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.”

Ottery Community Hospital – a campaigner speaks on council in-fighting

Text of address to Ottery Town Council by Philip Algar, a long-term campaigner for the Ottery hospital, including its in-patient beds:

“OSMTC 29th NOVEMBER 2018

As an interested member of the public, I have attended almost all the town council meetings over the last few years. During that time, I have seen the councillors confront many issues, some trivial and some serious. However, I have not seen a collective, note the word “collective”, and timely public effort by the council as a whole to support those of us who have been campaigning to save the Ottery hospital. I can think of nothing that is more important to the local people than having access to a well-located modern greatly-valued hospital and this, surely, justifies your collective support. Why has such support been missing?

Whenever the subject of the hospital’s future has been included on the town council agenda, the main speaker, often the only speaker, has been one councillor, who, quite correctly, has said that she does not speak for the council but for a group of which she is a leading member.

As recently as last August, I asked the council to adopt an official and supportive role but nothing happened and, as far as I know, my suggestion that the hospital should become a community asset, which was rejected by EDDC, was not challenged by this council, even although such status has, I am told, been granted to other hospitals. I had suggested in advance that it might be wise to devise a response in anticipation of a negative decision.
All this is why I shall no longer be attending your meetings which will be good news for many of you. Furthermore, the well-intentioned and hard-working unofficial groups have failed to make much progress with the official bodies and, apparently, admit this. That said, it would be helpful if they were more communicative with the public.

Given this lamentable situation, it was hardly surprising that three councillors, backed by a county councillor, suggested setting up a semi-official working group to solve the crisis. Three councillors voted in favour and six, according to the draft minutes of the meeting, abstained.
I was astonished to learn that, allegedly, some councillors construed this as a defeat for the trio. That is breathtaking and worthy of Private Eye. If this is true, it also exposes a level of ignorance that calls into question the competence of those involved. If it is not true, I withdraw this comment immediately.

Now, despite an objective explanation from Dr. Margaret Hall, explaining that, effectively, NHS groups, apparently, will only discuss matters with official groups or those under the aegis of the council, you still chose to organise this meeting, at an unusual time when so many residents are at work. I note the comments that this meeting was planned as councillors were attending a finance meeting. The claim by the abstainers, that they did not have sufficient information, has already been undermined by Dr. Hall’s contribution so why have another meeting?

This, presumably, is an effort to overturn the initial decision on the creation of a working group. The agenda also raises the possibility of supporting a decision that has already been agreed after a vote of three to nil, and which has now been explained by Dr. Hall. I find the possibility that organising a meeting to consider reversing the democratically-taken decision to be a truly ludicrous waste of time and totally unnecessary.
Those who were penalised by the decision to remove inpatient beds and now face the prospect that the hospital may not even become a hub, deserve much more from their councillors.”

End: 29.11.18

Chaos mounts on best way to save Ottery hospital – together or apart

Owl says: what a dreadful thing to make this issue an area for political point-scoring and petty feuds!

“Fighting for the future of Ottery Hospital should be ‘top priority’ says residents as they called for more support and transparency from town councillors.

The council chamber was filled to capacity for an extraordinary meeting re-examining a decision by the town council to support or rescind a motion to set up a hospital working group.

The proposal was passed at the start of the month, with many councillors abstaining as they said they did not have enough information.

Residents speaking at the meeting last Thursday said they felt there was lack of support from the council and were baffled to revisit the decision due to the weight and transparency a working group could show.

Stewart Lucas told members the council contributed hugely to the community but needed to listen to concerns as the town’s population continued to grow.

He said: “I for one believe the protection and the support of our local community hospital is an issue that should be right at the very top of the priorities of the council, and I feel the people of this town deserve to know that is a priority and that their feelings and opinions are valued and taken into consideration and that there is full transparency.”

Last week, health ministers gave firm reassurances the hospital has 
a ‘sustainable future’ but resident Ian Dowler said there needed 
to be more than a ‘glimmer of hope’.

Mr Dowler said: “Ottery does need to retain, not just the hospital services that it has at the moment but it needs to expand and utilise the space that’s there.

“With people living longer, Coleridge (Medical Centre) is bursting at the seams. Surely common sense would dictate that an overspill surgery be created at the hospital among other health departments, which would take some of the pressure off the RD&E?

“We need to take affirmative and positive action and no longer rely or applaud these sad and pathetic reasonings that all shall be well. It’s not acceptable.”

Councillors voted to defer making a decision until February to allow organisations involved in saving the hospital to meet and gather information.

Cllr Glyn Dobson said: “We all want to save the hospital, perhaps we want to do it in different ways. The health and care forum is doing a good job, there are five councillors on there and the results have come out this week in the Houses of Parliament that Ottery St Mary Hospital has a good chance of staying open.”

https://www.sidmouthherald.co.uk/news/calls-to-make-ottery-hospital-top-priority-following-debate-for-need-for-working-group-1-5808858

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

“More than 350 GP surgeries face closure in England alone over the next 12 months”

“Up to 3m patients are expected to lose their GP surgery within a year because of a shortage of doctors.

More than 350 practices face closure in England alone over the next 12 months, according to a survey of doctors for the Royal College of General Practitioners.

Doctors’ leaders, patients’ groups and MPs expressed alarm and warned that general practice was at “serious risk” of collapse.

Rising numbers of GPs are retiring early, becoming locums in the private sector, changing career or moving abroad.

As well as pressure to work longer hours and see more patients, the closures are being driven by GPs deciding to stop work when their pension pots exceed £1m and attract heavy taxes. They are not being replaced by trainees despite intense regional NHS recruitment drives and £20,000 golden hellos. GPs earn £92,500 on average.

In an interview with The Sunday Times, Britain’s most senior GP said surgeries were “haemorrhaging doctors”. Professor Helen Stokes-Lampard, college chairwoman, said she was “gravely concerned” by the findings.”

Source: The Times (pay wall)

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

“Out of hours service assigned just two doctors to 1.4m patients”

Coming soon to a county near you:

“Only two doctors were left to cover out-of-hours GP services in an area with a population of more than 1.4 million, it has been reported. GPs’ leaders condemned the situation as “completely unacceptable” after a manager had called the staffing level in Kent unsafe in an email to bosses.

The Health Service Journal (HSJ) cited a leaked email that said the two GPs in question were forced to decide who had priority for visits, including some patients in palliative care, besides their own duties during an overnight shift on a weekend in early September.

It said the email was sent at 8am, when the service across most of Kent had 130 people waiting for advice, 67 waiting to be seen at bases and nine visits scheduled. This included at least two palliative care patients in west Kent, one of whom was described as “actively dying” but waited six and a half hours for a visit.

“Patients can’t determine when they will fall ill and they should be able to access high quality GP care when they need to, either through our routine service or GP out of hours services,” said Prof Helen Stokes-Lampard, the chair of the Royal College of GPs.

“It is essential that any out-of-hours care services are staffed appropriately … If patients are unable to access GP care out of hours due to staffing shortages, and GPs working out of hours are being put in a position where they are having to make decisions about which seriously ill patient needs their help most, it is completely unacceptable.” She called for more investment in out of hours services.

According to the HSJ, the email to senior managers read: “I need to let you know that the service is currently unsafe and has been overnight. We had two GPs and one [advanced nurse practitioner] in East Kent and two ANPs in west Kent overnight.”

Out-of-hours cover is provided by the social enterprise IC24. Dr Andrew Catto, its deputy chief executive, said: “In common with many public services, staffing levels in out of hours primary care vary throughout the time our service operates, as certain times are busier than others – especially the weekends, when in-hours primary care is less available.

“It is well known that there is a shortage of GPs. This impacts on many GP surgeries and out-of-hours services. IC24 values the contribution of our GPs. But, in common with other out of hours providers, we benefit from having access to a team of healthcare professionals including nurses, urgent care practitioners and paramedics.

“These highly skilled healthcare professionals meet the clinical needs of our patients using out of hours care. The role of the GP is also changing; rather than needing large numbers of GPs to deliver hands-on care, GPs play an essential role in also providing high-quality expert advice to nurses and paramedics.”

A spokesman for NHS West Kent Clinical Commissioning Group (CCG) and four of the five east Kent CCGs said: “The CCGs monitor the performance of the out-of-hours provider daily, along with weekly reports. There have been no serious incidents reported. Where a gap in workforce is identified, for instance through sickness, the provider puts contingency plans into place. This means that patients will continue to have access to health professionals when they need it.”

https://www.theguardian.com/society/2018/nov/23/out-of-hours-service-assigned-just-two-doctors-to-14m-patients