Moretonhampstead Community Hospital, 6 November 2013
1.1 – How much money is being invested in community services?
About £64million of the NDHT’s budget is spent on community services through community hospitals in the Eastern Locality.
1.2 – Who funds the GPs?
Funding comes from NHS England.
1.3 – Who funds NDHT?
1.4 – Who sets the budget of the CCG for community hospital? / is there more or less money in the CCG pot? / Is reducing the number of community hospital inpatient beds a way of making savings?
We have to do more with less money in real term. / It costs more to provide services in Moretonhampstead than it does in larger towns because of rurality issues such as access and transport.
1.5 – Where does the money to look after people in their own home comes from?
It comes from local authorities and it is shrinking. It is more difficult to recruit staff in rural communities than it is in cities because of the way it is being paid for. Staff are being paid for each contact they make with patients not for the time they spend on the road.
1.6 – Is that set in stone? Can it change? How can you provide care in people’s home if you don’t have the carers?
We are currently unable to staff the hospital at safe level that’s why we had to close the inpatients beds temporarily. We can’t always hold onto staff that’s the problem. Even borrowing from other hospital doesn’t always work. There is a national nurse recruitment problem which even acute hospital suffer from.
1.7 – Shouldn’t the experience, knowledge and skills of the staff have been better managed to ensure the beds stayed open? Couldn’t have staff been circulated around so they could keep their skills up?
There is a difference between training and the experience gained in acute hospital where consultants, nurses are on hand at a moment’s notice with all the equipment and the experience gained in community hospitals where access to the same level of expertise and equipment might not be as high. Besides staff do not always want to work in small rural community hospitals.
1.8 – Have you decided yet which hospital will have inpatient beds or not?
No decision has yet been made. We are exploring what could work well where. We are trying to work out how many inpatients are needed or if people wouldn’t be better cared for at home or in the community with a wider range of care services on offer. There is an opportunity to increase the outpatient services in the community/hospital, by including the voluntary sector. No hospital is closing only inpatient beds have closed temporarily.
1.9 – Newton Abbot, Ashburton and Bovey Tracey have community hospitals but are covered by another CCG, is there any cross border cooperation between CCGs so people can choose to go to inpatient units in other places?
We do work with neighbouring CCGs and yes people can have that choice. Patients’ choice is paramount to us.
1.10 – Has there been any pressure on the bigger system (acute / bed blocking) as a result of the inpatient beds closure?
No. A lot of our budget is tied up in community hospital beds when it could be put into home based care which is what people tell us they want.
1.11 – Will the CCG be employing community nurses to work in people’s home and carry on providing care at home or is it going to be agency staff?
Both options are being looked at but first we need to find out what people’s needs are in the wider community.
1.12 – How will GP-led 7-day-a-week cover work?
This is a Government initiative at the moment and we are not sure how that would work. It is being talked about but is not in place yet. You probably need a big practice to provide 24/7 coverage especially in rural areas.
1.13 – What sort of services are being planned as part of the change of use at Moretonhampstead Community Hospital?
We will look at local needs and the existing facilities available. We can’t provide everything everywhere because some specialities need certain equipment such as X-ray or ultrasound machines which may not be available locally. In Moreton there is already a rheumatology service, we are working to set up a geriatrics clinic as well as a general medical clinic.
Services such as day care services (transfusion, IV drips etc ) are also services which could be provided at the hospital. We need to understand what the community wants in term of services which is not always what the community needs in term of healthcare provision. We also have to remember that we have a fixed amount of money.
1.14 – Will your process be transparent?
Yes. We will keep all stakeholders (including of course the general public) informed of our engagement process and any decision that is taken. But we can’t and we won’t take any decision without people’s involvement which is why we are asking people to join this conversation.
1.15 – Have most care homes got a waiting list?
In Tiverton we have spot purchased beds in residential care homes especially in winter with extra money from the CCG but not at the expense of long term placements.
1.16 – Who will decide to implement 7-day GP coverage?
This is a decision for NHS England. But at the moment you already have a cooperative of GP surgeries doing that kind of work in Devon. It is called Devon Doctors and they are very good.
1.17 – Is there a way of providing not just inpatients beds at the hospital but other things?
Cheriton Bishop Village Hall, 13 November 2013
2.1 – Where do people who would have gone to Moreton go now?
Okehampton, RDE, etc
2.2 – Are any beds closed in Okehampton ?
No. We have about 5 beds which are not in used in our area at the end of every day which means that we don’t have beds in the right place. In the east of the locality many beds are available. In Exeter and other parts of the county not so many.
The question is how do we spend money more efficiently? How does each bed go? Okehampton inpatients unit might have to be bigger. That’s why we are having this conversation with people. What people need to understand is that everything we do in the NHS is linked to everything else.
2.3 – How many beds are needed for a unit to be financially viable?
A 20-bed unit is more efficient than a unit with less than that. We have less and less money every year and demand for services is growing year on year by 5 to 25 per cent depending on the different services.
We have to look at what is the best value for ourselves and for the community. We know we can have the same number of beds in the community but if we configure the beds in the best possible way we could save £6.2million a year – money which we could then invest in high quality health care services in the community which could be accessed by the greatest number of people possible.
In the past we have spent money on beds. Our challenge is to manage our beds better. Some beds may have to be in bigger centres. We may need fewer bigger centres with greater integrated services and greater teams of staff and competencies. Is a 20-minute drive away from a bed acceptable?
2.4 – Is the hospital in Moretonhampstead closed?
No. Only the inpatients beds are closed temporarily because of staffing issues. Once we have established how many beds are needed and where we will have to establish how we pay for them.
But more importantly, do people need to be in those inpatient beds in hospital in the first place? Can’t they be cared for in a better way closer to home or in their own home? You don’t need to be in a community hospital to receive high quality care.
2.5 – If your budget is flat and you can’t raise money you will need to make cuts. Is that why you are cutting Moretonhampstead?
At the moment we can’t replace the nursing staff but if we release some money from the community hospital we will be able to spend that money on community nurses and improve and expand healthcare services in the community. Even if NDHT manage to get hold of staff for the community hospital it might only solve the problem for three months before we are faced with the same problems.
2.6 – You talk of working closely with the charitable sector but they are stretched thin already.
We will have to change the way we work so if we involve the voluntary sector in the provision of care in the community, especially patient transport charities and groups, we will go into contracts with them.
We will commission their service and they will receive grants from us. We want to hear from people in the voluntary sector on how we can work better together. We need to hold all our providers to account and if they don’t provide good care then we want to hear about it.
2.7 – Pensioners are being demonised in remote areas for bed blocking in hospital because they don’t have access to all the services other places have. Transport is an issue.
We are working with Devon County Council and all our partners to bring domiciliary care to remote places.
We know it is very hard to get care providers to travel any distance for a 30 minute visit especially if such visits are required three times a day. That’s why we need to grow our community services so people can receive the care they need closer to home.
2.8 – If you have a bed blocking problem in larger hospitals isn’t the only way forward to have good half-way house-type convalescent units dotted around? If you have that kind of support then it will help people who have been discharged from hospital get back on their feet who may not have any support at home.
2/5 of the people in hospital at any one time don’t need to be there. Most of the time the care people describe does not involved acute health, involving round the clock GP and hospital nurse coverage. What they describe is social care which can better be provided in the community.
Providing this sort of care in acute hospital is really expensive when the money could be used to provide healthcare services in the community. We need to look at what people can access in term of recuperation care after they have been released from an acute hospital. We are looking at prevention, keeping well and early intervention so people do not have to go to hospital needlessly.
We have been working with the RD&E on a flagship front door admission assessment system which helps move patients into the right care setting within the hospital. The RD&E is one of three A&E service in the country that is a beacon of best practice because it is good at looking after patients.
2.9 – There is a big transport issue in the community for accessing health care services you can’t just rely on charities. What are you doing about this?
We need to commission transport facilities as part of our role. We can also use our community hospitals as health and wellbeing hubs to bring in more services into the community and reduce transport issues.
2.10 – Performance for hospitals like the RD&E seems to be excellent but what is the outcome for patients?
The outcomes are usually good for patients.
2.11 – If you discharge patients from hospital straight into their homes will it not put extra pressure on GP surgeries to do extra care work?
The whole system is creaking. We are all under pressure. The local authorities are under even greater pressures than the NHS because they have to make massive budget cuts.
2.12 – There is an issue with transport and access to care. It will become more expensive to provide the same level of services in smaller towns compared with larger towns.
It does not mean that we will not do it. Some people will have to travel further and some services will have to be paid for by people. This is a possibility.
Our resources will have to be redistributed to meet the needs of people. That’s why we are talking to you so we can have a clear understanding of what people’s needs are. We will have to take transport and access to care into account.
3.1 – Why can’t you get the staff for Moretonhampstead Hospital?
We have tried very hard, but there’s a national shortage of nurses and those we can recruit prefer to work in acute hospitals or as district nurses, rather than in community hospitals. We have tried nationally and internationally. We’re up against big hospital that might want 200 nurses at a time and we have to compete, but we don’t have enough industry to bring people to Devon – even if the nurse has a job, there might well not be work for their partner.
There’s concern about the increasing acuity and dependency of patients, and about the medical support for them. It’s also difficult for nurses to maintain their clinical competency when they don’t see many patients. We’ve tried rotation between hospitals but the distances between them can be a problem for local staff.
3.2 – Is there really enough care in the community to support people outside hospital?
Many people say they don’t want to go into hospital, and we’ve got good nurses in the community – practice nurses and district nurses – who work well together.
Nursing ratios are also coming down from one per 10 patients to one per eight patients, following the Francis report in Mid Staffordshire. The reality is that a 24-bed hospital is 44% more efficient than anything smaller, which is important when commissioners have to look at every single penny so they can afford to pay for all the things people need – from new hips to dermatology. So can we justify running units with eight beds?
3.3 – Of course people want to be cared for in their own home, but here we don’t have personal carers.
If we didn’t have beds at Moretonhampstead, then clearly we would need to address that. Perhaps healthcare assistants could be trained as part of the community team, supporting people at home.
3.4 – Could we use the Moretonhampstead Hospital for dementia assessments and other things? What about residential care, because there’s a shortage?
We are struggling to provide an inpatient service, but we would not close the hospital. We’d love to see more people use it, with more services there and different organisations involved – maybe Age Concern UK, a memory café or clinics for neurologists.
3.5 – We need extra help within the community for older people, when there are so many here and the problem is going to get worse. Care at home and respite care are needed, not necessarily nurses.
We are trying to integrate social care, so people don’t get passed from one to the other. The NHS can’t solve all the social problems on this patch, but we need to be more focused on prevention, isolation and wellbeing. We could do much more to prevent falls, for example, or to help people with cognitive impairment or in the early stages of dementia.
But the money is locked up in the beds. Most of the money spent by Northern Devon Healthcare Trust on community services goes on community hospital beds which serve just 3,500 people – which is why we need to make some choices. Reconfiguring into bigger units could mean that we have as many beds without much extra travel, but save £6.2m a year for the other things.
3.6 – We’re told that the Moreton beds cost £500,000 a year. If we were to forego those beds, what would we get back – or would we just lose the money?
It comes down to what patients would need. Some of the money would go back into the community, but we have to make that money work harder.
3.7 – What about transport. Is there assistance for relatives so they don’t feel isolated? Rural areas always suffer.
We have done similar things elsewhere, working with the county council. Health commissioners can’t put £100,000 into transport, but we can put some in. One League of Friends has changed its constitution so it can support specialist transport to help frail older people get into the hospital, which can be good in itself but can also mean that the nurses can see more patients. We would welcome Acorn Community Matters approaching the Moreton League of Friends, for example.
3.8 – Why is Northern Devon Healthcare NHS Trust commissioned to provide our community services?
It wasn’t something that the Trust particularly wanted to do when community services had to be moved out of primary care trusts, but we recognised that the Trust was experienced in that field and was the most-appropriate organisation.
3.9 – Will that continue?
Northern, Eastern and Western Devon CCG is reprocuring the service for 2015. It will be a real challenge as organisations see demand going up and income staying flat.
3.10 – Should the service run by the Trust be split up – is it too big?
We have done lots in other parts of Devon, with rehabilitation and geriatricians operating in the community, for example. If you fracture your hip in Exmouth, we can now offer rehab at home and don’t need the beds in the community hospital. That means we can do things in different parts of the patch, see if they work, and then use that knowledge elsewhere and share good practice.
Exmouth is easy because it’s close to other places. Dunsford is a long way from anywhere else.
It’s certainly cheaper to run Exmouth Community Hospital, but we know it’s more expensive to run services in some places and money has to move to reflect that and give us equity for patients. Sidmouth has 22 beds and is very close to the hospitals at Ottery, Honiton, Seaton and Axminster – five hospitals for 70,000 people.
3.11 – It would be good to have rural representatives on the CCG’s committees.
The GPs from Moretonhampstead and Cheriton Bishop are very vociferous about their patients’ interests.
3.12 – Do GPs feel that care in the community is viable and do they support it?
GPs seem to be moving from “No” to “Yes, if…”. There’s increasing recognition that this is the direction of travel, especially with the national move on nursing ratios. GPs also like the idea of healthcare assistants coming out of the hospital. There’s a sense that things are changing and it’s a question of making the system work. That might mean using a single provider because there isn’t really a market in community-based care.
3.13 – Community nursing is good but needs to be expanded, so people don’t have to wait for a visit after coming out of hospital
If we had the £500,000 for Moretonhampstead, how much of that might be spent on community nursing? There’s an opportunity to test something here, with healthcare assistants as part of the NHS community team, specifically for people in this area.
3.14 – In North Yorkshire, they’ve re-opened a cottage hospital because of the demand
We need to have the beds in the right place, protecting the numbers but releasing money for reinvestment.
3.15 – Where would people go in the winter if they were poorly and needed 24-hour care?
We would be able to put carers in for 72 hours and make use of a rapid-response team to help people stay at home, like we do in Exmouth.
3.16 – You need to pay enough to recruit the right people to provide the service, so they get paid for travelling time etc
NHS staff would be on national terms and conditions.
3.17 – What about when winter comes and the roads are difficult – we’ve had farmers out to keep the roads open for nurses
We have winter contingency plans, so we are used to this. Among other things, we have access to four-wheel-drive vehicles to get our nurses about.
3.18 – If you changed the way Moretonhamptead was used from inpatient beds and looked down the residential route, could we train local people as healthcare assistants?
We’d need to make sure the Healthcare Assitants had the right skills, which comes back to working with patients and seeing what’s needed for their community – including social care, mental health – so the right person can be available. We’d have to ask how we could provide very local training, with one or two people involved in each area and the right governance structures. With that training comes trust. People want to be part of this, because we’re trying to enhance the community so people can look after themselves – it’s about finding people and giving them the support they need.
We’ll investigate this before the public meeting [Moretonhampstead Sports Hall, 6.30pm, 9 December], to give an idea of how we could bring people from the local community into roles like healthcare assistants.
3.19 – We have a lot of volunteer support, but there’s a limit to what they can do
For example, the Exmouth practice has a voluntary sector rep on practice meetings, and we know the voluntary sector is a huge resource that we might be able to tap into. We might be able to use Moretonhampstead as a hub for this sort of thing, linking everyone together, perhaps with a paid coordinator, so together people can come up with solutions. It is relatively easy to get people together in a small community.
3.20 – Are there too many health organisations, with the Health and Wellbeing Board (HWB) taking money as well now?
The HWB has limited money from, not a huge amount, for things like substance misuse and sexual health services.
3.21 – Do you talk with other people elsewhere in the country about good practice and ideas?
In fact we are ahead of the curve in Devon, because our demography – the number of older people – is 20-30 years ahead of most of the country. But we do talk, through clinical networks for example.
3.22 – Haven’t decisions already been made and these meetings are just a front?
No. These sessions do work, as we saw in Axminster when 700 people turned up to a meeting when the RD&E wanted to stop surgery there. There will be a decision in January on the way forward for Moretonhampstead, but that would then be subject to public consultation.
3.23 – GPs don’t provide 24/7 cover now. The practice here used to, but that was exceptional
What we ask of GPs is different from five or six years ago. We don’t want a tired GP, who’s been up all night, looking after us in the morning. We already have vacancies on GP conversion courses, and if we put too much pressure on GPs then we won’t get new ones in.
3.24 – If the pattern of GP care isn’t going to change, how do people get medical care at the weekend and out of hours? Will we still rely on Devon Doctors?
Yes. There’s talk of seven-day working for GPs, but we have a fantastic out-of-hours service compared to many other places. We won’t be going back to what we had before, but we aim to improve communication and the sharing of information, for example. DDoc also look after community hospital patients at weekends, and has always been responsive.
3.25 – We want the best for patients in this area, and that might mean changing the way that things have always been. We would need to know what wasn’t there anymore and what we had instead, and what we had in addition. That might take some getting used to, but we need to know what would be best value for the money available.
If you had a blank piece of paper and started a health service now, you wouldn’t have what we’ve got now. We have had these problems before at Moretonhampstead, so we really want to work with local communities and stakeholders to get the right, sustainable model of care.
3.26 – What’s the maximum number of beds that can be made available at Moretonhampstead?
The physical capacity is 10, but at one nurse per eight patients, we would have to staff for 16. So, in practice, the maximum would be eight.
3.27 – When you talk about care in the community, what will be made available?
Our vision would be of patients being looked after in their own homes, with 72-hour carer support and a longer package of care lasting up to 21 days. That’s what we have done in Woodbury and Budleigh, for example. It’s enhanced community care. Since temporarily closing the Moretonhampstead beds, we have increased nursing and rapid-response, but if we completely replaced the beds we would want to strengthen medical care and look at the possibility of using Continuing Healthcare funding.
3.28 – Dunsford is mainly retired people, which means retired people looking after other retired people, the elderly looking after the elderly. Younger people are commuting to work, which often means grandmothers looking after children as well.
That’s about how society as a whole organises itself, but it is a conversation that we need to have.
3.29 – You need to be careful about over-reliance on the voluntary and private sectors This can be seen as creating a market and the slippery slope towards privatisation.
You can’t have get an open market in a small community like this – it’s too small and too rural. Ultimately that might mean one provider and limited choice. GPs want the NHS system to work as well as it can, and that we can be proud of.
3.30 – We have to be cautious, so we don’t overwork our GPs. I wouldn’t want to think that we’re driving them away.
Yes, but if we stop doing some things in hospital, then GPs will need to do more. We need to make sure the resources are there for that.
3.31 – If the loss of eight beds means better care in the community for a lot more people, that’s an acceptable decision.
Thank you for all your comments today