To consider further information on the proposed closure of the Hillside Centre facility.

A presentation was given by the managing director, Wye Valley NHS Trust (WVT) and the director of operations, NHS Herefordshire Clinical Commissioning Group (the CCG). 

It was explained that some of the information provided had already been shared and it was intended to give more detail and update the committee since the meeting in November. Members were reminded that officers had also attended the meeting in August 2017 and talked through the process, and had taken members’ advice on the engagement process from that meeting.

In the presentation, the following key points were made:

·         There was a strong body of evidence to support not keeping people in a bedded environment, which included the degenerative impact, and to provide reablement

·         In terms of metrics, WVT performance compared well with other areas and as provision of care shifted it was expected to see improvement

·         The early supported discharge (ESD) team had transitioned care from other sites as well as the Hillside annexe and was providing high quality community-based reablement including dedicated stroke reablement in order to provide better outcomes. It was important to recognise this if performance were to be improved in addressing length of hospital stays and increasing the number of people who had access to care at home

·         6 additional staff had been recruited with a further 4 sought in the new financial year and there was confidence over capacity to meet the change in service. Double running of provision was in operation during February whilst stepping down the number of people at Hillside for the transition to be effective from 24 February 

·         There was close working between the health and social care teams to support the transition

The assistant director, operations and support, explained that around £1.2m had been spent on reablement and rapid response services, leading to the council forming the home first service. Investment would increase to £1.5m next year. Where previously around 300 people would have been in receipt of this service, it was expected to increase to around 1000. It was anticipated that this number could grow further as the new service became established.

A member asked what was included in reablement and rehabilitation and whether this included soft exercise. The managing director, WVT, confirmed that the increase in reablement staff included additional physiotherapy input.

Responding to a member’s concern over contingency plans in the event that the additional workforce could not be recruited, it was further clarified that there were staff in place. The assistant director added that 6 of the 11 posts in the adults and wellbeing team were being filled with 4 being recruited, and this would be an ongoing recruitment drive.

The member asked whether any staff from Hillside had joined the home first team, or if they had been redeployed elsewhere.

The WVT managing director explained that staff had a choice of vacant posts in the trust and that they were avoiding redundancies. It was not certain whether there had been any resignations as a result of the changes.

A member in attendance sought clarification on the skill-mix of the whole time equivalent number of staff mentioned in the presentation. It was clarified that these were clinical staff and not clerical staff and were additional staff as part of the wider service.

The member commented that experience had shown the difficulties in providing a stable workforce, especially in remote areas. She questioned why these changes had not been announced at the same time as the closure of the walk-in centre. She further commented that she did not accept the council’s response to the situation as she believed it had a duty of care to the population.

The CCG director of operations explained that they were in the flow of the engagement process so were not in position to say that it was the right thing to do and that the two issues were not running in parallel.

A member asked where the additional staff would be based, pointing out the issue of travelling times involved in getting from place to place in rural areas.  The managing director clarified that staff would be based at different sites, such as Hereford and Leominster. The member observed, in response, that from Leominster to some of the remote parts of north Herefordshire, travelling could be a challenge in terms of geography and timing, and so it would take up a lot of time travelling from person to person in some areas. Officers acknowledged that it was better to have staff in localities and this was the plan. The director of operations added that they had visited parish councils and talked about transport and getting this network to be effective. She added that GPs were encouraged to work together to look at practical solutions, but the system needed to get better connected.

The member noted that the health centre in Leintwardine, which was currently under used, would be an ideal base rather than Leominster.

The director of operations commented that as the locality projects, such as Kington and Leominster develop, surrounding areas such as Leintwardine would be included.  

The chairman commented that there were other market towns to be considered in the developments and asked whether use could be made of the community hospitals.   The managing director confirmed that there were already staff out there, so the work was augmenting those teams in order to be distributed as far as possible. 

The assistant director, operations and support described how adult social care was distributed and that with regard to home first, this could start to work more effectively on a locality basis to provide a standard level of support for people who need it.  He added that staff could work across areas and that with the redesign of the home first service, a new scheduling service supported through mobile devices was being commissioned and this would enable staff to be better located. It was expected this would be in place by the end of February and would involve a care co-ordinator with therapists offering goal oriented support. The design was intended to bring benefits that reduced the distances covered to reach people.   

The chairman asked how the disabled facilities grant (DFG) figured in the changes.  The assistant director explained that the expenditure was increasing. The Director for adults and wellbeing added that the element of the better care fund allocated to the DFG had tripled and the aim was to establish greater flexibility and a wider range of facilities to provide as this was an area that was proven to make a significant difference and so it was important to ensure that funding was being used and coordinated.

A member commented that parish councils had access to funding to establish community groups such as for soft exercise but they could be difficult to set up. He asked if it would be possible for a package of support for community groups to access to support people coming out of hospital.

The director for adults and wellbeing confirmed that there was a grant scheme which had limited funding. However, the incoming director of public health would be looking at a series of prevention funding to have a more coherent approach. He added that the public health grant was reduced but this work was identified as a priority for the director of public health to ensure organisations could be linked up to work together. 

The assistant director described forthcoming developments around operational practice which included the community broker function and locality based support from February to connect earlier for people who did not currently access support.  The wellbeing information and signposting service (WISH) was relaunched last week to support access to schemes. He added that where there were gaps were identified by the community brokers this would inform further commissioning of support. 

The vice-chairman welcomed the earlier comment raised about the remoteness of areas such as around Leintwardine. He welcome the investment in the home care service. He suggested that parish council meetings were a good way to get messages out about local issues and suggested that those meetings taking place in April and May would be a good opportunity to engage as it was more likely for members of the public to be in attendance. 

Discussion took place around how these service developments were all part of a wider piece of work such as discharging people to be assessed at home or care home facility rather than assess in an acute setting, extending the use of mobile technology for community health staff. The standard of mobile and broadband coverage was noted. Members commented on involving communities more as part of the solution and making use of the formal and informal support networks that existed in villages, including good neighbour schemes.

A member asked about home care and what contingencies were in place for people who were at home alone.  The assistant director explained that the adult social care pathways were redesigned to   discharge to assess using a strengths-based model to assess what people could do for themselves to identify the gaps and assess eligible need that could not be provided any other way. The community brokers would feed into the commissioning strategy to bridge some of the gaps.

The chair of the CCG offered some observations from a frontline clinical perspective, which demonstrated that older people did not want care in hospital and that families wanted to know there was an appropriate pattern of care. Care would be very specific and individualised as some people were very independent in older years, and others more dependent, so it was necessary to assure people that the breadth of need was being met. The system as it stood, had a disabling effect. For example, it was tradition to keep people in bed for 2 weeks following a heart attack, whereas in the USA people were up again very quickly. It was important therefore to avoid the long hospital stays associated with a culture of safety.

The facility at Hillside tried to put professionals together to rehabilitate people but this was artificial because it was not their home with their people around them.  Through evidence it was clear that people needed to be cared for at home and some of the work could be done on the acute ward so people could go home sooner.  The plan was to make this more consistent for others with frailty and degenerative conditions.  In allowing the shift in model it would be something that could be continued for future generations. This was achievable with the right support but it was necessary to be realistic.

A member commented that people were sceptical about changes. She believed it could work but it would be necessary to review it to see it was beneficial.  She realised that people worried about going into hospital and in the majority of cases, people wanted to be in their own home with their own people around them to care for them and be with them and whilst this was not possible in all cases, but it would be better if available to more people as long as it was better care than currently in place. The member concluded that it would be good to see the benefits and it was supported with caution, although the implication needed to be better understood.   

A member asked about access to exercise facilities such as Halo Leisure during rehabilitation. The CCG chair explained that all patients in the system were offered cardiac rehabilitation through the trust as this was the most effective intervention, but people then had to sustain the changes. Halo had a charging policy so it was not accessible for all people even with reduced or supported costs.

The member commented that it was important to invest in preventive measures.  The CCG chair responded that the medical model was not the only good approach and that the message was that exercise was the best medicine, as it promoted physical stability, helped to prevent falls, and promoted good mental and physical health. The opportunity to socialise was also important.

Members’ final comments included that the main concern was the ability to provide individual care plans within resources, and that the timing of these changes were not ideal as people needed to get over the winter.

The chairman reminded members that there was pressure on services all year, although it was different at this time of year with winter pressures and whatever the timing, effecting a change to service provision would present difficulties.

RESOLVED

That:

a)    assurance be confirmed regarding the measures in place to effect changes as smoothly as possible; and

b)    that an update be provided in 6 months’ time