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.”

http://www.claire-wright.org/index.php/post/halt_on_more_community_hospital_bed_closures_proposal_defeated_by_conservat

NHS: thank heaven for Claire Wright – but will she be listened to by stubborn, uncaring Tories?

Owl says: how will Randall-Johnson and her cronies try to malign Claire Wright on this one with the overwhelming evidence Claire and her committee produced to show that cuts have gone much, much too far – to the point where it seems basic human rights are being infringed every day particularly for the dying?

Could Randall-Johnson and her cronies imagine some of the things described below happening to their parents, partners, siblings, friends?

What happened to this country – and this county – that health care has been allowed (nay, encouraged) to sink so low?

And all a political choice, NOT an economic one.

Shame on you Tory Health and Wellbeing Scrutiny for allowing this to happen.

“A scrutiny review into the system that’s designed to replace community hospital beds is recommending a raft of measures that will be debated at Devon County Council’s Health and Adult Care Scrutiny Committee, on Thursday this week.

I chaired the review, which took place during the summer and found that the care at home (or Rapid Response) service was very stretched and care of the dying in particular was highlighted as an area of concern, especially since community hospital beds had been closed.

Over 200 Devon community hospital beds have been closed in the past five years or so.

We interviewed a range of witnesses, including Dr Paul Hynam, GP and Secretary of the Local Medical Committee, GP, Dr Mike Slot (whose concerns prompted the review), Ann Rhys, Assistant Director of Care at Hospiscare and Richard Westlake, Chair of Exeter Patient and Public Involvement Group.

Also interviewed were various senior managers from Devon County Council and the local NHS.

I proposed the Spotlight Review after Sidmouth GP, Dr Mike Slot, attended the January Health and Adult Care Scrutiny Committee to outline his concerns about how care at home (or Rapid Response) was working.

Dr Slot said that although he supported it in principle, there simply weren’t enough carers available to look after patients.

On Thursday (22 November) health scrutiny councillors will be asked to endorse 12 recommendations, including:

– No further community hospital bed closures
– Consideration of reopening some community hospital beds on a flexible basis to ease pressure on the system
– A review of all intermediate (temporary bed-based) care provision across the county
– A standardised approach to Rapid Response across the county, including having GPs on the team
– A review of Hospiscare’s role in end of life care, with a view to providing more financial support

Sadly, the biggest pressure on the local healthcare system seems to be care of the dying.

This outcome was predicted by some GPs before the community hospital beds were closed.

Hospiscare’s Assistant Director of Care, Ann Rhys, told councillors that since the community hospital beds had closed Hospiscare had seen a significant increase in pressure on the service and a resultant large increase of patients dying in their 12 bedded inpatient unit in Exeter.

In the last three months (reported over this summer) 40 patients have been unable to access Rapid Response.

Worryingly, staff can make phone contact three to four times a day to the Rapid Response service because there is NOT support available. This is very time consuming and has a significant impact on community teams.

Councillors were very concerned to hear that one East Devon Hospiscare nurse had reported that in just one month during the summer there were eight instances where no care was available.

GP feedback revealed that the service has led to a lack of confidence by some GPs who say they spend a long time trying to find carers to support a patient at home, only to find there is no support available.

The result is then an admission to the local acute hospital instead. Something the service was set up to avoid.

The NEW Devon Clinical Commissioning Group did not provide hospital readmission rates to the scrutiny review, despite being asked several times to do so.

A survey to GPs prompted responses mostly from East Devon. Some of the comments are below:

– “Sometimes it can take some time to get a call back informing you that they cannot get the care requested, meaning the patient needs to be admitted much later in the day.”

– “Since the closure of community beds and supposed reallocation of funds the service seems rather worse than better.

– “I take the view when with a patient that I won’t be able to access Rapid Response but if I can it’s a bonus.”

– “Sadly SPOA (Rapid Response) sounds great, but in reality, it’s a time-consuming referral with low probability of delivering the service you want.”

– “I have had three recent episodes where I have called SPOA (Rapid Response) in recent months and they have been unable to put in appropriate care. Patients have been sent to the RD&E for admission. It is a frustrating process – often not staffed well enough so details at the point of contact cannot be taken. Most cases seem to involve two to four calls back to speak to the right person. GPs under pressure are tied up for too long by the service. So long in fact it has made me not want to use the service. It would be easier to admit patients than it is to call SPOA and arrange care – or try to arrange the care…. “

– “Our allocated care agency handed back their contract and we have been left with very little support for care… when we need Rapid Response to support patients and prevent admission we cannot link into subsequent long-term care packages. I had one chap with a neurological condition who had Rapid Response for over a year!”

I am really really glad this piece of work was carried out and I am proud to be the spotlight review’s chair.

For years we have been told by senior managers that the system is working well, with just a few minor problems. This report and the conversations we have had with people who work at the coalface clearly shows a different picture. A worrying picture that needs fully examining.

I trust that councillors who sit on Devon County Council’s Health and Adult Care Scrutiny Committee will fully support the recommendations.

Here’s the link to the report, which will be debated and voted on Thursday (22 November) https://democracy.devon.gov.uk/documents/s22439/RR%20Report%20final.pdf

http://www.claire-wright.org/index.php/post/no_more_community_hospital_bed_closures_recommends_devon_health_scrutiny_re

DCC overspend jumps to nearly £10 million

“Phil Norrey, chief executive of Devon County Council, said he wanted to reassure councillors, staff and taxpayers about the impact of the savings strategy, saying it was ‘tight and good housekeeping’.

He said: “We are making sure that we have our house in order rather than panicking and walking over a cliff and the range of measures we are implementing we have looked at very carefully.

“There are pressures across the country and after around eight or nine years of extreme pressures on budgets, it has to come a point when we reach the end of the road on spending, and that will come in the next two or three years.”

https://www.northdevongazette.co.uk/news/devon-10m-overspend-2018-1-5782070

Devon £8m overspend, Suffolk £11.2 million overspend – dominoes fall

Devon is playing its cards close to its chest about cuts:
https://www.devonlive.com/news/devon-news/budget-overspend-forecast-devon-blamed-2005218

Suffolk proposes:

A 2.9% council tax rise next year
A halt to road sign cleaning, with only mandatory road markings being maintained
Reducing housing-related support for people in their own tenancies
A review of arrangements with district and borough councils for grass cutting and weed treatment services
Removal of the Citizens Advice Bureau grant
Reducing the legal, training and equipment costs at trading standards
Streamlining running costs in educational psychologists service, although there will be no cuts to frontline services

https://www.bbc.co.uk/news/uk-england-suffolk-46212757

Council leaders pledge to help Flybe

Looks like we are going to need the Magic Money Tree … again.

“Council leaders in Devon have offered to work with Flybe to keep it in Exeter.

In an open letter to the struggling airline, they say the airport brings in £150m a year to the local economy and creates “high value local jobs” which they do not want to lose.

Flybe is in talks about a possible sale of the group weeks after warning over profits.

Two-thirds of passengers at Exeter Airport fly with Flybe.

The letter was signed by the leaders of Exeter City Council, East Devon District Council, Devon County Council, Exeter College and the Heart of the South West LEP.”

https://www.bbc.co.uk/news/live/uk-england-devon-46102129

DCC considering recruitment freeze due to massive cost of children’s services

Devon County Council’s considering a recruitment freeze to deal with its £10m overspend on children’s services.

There’s been an increasing number of children who need to be housed in residential and secure units.

For example there are five children who cost more than £400,000 each a year to look after but they need round the clock one-to-one care.

The council’s also responsible for 45 children who cost around £4,000 a week to care for and house.

On top of that, the council’s also funding a rising number of children with disabilities who attend independent special schools and further education colleges.

The council is considering delaying filling vacancies for two months after the post-holder leaves, banning all non-essential overtime and ending attendance at conferences and some allowances.

Plymouth and Torbay are also having to take special measures to deal with the higher than forecast costs of looking after vulnerable children.”

https://www.bbc.co.uk/news/live/uk-england-devon-46042791