss of muscle tone) and infection associated with being in hospital, improving access times and improving integration of delivery (so, for example, people need fewer assessments). There is nothing that would suggest any of the options could not deliver a quality service to the standards that will be required in the future. The Clinical Cabinet agreed that, as the model described in Your future care is being delivered across all sites, there would be no difference between the options in terms of quality. This does not mean that clinical quality is not important, just that it does not differentiate between options Patient access The population of Eastern Devon is relatively old and there are areas of deprivation. Access to services is very important. However, the new model of care means that care will be delivered to the majority of people at home (or in their usual place of residence) rather than in a community hospital and this will be equally beneficial across all options. Patients will also be transferred from the acute hospital to the community hospital (if a community hospital stay is required) and then home. The distance to services in terms of accessibility for patients themselves does not distinguish between the options (it is more relevant patient s, carers and visitors and this important point is recognised under a separate evaluation criterion see Section ). The Clinical Cabinet agreed that, as patients will be transported to and from services; there is no difference between the options in terms of patient access Access for carers When people are in a community hospital bed, they will be visited by carers, friends and relatives, many of whom will be elderly. Travel time for visitors to services is therefore important. Although the number of people affected by potential changes is small (as shown in Figure 11-b), the Clinical Cabinet agreed that access for carers does differentiate between options and that further work would be done to assess options against this criterion. It was agreed that average and maximum travel times would be reviewed for peak, off-peak and public transport along with availability of parking. This would then be tested for particular impact on elderly carers, carers with disability and carers suffering a level of deprivation. 77

79 Figure 11-b: Number of people affected by proposed changes to community beds The impact of travel time on people with protected characteristics under the Equality Act 2010 was also reviewed as part of the Equality Impact Assessment 2. Those protected groups who are potentially affected by the proposals are older people and those with a disability, as the majority of people in community hospital beds are older and are therefore likely to have older carers Implementability Building work for ward reconfiguration will take time to complete. The Finance Working Group agreed that converting Exmouth into a 24 bedded ward not be a desirable option due to long time frame of building works (Exmouth would have to change from the current configuration of two wards of 18 and 12 beds to a single 24 bedded ward that conforms to the agreed staffing standard of multiples of 8 beds with no lone working). This is unfavourable, given that there are two existing 24 bed units at Sidmouth and Seaton that would be available for immediate use Finance The delivery of the new model of care for community hospital care in Eastern Devon is forecast to deliver gross savings of m m will be reinvested in community services and m will contribute towards reducing the financial deficit. This saving will be generated under all options and therefore does not differentiate between options. Although income and expenditure was nondifferentiating, the impact on capital costs showed some differences in terms of finance. 1. Impact on income and expenditure (I&E): The Finance Working Group agreed that there was no difference between options in terms of I&E (except as the consequences of capital investment which is pick up in the impact of capital costs criterion) because all options have the same size of units and the same level of workforce. 2 The Equality Impact Assessment is a process designed to ensure that a policy, project or scheme does not discriminate against any disadvantaged or vulnerable people or groups (who have protected characteristics under the terms of the Equality Act

80 2. Impact on capital costs: The hurdle criterion in Section 10.3 means that no new build or new sites will be considered. While there is significant backlog maintenance (which would have to be addressed) on some sites and projected capital spend for the future, this was not considered to be differentiating by the finance group as the costs relate to all services operated from the hospital, not just community hospital beds. The only capital cost for any of the options would be converting Exmouth from the current configuration of two wards of 18 and 12 beds to a single 24 bedded ward that conforms to the agreed staffing standard of multiples of 8 beds with no lone working. The Finance Working Group agreed that the capital cost of this option made this option extremely unfavourable, given that there are two existing 24 bed units at Sidmouth and Seaton that would be available for immediate use System impact The current community hospital beds do not exist in isolation and are provided alongside other services. This differentiates between options in two ways: 1. Co-location with other services: The Clinical Cabinet agreed that there are co-dependencies between the provision of therapies (strong co-dependency as therapists have substantial input into the rehabilitation of people in community hospital beds) and primary care (weak but present codependency as there can be cross-cover between MIUs and community hospital units. The Clinical Cabinet agreed that community hospital units that are already co-located with therapies would be evaluated most favourably and then those with primary care. 2. Flexibility of site: sites providing other services are generally more flexible in meeting the needs of the population over time and therefore sites with additional services and space outside the community hospital beds are more flexible. The Clinical Cabinet agreed that the largest sites providing the most services would be evaluated most favourably. The Programme Delivery Executive Group agreed that system impact differentiates between options in terms of co-location with other services and flexibility of site Rating each option for each criterion For each criterion, each option is given a rating. Rather than an absolute score, a relative evaluation is given to differentiate between options. The ratings are shown in Figure 11-c. Figure 11-c: ratings used in evaluation of options 11.2 Evaluation of options As outlined in Section 11.1, quality and patient access are extremely important but do not differentiate between the options. Detailed evaluation was undertaken on access for carers, finance and system impact. 79

81 Access for carers Average travel time impact was considered for the affected population. By weekday public transport By weekend public transport By peak travel time By off-peak travel time The analysis was performed for both the population as a whole and then for people with protected characteristics under the Equality Act 2010 (please refer to Appendix 17.3). For Eastern Devon, this analysis showed that for affected populations, travel time for carers to community bedded sites increase in most options, as shown in Figure 11-d. As the new model of care will mean that many more people are treated at home, the number of people expected to be treated in community hospital beds per year in Eastern Devon will decrease and it is the visitors to these patients who will be the affected population. Figure 11-d: Change in weighted average travel time by option for affected populations in Eastern Devon As a final check, the growth of the elderly population in the affected hospitals was assessed and this showed growth levels for the elderly over the period to 2021 to be in consistent between those areas affected (East Devon and Exeter and mid Devon) and the wider STP footprint; this is shown in Figure 11-e. 80

82 Figure 11-e: growth in elderly population in affected areas The outcome of the evaluation was that any option which resulted in an increase in average travel time greater than 60% compared to today would receive a low evaluation, an option that resulted in an increase in average travel time of less than 40% received a high evaluation, with the 40-60% group receiving a neutral evaluation. This was combined with an evaluation on parking, with a high evaluation for those sites that scored 5 or more (out of 10) from the estates and operational task and finish group, versus a low evaluation for those that scored 3 or less. Options with Honiton scored unfavourably on travel time evaluation criteria given its close proximity to Tiverton (fixed site). Figure 11-f summarises the evaluation of options on access for carers criteria. 81

83 Figure 11-f: Evaluation of access for carers criterion (Eastern Devon) Finance and implementability The estates and operational tasks and finish group concluded that converting Exmouth to a 24 bed ward configuration would have a capital impact on 1.2M and an extensive period of time to bring on line (suggested build time of 18 months). The finance working group concluded that the best option for a 24 bed unit was therefore either Seaton or Sidmouth. The group felt there was no difference between the other 16 bed options with regards to finance or implementability criteria. Figure 11-g: Financial and implementability evaluation criteria Options FWG Score 1 Seaton & Sidmouth Include 2 Seaton & Honiton Include 3 Seaton & Exmouth Include 4 Seaton & Exeter Include 5 Seaton & Okehampton Include 6 Exmouth & Sidmouth Exclude Based on timing and capital cost to expand Exmouth into 24 bed unit 7 Exmouth & Honiton Exclude Based on timing and capital cost to expand Exmouth into 24 bed unit 8 Exmouth & Seaton Exclude Based on timing and capital cost to expand Exmouth into 24 bed unit 9 Exmouth & Exeter Exclude Based on timing and capital cost to expand Exmouth into 24 bed unit 10 Exmouth & Okehampton Exclude Based on timing and capital cost to expand Exmouth into 24 bed unit 11 Sidmouth & Exmouth Include 12 Sidmouth & Honiton Include 13 Sidmouth & Seaton Include 14 Sidmouth & Exeter Include 15 Sidmouth & Okehampton Include 82

84 Ability to support whole system impact Clinicians identified the need to consider how the options for sites with community beds could fit with and integrate into the wider system of health and care delivery. To assess this, they considered a number of different measures which reflected the potential flexibility of a site with beds to be integrated into other relevant services now and in the future To evaluate system impact, seven whole system impact criteria were reviewed, these were: Gross internal Floor Area (M 2 ) was considered on the basis that the bigger the site, the greater the potential to situate more services on it that could connect patients and carers of community hospitals with other services, now and in the future. Extent of co-located service focused on those services that have a direct connection to community bedded services. Specifically: o the presence of physiotherapy on site was deemed to be critical because of the importance of physiotherapy in reablement and the return to independent living o co-located GP practices on site were seen as being valuable because of the potential they provide for medical cover to patients in community beds o total number of co-located services was considered to indicate the breadth of multidisciplinary team on site who could potentially contribute to the full and effective care for the patient whilst in a community bed and in preparing for their discharge Ability to add extra eight beds on site was considered as an indicator of flexibility to increase system configuration options in future Operational functionality was evaluated by estates and operations experts to consider the flexibility in suitability for delivery of patient care and hence the ability to add or change services that are delivered on site Environmental observation (visibility of patient location on the ward) was considered as contributing to the effectiveness of high quality care delivery Data reviewed as part of the evaluation criteria is summarised below by site. Community Hospital Figure 11-h: Ability to support whole system data Gross internal floor area (sq m) Colocated Physical Therapy Colocated GP Number of colocated services Ability to flex Ability to add extra Operational 8 beds functionality Environmental observation Configuration Seaton 24 2,190 Yes No 1 Yes No 4 2 Seaton 16 2,190 Yes No 1 Yes Yes 4 3 Sidmouth 24 2,836 Yes No 3 No No 4 2 Sidmouth 16 2,836 Yes No 3 Yes Yes 4 2 Honiton 16 3,574 Yes Yes 3 Yes No 4 3 Exmouth 24 5,174 Yes Yes 4 Yes No 1 4 Exmouth 16 5,174 Yes Yes 4 Yes Yes 1 4 Exeter 16 2,549 Yes No 1 Yes No 3 2 Tiverton 32 6,789 Yes Yes 5 Yes Yes - - Okehampton 16 2,795 Yes No 2 Yes No 4 4 A classification (red, amber, green) was applied to each criteria for each site, as shown in Figure 11-i. 83

85 Figure 11-i: Whole system impact evaluation classification Criteria Red Amber Green ('-1' assigned if equal or below...) (0 assigned if not Red or Green) ('1' assigned if equal or above...) Gross internal floor area Colocated PT No Yes Colocated GP No Yes # of colocated services 2 4 Ability to flex No Yes Ability to add extra 8 beds No Yes Operational functionality 2 4 Environmental observation 2 4 Whole system impact evaluation criteria scores were equally weighted to produce overall scores for individual sites. The individual site-level ratings were then aggregated for each of the 15 configurations (shown in Figure 11-j). Options with Exmouth included as a proposed site scored highly for this metric. Figure 11-j: evaluation of co-location of services and size of community hospital 11.3 Overall evaluation The combination of these criteria for finance, access and whole system impact was then used to create an overall evaluation of the 15 options. As a consequence of the finance assessment 5 options were eliminated resulting in 10 options to consider. In carrying out the appraisal of these, four were highlighted as being better that the other options: 84

86 Option 3: Seaton and Exmouth Option 11: Sidmouth and Exmouth Option 4: Seaton and Exeter Option 14: Sidmouth and Exeter. There is a genuine choice about which of these is the best option for NEW Devon. However, by a small margin, the preferred option would see community hospital beds consolidated in Seaton and Exmouth because combined across the evaluation criteria this combination optimises travel time and has greatest whole system impact. Note that as the benefits of the new model of care are fully realised, this number of beds and sites may reduce further in future. In all cases, Tiverton will continue to provide as many community beds as is possible because it is PFIfunded, would cost 35m should the beds be closed and provides a high quality environment delivering in-patient community beds. Figure 11-k below shows the application of all evaluation criteria to the 15 options and shows for each of the options how it ranks against the evaluation criteria. Figure 11-k: application of all evaluation criteria to 15 options 85

87 Option Summary 1. Seaton & Sidmouth Negative scores for both access for carers and whole system impact 2. Seaton & Honiton Neutral scores for both access for carers and whole systems impact 3. Seaton & Exmouth Preferred option to explore- positive score on whole systems impact and neutral score on access for carers 4. Seaton & Exeter Option to explore highly positive score for access for carers 5. Seaton & Okehampton Negative scores for both access for carers and whole system impact 6. Exmouth & Sidmouth Excluded by implementability and finance criteria 7. Exmouth & Honiton Excluded by implementability and finance criteria 8. Exmouth & Seaton Excluded by implementability and finance criteria 9. Exmouth & Exeter Excluded by implementability and finance criteria 10. Exmouth & Okehampton Excluded by implementability and finance criteria 11. Sidmouth & Exmouth Option to explore scores positively on whole systems impact 12. Sidmouth & Honiton Neutral scores for both access for carers and whole systems impact 13. Sidmoth & Seaton Negative scores for both access for carers and whole system impact 14. Sidmouth & Exeter Option to explore highly positive score for access for carers 15. Sidmouth & Okehampton Neutral score for access for carers and negative score for whole system impact Under the preferred option, there will be a removal of community hospital beds in Honiton, and Okehampton, Sidmouth and Exeter. In the four better options identified from the appraisal there would be removal of community hospital beds in Honiton and Okehampton. Honiton Hospital does not appear in any of the shortlisted options because it scored poorly on the travel time evaluation criteria. For Okehampton Hospital the influencing factors were travel time and on site GP practice. Some of these facilities would continue to be local health and social care hubs housing integrated teams of approximately 30 staff who will provide enhanced home and ambulatory care and other services such as therapies, outpatients and health and well-being services (Figure 11-k). This new model of care will deliver higher quality care, more quickly and more efficiently, which will benefit older people in particular as they make up the majority of people in community hospital beds. In carrying out the appraisal of these, four were highlighted as being better that the other options: Option 3: Seaton and Exmouth - scored moderately on carer access and moderately/high on whole system impact (refer to Figure 11-j) Option 11: Sidmouth and Exmouth scored moderately/high on whole system impact (refer to Figure 11-j) Option 4: Seaton and Exeter scored highly on access for carers Option 14: Sidmouth and Exeter scored highly on access for carers 86

88 The assessment of options by the NEW models of care group was followed by a task and finish estate and operational look at the options. This reported back through the Finance Working Group in relation to the assessment of sites. Figure 11-l: Remaining services in Okehampton, Sidmouth, Honiton and Exeter (under preferred option) 87

89 12 Quality Assurance 12.1 Four Tests (NHS England) Planning, Assuring and Delivering Service Change for Patients from NHSE (updated in October 2015) reiterated earlier guidance that proposals for service change must demonstrate that they satisfy the four tests of service reconfiguration and are affordable in capital and revenue terms. The government s four tests of service reconfiguration are: Strong public and patient engagement. Consistency with current and prospective need for patient choice. Clear, clinical evidence base. Support for proposals from commissioners. The four tests are set out in the Government Mandate to NHS England. NHS England has a statutory duty to deliver the objectives in the Mandate. CCGs have a statutory duty to exercise their commissioning functions consistently with the objectives in the Mandate and to act in accordance with the requirements of relevant regulations, such as Procurement, Patient Choice and Competition Regulations2 and associated guidance from Monitor Strong patient and public engagement Section 3 of this document sets out the extensive engagement work already undertaken. Stakeholder engagement work started at the beginning of the programme and built on work carried out over the last three years as part of the Transforming Community Services programme, in particular: 2014 Northern Locality Care Closer to Home 2015 Northern Devon Hospital Trust - Safe and Effective Care within a Budget (This programme is now being implemented and has resulted in many benefits) 2014 Western Locality Your health, your future, your say 2014/15 Eastern Locality Pathways for the future The document also sets out the plans for future engagement both on an ongoing basis and as part of the formal consultation process. Throughout the planning process we have aimed to build on the feedback that we have already received and have developed a set of statements outlining what local people want (the I statements) which are one of the key underpinning blocks of the new model of care Consistency with current and prospective patient choice. For the Department of Health, patient choice is balanced against centralised services: A central principle underpinning service reconfigurations is that patients should have access to the right treatment, at the right place at the right time. Services should be locally accessible wherever possible and centralised where necessary. Sir David Nicholson, 29 July 2010 Greater choice and control, published by the Department of Health in October 2010, identified increased choice as being good for patients in that: Choice promotes better outcomes for patients 88

90 Choice promotes confidence and recovery Choice has an important role in promoting equality and reducing inequality Choice encourages providers to tailor their services to what people want It is clear that there needs to be a balance between providing a range of choices without compromising quality. The emphasis needs to be on providing a choice of quality providers rather than simply a large number of local providers. This is particularly the case in rural populations where travelling times are a key factor in patient experience. Patient choice and patient experience are represented within the criteria for evaluating the options for reconfiguration and have therefore informed the decision making and options appraisal process. These factors will also likely to be key in the feedback we obtain from people during the consultation period which will help to determine the final configuration of services. People have already identified that care closer to home as part of an integrated network of health and social care is a priority for them. The community hospitals described in this document form only one part of this new model of care and wherever possible care will be provided in peoples own home Clear clinical evidence base. The Case for Change sets out clearly the evidence on gaps in existing services which we aim to address through the proposed changes. As part of this diagnostic work clinicians have undertaken a detailed review of care models for four groups of high-impact patients, who currently use significant resources in the community. This is based on identifying good practice both nationally and locally. In particular, the development of services in North Devon following development of community health and social care teams to be a single point of co-ordination for people with complex needs and a reduction in community hospital facilities Clinicians have led the programme throughout, working with wider stakeholders to develop these proposals, drawing on evidence base on interventions that prevent hospital admissions and reduce length of stay. A summary of evidence base is found in Figure 12-a. Figure 12-a: Summary of evidence base on interventions that prevent hospital admissions and reduce length of stay 89

91 Support for proposals from Commissioners The proposals outlined in this document have the full support of the CCG governing body, and the GP members of its governing body. The design work for the New Models of Care has been led by a multidisciplinary, multiagency task and finish group including GP representation. This group has developed options for presentation to the Clinical Working Group with final sign off from the clinical cabinet. Working through the success regime has allowed commissioners to work with providers and other stakeholders from an early stage which represents an unprecedented level of partnership working. Additionally, as part of the Success Regime process, NEW Devon has been working as part of the Wider Devon footprint with South Devon and Torbay CCG who are also undertaking a reconfiguration of community services. We can therefore be confident that the proposed changes are consistent with services across STP boundaries. 90

92 13 Benefits framework 13.1 Why a benefits framework is required The benefits framework allows us to quantify and monitor the successful delivery of benefits from the proposed changes, to patients, to staff and to the ways in which we run our services. The benefits framework: Is about compelling clinical and quality benefits. Provides a framework through which implementation can demonstrate its value and achievements Addresses the challenges in the case for change and supports the options appraisal process by aligning with the evaluation criteria Approach to defining benefits framework The benefits have been informed by: Clinical Cabinet New Models of Care Group Finance Working Group The involvement of patient and public representatives in key clinical and other meetings Feedback from patients and public at pre-consultation engagement events Feedback and consultation responses given during the previous Transforming Community Services programme The benefits framework clearly links improvements in service delivery to expected benefits Expected benefits The main benefits from the proposed changes to the service model will be around: Improved clinical outcomes for patients Improved experiences for patients and their carers Improved experiences for staff, due not only to improvements in patient care, but also improved team and multi-disciplinary working, improved integration across primary and secondary care, and increased opportunities to maintain and enhance skills Operating financially sustainable services How benefits will be realised and measured After the new model of care is fully implemented, it will be important to make sure that the benefits are realised. Benefits realisation needs careful management and close measurement. Benefits measures focuses on both outputs (e.g. reduced average lengths of stay, neutral impact on readmission rates) and expected outcomes (e.g. reduced waiting times) to demonstrate the success of delivery. A pragmatic list of measurable performance indicators, focused on patient outcomes and patient experience, including comparison against the current Equality Impact Assessment, will be used to measure progress. It is recognised that there can sometimes be a dip in performance during 91

93 implementation and that some changes will not always be viewed positively by individual patients or staff. Patient safety will remain paramount. After consultation, decisions will be made about which specific areas to measure. Wherever possible existing mechanisms and systems will be used to monitor the realisation of benefits, rather than creating an additional data burden. Figure 13-a: Benefits realisation Draft implementation plans have been included in this Pre Consultation Business Case and are part of the public consultation process. Following decision-making, changes will start straight away and realisation of benefits should follow. All benefits, particularly whole system benefits are likely to be maximised after the plans are fully implemented. Clear benefits realisation will be part of implementation and will include: Clear and comprehensive implementation plans will be developed with clinicians A pragmatic benefits realisation framework, with associated governance arrangements and processes will: o Track progress of benefits realisation o Identify actions that are required in response to any benefits not being realised o Define reporting requirements visible to all organisations involved, patients and the public, to monitor benefits realisation. Further work to develop the approach to benefits realisation will be required after consultation. This would be likely to include reviewing potential metrics to be used to support benefits realisation. 92

94 14 Implementation of the proposals 14.1 Background to implementation Implementation of elements of the new model care has already started and has already reduced the use of community hospital beds in Eastern Devon. We also know that the implementation of the new model of care in Northern Devon has led to a number of tangible improvements for patients as described in section 8.1 of this document. Learning from this, it will be crucially important to make sure that services are available to support the changes as they are implemented Implementation plan Assuming the decision following consultation supports the proposal, it is envisaged that the process of implementation of the changes will start as soon as the decision is made, delivering benefit through 2017 and will be completed as soon as possible in line with a local gateway process, as shown in Figure 14-a. Figure 14-a: Draft implementation plan The implementation of any significant change requires a clear understanding of the risks involved, and where the change is across a number of organisations, this understanding must be shared by each. Key conditions will need to be met during each of the three phases, pre-implementation, implementation itself and post-implementation. The purpose of these conditions is specifically to manage the risks involved in making the changes required, and a clear description of both the risks and their required mitigations also assists in balancing opposing risks, such as the risk of making the change against the risk of not doing so. A process is also required to ensure the risks and mitigations are reviewed at an appropriate level, and residual risks are shared appropriately. 93

95 Clinicians have developed a series of tests, building on a similar process used to support the implementation of changes in Northern Devon, forming a local gateway process to underpin the implementation plan. This gateway process will ensure that local clinicians have confidence in a safe implementation of new models of care and includes steps to measure the impact of the new models of care that will be in place across both Primary and Secondary care settings, and will be refined as required. Each of the following questions should be answered yes, and supported with the appropriate evidence: Pre-implementation The model of care: Does the new model of care align with our overriding ambition to promote independence? Is there clinical and operational consensus by place on the functions of the model and configuration of community health and care teams incorporating primary care, personal care providers and the voluntary care sector? Is there a short term offer that promotes independence and community resilience? Is there a method for identifying people at highest risk based on risk stratification tool? Are the needs of people requiring palliative and terminal care identified and planned for? Are the needs of people with dementia identified and planned for? Is support to care homes and personal care providers, built into the community services specification? Is support for carers enhanced through community sector development support in each community? Has the health and care role of each part of the system been described? Have key performance indicators been identified, and is performance being tracked now to support post implementation evaluation, including impact on primary care and social care? Workforce: Is there a clear understanding of the capacity and gaps in the locality and a baseline agreed for current levels and required levels to meet the expected outputs of the changed model of care? Is there a clear understanding of and plan for any changes required in ways of working: o thinking o behaviours o risk tolerance o promotion of independence, personal goal orientation Have the training needs of people undertaking new roles been identified, including ensuring they are able to meet the needs of patients with dementia? Do we have detailed knowledge with regards to investment, WTE and skill mix across the locality and a plan for achieving this? Are system-wide staff recruitment and retention issues adequately addressed with a comprehensive plan, and where there are known or expected difficulties have innovative staffing models been explored? 94

96 Governance, communications and engagement: Is there a robust operational managerial model and leadership to support the implementation? Has Council member engagement and appropriate scrutiny taken place? Is there an oversight and steering group in place and the process for readiness assessment agreed? Have providers, commissioners and service users and carers or their representative groups such as Healthwatch agreed a set of key outcome measures and described how these will be recorded and monitored? Is there a shared dashboard which describes outcomes, activity and productivity measures and provides evaluation measures? Is there an agreed roll out plan for implementation, which has due regard to the operational issues of managing change? Is there a comprehensive & joint communications and engagement plan agreed? Is there a need for a further Quality or Equality Impact Assessment? Implementation Is there a clinical and operational consensus on the roles of each sector during the implementation phase including acute care, community health and care teams, mental health, primary care, social care, the voluntary care sector and independent sector care providers? Is there an implementation plan at individual patient level describing their new pathway, mapping affected patients into new services? Are the operational conditions necessary for safe implementation met? Have the risks of not implementing the change at this point been described and balanced against any residual risk of doing so? Post Implementation Is there a description of the outcomes for individuals, their carers and communities? Are the mechanisms for engagement with staff, users of services and carers in place and any findings being addressed appropriately? Is there a process in place for immediate post implementation tracking of service performance including financial impact to all organisations? Is longer term performance and impact being tracked for comparison against pre-implementation performance? Have we captured user experience as part of the process, and have findings been addressed and recorded to inform the planning of future changes? Are there unintended consequences or impacts (e.g. on primary care or social care) which need to be addressed before any further change occurs? Is there a clear communication plan for providers and the Public describing the new system and retaining their involvement in community development? 14.3 Communications & engagement We will need to continue to actively engage stakeholders during implementation including the following groups: 95

97 Patients & public - we need to ensure that patients are well informed about what changes are proposed and have a say in how they are to be delivered Providers - will be taking a lead in the planning and implementation of service change NHS staff - we need to actively engage with staff to build awareness of the proposals and to consider and promote their central role in making these changes happen Clinicians - will need to be actively involved in the planning and implementation of service change to ensure patient safety is not compromised as changes are made Local authorities - in particular, we need to work together with our partners in social care to codesign and begin to deliver the transformation to community services which are critical to the success of the new model of care Governance Implementation of the CCG decision will be driven through business as usual commissioning arrangements wherever possible. It is proposed that: The Sustainability and Transformation Plan Lead CEO will lead implementation of the plan The Programme Delivery Executive Group meets at least quarterly to plan, and will receive reports of progress. There will be an escalation process should it be necessary for input of PDEG to resolve issues. This will consist of CCG, local authority and provider representatives and will be chaired by the STP / Success Regime Independent chair The service providers will develop and manage progress of an implementation plan, in close partnership with social services. The CCG will oversee implementation in the context of the wider NHS, Joint and Health and Wellbeing Strategies. The provider will be required to develop a detailed implementation plan and establish appropriate governance arrangements reporting to the CCG for delivery. Significant risks and dependencies will be subject to an escalation process. Following decision making, the CCG will work to integrate proposals into contracts for 17/18 onwards, in particular developing performance metrics to track and manage progress against key milestones or enablers of change 14.5 Implementation risks and dependencies We regularly review risks to delivery. Currently, there are 21 major risks that need to be monitored and managed to enable completion of the proposed reconfiguration to the timescales indicated. We will develop robust mitigation and regularly report these risks through our governance structure as described above Measuring the impact of change As set out in Section 13, we have established a benefits framework to describe the patient, clinical, staff and operational benefits that we expect to realise across care setting through successful delivery of our proposals. The benefits framework will be for the entire programme of which the changes proposed in this document are only a small part. Outcomes and key performance indicators will be focused on patient outcomes and patient experience. These will be firmly embedded within performance management arrangements under business as usual, both to minimise additional reporting requirements and to ensure that the performance improvements are embedded within performance management processes in the long term. 96

98 15 Preparing for consultation 15.1 Purpose of undertaking consultation Under Section 14Z2 of the NHS Act 2006, the NHS has a duty to ensure that service users are involved in the development and consideration of proposals for change in the way services are provided. In addition, we are required to consult with local Health Overview and Scrutiny Committees (HOSCs) in the Local Authorities where patients are impacted. For this consultation, Plymouth City Council HOSC and Devon County Council HOSCs will need to be consulted. These Local Authorities are required to form a Joint HOSC for purposes of consultation on such proposals. Through public consultation, we aim to obtain a broad range of views on our proposals whilst they are still in development in order to help us to identify the optimal solution for NEW Devon. The public consultation on our proposals is guided by the principles for all stakeholder engagement set out in Section 3.2. Public consultation will also be underpinned by the four over-arching NHS England tests: Clarity around the clinical evidence base the Case for Change must be widely understood and there should be clear, clinical evidence of the benefits of the proposals being consulted on. Support from GP commissioners must be clear and unequivocal and there should be involvement and ambassadorship of the programme by them throughout. Promotion of genuine patient choice we should be able to demonstrate that patients, residents and other stakeholders have understood how and why the proposals will benefit them and offer a better way forward for their healthcare needs. Genuine engagement with the public, patients and local authorities we will strive at all times to reach as many people as possible, put the proposals forward in a clear and comprehensible way and listen and respond to people throughout the process Alongside this the following objectives will apply to the consultation itself: Ensure the process, scope and scale of the consultation is of a sufficient level to demonstrate all CCG, NHSE, legal and statutory assurance tests have been met. Achieve, and provide evidence of, deep engagement, using a range of methods to do this with communities and diverse groups across NEW Devon and providing a log of engagement. Meet equality assessments and ensure materials are accessible on request. Ensure that the final decision is developed through genuine engagement and involvement with local communities. In line with our principle to be open and transparent, we will: Offer the same level of information to people attending our events and/or who ask to be given updates. Put as much information as we can on the web showing the clinical and demographic evidence behind the need for change and for planned proposals. Put meeting papers and other key decision documents on the web. Provide regular updates to everyone in the local health and care system about progress and next steps in the programme. 97

99 Enable our clinicians and other key programme decision-makers to have wide-ranging discussions in safe forums which enable challenge and debate. The consultation and communications for the programme will be run by the programme communications team out of the CCG with support from advisers, and will: Meet regularly with communications colleagues from across the county s health and care system, including the relevant local authorities and update them on progress. Work with groups such as HealthWatch and local PPEC groups to ensure the patient s voice is heard in discussions and decisions. Be accountable to the PDEG and provide regular updates to it, as well as to NHSE and other key stakeholders such as ministers and MPs. Be staffed by the programme, but draw on advice and support, and some resource from local Trust teams. Draw on and manage outsourced resource e.g. for focus groups, design, print and distribution Consultation methods A consultation document will underpin the consultation process and this will set out information and invite responses to ensure a range of views are obtained. A wide range of consultation methods will be utilised during the public consultation phase. All these methods are being incorporated to give the widest reach possible to the general population, staff and other interested parties, in particular to seldom heard groups. Figure 15-a is a summary of the different methods that will be used during the consultation. Figure 15-a: Consultation methods to be used Consultation method General publicity advertising in local media, posters and postcards, support on social media, as well as via NHS organisations and established stakeholder channels such as HealthWatch and local voluntary group networks Public meetings an effective way of engaging with a wide range of interested parties in the local health economy as well as patients and the general public Drop in sessions to provide an opportunity for detailed conversations with the public, local commissioners and acute trusts about their specific priorities and interests Focus groups will be held to target identified heard to reach groups, in conjunction with the Equality Impact Assessment work Staff engagement Implementation assumptions Information about consultation and public events available in GP waiting rooms, hospital waiting rooms, libraries, town hall and other civic and community centres Publicity in local papers to promote specific local events Website and Freephone telephone line advertised widely to drive responses Any invitation to attend a public meeting (whether campaign group or community group) to be considered and, within reason, accepted Drop in / market stall events held in areas most affected by proposals Include static and interactive elements including the ability to fill-in the consultation questionnaire Focus groups during consultation, with numbers and frequency are being planned with the support of Health Watch in accessing key hard to reach groups. Trust-specific events to engage with staff, supported by the programme. Key clinicians supported to lead 98

100 Consultation method One to one or small group meetings for key individual stakeholders such as MPs and councillors Website / online media for all stakeholders to access information and provide further background information Telephone and freepost the consultation team will be directly accessible via telephone and post mechanisms in addition to online contact information Implementation assumptions this process Key stakeholders have been written to proactively and meetings offered All requests for meetings and briefings to be considered and, within reason, accepted Website with comprehensive guide to consultation, events and activities, regularly updated Including information to help the public to understand the impact of the proposed changes on them individually To support open communications between the programme and interested parties Throughout the consultation, the communications team will continue to work with the communication teams at each of the different providers in NEW Devon. Communication leads from each of the providers will continue to be involved in regular steering group meetings and will be able to use standard communications materials such as slide decks and leaflets at any internal meetings or events they may be holding. The communication leads from providers are leading the setting up of the hospital site events Consultation materials The core product will be the consultation document, which will be adapted and developed to encourage maximum participation in the process, as follows: A core narrative, associated messages, and both FAQs and Q&As, will be developed with input from clinicians, HealthWatch, and other advisers as appropriate, and used to generate key content for the consultation, including the main document. The document and all other materials will be written as clearly, simply and in as compelling a way as possible, avoiding jargon and complex technical language. All core materials will be tested for accessibility with key user groups, such as HealthWatch. There will be a summary version available. There may be hard copies of the main document and/or summary posted out to areas defined as relevant to the programme, in recognition that not everyone wanting to respond may be able to do so online. There will be special versions such as audio or translated versions made available on request. Graphics and video material will be used to make the concepts and information more accessible to audiences. The Your future care branding will be used to clearly identify the programme and materials External assurance of consultation plan A working group of The Patient and Public Engagement Committee has been formed and has met weekly. This group has reviewed and fed back on the developing consultation plan. 99

101 All stakeholder feedback has been taken into account in finalising these materials Handling responses It is vital that patients, the public, staff and other interested parties feel that their feedback is valued and that they can give feedback easily and directly. The mechanisms for response will include: A Freephone telephone number Freepost address A dedicated address An online response form. A dedicated response unit will be in place for the consultation period. The response unit will work closely with the communications team to ensure that responses that require a reply will be actioned in good time. A protocol will be in place to govern this process Website The consultation document and associated materials will be published on a dedicated section of the NEW Devon CCG website. This will be branded Your Future Care and host: General information about the SR, including structure charts and maps Meeting papers and other key decision documents Clinical evidence and data used to inform decisions Documents and data relating to programmes such as Transforming Community Care which are relevant to SR, or links to these The consultation questionnaire. This will enable people to easily visit and respond to the consultation online (with the caveat noted previously) News and media News media will be kept informed and press releases and interviews provided as appropriate. Media enquiries will be handled as swiftly and accurately as possible and inaccuracies challenged and rebutted, based on a set of agreed and updated Q&As. Local newspaper adverts may be considered as a way of providing information about events. Specific media handling plans will be created for significant milestones throughout the consultation, including in each case: Key messages Detailed Q&As Targeted media Arrangements to offer broadcast interviews and photograph/filming opportunities A record of who we have approached and briefings we have offered. For the consultation, a media strategy will be put in place to cover the launch, proactive public relations activity and reactive communications. A bank of stories and case studies that illustrate our case for change and the benefits of our shortlisted options will be developed. An efficient and effective approvals process will also be important in terms of reacting quickly to negative or inaccurate articles. 100

102 A number of proactive approaches to engage more closely with the media are being considered to ensure that we adopt a particularly open and transparent approach. The principle is that the programme has nothing to hide and that it can only benefit by providing access to the media and showing, as objectively and transparently as possible, the current challenges facing healthcare across NEW Devon, how the proposals are being driven by local clinicians, and how the proposals will ultimately benefit the communities in which they happen. We are currently assessing an approach to future media relations which may include any or all of the following: Attendance by the media at key programme meetings, such as for example a Clinical Cabinet session, to demonstrate the openness and transparency of the programme, and also emphasise that it is truly being led by clinicians Organising a media round table debate where a select panel is invited to discuss the proposals with members of the media Offering top clinicians for features pages and similar to voice their own opinions about the changes happening this may be particularly appropriate for local and trade media Readers Questions where local newspaper readers are invited to submit any questions to local NHS staff to answer, publicly, in the news pages about what is proposed for their local services. The media strategy includes provision for adverts and inserts to be put into local newspapers, and possibly borough publications. These can offer an efficient way of reaching individual household letterboxes, but will depend on the feedback from the relevant council or paper Social media This will be used to reinforce and bolster other channels as appropriate, and monitored for relevant feedback Consultation events A number of different events will be held to ensure that: There has been pre-consultation on the proposals, in addition to earlier consultation and engagement via the Transforming Community Services programme, so that any plans then consulted on have been informed by engagement with the public, patients, and key stakeholder groups. The consultation itself can be shaped by early feedback, for example on format and language. During consultation, as many responses as possible are encouraged from the communities and populations potentially most affected by the plans. The wider context of any specific local proposals is considered, particularly in the light of the previous Transforming Community Services consultation in NEW Devon and current consultation in South Devon and Torbay. These events will comprise: Large, system-wide events with a focus on Eastern Devon Engagement events in the three key locations of Barnstaple, Tiverton and Plymouth (representing North, East and West Devon, respectively) before, during and after consultation. Smaller mobile events or roadshows in each of the local towns affected most directly by the local proposals relevant to them. 101

103 Three pre-engagement events were held in September 2016 with a specific focus on the East Devon area. These took place in Honiton, Okehampton and Exeter (Kenn). These followed May / June stakeholder engagement events (Barnstaple, Tiverton and Plymouth) and brought the total number of pre-engagement events (including Tiverton) in East Devon to four. For the September 2016 events particular effort was made to ensure that groups unrepresented at the previous Tiverton event were invited. It will also be important to reach out to health and care staff in Devon so they are aware of, and can get involved in, the consultation. The programme will therefore: Provide briefing materials and information to local trust and other partner organisation communications teams so they can then lead the staff engagement process from within their individual organisations. This could (if appropriate for the organisation) include template materials and content which trusts can easily use to encourage participation by placing on websites, sending out via , using at staff events, and so on. Ensure copies of both hard copy materials are available at relevant staff sites and digitally on appropriate websites. See also Section 15.2 for engagement aimed specifically at seldom heard groups though focus group work Consultation plan An initial plan for consultation has been prepared, as shown in Figure 15-b. Figure 15-b: Initial high level consultation plan OCTOBER NOVEMBER DECEMBER Key high level political meetings/decisions Political and other formal/group responses to the consultation Political and other formal/group responses to the consultation Events in localities Events in localities Consultation end Consultation analysis spec finalised Consultation analysis starts Consultation analysis starts EIA and focus groups EIA and focus groups EIA and focus groups Monitoring It is possible that other developments will take place during consultation that will affect the programme. For example, we know that South Devon and Torbay CCG are also planning to consult on their plans for community hospitals some time later this year. We maintain close links with those programmes or initiatives which are likely to impact upon our proposals and will maintain these throughout consultation, working with our partners as their programmes develop and adapting our plans where required. 102

104 16 Next steps 16.1 Summary of recommendations The Programme Delivery Executive Group discussed this pre consultation business case at their meeting on 15 th of July and recommended: Subject to exploring a preferred option that the pre consultation business case would be recommended to the NEW Devon CCG on the 28 th July. On 28th July the CCG Governing Body met and approved the continued work to finalise proposals (including the PCBC and consultation plan and document), in order to be able to move to make a final decision to consult in public at a governing body meeting on 28th September Approvals process Consultation is planned to commence on 7 th October 2016, subject to success in the Approvals process (Figure 16-a) Figure 16-a: Workplan until consultation The consultation will provide the opportunity to hear the views of the public and key stakeholders and the feedback from the consultation will be fully addressed before any final decision is made. It is anticipated that a final decision will be made by March