Chilling report on NHS sustainability – it isn’t sustainable

Owl says: anyone who cares about the NHS should read EVERY PAGE of this 58-page report, which is written in clear and accessible language.

Every page signals a death-knell for the NHS sooner rather than later.

It is hard to pick out anything – every page tells a story of (deliberate?) mismanagement, underfunding and chaotic accounting.

For example:

“Key findings

The funding settlement for the NHS long-term plan

8 The long-term funding settlement does not cover key areas of health spending. The 3.4% average uplift in funding applies to the budget for NHS England and not to the Department’s entire budget. The Department’s budget covers other important areas of health spending such as most capital investment for buildings and equipment, prevention initiatives run by Public Health England and local authorities, and funding for doctors’ and nurses’ training. Spending in these areas could affect the NHS’s ability to deliver the priorities of the long-term plan, especially if funding for these areas reduces. The government will consider proposals in these areas as part of its 2019 Spending Review. In addition, without a long-term funding settlement for social care, local NHS bodies are concerned that it will be very difficult to make the NHS sustainable (paragraphs 2.27 and 2.28).

9 There is a risk that the NHS will be unable to use the extra funding optimally because of staff shortages. Difficulties in recruiting NHS staff presents a real risk that some of the extra £20.5 billion funding will either not be used optimally (more expensive agency staff will need to be used to deliver additional services) or will go unspent as even if commissioners have the resources to commission additional activity, health care providers may not have the staff to deliver it (paragraphs 1.19 and 2.29).

10 From what we have seen so far, the NHS long-term plan sets out a prudent approach to achieving the priorities and tests set by the government, but a number of risks remain. The long-term plan describes how the NHS aims to achieve the range of priorities and five financial tests, set by the government in return for the long-term funding settlement, which NHS England believes are stretching but feasible. As with all long-term plans, it provides a helpful indicator of the direction of travel, but significant internal and external risks remain to making the plan happen. These risks include: growing pressures on services; staffing shortages; funding for social care and public health; and the strength of the economy. Our reports have highlighted how previous funding boosts appear to have mostly been spent on dealing with current pressures rather than making the changes that are needed to put the NHS on a sustainable footing (paragraphs 2.24 to 2.26).

Financial and operational performance of NHS bodies

11 In 2017-18, NHS commissioners and trusts reported a combined deficit of £21 million. This was made up of:

The combined deficit of £21 million does not include adjustments needed to report against the Department’s budget for day-to-day resources and administration costs.

12 It is not clear that funding is reaching the right parts of the system.
The overspends by trusts and CCGs were broadly offset by the underspend by NHS England. In 2017-18, NHS England’s underspend included: £962 million from non-recurrent central programme costs, including efficiencies from vacancies;

a £280 million contribution to the risk reserve and £223 million from centrally commissioned services, mostly specialised services (paragraphs 1.4 and 1.8).

13 Most of the combined trust deficit is accounted for by a small number of trusts, while the number of CCGs in deficit increased in 2017-18. The net trust deficit hides wide variation in performance between trusts, with 100 out of 232 trusts in deficit. In 2017-18, 69% of the total trust deficit was accounted for by 10 trusts. NHS Improvement has committed to returning the trust sector to balance in 2020-21, but it is difficult to see how this will be achieved for the worst-performing trusts under current arrangements. Although support provided to trusts in NHS Improvement’s financial special measures programme has been successful in improving the position of some trusts (by £49 million in 2017-18), the financial performance of the 10 worst-performing trusts deteriorated significantly in 2017-18. Between 2016-17 and 2017-18, the number of CCGs reporting overspends against their planned position increased from 57 to 75. The NHS long-term plan sets out the national bodies’ aim that no NHS organisation is reporting a deficit by 2023-24 (paragraphs 1.6 and 1.11).

14 There are indications that the underlying financial health in some trusts
is getting worse. In 2017-18, trusts reported that their combined underlying deficit was £4.3 billion, or £1.85 billion if the Provider Sustainability Fund (which replaced the Sustainability and Transformation Fund in 2018-19) is allocated to trusts in future years. There is no historical data on the underlying deficit that takes account of one-off savings, emergency extra cash and other short-term fixes that boost the financial position of the NHS, so it is not clear whether this position is getting better or worse. However, indicators such as cash support and one-off efficiency savings suggest the position has not improved. For example, in 2017-18, the Department gave £3.2 billion in loans to support trusts in difficulty, up from £2.8 billion in 2016-17. In 2017-18, 26% of trusts’ savings were one-off. Trusts will need to make additional savings in 2018-19 to replace these one-off savings (paragraphs 1.13, 1.14, 2.13, 2.17 and 2.18).”

https://www.nao.org.uk/wp-content/uploads/2019/01/NHS-financial-sustainability_.pdf

“Andrew Lansley law that forced hospitals to compete could be axed”

Note: this 10-year plan does not tackle the crisis in social care nor the bigger crises of not having enough staff for either service.

[Andrew Lansley’s 2012 act made local GP groups “customers” to buy services from competing hospitals]

“Implementing the new ten-year plan could involve the reversal of market-based reforms introduced in 2012 by the former health secretary Andrew Lansley.

More than 100 local bodies would be merged under proposals to move away from internal health service competition and make parts of the NHS work more closely together.

The request for new laws by Simon Stevens, head of NHS England, sets the government up for a battle in the Commons. The reversal of the reforms is also likely to prove embarrassing for the Conservatives. Labour has already demanded an apology for a “bureaucratic disaster” that it says wasted billions.

The Health and Social Care Act 2012 made local GP groups “customers” to buy services from competing hospitals and other providers. It provoked opposition from health unions who said that it would fragment care. Senior Tories came to regard it as the coalition government’s biggest mistake.

Ministers will seek to present the changes as commonsense tidying up measures requested by the NHS. They hope that this will avoid a divisive political battle, but while opposition to privatisation was a key Labour objection to the act the party is unlikely to back a Conservative NHS reform.

In the ten-year plan Mr Stevens argues that there are too many NHS institutions working autonomously when they need to work together to join up care for patients. While arguing that his plan could be achieved in current structures, he said that changes to the law “would support more rapid progress”.

Matt Hancock, the health secretary, said: “We want to foster a culture of ambition and innovation in the way our health sector organises the services it delivers. I am prepared to make the changes necessary for this to become a reality, including changing the law.”

Jonathan Ashworth, the shadow health secretary, said: “The fact NHS bosses are now proposing significant changes to the Health and Social Care Act confirms what a wasteful, bureaucratic disaster it was in the first place.”

Source: The Times (paywall)

NHS – inequality between regions

“The government must show more urgency in addressing regional health funding imbalances, MPs have warned.

The Public Accounts Committee has also expressed concern about the Department of Health and Social Care’s lack of planning for staffing and medical equipment after Brexit, in a report out today.

The MPs noted there was “significant regional variation” in funding of NHS providers and clinical commissioning groups. DHSC’s 2017-18 annual report and accounts suggest an improvement in finances when taken as a whole but this “masks the underlying deficits at local level”, the PAC report said.

MPs said the department was performing a “balancing act” by offsetting NHS providers’ deficits with a surplus from NHS England’s finances. In 2017-18, 101 of 234 NHS providers were in deficit, although this was mitigated by NHS England’s surplus, the report said. Although, 75 of the 207 CCGs reporting an overspend in the same year.

PAC chair, Meg Hillier, said the number of CCGs overspending was “concerning”.

She added: “The Department of Health and Social Care must show far more urgency in getting to grips with regional funding imbalances and demonstrate it understand the effects these have at the frontline.”

The report was also critical of DHSC’s planning for Brexit, especially around staffing and medical equipment.

It said there is a “lack of a clear plan” for recruiting staff post-Brexit and added: “We are not reassured by the department’s assertion that it has not seen a large exodus of staff since the referendum and that the number of people from the EU working in the NHS has increased.”

Health bodies recently warned that the NHS workforce shortfall could jump from 100,000 at present to almost 250,000 by 2030 without effective planning.

Despite the NHS procuring 56% of medical consumables (gloves, dressings, syringes) from, or via, the EU, DHSC is not putting specific contingency measures in place to stockpile this type of equipment, the PAC revealed.

Hillier said: “The department’s lack of clear Brexit planning could threaten the supply of medical equipment. Staff shortages could deepen. The potential consequences for patients are serious.

“These and other uncertainties are amplified by the continued absence of the government’s promised 10-year plan for the NHS, its promised plans for social care, and its promised plans for immigration.” A DHSC source has confirmed to PF the social care green paper and NHS 10-year plan are now likely to be published in the new year, rather than by the end of this year, as originally intended.

Regional variances in staff vacancies could also be overlooked, the PAC noted. The NHS examines vacancy rates at a national level – rather than a local level – which “hides underlying disparities in specific specialisms and local areas and does not allow them to fully understand the impact of staff shortages,” the report said.

The report also expressed concern that the NHS staff pay rise announced earlier this year would not be distributed fairly. By funding pay awards through the National Tariff the PAC is concerned that NHS Providers in more affluent areas will receive “disproportionately higher share of funding” because the tariff accounts for the cost of operating in different geographical locations.

DHSC has been contacted for comment.”

https://www.publicfinance.co.uk/news/2018/12/government-must-address-health-funding-imbalances-say-mps

“NHS commissioning ‘needs period of stability to transform’ “

Owl says: You cannot make it up – body set up to transform the NHS needs time to transform itself before issuing its transformation policies to transform anything else!

“NHS commissioning needs a prolonged period of organisational stability after almost three decades of change, according to the UK’s spending watchdog.

Continued organisational restructuring causes major upheaval and commissioning in the health services needs stability to transform, the National Audit Office urged in a report released today.

Amyas Morse, head of the NAO, said: “We have seen almost three decades of change to NHS commissioning.

“It would be a huge waste if in five years’ time NHS commissioning is undergoing yet another cycle of reorganisation resulting in significant upheaval.”

He added: “The current restructuring of Clinical Commissioning Groups must deliver balanced and effective organisations that can support the long-term aims of the NHS and deliver a much-needed prolonged period of stability.”

A period of stability would allow commissioning groups to focus on transforming and integrating health and care services rather than on reorganising themselves, the report said.

Since CCGs replaced primary care trusts in April 2013, there have been eight formal mergers, reducing their numbers from 211 to 195 in April this year. Further mergers are expected.

The report also highlighted an increasing number of NHS commissioning bodies in England were exceeding their planned expenditure.

A total of 75 of 207 (36%) CCGs went over their budgets in 2017-18, the NAO noted. The total overspend across the groups was £213m.

This compared to 57 CCGs over spending on their budgets in 2016-2017 and 56 in 2015-2016.

“Many CCGs are struggling to operate within their planned expenditure limits despite remaining within their separate running cost allowance,” the report warned.

Increased pressures, the uncertain futures of CCGs and a lack of access to training and development were cited as reasons for the continuing issue of commissioning bodies being unable to attract and retain high-quality leaders.

Even though “both NHS England and the CCGs stressed [to the NAO] the importance of high-quality leadership”.

The watchdog also warned with further mergers there was “a risk that working across greater areas will make it more difficult for CCGs to design local health services that are responsive to patients’ needs”.

The total net expenditure of CCGs in England in 2017-18 was £81.2bn with net running costs at £1.1bn. Staff costs made up 57% (£693 million) of CCGs’ running costs, the NAO noted.

A 10-year long-term plan for the NHS and how it will spend an extra £20.5m a year was expected to be released by the end of this year.

A source from the Department of Health and Social Care has confirmed to PF it is now “likely” this plan will be release next year.

Responding to the report, chair of the Public Accounts Committee Meg Hillier said: “We should be concerned that increasing numbers [of CCGs] are overspending against their budgets.

“Like previous changes to NHS commissioning, CCGs are going through more change and the NHS is crying out for stability.”

She added: “It is vital that further restructuring supports the 10-year plan and isn’t an unnecessary distraction to addressing the real challenges in the health service.”

https://www.publicfinance.co.uk/news/2018/12/nhs-commissioning-needs-period-stability-transform

Another NHS campaigner speaks out

Roseanne Edwards, who is fighting to “Keep Our Horton General” in Oxfordshire writes:

“From our fellow campaigners who are fighting as hard as we are for their local hospital. It is a copy of what is being done to services in Oxfordshire. It is happening all over England.

The background their hospital is set against is the same politically inspired NHS reorganisation we are all victims of.

“Following the 2010 election which returned a Coalition Government of Conservatives and Liberal Democrats, the Department of Health was too busy with the torturous passage through the House of Commons and Lords of the Health and Social Care Bill, which became the Health and Social Care Act 2012, and took their eye off the ball, neglecting to commission training places in Universities for Doctors, nurses physiotherapists and other valuable and essential health professionals.

This resulted in a national shortage which we are seeing today, in A&E surgeons, paediatricians, nurses and other staff.

The outcome may have been intentional. Michael Portillo speaking on the BBC Parliament channel following the election, said that the Conservatives kept quiet about their intentions for the health service because they knew that if their plans became known, they would not be elected.

The intended change was to the fundamental foundation of what used to be the National Health Service, the Secretary of State’s duty to provide, which was removed and a system of contracting services out to tender to enable more profit making companies to siphon off the NHS revenue put in place with competition law operational.

Martin Barkley says that the Care Closer to Home model of service provision will be sustainable. This is government propaganda. What does sustainable mean? The funding for the health service is a matter of choice. Government chooses to fund it or not. This government and the Coalition, chose not to. Even when ‘Care Closer to Home’ is put in place and Dewsbury Hospital downgraded, completely as planned for spring 2017, the government could choose to reduce funding still further.

This is exactly what is happening with the mandatory and secretive Sustainability and Transformation Plan (STP) agenda, being worked up by the Councils, CCGs and Trusts, in West Yorkshire footprint number 5. The West Yorkshire STP has to save money as part of West Yorkshire’s share of the £22billion ‘efficiency savings.’

There is NO EVIDENCE to show that the cuts to hospital provision and services at home, are less expensive than inpatient stays. The pilots in Torbay were inconclusive. In fact they may prove to be more expensive. The expenditure of the National Health Service model as it had been and the treatment it carried out, was consistently found by OECD studies to be the most cost effective in the developed world, treating everyone according to need. This was the case even including the increased costs and associated difficulties caused by the marketised Foundation Trust system.

(The CCG CEP) Dr Kelly outlines what he describes as a “whole system change” in the NHS. What the describes, is chopping the services into tiny bits and letting private profit making companies provide the cheaper, less complex services, such as the dermatology he mentioned http://www.priderm.co.uk and the opticians on the high street. This denies revenue to the Hospital Trust, destabilising it. A new contract announced after the public meeting for Musculo- Skeletal services has gone toprivate company ConnectHealth:

http://www.connecthealth.co.uk

redirecting even more revenue away from the Trust:

https://www.northkirkleesccg.nhs.uk/news/patients-shape-musculoskeletal-service./.

The ‘Right Care ‘ initiative mentioned is an import from the US. What does ‘redesigning therapies’ mean? The Right Care programme, is looking at money. Is this the first step to withdrawing what was once available?

The Royal College of Surgeons has criticised the policy of withdrawing treatments now evaluated as procedures of limited clinical effectiveness (PoLCE) or procedures of limited clinical value (PoLCV). There is no national list of these, as CCGs are free to choose which ones to fund and which to not. The Royal College of Surgeons states that the growing list is “extremely detrimental to patients across the NHS, removing equality of access to treatment, creating postcode lotteries, lowering the standard of care provided in the NHS and potentially reducing the quality of life for some patients.”

Following the fragmentation described here, the architects of the STPlans want an Accountable Care Organisation (ACO) to put it back together, with the private sector cocooned and shareholding, in the provider structure.

Dr Kelly speaks of the Hospital Avoidance Team, going into hospitals to facilitate early discharge. What we have learned since the public meeting is that there is a postcode lottery with regard to what is on offer following a hospital stay and hospital nurses and other staff have to know where you live, because North Kirklees patients can not have what Wakefield patients get.”

NHS: Ministers want NHS head to promise he can run the service with unicorns

Owl says: Actually the government just wants him to lie for their next manifesto – and then, when it all comes tumbling down, they will then probably fire him – for lying.

“The head of the NHS and the government are at loggerheads over how much the health service can be improved for the £20.5bn extra Theresa May has pledged to give it, the Guardian can reveal.

Simon Stevens, the chief executive of NHS England, has been having major disagreements behind the scenes in recent weeks with Downing Street, the Treasury and Department of Health and Social Care about how much the forthcoming NHS long-term plan can promise to boost care.

“Tension” and “difficulties” have emerged during detailed horsetrading between the two sides amid sharp differences of opinion over the extent of the document’s ambitions, well-placed NHS and Whitehall sources have told the Guardian.

Negotiations have left ministers “fed up” and “deeply irritated” that Stevens is refusing to include explicit guarantees they believe will reassure voters that the service will improve dramatically over the next five years thanks to the extra money.

The plan, which will set out how the extra money will be spent, had been due to come out earlier this week but was delayed and is likely to finally appear in the week after next, subject to events at Westminster and further discussions between Stevens and ministers about its contents.

Ministers have told NHS England the plan should include specific annual improvements it will promise to make every year between 2019-20 and 2023-24 in its most challenging areas.

They want milestones written into it spelling out how close in percentage terms the NHS will get every year to once again meeting key waiting time targets covering A&E care, cancer treatment and planned operations, and also by how much the service’s dire finances will be turned round.

However, Stevens has left ministers frustrated by telling them privately that their ambitions are not realistic. Allies say he believes the £20.5bn more by 2023-24 is not enough for hospitals to get waiting times back on track after years of struggling to meet them and simultaneously honour headline-grabbing promises May and Philip Hammond have made recently, ahead of the plan being published, to expand and improve cancer and mental health care. They also want the money to pay for care to be transformed, with a major expansion of out-of-hospital services.

NHS England set up 14 different “workstreams” in the summer to draw up detailed proposals for how key areas of care needed to change to improve the nation’s health and keep the NHS sustainable, given the pressures of the ageing and growing population.

Stevens’s realism about the limits of the plan’s ambition has been reinforced by that process identifying improvements that would between them cost £80bn a year extra, four times the £20.5bn May has pledged. That has forced him to order a drastic culling of those proposals that are too costly to include in the plan.

Stevens has also warned them that the NHS’s chronic lack of staff – it is short of 103,000 doctors, nurses and other personnel – will also make it hard to drive the measurable progress they are seeking. Gaping holes in the NHS workforce are “dreadful and getting worse”, one senior figure said.

“Simon wants one thing and the politicians want another. The Treasury want to pin him to the floor over the action he will take to get all the waiting time targets back on track over the next few years, and he is resisting that. He wants flexibility,” said one source close to the discussions.

The Treasury is particularly exasperated by Stevens’s stance. But allies of the NHS chief say that he does not want to have his hands tied, sign up to timescales for progress that are likely to prove impossible to meet and to open himself up to criticism in the future for not delivering them.

One ally said: “The Treasury are the ones who are especially looking for high-profile and concrete improvements in care that the government can sell to the public in return for the £20bn. There is a lot of anxiety [among NHS leaders] because everyone knows the extra money is barely enough to maintain current standards, let alone transform services.”

Stevens is understood to feel unable to make public his reservations about how much progress ministers should expect for the £20.5bn given that he welcomed the money – which May gave to mark the NHS’s 70th birthday in July – at the time as “a change of gear, a step up” after eight years of tiny 1% annual increases. Its budget will rise from £115bn now to £135bn in April 2023.

Another NHS leader said: “Ministers want all the key targets back to where they used to be, the £1bn annual deficit down to zero and a host of new commitments delivered, all within the 3.4% annual budget rises over the next five years that the £20bn involves. But the numbers, and the whole thing, just don’t add up. You simply can’t get all those improvements on those timescales on 3.4%. It isn’t deliverable. But that’s what the government wants.”

NHS Improvement, the service’s financial regulator, is helping to draw up the plan. It warned last week that hospitals had already overspent by £1.23bn by the end of September, halfway through the service’s financial year, and that it may take five years to restore waiting time performance.

Niall Dickson, chief executive of the NHS Confederation, which represents organisations across the healthcare sector, urged ministers and the public to be realistic.

“The NHS long-term plan is a vital opportunity to improve patient care and change the way we deliver services to the public. But we should not underestimate how difficult it will be to recover performance on waiting times and to move NHS trusts and other organisations back into the black.

“We must be realistic about what is possible within the extra £20bn – the last thing we need is to set local services up to fail. And, above all, we will need a plan for securing the staff we need to respond to changing healthcare needs.”

NHS England denied a rift, saying: “The NHS, patient groups, clinicians and government are working closely together to finalise the NHS long term plan ready for publication before Christmas.” The Department of Health and Social Care also said there was no dispute, and they were “working closely with NHS England and NHS Improvement to develop an ambitious long term plan for our health service.”

https://www.theguardian.com/society/2018/dec/06/ministers-and-nhs-england-chief-at-loggerheads-over-targets

Thank you Devon Tories for killing off not just our NHS – the day the NHS died in Devon

From the blog of Claire Wright. P!EASE READ EVERY SINGLE WORD OF THIS LONG BUT VERY IMPORTANT POST:

“A recommendation urging no further community hospital bed closures in Devon has been voted down by Conservative councillors on Devon County Council’s Health and Adult Care Scrutiny Committee.

The recommendation, which was debated on Thursday (22 November) was part of a set of measures set out in a scrutiny spotlight review aimed at supporting the care at home service (or rapid response) to be more effective.

Highlighted in particular as a challenging area were services for end of life care, which have been put under considerable pressure, especially since the loss of community hospital beds.

I chaired the spotlight review, which took place this summer and published its findings last week in a report that can be found here

https://democracy.devon.gov.uk/mgConvert2PDF.aspx?ID=22439

Also struck out by conservative councillors was a proposal to review all intermediate care provision (bed based care for people are not yet well enough to return home after hospital) with a view to reopening some community hospital beds on a flexible basis.

Over 200 Devon community beds have been cut in the past five years and the facility known as rapid response, which provides care at home, was supposed to have been beefed up to cope with the extra demand.

Unfortunately, this does not appear to have worked due to a lack of staff, particularly in the Exeter and East Devon area.

The local NHS and Devon County Council have (and are still) advertising extensively but still many vacancies remain.

Some GPs, particularly those in East Devon, have outlined problems with availability of paid carers (see appendix to the main report), and stated that they have lost confidence in the system and are instead admitting patients to hospital, because it takes so long to arrange care, or because care is simply unavailable.

Rapid response was established to avoid hospital admissions where possible and instead care for people in their own homes.

Care of dying patients, very sadly, appears to be the worst hit, with a director from Hospiscare confirming that care from rapid response is too often not available.

Ann Rhys, assistant director of care with Hospiscare, told councillors that in a three month period over the summer, 40 end of life patients were unable to access rapid response.

In one month during the summer one East Devon Hospiscare nurse alone reported eight instances where no care was available.

Hospiscare has seen a “large increase” of patients dying in their in-patient unit in the past 12 months, as a result.

The community hospital beds recommendation proposed to be deleted by Exmouth councillor, Richard Scott was seconded by Cllr Paul Crabbe, who described the proposal for no further bed cuts as “nonsense.”

Cllr Scott claimed there was no evidence for the proposal and replaced it with what I can only describe as a rather meaningless collection of words, which I had to ask for clarification on twice.

Voting in favour of deleting the community hospital bed recommendation was one Labour councillor and all the Conservative councillors on the committee, except chair, Cllr Sara Randall Johnson who abstained. A LibDem councillor and I voted against.

The rest of the recommendations, which can be found in full here at the beginning of the report were supported with one or two with minor tweaks – including writing to the chief executive of the NHS and the Health Secretary about a review of wages for paid carers. https://democracy.devon.gov.uk/mgConvert2PDF.aspx?ID=22439

Also, remaining was a recommendation urging the local NHS to review its funding for Hospiscare and other local hospices.

Hospiscare receives £1m from the NHS and must fundraise for the remaining £7m and this is becoming harder as pressures on the service increase.

Before the vote I reminded the committee of the words of the county solicitor who addressed the committee earlier this year on our role on the committee as community representatives.

I said we were on the committee as representatives of local people not mouthpieces of council officers and NHS managers.

The webcast is a little out of kilter and some of it seems to be missing, but if you’d like to watch the debate the link is here starting at item 12 – https://devoncc.public-i.tv/core/portal/webcast_interactive/369535

The spotlight review report is a summary of discussions and it is not the convention to publish witness statements. However, Local Medical Committee Secretary, Dr Paul Hynam, Sidmouth GP, Dr Mike Slot, Hospiscare director of care, Ann Rhys and Exeter based Patient and Public Involvement lead, Richard Westlake have kindly given consent for me to publish their full witness statements, which are below:
**************************************
Witness Session: Dr Slot, GP at the Sid Valley Practice
Dr Slot followed his original representation to committee and outlined his concerns, namely that the rapid response service was a well thought out service, with helpful and creative staff.

However there have been a number of occasions when the service was unavailable. This had meant that patients had had to be admitted to hospital. Dr Slot had experienced two occasions last year when there had been no capacity and patients had to be admitted but, on the most recent three occasions that he had contacted the single point of access, they had been able to help and admission had been avoided.

Dr Slot is a member of Devon Local Medical Committee and had gathered some feedback from other GP members and from his own practice. The feedback referred mostly to capacity issues.

Views of other GPs
Dr Slot had contacted GPs across Devon to understand their experiences. Overall there was a mixed response with colleagues.
– Dr xxx said RR had been working well
– Dr xxx now had to ‘force himself’ to ring the contact number. Following a number of occasions when the service had been unavailable.
– Dr xxx had also had issues in North where the service was unavailable.
– A Hospiscare nurse in East Devon had experienced eight instances in the last month where there was no care available.
– One of the GPs in East Devon had had three recent experiences when there had been no capacity and patients needed admission.

Dr Slot has undertaken to get the agreement of colleagues to share more fully their responses with the Spotlight Review.
Capacity.

Dr Slot was clear in highlighting that in his opinion the issue was one of capacity, not skills or training with staff. The single point of access will often say ‘there is not capacity today and to call tomorrow’. The impact on the patient may be that they are unsafe to stay at home and have to be admitted to hospital.

This includes patients who are at the end of their lives, who may have to die in hospital when they would have preferred to have died at home.

The impact on the GP for the service being unavailable is usually one of time, where alternative lengthy arrangements need to be made or repeated phone calls to the single point of access to try to put something in place. Whilst GPs may only ring the service an average of twice a month, there is significant reputational damage if the service is repeatedly unavailable.

Looking at the figures for referrals and in particular when the service was unavailable, GPs had expressed concerns about whether all of the calls were being logged. Within the figures the number of calls logged does not differentiate between different patients, and a patient could be referred more than once if there was no capacity. There is concern that these calls are not being logged anywhere in the system. The outcome of declines is not recorded and could be an admission, or a decision to stay at home.

Within the NHS there is the generally accepted capacity of hospitals ideally having bed occupancy of 85%, allowing for flex in the system. In community services the research has not been carried out to understand what the ideal service take up is, however suspect that it is similar. It feels like the service is often working at 100% capacity.

Timing of Referrals
Referrals frequently come in later in the day (when relatives worry towards end of day and call GPs) but most staff are then going home. Early referral would be more helpful, but is not always possible.

Ann Rhys
Assistant Director of Care, Hospiscare

Hospiscare covers the area of Exeter, East and Mid Devon, including Tiverton, Crediton, Okehampton, North Dartmoor, Dawlish, Exeter and the Coast to Seaton, Axminster and Honiton. Working alongside NHS colleagues, together with inpatient and community teams, they work in support to co-ordinate packages of care to prevent unnecessary admissions. RR support impacts on many patients and families across the whole area.

Issues with RR
Exeter works well and is responsive, but the majority of RRS teams struggle to cope. Hospiscare log as many instances as they can where patients need access via RR and, in the last 3-4 months, around 40 people have been unable to access RR.

There have been instances in the RR team covering East and Mid Devon (Seaton/ Ottery/ Crediton), when there is no capacity, for the RR team to say to “put on the reject list”. For RR teams to use this phrase is very poor practice. Also, when there is no capacity, the patient’s name is not taken and, in all likelihood, is probably not logged.

When there is no capacity, this is very time consuming as a further call to RR needs to be made, thereby creating a huge impact on community teams. Clinical nurse specialists could make phone contact 3-4 times per day

Other instances have occurred where families are waiting for RR to arrive, only to be phoned and told that RR has been delayed and, as a result, sometimes it may be that pressure is exerted to not come at all – and care is then removed – with the potential risk of being admitted to the RD&E

A further situation arose when the RRS was phoned about a Mid Devon patient who was registered with a GP in Crediton, but lived closer to Tiverton, the RRS said that although there was a carer available in Tiverton, they could not access that carer because of the patient being registered in Crediton and not Tiverton.

End of Life patients
A large proportion of patients prefer to remain at home for end of life. If patients cannot be supported, the Hospiscare community team help to try and provide what is needed. I have received almost tearful feedback from Hospiscare nurses frustrated that it is difficult to source the care required, with many patients close to end of life who just wish to stay at home and this is creating a huge strain on the nurses involved.

Hospiscare have seen a large increase of patients dying in their 12-bed Inpatient unit over the last 12 months. Help is required when patients leave their Inpatient unit to go home, and there is a gap in support here.

We see a lot of people retiring into this area this can mean that there is a lack of social support with families being at times geographical spread, or when this is not the situation families taking on the carer role which can result in a post bereavement risk. Trajectories of illness currently seem to be that patients are stable for longer but then are deteriorating very rapidly at the end of life, which can result in crisis needing urgent support which is not available.

Community hospital closures
Up until 2012/13 the RRS worked well, but this changed when the community hospitals closed and has created a huge impact. Patients say they prefer to be at home or in a community hospital but, with the closure of community hospitals, there are not enough care packages to support this. Acute setting deaths are increasing in some areas, while home deaths have decreased. Consequently, the closure of community hospitals could be said to have had a poor outcome for a number of our patients.

Also, since the closure of further community hospitals last autumn, there has been an increase in Hospiscare patients referred to our inpatient unit due to social care breakdown.

Hospiscare@Home teams
The Hospiscare@Home team that operates in Exmouth, Budleigh Salterton and Seaton evolved on the back of decreases in support options for patients at the end of life after community hospitals began to close.

Our statistics show the Hospiscare@Home teams are able to keep over 90% of their patients at home if that is their preferred place of death and nearly 90% of these patients would otherwise have been admitted to an acute setting. Hospiscare do everything they can to provide help at home if there is a Hospiscare@Home team available.

NHS community nurses work alongside Hospiscare@Home teams and,where these teams do not exist, the NHS community nurses and our own Hospiscare Clinical nurse specialists go above and beyond to try and support people to remain at home.

Hospiscare Funding
Around £1m of funding is provided by the NHS each year to support the running of Hospiscare, but an additional £7m is needed to be raised from funding events, charities etc. Hospiscare can choose where to invest these monies, but strains are becoming more intense.

Conclusion
Devon has an ageing population with complex needs that need responding to, and this situation will continue to grow. Some people have retired to this area, without family nearby, and are often on their own and require support. Any season of the year can be difficult, but winter tends to be a busy period, and this is when we saw an increased dependency on our inpatient beds this year.

The sadness is that RRS used to be a good service, but cracks are now appearing through the lack of support available. The problem with RR is one of capacity – a lack of staff.

Dr Paul Hynam
GP and Medical Secretary, Devon LMC

GP Feedback
Although Dr Slot had made further enquiries requesting feedback from other areas, nothing further had been received apart from that already provided from the East, which mostly highlighted difficulties in capacity, however, he felt the RRS were working flat out and were fully engaged in trying to keep patients out of hospital.

Why isn’t it RR working?
There is no clinical experience in either Out of Hospital teams or Admissions to support some patients. Although there are community matrons, they are not sufficiently qualified and the teams lack clinical experience. Also, the service is structured in such a way that it is weighted towards non-qualified people, but it is qualified nurses that are needed, across all areas of Devon.

South Devon and Torbay CCG have intermediate care in place where there are qualified GPs on the team looking after patients. This model is proving much more successful and a move towards this model of care in other areas would be welcome.

Most of the hospital Community Urgent Care teams (which are similar to RRS) are too busy engaged in facilitating the discharge of patients, rather than going into homes to support, but no attempt is made to plug this gap. The impact of this means there is less care being provided at home and more patients having to be admitted.

From the point of discharge, some patients who might have gone into a community hospital are now going home, but the lack of available staff to support those patients, mean that re-admission numbers are high.

GPs try to avoid admission because the patient is much better looked after at home thereby avoiding the risk of infection.

When patients are discharged, it feels like there is no support, as the right support team is not in place. Patients are not discharged too early, but it is the team that cannot support them, e.g. out of hours care for washing, dressing and night sitting.

It is hard to find care for this. I can ring RRS on a Thursday or Friday and be told there is no care available until the following week. I then have to re-admit – this change has happened in the last couple of years.

Over the last few years, it has become much more likely that the RRS is unable to help. GPs are often being contacted to manage problems for patients who should really be in hospital. There is an early response team that should be helping them here, but this does not happen, and is a concern for many GPs.

I am starting to give up on using RRS as it is so time consuming. For instance, I can spend a long time on the phone to RRS and then wait for a call back, sometimes hours later, only to be told there is no care available. Using the hospital admission process is much quicker.

GP practices however are working much more closely, with many GP surgeries merging and some sharing the same ICT infrastructure.

Recruitment/Retention
The lack of capacity within the RRS means the teams do not have enough time. Additional workforce is needed across all sectors and there is currently a big international recruitment drive taking place in Devon. Medical students don’t want to come into the profession, as they see it as a ‘bad deal’, i.e. low pay and stressful conditions. Staff who are unsupported become stressed and leave.

When training was slashed in 2010, it was reported that there would be a knock-on effect in 7 or 8 years’ time – and this is now happening.

Yellow Card scheme
Dr Hynam said he used the yellow card system and that ensuring the patient can safely discharge to their home is the absolute minimum.

Mr Richard Westlake
Chair of Exeter Patient and Public Involvement Group
Meetings of the Exeter PPG are held every quarter where two representatives from each surgery in Exeter attend to discuss issues affecting patients in Exeter and Cranbrook.

Exeter PPG has had contact with some GPs who say they use other services now, instead of RR, and liaise with the RD&E.

The Ambulance Service frequently are called to admit a patient who has fallen at home. If care packages fail – it falls back to the RD&E.

Feedback
Exeter PPG had asked for feedback from family members and others (around 25/30 people in the Exeter area).

About 80% said patients were being discharged too early and then having to be re-admitted or placed in residential accommodation as there was no care package in place, or parts of the care package were missing. Family members or neighbours would often have to step in to dress etc. However, they said once a care package was in place, it was very good.

On occasions, patients are discharged as fit, but it is their home that is unfit for them to be discharged to, e.g. stairs that can’t be climbed properly where the bed or toilet is upstairs. It seems that assessments are being carried out at the hospital, instead of at home, where stairs and steps can vary hugely.

Some patients are discharged to residential homes and then to home, but this was on few occasions.

There is a lack of recognition of couples and their reliance on each other. Those couples keep themselves well, but if one falls ill, there is often difficulty, as there is little support for the other person who is not in the care system. The whole couple unit should be looked at and not just the individual.

Urgent recruitment of staff is needed.”

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