To consider the findings of NHS Herefordshire CCG’s recent public engagement on transforming Community Health Services: “Let’s plan health and care in your community”

To identify the committee’s preferred approach to the programme as it progresses.

To enable the committee to fulfil its function to review and scrutinise the planning, provision and operation of health services (not reserved to the children and young people scrutiny committee) affecting Herefordshire, and to make  reports and recommendations on these matters.

The director of operations, NHS Herefordshire Clinical Commissioning Group (CCG) introduced her report and reminded members that the CCG presented information on the engagement approach around developing community services to the committee on 23 August 2017. The approach had been adapted in response to the committee’s recommendations. Healthwatch had contributed to the work, by running some of the events and attending the public meetings.

A lot of information had been provided for the meeting, although it was structured for officers to guide through.

The deputy director of operations presented the report, drawing attention to the following:

·         the process of engagement commenced at the start of July, and ran through to the end of October. 

·         There had been inter-agency involvement between 2gether NHS Foundation Trust, Wye Valley NHS Trust and Herefordshire Council in facilitating the discussions.

·         The approach to engagement recognised the diversity and rurality of the county and sought to get to the depth of conversations at various locations including doctors’ surgeries and supermarkets.  It was intended to hear from people who did not tend to come to public events so social media were used.  All types of care experiences were heard and the process explored what healthcare looked like. Parish and town council were attended and an ongoing dialogue was established.

The findings from the engagement exercise and locality information were shown in appendices 2 and 3 and all information had been shared with participants.  The key areas of interest were summarised as:

·         barriers to accessing services, such as transport, and perceived barriers such as not wanting to be a burden on system.

·         overwhelming feedback for services not to rely on the internet. There was too much information so it was hard for people to filter out unhelpful information, and other people wanted to speak to someone to check their problem out.  

·         prevention was a key activity and it was important to recognise that the NHS was not a finite resource.

·         Addressing rurality and how to identify issues regarding frailty and mental health was part of the community resilience approach. 

The chairman noted that the 803 members of the public who participated amounted to 0.5% of population and represented a statistically limited representation of the county’s demographic. She particularly noted the deficit in responses from younger people and commented that the choice of venues was not user friendly.  It was acknowledged that this was a small number over a 3 month period, and experience showed that it was difficult to engage with the diversity of people who did not think the subject was relevant to them.  A range of venues were visited, including children’s centres and maternity clinics as well as making use of social media.  

A member commented that the flaw in the exercise was that people who were not users would not engage, and wondered where this approach originated from if it were a waste of time.  He commented further that some of the issues were not being taken seriously enough, such as population growth in near future anticipated with the university development, and that there was insufficient information to inform this. The member expressed reservations about the approach that had been taken and commented on a need to look at the model for information gathering and how to achieve better representation.

The CCG accountable officer responded that it was recognised that the demographic was changing and it was necessary to plan for the future. He added that the NHS worked to a centralised planning process which did not always work. In this engagement exercise, the intention was to be open and transparent about the position and supporting choices about people’s healthcare. In terms of whether the engagement had taken the right approach, it was agreed that the percentage level of response was small, but the quality of the engagement with those people was good. It was difficult to engage people unless they were using services, but the data collected was rich and would influence how health services would be designed for the future. 

The Healthwatch representative commented that the level of engagement was good as it was about the breadth of opinion and the views that were given. It was difficult to engage with people in Herefordshire, but the approach yielded a decent amount of engagement.

The member responded that the point of the exercise was to gather information, and that it seemed the public had not been given the information they could relate to in order to obtain a level of meaningful engagement. 

Responding to the comment, the accountable officer explained that the informing piece was the national NHS strategy led by the 5 year forward view which set out the broad strategic direction disseminated to the 44 sustainability and transformation partnerships.  The Herefordshire and Worcestershire plan was about getting the NHS fit for the future and to manage resources, and there had been extensive engagement around this. The recent engagement was intended to establish what this meant for families, carers and relatives, using a locality based approach to find local solutions for local problems.  

The director for adults and wellbeing observed that there had been significant forward planning and analysis and the projected demographics over the next 15 years were understood, and the growing cohorts of older people and the university population would inform the planning.  It was recognised that the current model was not sustainable and although NHS budgets were increasing in real terms this was not reflective of the projected growth in demand.  The county had to be financially sustainable by 2020, so it was essential for the population to live healthier lifestyles with low level needs and reducing long-term reliance on the acute care sector.  It was essential to talk to as many people as possible to gather views but there had to be a shift in the basic model so people were in their own homes and not demanding hospital services. 

The director of operations explained that the CCG governing body supported the locality based dialogue on living well at home and self-care with the demand for more support for people to keep well. Referring to the clinical case for change summarised in appendix 6 of the papers, she described that the health and care system was working as one to support people to help themselves and be supported at home. She added that it was essential to have plans that were sustainable in the long term so the system worked together to produce a clinical case for change, which was endorsed by the West Midlands Clinical Senate which had tested the clinical viability and credibility. It was concluded that there were workforce development needs which were being addressed, along with the ongoing engagement. The senate supported the model with regard to choice and consistency with national strategy. Appendix 6 showed the facts and nature of Herefordshire such as transport, supporting people to access care and bringing it as close to them as possible. To further this plan, there was investment in additional care such as the home first service, and in community services teams and moving away from bed-based care.

The Wye Valley NHS Trust director of community services added that the work to support people in their own homes was an integrated approach through the home first team and it was intended from 1 December to deliver patient care to those whose care was best provided in the community. It was well known that people become less independent the longer they stay in hospital and it was possible to support people more quickly with plans in place in their own home.

Responding to the points raised, the chairman recognised the difficulties in maintaining consistent standards of home care and finding staff to care in rural areas. She pointed out that community hospitals pre-dated the NHS and were cherished by communities and so attempts to downgrade them would be a challenge without a convincing argument. 

The director responded that there was no risk to the community hospitals as they were at the heart of the community and this was not about taking the resource away from communities. The engagement work would tell people that they are seen them as hubs for the future. The challenges around community care were recognised and work had identified that teams needed to feel they had wider support and a network, which would help teams to recruit and retain people.

A member in attendance commented that the plan was about the withdrawal of intermediate beds from market towns and observed that the engagement exercise was resource heavy with little response and low-key publicity, which did not find out what the public wanted. He suggested that whilst this was about meeting central requirements, the public would not engage in the removal of intermediate care and introducing potentially poor quality and costly home care. It was clear what the public wanted, which was a decent healthcare system and to be treated when they needed it.  He added that there were issues regarding resources over winter and the impact of Brexit on the workforce.

The accountable officer reminded members that this was about reducing reliance on beds and increasing support for home care. The plan was designed to ensure this was a meaningful local strategy and ensure due process for engagement, which has gathered feedback to support a reduced reliance on beds and support people to be cared for at home. The plan made financial sense and reflected national strategy.

The director of operations identified the next steps; to move forward in using additional capacity and shifting how care was supported.  It was proposed that the Hillside beds would be withdrawn by February 2018 with a period of transition for the workforce to adapt and to recognise the better ways of supporting people. The locality discussions would continue, being clear about the resources available. 

A member expressed that the suggestion of Hillside being reduced or ended was appalling.  She asked about the rationale, the data regarding occupancy and the views of staff regarding their redeployment. She also expressed concern about the timing as February presented issues for winter care needs and bed blocking. The member believed that this was an annexe that was greatly needed.

In response, the Wye Valley NHS Trust managing director explained that an audit of needs and evidence base that showed that people’s care could be better provided at home and needs could be met. There had been consultation with staff on the changes.

The director of community services added that staff were aware of this meeting and had started to engage on their feelings, that they were proud of their service and recognised that the site presented challenges and did not provide for care of individuals.  The aim was to retain as many as these staff as possible within teams in the community.

A member made the observation that last winter the services were well-used,  suggesting that people would not receive that level of care within the community because staff would not have the same amount of time to spend with people. There was also the scenario of people being left unsupported in between visits. 

The director of community services clarified that the intention was for those people who were medically stable to be supported to go home as soon as possible, rather than those with acute needs. The Hillside Centre saw 400 patients per year, and there was more than sufficient capacity to care for those people in the community who were best placed in their own home.

The CCG accountable officer added that it was necessary to make decisions without immediately available replacement services but as this was a necessary direction, the two provisions were working in tandem.  It was envisaged that a settling in time would be needed ready for end of winter in February. He added that the new approach would more than provide what was required and although the Hillside Centre was the right facility 15 years ago it was not recognised that people needed to be supported at home. It was made clear by the CCG governing body that this was a clinical decision around quality of care.

The member replied that there remained a concern regarding bed reduction and an increase in delayed transfers of care.

The vice-chairman commented that the perceived threats to services were inflammatory because local community hospitals in market towns were hugely valued by the public, although it was recognised there was financial pressure and most people would prefer to be at home. He added that this, however, needed resources, and asked about the practicalities of deploying people locally to look after people at home.  

The director of community services explained that it was possible to maximise support at locality level and the locality teams would include the voluntary and third sector although it was necessary to expand this to make the pathway clearer and deliverable.

A member asked whether it were possible to retain the Hillside building in case required in an emergency.  The CCG accountable officer explained that the Hillside Centre building was owned by the council so it was for the council to determine its use.

The director of community services added that the wish was for the Hillside staff to be redeployed to community teams as a priority, or to other parts of the acute service.

A member in attendance commented that it was not sustainable or safe to rely on volunteers.  The director of community services explained that the vision was for localities to work together to increase professional staff but also to recognise that there were people in communities who contributed.

A member in attendance referred back to the earlier point regarding the opening of the Hillside Centre as at the time assurance was given that the new facility would meet demand. The proposals suggested that the population forecasting was wrong at that time, and asked what assurance there was that it was right this time. 

The accountable officer explained that the demographic changes such as an increased burden of supporting frailty and long term conditions that were shared by social and health care had not been fully taken into account. 

RESOLVED

That:

(a)  Improvements to the delivery of care at home be supported;

(b)  The ‘double-running’ arrangement during the transition period into community provision be supported;

(c)  That the principle of keeping services local be supported;

(d)  NHS Herefordshire Clinical Commissioning Group provide an update to the committee at an appropriate time in 2018.