Torrington questions and answers
Drawn from drop-in sessions, website and letters
Why did you pick on Torrington for this pilot project?
The needs in and around Torrington are particularly acute, given that it is quite isolated. That means it has the most to gain if the model of home-based care works. But if it does show real benefits, the Torrington model might be transferable elsewhere.
Torrington has had significant additional investment into its community health care services over the past year, totalling £383,000. This investment has enabled the Trust to develop community rehabilitation and nursing teams who have the skills, experience and expertise to treat and support people in their own homes.
Our town is growing. It’s a much bigger town with a lot more elderly people. What about Bideford? Is that closing? We’re nearly as big as them now. Have you taken the new proposed housing developments into consideration?
Proposed housing developments and the consequent increases in population are accounted for in the strategic planning for the Northern Locality, as part of the NEW Devon CCG and public health strategic needs analysis, which is refreshed every year.
Part of the purpose of trialling the enhanced model of community care is to ascertain what capacity we would need to serve the needs of the ageing population.
What is the composition of the community team?
The community team comprise:
- Community Matron – Registered nurse and enhanced prescriber
- Community nurses
- Occupational therapists
How many community nurses are there?
The nursing team serving Torrington has been increased from 7.4 whole-time equivalent staff to 12.2, supporting approximately 100 patients.
In addition, the number of therapy staff serving Torrington has increased from 1.44 to 4.13 whole-time equivalents. Their caseload is approximately 80-100 patients at any one time.
Patients are seen according to the clinical needs,which means that visits are as frequent and long as required.
Will that be enough staff, given the increase in workload and the ageing population?
In the short term, the increase in workload is not expected to be very great. The nursing team already support around 100 people in their own homes at any one time, while only four or five people are typically in the community hospital. Looking after 105 people is not a huge difference.
However, the pilot project is designed precisely to test these sorts of assumptions, so we won’t know for sure until we’ve done it and assessed the outcome. If it did work well, we would nevertheless need to keep services under review as demand grew over time.
Do the rehabilitation teams have the same experience and expertise as the hospital staff have?
Yes – for rehabilitation they are the same staff. Part of the idea of this project is that specialist nurses can carry out procedures that would have originally been done in hospital, such as administering intravenous antibiotics, at home.
Are all the social carers from private agencies?
Nearly all, but they would play an important part in the project. The agencies could help identify any shortcomings in healthcare, for example, because they will often visit several times a day and will notice small differences in capacity. The agencies should be flexible about timings of visits, agreeing with individuals and their families the most suitable time for timings of visits. There are also personal budgets for people to spend on social care, so they can tailor support to suit their needs.
Current use of the hospital
Have you done a capacity analysis of the beds during the past few years?
We are clear about bed usage and have collected this data for all our hospitals and wards every month, dating back many years. There is a very clear correlation between declining use of beds at TCH and the increasing numbers of people cared for at home by our community team.
Acuity audits – carried out each year to look at the needs of patients – also suggest that around40% of inpatients across all our community hospitals do not need to be there, even in areas without enhanced home-based care.
How many staff does it take to keep one bed running?
We must have a registered nurse and a healthcare assistant here 24/7. You also need physiotherapy and other staff, including administrators, so it may be about 20 staff.
On leaving NDDH, patients should be able choose if they go to Torrington rather than Bideford, Holsworthy or South Molton.
In the last week (early Sep 2013) we have received two referrals for Torrington Community Hospital. We were able to support one patient at home with the help of an OT. The other patient needed more intensive rehab, which had to be done in the acute setting at NDDH. One person also went to South Molton, but that was at the request of the patient so they could be nearer their family.
In terms of people going to a nursing or residential home in order to prevent hospital admission, this has not happened often. There was one admission in March, one in May and one in August this year. Where possible we would prefer to care for someone at home, providing overnight care and support if necessary. In May – July we commissioned 14 nights ‘night sits’, which are done by competent agency carers using three different agencies.
If a patient is at risk of an event, which could happen 24/7, they will be kept in the acute setting of NDDH. Those people at home aren’t considered at risk of an event, and thus can stay at home with the help of care assistants etc.
How many transfers are there to and from Torrington Community Hospital?
There are on average 20 transfers annually between northern Devon community hospitals for clinical need (1% of total admissions to community hospitals). For example, on average 5 of these form part of the stroke pathway.
There are on average 1,580 transfers of patients between community hospitals and NDDH for clinical need – 1,040 from NDDH; and 540 into NDDH. 10% of these flows in either direction are part of the stroke pathway.
How many patients have been discharged from NDDH on escalation (i.e. early to free up beds)?
No matter how busy or under pressure the healthcare system is, we do not transfer patients early just to free up a bed. Whilst managing the flow of patients through our hospitals is a challenge, their care is not compromised
How many patients have been discharged directly to their home unsupported (without care provision….or even food)?
NDHT has a clear process for managing the discharge of patients. Each patient has a care plan which identifies their onward care needs. Our Pathfinder Team, Complex Care Teams and Complex Discharge Coordinators work together to ensure the right package has been established to enable a patient’s discharge to take place. The Red Cross is also commissioned to provide a hospital-to-home service to support vulnerable patients on discharge, ensuring heating is switched on, food is bought and the patient is all right on arrival home.
Evidence of effectiveness
Where else in the country has the pilot model of care been successful
These include Gloucestershire, Cumbria and parts of London.
How would we cope if the beds closed?
Many people want to come to the community hospital to die. Would they be stuck at NDDH?
No. One of the things our community staff are really passionate about is helping people at the end of their lives. In the first week of August, they were able to provide support at home for two people who wanted to die at home, which they did, peacefully, and surrounded by their families.
What about end-of-life care? We have a very ageing population.
Since April 2012, 10 people have died at the hospital. In the past year alone, 61 people have chosen to die at home under the care of our community nurses. We can put in overnight care, including qualified nurses where required, to support the individual and their families, and enable them to them to die at home.
What happens if people don’t want to die at home?
We are looking at the options because not everybody wants to die at home. We are seriously considering options such as the provision of beds for end of life. Chris Bowman is looking into this with nursing homes, etc. We understand that some people don’t want to go to Hatchmoor..
We have had family use of the hospital over the years, particularly my father who spent his final few days there with 24-hour care available, particularly valuable when he died in the night. Under the new system my elderly mother would have had to deal with this crisis at a time when the community nurses would have been off duty.
In terms of end-of-life care, the community team feel passionately that this is something they can – and do – provide extremely well. There is 24-hour cover if needed, with overnight carers and nurses available through the hospice and Marie Curie if required, as well as rapid access to out-of-hours nurses via Devon Doctors.
Who should we contact overnight if we need medical or nursing help?
Contact Devon Doctors, as now. It would be useful if The Crier included these sorts of numbers regularly, as they are all publicly available.
What would happen if you needed respite care when there were no hospital beds?
That is primarily a social care function, while hospital beds are for people who have clinical needs. However, respite care should be flexible, so you should be able to take it when you need it.
What happens if people are on their own in outlying areas and nurses can’t reach them because of bad weather? Shouldn’t they be in a community hospital bed?
Our staff haven’t had any real difficulties, but if there was bad weather approaching we would assess the risks for vulnerable patients to make sure contingency plans were in place for each, as we currently do.
It’s TLC that people need and that will be lost if the hospital beds close
Loneliness and social support is a big issue for wider society. We can’t provide social care, as money is very tight and our responsibility is for people’s health. Having said that, we recognise the role of social support in keeping people well and independent, which is why the creation of a vibrant community hub at the hospital could be a huge asset for the people of Torrington. By opening up space at the hospital for other uses, we might be able to host forms of social support – please let us know your suggestions.
How are you planning to compensate the community for the loss of the social function of the hospital?
This is an interesting point and one that has come across through the feedback at the drop-ins. It is important to note that our role is to commission and provide health services, not social care.
However, our view would be that if the test of change is evaluated to be successful, we would look to turning Torrington Community Hospital into a vibrant social and health hub for the community. At the heart of the consultation, we will be asking what services we might be able to run at the hospital.
So far the community has suggested ideas such as exercise classes, leg ulcer clinics (which work really well in other northern Devon towns), and offering use to the voluntary sector, sexual health and family services amongst many more.
We are limited by space so many of these clinics and ideas would only be possible if the beds were no longer at the hospital. And this decision would be taken, in partnership with the local community, at the end of the consultation.
What happens if I need physiotherapy, which would have been provided in the hospital?
Outpatient physiotherapy will continue and could possibly expand at the hospital. If you were unable to leave your home, you would have your physio at home, as many people do already, so no need to travel at all. This would be especially useful for people from outlying areas who find even the trip to Torrington difficult.”
What will happen to the people who are recovering from major surgery – eg hip operations who would have originally stayed in hospital for a few weeks before they are well enough to go home?
They will stay in one of the larger hospitals eg Barnstaple for a bit longer and have more intensive rehab. When they are well enough to be discharged home, they will be admitted to the ‘virtual ward’ and provided with increased and adequate support at home.
What if someone requires more care than someone popping in a few times per day?
People will not be discharged from hospital unless they are fit and well enough to be at home with the added support from the community and nursing rehabilitation teams. Our teams will visit as often, and for as long, as necessary.
There is no direct transport link between Torrington/Holsworthy or Torrington/South Molton for people wishing to visit sick relations or friends and would this be provided?
Why should people from Torrington end up in a community hospital at South Molton or Bideford, away from friends and family?
We do not want to see Torrington in another community hospital when they don’t want or need to be there. People might have to stay slightly longer at North Devon District Hospital, but the aim would then be to get them back home – or sometimes a care home – with all necessary support in place. The aim is to ensure that all someone needs to keep them at home, as independent as possible, is available. So while we cannot provide transport to Holsworthy or South Molton, for example, we aim to ensure that it’s unnecessary anyway.
Will families be paid travel expenses if going to other community hospitals? There are no buses that go direct to Holsworthy while a taxi would cost £60.
Unless there is a clinical need, people will be treated at home. There is a reimbursement scheme for patients, but not for relatives (apart from parents taking children to hospital). This is one reason why we are keen to bring services such as out-patient clinics to Torrington, making it easier and cheaper for local people to get the care they need. Bear in mind as well that people in outlying villages also need transport to Torrington Community Hospital.
I am very concerned that the ‘pilot’ due to start on Sept 1st was a myth in that patients have not been accepted into Torrington Community Hospital since 25th July. The deed of closing the beds has been done before consultation…How do we know the care is in place?
We are working to make sure there are enough staff so that six beds can be open for admissions while we run a consultation exercise from later this month. Full details of the consultation and other arrangements should be available very soon.
Please could you tell us when the beds will be available again in Torrington. This is a matter of urgency?
We are working to make sure there are enough staff so that six beds can be open for admissions while we run a consultation exercise from later this month. The exact timing depends on securing the right skills and on staff preferences. Full details of the consultation and other arrangements should be available very soon.
How are you going to reassure the public that this is not a done deal?
We have been clear throughout that the beds will reopen if the test of change is not successful. The staff remain on substantive contracts, with Torrington as their base. No final decision will be made until early 2014 which will have to be signed off by boards of the locality, CCG as well as NDHT. Any significant service change, such as closure of the inpatient beds, would also be subject to further, formal public consultation.
Why have you cancelled the public meeting?
We have had discussions with councillors and the MP, and it’s clear that we need to do more engagement and consultation work before temporarily closing the beds. A lot of people don’t know what we are trying to do and why, which is why the drop-in sessions every Friday (10am-12pm) are so important. And we want to be able to go to the rearranged public meeting with answers to all questions, with a clear idea of what the hospital could be used for in the future.
Shouldn’t you have consulted people earlier about the project?
Yes, we should. The CCG is a new organisation, but it is learning fast.
Why have you started the project already by putting people in other community hospitals, when it’s not meant to begin before 1 September?
We haven’t. All that’s happened is that the number of in-patients will reduce in the run-up to 1 September, as they are fit and ready to leave. The alternative would be simply to move everyone on 1 September, regardless of how unwell they were; that would be unsafe and unfair to the patients.
How will you publicise what you are doing?
We will use the Gazette and the Journal, and are working on a consultation document that we would like to deliver around the Torrington area. We will also be talking with local groups, will continue our weekly drop-ins at the hospital and will be holding public meetings. The most up-to-date source for people is the NDHT website, where all the background material and latest news is kept. See: www.torringtoncares.co.uk
Can you please publish information and contact numbers in The Crier?
We have put some initial information in The Crier, and will continue to add to this. However, given its print schedule, we will also try to keep people up to date in other ways. As well as the website, which is updated frequently, we have been doling weekly drop-in sessions and are staging a public meeting. We will also print important information and are looking at other means of getting information out to people.
How can you reassure us that this isn’t just a backdoor way of shutting the hospital?
This is a project to test out new ways of caring for people in their own homes. There are really exciting possibilities that we believe could have major benefits for people not just here, but in other parts of the county. But we won’t really know until we try it. So we will try these new ways of working for seven months – the hospital remains open but the beds are not used. If the project doesn’t work, then we’ll re-open the beds. Whatever happens, we want to make best use of the hospital itself, so in the mean time we’ll be looking at bringing in other services, such as more out-patient clinics or community support.
How will you work out whether the pilot project has been a success? People will just tell you what you want to hear.
We are working on the criteria for assessing the project, with input from local people, for publication so everyone can see. The focus will be on the care and experience of patients who receive the new model of care, with feedback gleaned independently – we want to know what’s gone wrong as well as what’s gone right. That feedback will be used throughout the project, so we can identify any problems early and do something about them quickly.
Are we going to be told the evaluation questions and answers? I want to know them. How will the questions be worded? Will they be designed to give you the answers you want?
Yes, we will set out the criteria so everyone can see.
Why can’t we have real representatives of Torrington people on the working group, rather than the town council?
We are working with the town’s elected representatives. However, there are lots of other ways in which ordinary people can let us know what they thing, via the drop-in sessions, the public meeting or the website, for example (see main web page).
I understand that the two local surgeries are not in favour of the proposed closures. Don’t they have some role in this decision-making process?
Rightly the GPs want the best for their patients. They wish to ensure that as many individuals as possible have local access to as wide a range of health services as practicable. The community hospital has provided good care for those needing it. Obviously they would want to ensure that any change to that provision provided as good as, if not a better level of care. They are supportive of the test of change but remain committed to the Community Hospital and its future development.
Dr Chris Bowman has a continuing dialogue with the local GPs to support their engagement with this project and to ensure that any problems they identify can be addressed promptly.
Are GPs involved in the project or showing any interest?
We’ve engaged with them throughout the process and have promised to give them regular updates. We have spoken to them about IV antibiotics and UVI, etc. They have asked for geriatrician support and this could copy a model in the East, where they have a consultant geriatrician.
Some members of the CCG have their own interests, including monetary
All GPs have to declare if there is a conflict of interest.
Ideas for use of hospital in future
Why not have a day hospital in the building, like there used to be? It was so good for people on their own
We would very much like to see the hospital become a vibrant hub for the community, so a day hospital or even just a social drop-in might be feasible. We will investigate all these possibilities, so please keep on making suggestions about what you would like to see.
Can we reopen the day centre? Holsworthy are doing well with theirs.
We are certainly considering this and can look into what’s working well at Holsworthy.
Could family planning clinics and mental health care come to the hospital?
These are exactly the sorts of things that we might be able to offer if there were no beds. We are investigating these sorts of options so we can let people know what might and might not be feasible.
Will there be intravenous antibiotics, blood transfusions and chemotherapy art the hospital?
We might be able to do these at the hospital, and even, for IV antibiotics and chemotherapy, in people’s homes. This is being investigated.
If there were enough volunteers, could we re-open the day centre?
Could we have classes like pilates or tai chi in the hospital?
We would love to see the hospital develop as a vibrant community hub, so these and any other ideas will be explored. Obviously, the NDHT does not itself provide these sorts of things, but we would be more than happy to work with groups that do.
They take pressure off A&E in Barnstaple, could you reinstate a minor injury unit?
We will certainly look at this as we consider how best the building should be used.
Could we have a Devon Doctors base at Torrington, because by the time they call back at night, we could get to A&E at Barnstaple?
This would probably be too expensive, but again it’s an idea that we need to bear in mind. We will consider all ideas put forward by people in the area.
Is the building going?
There are absolutely no plans to shut the building. We want it to be used to the maximum for health and associated carer and support. We’ve got the children’s centre; the hospital could be a similar, vibrant centre for adults and older people.
If people in Torrington were prepared to sponsor a bed, how much would it cost?
We can’t rely on charitable donations to ‘sponsor’ beds, because that calls for ongoing support rather than one-off contributions. However, there’s no reason why people should not continue giving to the League of Friends, for example, as there are always things that need doing to the fabric of the building.
Can we have a minor injury unit back in Torrington? It would ease the pressure on A&E at NDDH.
Not many people are injured in Torrington. With an MIU that is quiet, it would be difficult for a nurse to maintain her skills and competencies when seeing so few patients. With SWAST, we are looking into the idea of having an Emergency Care Practitioner (ECP). This model has been used elsewhere. ECPs can get to people quickly, either in the hospital or in people’s homes, and are able to diagnose and prescribe, and signpost for tests accordingly.
Can your 10 community nurses come in and do certain work in the hospital on a rota basis, such as dressings and blood transfusions? It’s so busy down at the health centre, and it would be nice to have a back-up. They could also do it out of hours.
We are looking at blood transfusions and this is an area we could develop. We are also considering having a single point of contact for advice on health and social care. It could be a ‘hub’ for advice.
Can you have bed and breakfast beds, as respite for carers?
We certainly need to look at what can be done to support carers, but this is a social services function
Could pre-op assessments be held in Torrington?
They could be done, but we need to think of the logistics. It could certainly save the time and expense of going to Exeter or NDDH. Also, there is a possibility home visits could be done ahead of hip replacements, etc.
Will a family planning clinic be returning to Torrington? It closed with no warning previously. There are lots of young ladies and men in Torrington who could benefit from it. At the hospital they could go in quietly, whereas at the health centre they may be put off as their name is called out, etc.
We will look into this possibility.
Could we have a social tea and chat clinic, to bring people out of their homes if they are isolated? This could be ideal for people being looked after at home by community nurses. They have a similar clinic in Holsworthy.
The Red Cross are very keen to support us in Torrington and could help us with transport. It could be good to bring together groups of patients with similar conditions for befriending and support. We have a project leader, a hospital matron in East Devon called Emma Bagwell, who is coming to look closely into what new services we can put into Torrington.
Can we have a dialysis unit here, because at the moment people have to go to South Molton, and can get travel expenses for this. The LOF may consider purchasing a machine if it’s worthwhile.
We are looking into the numbers of people with Torrington postcodes who use these services elsewhere. We need to consider the costs for a machine, maintenance, fluids and the staff to run it. It would be nice if it was done locally as dialysis can be intrusive.
Can you do chemotherapy here, because a lot of advances have been made in recent years, including the use of pills?
We can look into this. It could be a pill or intravenous. Money may be an issue if we needed more technical equipment.
Costs and finance
How much is the consultation costing?
Not a huge amount in cash terms, with publications, advertising and room hire for example, but a lot of staff time is involved – not least in coming out and talking with people about the project.
Wouldn’t it be cheaper for people to come to hospital for care, so community nurses didn’t have to spend so much time on the road?
Possibly, but community staff know their job is to be on the road, going out to patients at home for day-to-day care. That saves the patients a journey. But some types of care could be provided at the hospital – perhaps leg ulcer clinics, for example, when a specialist nurse comes to Torrington.
If the system you’re trying saves money, will it go ahead? People think it’s all about the finances.
The pilot project is about providing better care. It’s also about getting better value, because we do have a limited amount of money. We are very aware of the population projections, so this is a means of future-proofing Torrington as more and more people live to old age. If we kept to the current model, we might have to fill three community hospitals, but that is not possible.
If we can keep people more independent in their own homes, it might be that the real financial benefits don’t show up for a long time, in terms of avoiding falls, acute hospital admissions and ambulance journeys, for example. By taking social considerations into account as well, by making greater use of the hospital building, we might see further savings down the line because people are less lonely and better able to live the lives they want.
Who pays if a patient ends up in a care home instead of a bed at Torrington Community Hospital?
The NHS pays for nursing and medical elements, but individuals are responsible for ‘hotel’ costs, such as meals and laundry, and for social care costs. Payment is means-tested, as it has been for many years. In practice, there should be no difference, because patients should only be in community hospital beds if they have a clinical need. In fact, by being supported at home, people would avoid care-home costs.
Why don’t you admit that this is all for financial reasons?
Providing care in people’s homes isn’t necessarily any cheaper. The project is about providing better care than we are able to provide now. At the same time, we have a limited amount of money, so we have to make sure we spend every penny in the best-possible way, so any revised system would have to be affordable. Ideally, we will move in the longer term to a model of care where we always seek to keep people well and independent, rather than being limited largely to reacting when they suddenly fall ill or suffer an injury.
Will this not end up costing North Devon Hospital more money as people will need to stay there for longer?
Discharge Coordinator posts have been created to facilitate quick, safe and suitable care packages for people when they are discharged from the acute hospitals and back home.
How is the increased community care that people will need going to be funded?
Over the past year, significant investment has funded the formation of the Trust’s community rehabilitation and nursing teams which include specialist nurses, physiotherapists, occupational therapists, community nurses.
We asked if you could furnish us with their financial budget, costs of additional care in the community versus savings of a 10 bed closure.
We can offer figures in many forms, but this exercise is not about cost in the community versus the cost of 10 beds.
Rather, this is about a testing a model of care. Our anticipation is that there may well be a greater investment in the community services, but the research from the King’s Fund shows that as a result of this, savings tend to appear initially in outpatient settings and primary care (Kings Fund). We also anticipate savings in social care, although that is a different data exercise.
The project will help us build the economic analysis, but that would only come into play following assurance that this model of care was better for patients in clinical terms.
Do you have a budget for NHS patients who will use the services of Hatchmoor nursing home?
The expectation is that the vast majority of people would be able to be cared for at home, and that when their needs required the expertise of a district hospital, they would be admitted to Northern Devon District Hospital.
However, there may be a small group of patients who need to be cared for in a bed other than their own; part of the test of change is to check that out.
Hatchmoor, Woodland Vale and The Castle are the three care homes in Torrington that may be suitable to receive such patients, if appropriate. There are three discrete funding streams which could be used to support placements there as long as the criteria were met for clinical need. One funding stream is for rapid response, a second continuing healthcare and a third is recuperative care.
If someone wanted to sponsor a bed, how much would it cost?
In the NHS, we can’t accept private money for NHS care. A bed in a community hospital costs around £355 a day. A problem in Torrington is that, because it’s small, costs per bed are relatively high.
Community funding and ‘ownership’ of the hospital
Who now owns the building and land which were gifted to the town?
It is on the Land Register as belonging to the NHS.
What happens to specific collections from funerals and bequests – do these go to the NHS?
Only if specified by the deceased or their family, and then only for the purposes specified. Someone can state that they want the money used for patients in the Torrington area, for example, and that’s exactly how it would be used.
What happens to all the League of Friends money? Won’t that now be swallowed up by NDDH or somewhere else?
No, money given for a specific purpose has to be used for that. It’s the same for legacies and other gifts to the Trust.
Is LOF money that is meant to be spent here at Torrington actually going into a wider NHS pot at NDDH? If people write a cheque out to Torrington Hospital, it goes to NDDH and then you have to apply for it through a central pot.
It goes into a central Trust pot for charitable funds but is allocated to a Torrington budget, so the money will still be ring-fenced for Torrington. There are three specific funds:
- Fund No: 1401 (Torrington General Fund)
- Fund No: 1402 (Torrington Staff Fund)
- Fund No: 1403 (Torrington Staff Fund)
Is it right that you accepted a Hi Lo bed that was purchased by the LOF AFTER you decided to remove the beds? If so, it’s bordering on fraud.
No, the bed was purchased in November 2012 and delivered in January 2013.