Agenda item

11:30

At the request of the Committee at its last meeting, Paul Brennan, Director of Clinical Services, Oxford University Hospitals Foundation Trust (OUH) will attend to answer more detailed questions on proposals to further develop an outpatient (ambulatory) model of care across the Trust.

The Committee will determine whether it considers the proposal to be a substantial service variation requiring consultation.

The impact of the proposal on patients, staff and partners will be explored in greater detail, including the impact of reducing the number of beds across several of the Trust’s hospitals.

The OUH reports on the proposal, which were first published for the Committee’s 15 September 2016 meeting, are attached again for reference (JHO5).

Prior to consideration of this item the Committee received advice from Nick Graham, Chief Solicitor, OCC. He advised the Committee to determine the question of whether the closure of the beds amounted to a substantial change in service, and to try as far as possible to reach agreement with the Trust. If this was not possible then it had recourse to refer the matter to the Secretary of State.

The following representatives attended for this item:

-        Lily O’Connor – Division Nurse, Medicine, Rehabilitation and Cardiac Division, OUH

-       Paul Roblin  - Chief Executive, Local Medical Council

-       James Price – Consultant Gerontologist & Divisional Director for Acute Medical, Rehabilitation & Cardiology

-       David Smith – Chief Executive, OCCG

-       Stuart Bell – Chief Executive, Oxford Health

-       Andrew Stevens – Director of Planning & Information, OUH

-       Cllr Mrs Judith Heathcoat – Cabinet member for Adult Social Services, OCC

-       Seona Douglas – Deputy Director for Adult Social Services, OCC

Paul Brennan began by stating his reasons for the proposal not being a substantial change in service. Firstly, the Trust was investing £4m in services to enable Health to support patients in their own home. Secondly, there would be no change in access to services and no change in services provided. Thirdly, integration of non-bed services provided by Oxford Health and by OCCG would continue in order to make services more responsive to patients in the right environment. Finally patients could be managed in the most suitable environment to get the best care needed.

Mr Brennan clarified at the request of the Committee that the original plan in relation to DTOC (Delayed Transfers of Care) was, via the work of the Liaison Hub, to get to 150 beds, 137 was then reached, and it was then agreed to drop down to 55 beds, which took place in July.

Mr Brennan was asked if the Hub had managed to maintain the flow of patients through the system. He responded that this had happened, and more had been done due to investments made in hospital integrated services. The OUH had invested £1.2m jointly with Oxford Health (OH) and the OCCG to keep the Liaison Hub. £1.6m had also been invested in additional nursing and medical staff to run the community services. The Hospital Discharge Team was seeing more patients managed on a non-bed pathway despite rising demand (6 – 8% increase in emergency attendance). He added that taking forward stage 2 had not led to any additional cost to Social Care – there had been no evidence provided of this. He reminded the Committee that phase 2 of the programme had started 4 months ago and half of it had already been implemented, with no additional charge on Social Care.

A member asked about how this wider remit with the Liaison Hub was working out with Adult Social Care (ASC). Lily O’Connor responded that alongside the 55 beds already highlighted, there were 49 intermediate care beds at Chipping Norton, Isis and Watlington, working with Orders of St. John and Sanctuary Care. The Trust was also working with CHC (Continuing Health Care). She added that 18 interim care beds had been funded by OCC and that OUH was working with OCC to ensure that patients were identified. She added that no beds were lying empty unnecessarily.

A member asked whether this reconfiguration would create more bed blocking further down the chain, and whether preventing admission would cause a problem with sick people at home requiring the attention of GP’s and ASC. Dr James Price explained that there were many studies which supported this care journey. One particular study focused on the quality of care for older people with emergency care needs, emphasising that it was essential that these services were person-focused and driven by the individual’s needs. Early, good quality services were very important. He added that many patients were sensitive to delays in patient care, thus, initial, speedy decision-making focusing on ambulatory care (day care in a hospital, heart centre or other setting) which supported patients at home or closer to home overnight was vital. The historical model that saw patients being admitted to wards after having been assessed by a doctor, then by a ward consultant the next day, was no longer acceptable. He added that for some people who required frequent attention, this mode of care would not be right for them. Then their stay in hospital would be decreased and they would be cared for in their own home. Older people were often admitted due to a lack of timely care in their own home. Evidence had made clear that fewer patients require institutional care via the hospital path. Age UK research had shown that avoiding admission when appropriate made a significant difference to people’s lives. Local experience and incremental evidence had shown (over a period of 4 years in Abingdon) an early manifestation of this. Doctors, nurses and social workers were working closely together, and close to the patient’s home, to make good quality decisions. Upon going home, OH and Principal Medical Ltd (PML) were giving good care at home. This had been extended to the north and south of the county and in day care assessment units.

It was Cllr Mrs Heathcoat’s view that if beds were being closed, there was a need to consult. She asked why move ahead of the Transformation Programme plans for re-designed services? She added that ASC supported people in their own homes where they feel more secure, but asked if there would be increased activity to local primary and social care, as most people would require it.

Seona Douglas added that ASC did a lot of work on a joint basis, stating that it was difficult to quantify what prevention was. If patients were discharged into the community they may require assistance with mobility, cooking etc. Mr Brennan responded that talks about services required were in place. With regard to the prevention agenda, this could not be quantified because there was no resource to say how much it would cost. The Trust’s commissioners had not received the modelling to be able to quantify it.

In response to a question from the Committee about what the impact would be on GPs, Paul Roblin stated that GPs supported the direction in travel. The move to daytime hospital care did however need resourcing in order to deliver more activity in the community. Discussions were ongoing on new models of care that may deliver new solutions. However, he warned that in a situation of national austerity, promises may not be delivered. He stated that there was a need to work together as an integrated Health service towards solutions and the direction of travel in terms of the practicality of delivery in the community needed to be looked at closely.

David Smith spoke from the financial position that the NHS was currently in. If one came to the heart of what needed to be done for the Transformation Plan, then resources wold have to be shifted in the GP/ASC direction, and things would have to be done properly. He added that unless there was proper integration of Health and Social Care via a single pooled budget then delivery would not happen. Mr Brennan, in response to the concerns of ASC and OCCG, referred to page 9 of the paper which stated that whilst releasing the beds, the Trust was spending an extra £1.4m on ASC (personal care) over and above what OCC were providing, in addition to the original  £1.5m funding into ASC by the OCCG. He also pointed out that OCC’s own strategy centred on the increased impact and demand on ASC, if patients stayed in hospital beds longer. All evidence pointed to reduced costs.

Seona Douglas added that there were issues regarding funding into the reablement service. Funding was predicated on 28 beds a week. She asked if it was over and above the 28 beds that was included in the costings for the original contract. She added that Social Care did not know the position at this stage 2 to make that assessment. Paul Brennan commented that OCC had spent £1.5m lower on the Supported Hospital Discharge Service (SHDS. He undertook to provide that information.

Members of the Committee commented that there was no argument with the principles of the changes. However there were concerns around pressures on GPs leading to the closure of a number of surgeries across the county, together with pressures on community hospitals. There were concerns about the sufficiency of staff to run Witney EMU, for example. In light of the interaction with ASC today, there did not appear to be a united front. There was also concern that the public had not had the opportunity to speak about the further closures of beds and the impact of this. There was also concern that it was not understood by the public.

Stuart Bell, OH, pointed out that in circumstances that were in reverse to the national trend, to date the plans had largely worked out and patients had been moved to a more appropriate setting. He stated that this was the best means possible of being able to release resources to assist people in their own homes via community services and ASC, and to unlock potential investment in primary care. Questions to be answered centred around how to release the resource in patient care? What sort of contractual and work place models exist to do it? What are the issues around moving staff from acute to EMU’s? All these answers would be included in the next stage of the Transformation Plan. When the formal consultation was launched there would be permanent change to consult upon. Mr Bell assured the Committee that there would be a united front, adding that the biggest issue was that of staffing – and that staff could be deployed under the new Transformation Plan.

The Committee were in favour of the principles of the reconfiguration programme, but felt that the OUH were no yet in a position to carry it out. It was aware also that the GPs were also in favour, but the way they were organised at present made it impossible due to lack of resources .It was understood that the forthcoming Transformation Plan consultation would have a knock on effect. However, if the consultation was delayed until after the OCC election, there would be no decision made for a year. It also recognised the difficulty in recruiting carers and asked who would be responsible to be with patients at home during the night? Mr Brennan responded that it had been a challenge, but to date 47 carers had been recruited, predominantly from the retail sector.

A member asked what would be the effect of bed closures on the Nuffield Orthopaedic Centre? Mr Brennan explained that this was an evolving programme and needed a reasonable conclusion. Paul Roblin stated his view that the redeployment of existing hospital staff into the community based model was not practicable. Lily O’Connor commented that patients could be looked after in their own home and that the Plan was individual patient-based. Those patients who expressed an anxiety about it would not be placed into the service. However, many patients did ask for outreach into their own home. She reassured all that this would be set up, planned, recorded and monitored in the Liaison Hub.

A member asked where the care home providers for the Banbury area would come from as in Banbury, 5 doctors had left one surgery alone and it took 2-3 weeks to set up a GP appointment. Mr Brennan commented that if the care provider had closed down then that was an issue for OCC. Beds were provided at Chipping Norton Hospital. Paul Roblin commented that there was no question that the GP service was in crisis. He did not believe, however, that this was linked to hospital configuration and hospital beds.

A member asked about travel time once home care had been introduced. Paul Brennan explained that the Liaison Hub would still run at the JR, and the SHDS service would operate from bases in the north and south of the county to enable staff to do the work at home.

A question was asked about Out of Hours cover and medical nursing care services. Lily O’Connor responded that this would continue 7 days a week and there was no expectation that others would take the service. It had been found that packages of care had been reduced. It was expected that patients cared for at home would be more mobile and mortality would be lower. They would reach independence sooner or they might not even need the service any more.

The Committee asked what would be the impact of launching a consultation if 50% of stage 2 had already been implemented. Paul Brennan responded that one further change was essential to make in the following week and then a series of changes would be made later this year and early next year.

A member of the Committee suggested that success at stage 2 would be good evidence to include within the Transformation Plan consultation next year. An added benefit of this would be that it could then be articulated more clearly to the public. Paul Brennan agreed that this was a good point and if this was the view of the Committee, it could be an advantage of engagement. To consult on stage 2 now would only serve to confuse the public.

David Smith commented that if the Committee stipulated that there must be full consultation now, the OCCG would have to write the consultation document for submission to the OCCG Board in November. This would run into, and overlap the main Transformation Plan consultation which was scheduled to begin on 4 January 2017.

Paul Brennan was asked if consultation was required now would it stall all the good work already taking place? He agreed that it would, and services would be sat with empty beds. He suggested that, as a compromise, the Trust would agree to a short period of consultation. Paul Roblin expressed the view that this would divert attention from delivery of the full provision and that the STP already contained a large element of what had been discussed.

Dr Price put forward the view that to delay would be a problem for patients and carers.

In considering the way ahead the Committee AGREED (unanimously) that OUH’s plans for acute bed and service reconfiguration constituted a substantial service change that required consultation.

To this end, it was AGREED with OUH that the scope of the ‘Rebalancing the System’ pilot be extended to incorporate this proposal and that no changes would therefore be made that were irreversible. The pilot outcomes would be used as evidence to support the transformation consultation in January 2017. Should the Transformation Plan consultation be delayed further, the OCCG would hold a 12 week consultation on this proposal, starting in January 2017, to fully understand the impact on providers, partners, patients, the public and staff.