Agenda item

This report provides the Committee with an overview of the purpose, scope and progress of South Warwickshire Foundation Trust’s Community Hospital inpatient review. It presents findings of the initial engagement as well as the future plan and indicative timeline for the review.

Katie Herbert introduced this item on behalf of South Warwickshire Foundation Trust (SWFT), to provide an overview of the purpose, scope and progress of its community hospital inpatient review. It presented findings of the initial patient, carer, stakeholder, and staff engagement as well as the future plan and indicative timeline for the review. There was a requirement to consult on substantial developments or variations in the provision of health services.

Sam Owen Head of Nursing for out of hospital at SWFT then took members through the detail of the report which covered the following areas:

Community Hospital Inpatient Provision

Background was provided on community hospitals and the facilities in the south of Warwickshire. Ellen Badger Hospital in Shipston on Stour had 16 inpatient beds and the Nicol Unit at Stratford Hospital had 19 inpatient beds. The bedded offer at the community hospitals was broadly split into two areas providing for acute discharge and admission prevention beds. There was currently no provision in the north of Warwickshire Rugby areas. Within those areas, patients’ needs were met via a mix of primary care, community and acute provision. 

The review of Discharge to Assess services

A system wide strategic review of discharge to assess (D2A) services was agreed by all local system partners in 2019. The report outlined this review which was now moving into its implementation phase. Recommendations within the review were to move towards a simplified, clear and fit for purpose D2A offer. Community hospitals formed part of that offer within south Warwickshire. A table within the report provided a breakdown of the different pathways available to patients at the point of discharge, including community hospital inpatient beds, which should account for no more than 4% of all discharges from acute hospital within the over 65’s population.

Hospital Discharge Policy 2020

This was one of the central policy drivers for the D2A review, setting out the responsibilities of service providers. The report included an outline of the original guidance, the ambitions within the hospital discharge policy and its supporting guidance. This approach to ‘Home First’ stated that ‘every effort should be made to follow home first principles, allowing people to recover, re-able, rehabilitate or die in their own home’.

The case for change

The community hospital review took place within the context of wider changes within both health and social care, the Integrated Care System (ICS), the development of out of hospital services, the wider availability of D2A services and the prevalence of preventative programmes. Community health/out of hospital services had developed and were able to support much higher levels of patient need with a focus on admission prevention and supported discharge. Therefore, community hospital provision should be reviewed within the context of this enhanced and broader community offer. Some patients went to community hospitals to die, but there were inpatient and outpatient hospice facilities available. A multi-agency audit of patients using the community hospital inpatient facilities was undertaken in the spring of 2021 and the findings were reported.

Current utilisation, need and demand

Data was provided on the 923 admissions via this pathway, along with a typical patient profile, their home location, average length of stay and discharge destination.

Katie Herbert then spoke to the following sections of the report.

Engagement approach and findings

This included engagement with people who had or may use community hospital services, key stakeholders and groups who should be targeted. The approach to engagement was primarily to target those groups with personal experience of community hospital inpatient provision. Healthwatch Warwickshire (HWW) was commissioned to undertake the survey and independently to analyse the survey results. To gain further rich and in-depth insight 27 face-to-face patient interviews were conducted. Staff and wider stakeholders with an in-depth knowledge were also asked for their views.

The key themes from the patient surveys, patient interviews and staff and stakeholder surveys were summarise, together with quotes from those consulted and graphics to demonstrate the feedback from staff and professionals.

Ongoing engagement with key groups as well as the formation of a community panel would help to refine the key themes such as ‘increased therapy’ and what this should look like within the future community service.

The report outlined the equality impact assessment undertaken. A technical panel was formed to consider the long list of 14 proposals put forward from the public engagement and to consider these against a set of ‘hurdle criteria’ (patient safety & quality, workforce delivery, national/local direction and affordability), with a key aim of agreeing the viability of each proposal. From this, a table showed the proposals which had been deselected.

This was followed by the convening of a community panel to consider the remaining proposals. The groups represented in the panel were reported. It collectively agreed desirable criteria, which were represented visually in a word cloud. The outcome from this process was reported in a table showing the proposals and ranking the community panel preferences. This resulted in three proposals to be taken forward as part of the review for further exploration, as shown below:

1. Retain the Community Hospitals offer but change the type of services e.g.:
   • Diagnostics
   • Frailty Chair
   • A combination of the above or ‘other’ to be identified service offers alongside business as usual or reduced number of community beds.

2. Continue with some of the community hospital beds and invest in homebased alternatives such as package of care or therapy and/or a virtual ward in the community.

3. Retain the Community Hospital offer but change the location.

The report concluded with milestones, next steps and conclusions. Members of the Committee were invited to submit questions and comments:

• It was noted that there was no community hospital provision in the Warwickshire North or Rugby areas. A member viewed that this was irrelevant to this service review.
• Reference to the scope of this review and exclusion of some services currently delivered from these premises. Any services removed would impact elsewhere in the local system and a holistic approach should be taken. People valued these facilities and reference was made to the current challenges for acute services, notably in accident and emergency departments. In response, it was confirmed that the work on minor injuries was progressing, but not as part of this review. However, there were clear interdependencies.
• No details of comparative cost had been included in the report. There were questions around the efficiency of staff travelling to deliver care at homes rather than in a bespoke unit. Katie Herbert clarified that no decisions were required on the preferred option at this stage. Consent was being sought to explore further the three preferred options identified in the report. The costs and full details would be shown in the subsequent business case.
•  A question why the option of increasing bed capacity had not been included as a measure of increasing efficiency and supporting the acute hospitals, looking at the whole system, rather than taking this review in isolation. Such an option to increase bed capacity had been considered but removed as it did not meet the hurdle criteria.
• There were interdependences between these services and the whole system approach through the ICS. Points about the drive towards ‘home is best’, the data showing that one third of patients at community hospitals could have been cared for at home and some wider benefits like retained mobility from care at home. Improving the community offer should reduce the requirement for hospital-based provision. This review focussed on making the best use of community hospital bed provision.
• There were demands on the acute hospital sector evidenced by ambulance waits at hospitals, the length of waits in the A&E departments, which in part was due to lack of inpatient bed capacity and also related to discharge delays. By providing step down care at community hospitals and at home it would ease these pressures.
• It was questioned if there were sufficient staff to provide care at home. There was a plan for workforce development to provide the service. Other aspects were admission avoidance, removing the emergency calls and transport to hospital with support and care at home. An acknowledgement that workforce was a major concern for both health and social care and there was a need to coordinate activity.
• The lack of community bed provision in the north of Warwickshire was raised. It was stated that there were different arrangements for step-down care in the north of the county and whilst it was not a community hospital, provision was made. This review concerned provision in south Warwickshire. Members replied that community bed provision in the north had been closed.
• Praise for the excellent services delivered at these community hospitals and a view that the services should not be changed. The data showed increasing usage of the facilities. The survey had been undertaken during the pandemic and may have produced different results at another time.  The presumption that people wanted to receive care at home after a major incident was not always correct. The benefits of care by specialists in the community hospitals was stated. The costs of delivering services like physiotherapy at home would be significantly more. Whilst some minor adjustments may be beneficial, the service was working well.
• A suggestion for a similar review of provision in the north of the county.
• The service needs and priorities varied across each area. Services should be patient centred and in their best interests. They may prefer to recover at home, but this may not be advisable for some, especially those who lived alone. Reference to service integration and an outcome from the review could be the co-location of health and care staff at the community hospitals.
• Comment that 40% of patients using these centres came from Warwick and Leamington and perhaps the provision should be made between these locations.
• Katie Herbert clarified that only one of the proposals concerned reducing bed numbers with provision at home. Furthermore, the home provision included care and nursing homes. The other options retained the same bed numbers, looked at service enhancement and ensuring provision was located appropriately.
• Sam Owen gave details of the successful D2A pilot in the north of the County, which had been oversubscribed. This evidenced that such initiatives worked. For this consultation, she confirmed that the option of removing all bedded provision had been discounted. She touched on the NHS plan, the ‘home first’ principles and the additional service areas and workforce aspects which needed to be explored.
• A comment that this was not the time to reduce bedded provision, given the need to address service backlogs due to the pandemic and for other reasons. Reassurance was provided that the process would take time to complete before any changes were implemented. This review aimed to provide future sustainability and a range of issues would be weighed. This was early engagement in the process.
• A series of questions were submitted about the provision of respite care as part of this pathway and to complement the services provided at community hospitals. Respite services were provided in the county, but not as part of the community hospital remit. A parallel was drawn to the admission prevention services. The councillor clarified this was about complementing community hospitals, covering gaps between acute hospital discharge and returning to home. It was part of the discharge to assess process.
• Chris Bain spoke on behalf of HWW. There were anxieties between the proposals in this review and the accelerator programme, which sought to address the NHS backlog and to reduce waiting times. He referenced the HWW survey of carers. If they were consulted on the proposals, the feedback would differ from that reported. Carers were concerned about cover for patients if the carer became ill. Feedback from some people showed a view that services were still ‘done to’ them.  Considerable work was required to ensure that this review met what HWW had heard from residents about the discharge provision and care at home required. The workforce issues were significant to ensure patients could be discharged to home safely. Reassurance was sought.
• Sam Owen spoke about the need to move away from current models of prescribed social care to provide services that met the person’s needs. It was accepted that there were interdependencies between this review and many other areas. This review looked at different models of care, future proofing and addressing workforce aspects. There was a lot of work to do and approval was sought to do that work. Katie Herbert added that the engagement would continue with the aim of capturing richer feedback. This was the start of the engagement and future stages would seek feedback from those with lived experience of the community hospitals and those who may use them.
• Several members referenced the workforce issues and vacancies within the care system. Addressing this was essential to ensuring hospital discharge, especially for provision of care at home. It was a particular challenge for rural areas. The benefits of step-down care in a hospital setting were emphasised, with reference to a successful example, helping a resident to continue living independently afterwards. 
• Sam Owen emphasised this review concerned the SWFT out of hospital care offer before people returned to longer-term care. As context it related to 4% of discharges and did not just concern home care. Katie Herbert commented on the workforce issues, the aims of this review to plan for the future, sustain and provide different options. Also, there were opportunities for different ways of working, training and career pathways. 
• Discussion about the options that had been deselected and those proposed for further consultation. Affordability and workforce issues had been quoted as the reason for not progressing some options. One of the current proposals was to relocate the current service provision, for which the affordability was challenged. Furthermore, there were concerns about reducing bed numbers which could be incremental and then make community hospital provision unviable or inefficient. ‘Levelling up’ services was also raised, with reference to the lower life expectancy in the north of Warwickshire where there were no community hospitals and this could be a contributor. The member urged retention of the community hospital beds.
• Councillor Bell, Portfolio Holder shared the NHS vision that home was best where possible. However, if that could not be delivered due to workforce capacity of both care staff and therapists, and especially in times of crisis, there needed to be another option. This could be to either increase or have flexibility to increase the bedded offer. A need to ensure that acute hospitals did not become ‘clogged’. It was estimated that 4% of people discharged from acute care would need care in a bedded facility. She would like to see how many people that equated to across the whole county and that the review include both the Warwickshire North and Rugby areas. There was a need for realism that the vision could be delivered. The review was timely and was identifying key issues. She supported other speakers on the benefits of the current arrangements, notwithstanding that improvement could always be made. A need to ensure the best practice across all of Warwickshire.
• Several members supported the addition of an option to retain or increase the service provision at these locations. With an aging population this needed to be considered. It was not viewed that the relocation of the service was feasible and therefore this option should be withdrawn.
• Further reference to the workforce issues and the challenge for getting care at home, especially in rural areas. There was praise for the specialist role of carers. A need for good and consistent training, a career path and to make this an attractive career so there were sufficient staff numbers. The two existing centres would provide an excellent location for such training. Sam Owen responded on the joint work on blending the NHS and social care workforce. As a result of the pandemic, a lot of work had taken place and it was continuing. Further points that care was in itself a career and not necessarily a route into the NHS.
• On the option for reviewing the location, this was a choice of the panels in the earlier consultation stage. Reference to the rehabilitation centre at Campion, Royal Leamington Spa which provided a larger bed space to respond to surges in demand. 
• The provision of training for carers, including college courses had been discussed previously by the Committee. There seemed to have been no progress with this. A personal reflection on the inadequate care provision at home when the visits were only for 15 minutes.
• Chris Bain spoke of the analysis undertaken of a 30 minute care visit. This showed that carers completed 43 tasks during such visits, which prevented adequate human contact. He then spoke about the time taken to complete such detailed reviews. Changes to services impacted on people. The review needed to be completed efficiently, whilst not losing the things that currently worked well.
• Sam Owen provided information about the care certificate, which  could help with career progression. It was viewed that the career pathway was now in a much better place than previously. Becky Hale echoed this, giving an outline of the joint health and social care funded learning and development partnership. This enhanced and delivered training across the whole workforce, working with external providers to support the care market. She reminded of the item considered on workforce at the January HWBB and the commitment to develop a strategy on supporting the commissioned workforce. It was confirmed that the former NVQ qualifications for care staff had been replaced by the care certificate. An offer to share more information about the training.

The Chair provided a summation and the Committee agreed that an additional proposal to retain or increase the service provision at these locations should be included in the options, especially in view of the aging population. The proposals submitted would be accepted for the next step of the review. She emphasised that this was the very beginning of the review, which would take time to complete.

As a separate recommendation the Chair proposed a review of the arrangements in the rest of the County be undertaken to provide parity of provision for the Warwickshire North and Rugby areas. Committee members signified support for this. Nigel Minns clarified that such a review would need to be led by the CCG and ICS. The Chair agreed, reminding of the CCG merger, which in turn would become the ICS in July. There was a need for parity and she reminded of the State of Warwickshire item considered at Council and the health findings for the north of the County.

Resolved

That the Committee:

1. Notes the scope and progress of the community hospital review in Warwickshire, including engagement feedback received to date.

2. Supports the planned approach to ensuring Warwickshire patients, carers and families are involved throughout the review process.

3. That South Warwickshire Foundation Trust be requested to include a further option in the rest of the consultation processes to retain or increase the service provision at the Ellen Badger Hospital and Nicol Unit at Stratford Hospital.

4. Requests the Coventry and Warwickshire Clinical Commissioning Group and the Integrated Care System to undertake a similar review of bedded stepdown care provision for the Warwickshire North and Rugby areas, to provide parity of service across the whole of Warwickshire.