Community Hospital Service Review – Outcomes Paper

Title of paper: Community Hospital Service Review – Outcomes Paper

Author: Tom Elrick, Urgent Care Programme Lead

Exec Lead: James Blythe, Director of Commissioning and Strategy

Date: 25 September 2015

Meeting: Governing Body

Agenda item: 11 Attachment: 5

For: Decision

Executive Summary:

To present the final Outcome Report for the community hospital services review.

The attached paper outlines the process undertaken in conducting the review of services delivered from the community hospital sites in Surrey Downs. The paper describes the current services commissioned by NHS Surrey Downs CCG, both for inpatient and outpatient care.

The purpose of this paper is to present the final recommendations and options from the review for discussion and to seek the Governing Body’s approval to proceed to public consultation on the options presented.

Compliance section Please identify any significant issues relating to the following

Risk Register and Assurance No issues identified as yet. Framework

Patient and Public Full communications and engagement plan adopted Engagement throughout the review, with appropriate stakeholder engagement. Engagement log presented as appendix. Ongoing engagement with Surrey’s Wellbeing and Health Scrutiny Board and Healthwatch Surrey throughout process.

No issues identified – considered as part of EQIA. Patient Safety & Quality

The emerging options have some financial Financial implications implications which will need to be developed and fully considered. A number require investment, however there are some potential cost savings in the long- term from better use of estates. A full financial evaluation will support the public consultation. No issues identified as yet. Conflicts of interest

No issues identified as yet. Information Governance

Equality and Diversity An EQIA has been completed as part of the project team and aligned to the Communications and Engagement plan. This document has been through the review Programme Board and agreed on 28 April 2015.

Any other legal or Any substantial service changes would be subject to compliance issues public consultation.

Accompanying papers (please list): Appendix 1: Community Hospital Services Review: Outcomes Paper Appendix 2: Engagement log

Summary: What is the Governing Body being asked to do and why?

To discuss the attached paper, including recommendation and options. To approve that the options proceed to public consultation in line with the arrangements specified.

Community Hospital Services Review: Outcomes paper summary

Introduction

NHS Surrey Downs CCG (SDCCG) has undertaken a review of the services provided from the five community hospitals within its geographical boundaries. The review has focused predominantly on the future requirements for inpatient rehabilitation services, but has also included an examination of the volume and types of outpatient services delivered at each site.

Background on current services

Surrey Downs CCG has five community hospitals located within in geographical boundary. The table below provides details of the hospital locations, their inpatient bed numbers and the outpatient services provided.

Table 1 – Community Hospital bed capacity

Hospital Locality Beds available Beds open Leatherhead Epsom 18 0 Dorking Dorking 28 28 Molesey East 18 12 Elmbridge New Epsom Epsom 21 20 and Ewell Community Hospital (NEECH) Cobham East 18 0 Elmbridge Total 103 60

As the information above clearly demonstrates the CCG has significant unused community hospital bed capacity. Cobham Hospital has not had inpatient services for a number of years, although the ward space remains available for use. Leatherhead Hospital had the inpatient bed capacity transferred to the other hospital sites in November 2014 to allow CSH Surrey the ability to consolidate their clinical staffing resource on three locations.

Review process

The review process was split into three distinct phases:

1. Activity review (May-June 2015)

This phase saw the review team spending time at each hospital site, working alongside the clinical delivery teams to understand what services were being delivered, how they were delivered and what factors were impacting on the care delivery. Inpatient care is currently delivered from three hospital sites; New Epsom and Ewell Community Hospital (NEECH), Dorking Hospital and Molesey Hospital. The quality of care delivered from the three inpatient units was found to be exceptionally good. Each hospital had similar types of patients, of similar age groups and common presenting conditions. The quality markers, infection rates and patient satisfaction surveys for each site were comparable and therefore did not act as a key differentiator in the assessment process.

2. Outcome review (June 2015)

This involved an analysis of the key quality measures provided by the community hospitals and comparing them to national data. One of the difficulties with this phase has been the lack of nationally defined models of excellence in the Community Hospital Setting, with little research available for the UK. There are a number of case studies which detail community-based rehabilitation pathways, but these are not hospital based. The review team used data from the Community Hospitals Association to locate ten benchmark hospital sites, then contacted each and data gathered on their service structures and performance.

The outcome review also examined the expected changes in patient population in Surrey Downs over the next ten years. For both inpatient and outpatient services it is essential to understand how the population groups aged 65 years and over will change, as these are the groups most likely to be accessing inpatient rehabilitation care from the community hospital facilities.

3. Recommendations preparation (July 2015)

The outcomes paper covers the following areas:

• A description of the current Community Hospital Services, including both inpatient and outpatient functions. • A detailed review of each hospital site, exploring current services • A summary of the expected changes in the patient population, particularly in the over-65 year age group. • An indication of the expected non-demographic population changes • A detailed list of the options explored and the recommendations for service improvement

The paper also provides a series of five recommendations and four options for the overall provision of Community Rehabilitation Services based on the anticipated needs of the changing population. Each recommendation has come from observed issues in care delivery as well as benchmarking of best practice. If approved by the Governing Body, the development of these options will be assessed against criteria which have been developed with input from the public engagement groups.

Engagement

Extensive public and wider stakeholder engagement has been completed as part of this review, following the communications and engagement plan previously agreed at Governing Body.

Between April and September 2015 the CCG has:

• hosted four launch events (in Leatherhead, Dorking, East Elmbridge and Epsom)

• held 20 public workshops (five in Leatherhead, Dorking, East Elmbridge and Epsom). Total workshop attendance was 111 individuals

• facilitated 24 drop-in events with CSH Surrey staff, held at the community hospital sites

• met with 271 members of local Residents Associations, League of Friends groups and local councillors

Public workshops have been used to co-design key elements of the review. As well as commenting on the process and feeding in the views and experiences of local people, attendees have created the evaluation criteria that would be used to assess any potential options and contributed ideas for future engagement, including engagement channels that could be considered as part of a public consultation. A full engagement log, with details of engagement undertaken as part of the review is attached as an appendix with this document.

The Communications and Engagement team have been represented on the Programme Board and have been fully engaged in the review process.

Healthwatch Surrey and the Wellbeing and Health Scrutiny Board have been engaged throughout this process and two representatives from the Wellbeing and Health Scrutiny Board have been members of the Programme Board. The review team presented formally to the Board on 16 September 2015, who approved the review process. At the meeting it was agreed that a sub group comprising four committee members would continue to be involved in the process and would contribute to the CCG’s consultation planning.

Outcomes of the review

Following extensive public and stakeholder engagement, a comprehensive review of each hospital site and an examination of best practice models, the Programme Board identified a number of key service configuration proposals for the Community Hospital Services. These four principles underpin the final recommendations and options made within the outcome paper:

Three Ward Model

Key to the Surrey Downs-wide approach is the adoption of the three-ward model. Historically the community inpatient rehabilitation services have operated across four, small volume wards. The relocation of the Leatherhead beds in December 2014 demonstrated the potential for improvements in efficiency achieved through larger inpatient units. The benchmarking exercise identified the minimum number of eighteen beds to achieve long term efficiency in both length of stay and occupancy levels.

The Programme Board recommends delivering inpatient care from three sites.

Dorking Hospital

The inpatient services provided from Dorking Hospital have proven to be an on-going example of best practice. The increase in bed numbers in December 2014 from 12 to 22 and then 28, saw a significant reduction in average length of stay and a corresponding increase in occupancy levels. The combined workforce from Dorking and Leatherhead gave the provider the opportunity to develop innovative care models including the appointment of a dedicated discharge planning nurse. The Programme Board feels any reduction in bed numbers may have a negative impact on the good patient outcomes being achieved at the site.

The outpatient department including the physiotherapy service provides care to 26,880 patients per year. No single site within the Dorking locality could accommodate the services delivered from Dorking Hospital. The outpatient services could be split between a number of sites, but the Programme Board feel such a split may reduce the efficiency of the services provided and potentially impact on clinical outcomes.

The Programme Board recommends Dorking inpatient and outpatient services remain in their current site and configuration.

Leatherhead Hospital Inpatient Ward

The inpatient services at Leatherhead hospital were transferred to Dorking Hospital and NEECH in December 2014. The transfer of the beds allowed CSH Surrey to introduce new and innovative practices, achieved in part through the economies of more beds per site. The Programme Board recommendation of a three site model prompted a close examination of which community hospital sites best served the needs of the population. It was concluded that each of the three localities (Dorking, East Elmbridge and Epsom) require inpatient beds, however, only Epsom has two recently functioning inpatient sites. The three site model led to a straight choice

between the Leatherhead and NEECH inpatient wards as a preferred site for the Epsom locality. NEECH inpatient ward was refurbished at a cost of £380,000 in 2014. Leatherhead inpatient ward requires upgrading and investment. NEECH provides both inpatient and outpatient neurological rehabilitation services. The Poplars unit has been specified to support the outpatient rehabilitation service. Leatherhead would require significant investment to accommodate the neurological rehabilitation function, particularly the outpatient service.

The Programme Board recommends the permanent closure of the inpatient ward at Leatherhead Hospital

Leatherhead Hospital Outpatient Services

The Leatherhead Hospital outpatient department, including the physiotherapy service, provides care to 37,190 patients per year. No single site within the Epsom locality could accommodate the outpatient services delivered from Leatherhead Hospital. Epsom & St Helier University Hospitals NHS Trust has stated that it cannot accommodate the outpatient services it delivers from Leatherhead on the Epsom Hospital site. The expected increase in population numbers associated with projects such as Transform Leatherhead will increase demand for the outpatient diagnostic and planned care services within Leatherhead and the surrounding areas. The outpatient services could be split between a number of sites but the Programme Board are clear that such a split would reduce the efficiency of the services provided and potentially impact on clinical outcomes.

The Programme Board recommends that Leatherhead Hospital is developed as a Planned Care hub, which includes diagnostic services.

Final recommendations and options

The Programme Board has six recommendations for approval by the Governing Body which are listed below:

1. Work with providers to ensure compliance with a single Surrey Downs community bed approach where patients are placed in the first available, suitable rehabilitation bed regardless of which hospital the bed is available in.

2. Review the scope and capacity of the NEECH neurological rehabilitation beds in the context of both current and future demand for services and the outcome of the Surrey-wide stroke review.

3. Consider the requirement for a distinct type of community inpatient service, separate from the current rehabilitation beds, that can accommodate patients who are awaiting long-term placement but not acutely unwell. Whilst this could be part of a community hospital model, other settings of care may be more appropriate and cost-effective. In the interim the CCG has set aside System Resilience Group (SRG) funding for this capacity to be secured from the nursing home sector over this winter, in line with the successful scheme deployed last winter.

4. Work with the new community hubs to consider the case for introducing ambulatory rehabilitation services. This will both complement the hubs and manage some of the future demand, which may otherwise fall on inpatient rehabilitation care.

5. Operate a model where no fewer than 16 beds (and ideally 18 – 20) are typically open in an inpatient rehabilitation facility. Ensure that a common and appropriate level of support is provided to patients on admission, during admission and at discharge to maximise the benefits of this model.

6. Increase the amount of physiotherapy and occupational therapy time commissioned for each patient during their care episode at a community hospital. At present the CCG commissions 1 hour of therapy time per week against the benchmark of 1.6 hours of therapy time per week. The increase in therapy provision will be funded through improved efficiencies obtained through reduced length of stay and improved bed occupancy. Funding through the 2015 System Resilience Group (SRG) monies has been allocated for additional therapy time over the winter period to confirm proof of concept.

The Programme Board requests that the following four options are agreed by the Governing Body as the options that will be taken forward for public consultation:

Option 1 - Maintain the current three-ward model with inpatient wards at Dorking, Molesey and NEECH. Develop Leatherhead planned care services (Leatherhead inpatient services remain closed).

Option 2 - Transfer NEECH inpatient services to the Epsom Hospital site and transfer outpatient services elsewhere in the locality. Develop Leatherhead planned care services (Leatherhead in-patient services remain closed).

Option 3 - Transfer Molesey inpatient and outpatient services to Cobham Hospital. Develop Leatherhead planned care services (Leatherhead in-patient services remain closed).

Option 4 – Both options 2 and 3 above

Next steps

If the recommendations and options presented are approved by the Governing Body these will be developed and go forward for public consultation, subject to NHS England approval.

The suggested period of time for public consultation is from the end of October/ early November 2015 to February 2016, with consultation outcomes presented to the Governing Body in spring 2016.

It is recommended that the public consultation process would include the following:

• Programme Board membership and terms of reference to be reviewed to ensure appropriate mandate and involvement for the consultation phase – to be agreed by the CCG Executive team with delegated responsibility for signing off the consultation plan

• As agreed, a sub group of Wellbeing and Health Scrutiny Board members will contribute to planning the consultation, providing feedback and scrutiny on key areas and draft materials to ensure a robust process

• Patient representatives will be involved in the development of the consultation plan and consultation document

• Consultation will launch at the end of October, early November and run through to January/ February (depending on launch date)

• Evaluation of options will take place as part of the next round of public workshops

• The Governing Body will receive an update on the consultation during each forthcoming meeting, and approve any necessary materials

• Feedback from the consultation and final recommendations will go to the Governing Body in spring 2016 Appendix 1

Community Hospital Services Review Outcome report September 2015

Contents Page

Glossary Page 3

Introduction Page 4

Section 1 – Description of the review process Page 7

Section 2 – Current picture Page 12

Section 3 – Inpatient services Page 26

Section 4 – Research and best practice models Page 34

Section 5 – Mapping future demand Page 38

Section 6 – Modelling future bed requirements Page 44

Section 7 – Estates Page 53

Section 8 – Other service developments in the CCG Page 58

Section 9 – Conclusion and recommendations Page 61

Section 10 – Appendices Page 89

Glossary

Ambulatory Rehabilitation Unit (ARC) – A day rehabilitation service that enables patients to receive rehabilitation as an outpatient, instead of staying in a community hospital overnight

CCG - A clinical commissioning group is an NHS organisation that brings together local GPs and experienced health professionals to commission healthcare for local people

CHC – Continuing Healthcare (CHC) is the name given to a package of care that is arranged and funded solely by the NHS for individuals who are not in hospital and have been assessed as having a "primary health need".

CSH Surrey – a social enterprise organisation formed in 2006 which is commissioned to manage community hospital services in Surrey Downs

HCA – Healthcare Assistant

Length of stay – the number of days a patient stays in hospital. This is used as a way of measuring how well a hospital is performing and how quickly a patient is able to return home following rehabilitation

NEECH – New Epsom and Ewell Community Hospital in West Park, Epsom

Occupancy - the measure of how the bed capacity of the ward / hospital is being used

ONS – Office for National Statistics

Risk stratification – a modelling tool that categorises populations and groups of patients depending on their health needs. Patients who are considered to be at low risk are considered to be ‘healthy’, whilst those with complex health problems are ‘high users’ of health services. By modelling the health needs of the population in this level of detail, we can match health services to local need.

Surrey Downs Clinical Commissioning Group – the NHS organisation responsible for commissioning local health services in Surrey Downs

Introduction

Summary

This review explores the current provision of community beds across the Surrey Downs Clinical Commissioning Group (CCG) area and summarises the analysis undertaken during the four month community hospital services review process. The report uses both qualitative and quantitative data to analyse activity, provision of services, profiles of patients requiring access to community hospital services, and existing estate. The focus of the review has been on achieving the best clinical outcomes for Surrey Downs’ patients. The review process has been clinically led.

Background

Community hospitals are loosely defined as small hospitals with few on-site diagnostic facilities or specialised services (Young & Donaldson, 2001). They are facilities caring for people with needs that are often summarised as ‘step‐up’ or ‘step‐ down’ care.

Many community hospitals have close links with wider intermediate care to facilitate pathways from acute to community beds and out into the community. Intermediate care may be seen as a set of bridges or key points of transition in the person’s journey from hospital to home (and vice versa) and from illness or injury to recovery (Godfrey et al, 2005).

Intermediate care was initially introduced to target services and support elderly people who would otherwise face unnecessarily prolonged hospital stays or inappropriate admission to acute in‐patient care, long‐term residential care or continuing in‐patient care. It was understood as being time‐limited to no longer than six weeks (Department of Health, 2001).

Strategic context

Surrey Downs CCG has a significant number of community inpatient beds and outpatient services across its locality and currently commissions sixty beds. Of the commissioned total, fifty six beds are for general rehabilitation and four beds are for neurological rehabilitation.

All five sites provide outpatient services, with Leatherhead and Dorking hospitals having the largest number of clinics, followed by Cobham, Molesey and the New Epsom and Ewell Community Hospital (NEECH).

Surrey Downs has a large older population, with the over 65 age group accounting for 20% of the total population in 2015. This is expected to increase to 27% of the

4 total population by 2025. Demand for both inpatient and outpatient services at the hospital sites is expected to increase in the coming years.

It is widely acknowledged by the CCG and the wider health community that the current community bed provision has some issues which are in need of urgent consideration and review. This includes:

 a lack of consistency in the admissions criteria  variable discharge support arrangements, access to domiciliary care and community services  hospital estates of varied quality, with at least one of the sites in need of urgent repairs.  Each site faces different challenges in term of capacity and layout.  Occupancy rates and length of stay are inconsistent across the current sites.

These combined factors have led to the CCG’s decision to undertake a comprehensive review to determine the best model for local service provision, which is sustainable over the next ten years.

In addition to the review of community hospitals, a separate programme is being undertaken to determine the acute hospital bed requirements for the Surrey Downs population over the next ten years. For consistency, this piece of work is using the same data sets and assumptions relating to population change and disease profiling as this review.

The CCG is also improving how care is provided in the community. At the forefront of this is the launch of our new community hubs, which went live at the beginning of July 2015. The hubs consist of teams of GPs, nurses and other healthcare professionals who are focused on managing patients over 75 years of age who have one or more chronic health condition. These patients are commonly cared for at community hospitals so it is inevitable the work of the new teams will impact on the demand for inpatient beds at the hospital sites. It is therefore clear that the impact of this new service needs to be taken into account as part of this review and any recommendations that emerge.

Purpose of this report

As a commitment to an open and transparent process the CCG is publishing this document, and sharing it with the public and key stakeholders, as a draft report which includes a number of emerging options. These are not final options for consultation, but are a summary of possible options that have arisen through the review process and include ideas put forward by members of the public.

By publishing this draft report we want to facilitate further widespread engagement

5 and discussion on the emerging options. Feedback used from this next phase of engagement will allow refinement of the proposed options.

The final report will ultimately provide the intelligence required to enable the CCG’s Governing Body to make an informed decision on next steps, which could include going out to public consultation.

Section 1

Review process

Section summary

This section of the report outlines the aims and objectives and the governance structure for the review.

Aims and objectives

The community hospital services review started in March 2015.

The review process was clinically led, with the overall aim of reviewing the current service model to ensure services are high quality; delivered in line with best practice; and will meet the changing needs of the Surrey Downs population.

The review objectives were to:

 Undertake a comprehensive review of current inpatient and outpatient services undertaken at the five community hospital sites in NHS Surrey Downs CCG’s catchment (Molesey, New Epsom and Ewell Community Hospital, Dorking, Leatherhead and Cobham).

 Determine the long term inpatient and outpatient care requirements of the patient population from community hospitals including the number of beds required across both acute and community sectors combined

 Propose what services should be provided in the future drawing on the CCG’s commissioning strategy and established best practice

 Link with a review of the community healthcare estate to determine the best fit of the future service model with the available estate and its suitability to meet future needs. This will inform options as to where services are provided

The review is mindful of the need to provide a degree of clarity over the future of the community hospital sites. This clarity will facilitate investments that are supportive of the overall direction of travel, and provide stakeholders, patients and staff with a clear framework for decisions regarding the future of hospital sites.

The review has not focussed on the costs of providing care from the community hospitals, or of running the estate. However, some cost information has been collated in order to illustrate points regarding the condition and suitability of the estate, and the relative efficiency of running services at different scales and from different layouts of community hospital.

Governance

At the start of the review process a Programme Board was convened to oversee the review process, providing valuable input, guidance and scrutiny to the process.

The Community Hospital Review Programme Board was chaired by Dr Jill Evans, CCG Governing Body representative for the East Elmbridge locality and local GP. Dr Evans has extensive experience of the community hospitals, having worked at various points in Molesey, Leatherhead, NEECH, Cobham and Dorking Hospitals.

The Board membership comprises CCG representatives, patient representation, provider organisations and representatives from Surrey County Council’s Well-being and Health Scrutiny Board. The full list of programme board invitees is included below:

Table 1 – Programme Board membership

Name Role Organisation

Dr Jill Evans Governing Body GP member for NHS Surrey Downs CCG (Chair) East Elmbridge Locality and local GP James Blythe Director of Strategy and NHS Surrey Downs CCG Commissioning Tom Elrick Programme Lead for Urgent Care NHS Surrey Downs CCG and qualified nurse Suzi Shettle Head of Communications and NHS Surrey Downs CCG Engagement Julian Programme Lead for Primary Care NHS Surrey Downs CCG Wilmshurst-Smith and Estates Helen Cook Programme Lead for Integrated NHS Surrey Downs CCG Care Eileen Clark Head of Governance and Quality NHS Surrey Downs CCG and qualified nurse Cllr Lucy Botting Councillor and registered nurse, Mole Valley Council and who also works for Surrey’s GP out Surrey County Council of hours service. Well-being and Health Scrutiny Board Cllr Tim Hall Councillor Mole Valley Council and Surrey County Council Well-being and Health Scrutiny Board Jacky Oliver Patient representative and NHS Surrey Downs CCG Governing Body Lay Member for Patient and Public Involvement James Page Estates Lead NHS Property Services

Victoria Griffiths Director of Clinical Services CSH Surrey James Kraft Regional Director Virgin Care Jackie Sullivan Chief Operating Officer Epsom St Helier University Hospitals NHS Trust Jim Davey Director of Operations Surrey and Sussex Healthcare NHS Trust Tracey Moore Urgent Care Lead Kingston Hospital NHS Trust Michael Arnaud Director Dorking Healthcare

The members were selected to ensure organisations that currently provide services within the community hospitals, and those with an interest in the review, were represented. Their primary role at the meetings was to provide clarity on how services are currently delivered within the community hospitals and to offer insight into any planned future developments so these could be taken into account if the hospitals’ infrastructure were to change following this review.

All members were invited to attend full meetings which were scheduled at four week intervals. Other scheduled meetings focused on specific hospital sites, with members being given the opportunity to opt out of attendance if their organisation had no presence at the site being discussed.

The Programme Board discussed and confirmed the emerging options included in this draft report.

Engagement

The CCG has undertaken a comprehensive engagement programme as part of the review process, underpinned by a detailed Communications and Engagement Plan.

Between April and July 2015 the CCG has:

 hosted four launch events (in Leatherhead, Dorking, East Elmbridge and Epsom)

 held sixteen public workshops (four in Leatherhead, Dorking, East Elmbridge and Epsom). Total workshop attendance was 295 individuals (some people attended more than one workshop)

 facilitated sixteen drop-in events with CSH Surrey staff, held at the community hospital sites

 met with 271 members of local Residents Associations, League of Friends groups and local councillors

Public workshops have been used to co-design key elements of the review. As well as commenting on the process and feeding in the views and experiences of local people, attendees have created the evaluation criteria that would be used to assess any potential options and contributed ideas for future engagement (including engagement channels that could be considered if the programme moves forward to public consultation).

Despite advertising these events in the local media and through social media and other channels, it is noted that attendance at these workshops has been limited. Furthermore, the majority of attendees have been over 50 years of age and therefore views have not always been representative of the wider population.

Section 2

Community hospitals: the current picture

Section summary

This section of the report provides a summary of the five community hospitals and the range of services they currently provide.

There are five community hospitals in the geographic area covered by Surrey Downs CCG (see map below). These are Cobham, Dorking, Leatherhead, Molesey and the New Epsom and Ewell Community Hospital in West Park, Epsom.

The following table provides a high level summary, and comparison, of the sites.

Table 2 - Community hospitals – an overview

Site Molesey Dorking New Epsom Leatherhead Cobham and Ewell Community Hospital (NEECH)

Inpatient 12 beds 34 bed 21 bed 18 bed ward 18 bed ward capacity open. Total capacity capacity with – currently – currently capacity of with 28 20 beds not in use. not in use. 18 beds. beds open. open. Had 3 Ward closed escalation Two side Beds in 2004. beds open rooms One side relocated to over winter. currently room being NEECH and Currently Additional being used used for used as Dorking in capacity for by physio admin admin office. December 2 beds in service. offices. 2014. ward physio 16 beds for gym if Scope to general needed. increase rehab plus 4

capacity beds for using neuro rehab Extensive land around basement current space Capacity to hospital occupied by expand into building if SECAmb Poplars unit. extension for admin required offices. Land available on Building hospital site if landlocked extension is so no ability required to extend footprint

Medical East Dorking East No inpatient No inpatient support Elmbridge Community Elmbridge services at services at Community Hub Community present. present. Hub providing Hub providing medical medical support to providing support to ward. GPs medical the ward. attending support to On call 7 site 5 days NEECH.

days per per week. Attending site week and Daily ward 5 days per Bank session week. Daily Holidays, 2 plus on call ward session sessions on Monday to Saturdays Friday. plus on call and 1 on Weekend Monday to Sundays and out of Friday. and bank hours cover Weekend holidays. provided by and out of Additional Care UK hours cover out of hours provided by cover provided by Care UK Care UK

X-ray Not Yes No Yes No currently functioning

Nearest acute Kingston East Surrey Epsom Epsom Epsom trust Hospital Hospital General General General / St Hospital Hospital Peter’s Hospital

Ultrasound No Yes No Yes Yes

Physiotherapy Yes Yes Yes Yes Yes

General Yes Yes No Yes Yes outpatients

Podiatry No No No No Yes

Day surgery No No No No Yes

The following section provides details on each individual site.

Cobham Hospital

Cobham has had a cottage hospital since 1905 when the first building opened with 10 beds. The hospital grew during the 1920s and 1930s. By the mid- 1950s the hospital had expanded to 20 beds and had a physiotherapy department.

In 1994 the old hospital was demolished and work commenced on the new building. The new Cobham Hospital opened in 1998.

In 2004 the inpatient ward was temporarily closed for refurbishment, however physiotherapy services continued to be provided on site. In 2007 the Cobham Day Surgery Unit was opened and in 2012 a Sexual Assault Referral Centre opened on the site.

The hospital has a ward with capacity for 18 beds. However, the ward area at the hospital has remained closed since 2004, with local NHS organisations of that time stating that the bed capacity was no longer required.

There are a significant number of outpatient services based at Cobham Hospital. The majority of these are provided by EpsoMedical. The table below details the clinics and the numbers of patients seen at each.

Table 3 – Activity at Cobham Hospital

Service / clinic type Provider Annual patient volumes Physiotherapy CSH Surrey 4,767 Cardiology Epsomedical 63 Dermatology Epsomedical 2,549 Ear, Nose and Throat Epsomedical 383 Gastroenterology Epsomedical 253 General Medicine Epsomedical 3 General Surgery Epsomedical 113 Colonoscopy Epsomedical 2

Colorectal Epsomedical 325 Gastroscopy Epsomedical 33 Gynaecology Epsomedical 103 Ophthalmology Epsomedical 998 Orthopaedics Epsomedical 1,447 Pain Management Epsomedical 1 Plastic Surgery Epsomedical 197 Respiratory Medicine Epsomedical 205 Rheumatology Epsomedical 622 Urology Epsomedical 218 Vascular Epsomedical 51 Total outpatient attendances 12,333 Total inpatient attendances 0

 There were no inpatients in the community hospital last year as the ward is currently closed.

 In the last twelve months there were 12,333 outpatient attendances at the hospital. This outpatient activity represents 100% of the total activity conducted at the hospital (excluding the Sexual Assault Referral Centre which is a Surrey-wide and Surrey Police led service)

Dorking Hospital

There has been a cottage hospital in Dorking since 1904. Located close to Dorking town centre, the current hospital dates back to the 1970s.

At its peak Dorking Hospital had 56 beds, an operating theatre and x-ray facilities.

Today Dorking Hospital retains the inpatient beds and x-ray department but the operating theatre is no longer present. The hospital site now offers a wide range of outpatient clinics and has a large physiotherapy gym. The ward contains 28 beds; 12 beds from its original capacity, 10 beds transferred from Leatherhead in December 2014 and a further six beds opened to alleviate winter pressures but retained until at least September 2015.

The current inpatient bed configuration is as follows:

 12 male beds  12 female beds  4 side rooms

There are a number of outpatient services based at the Dorking Hospital site. These are mostly provided by Dorking Healthcare and CSH Surrey. The table below details the clinics provided and the numbers of patients seen at each.

Table 4 – Activity at Dorking Hospital

Service / clinic type Provider Annual patient volumes Physiotherapy CSH Surrey 11,227

X-ray Global Diagnostics 2,156

Colorectal surgery Dorking Healthcare 433

Dermatology Dorking Healthcare 1,645

Diabetes Dorking Healthcare 731

Ear, Nose and Throat (ENT) Dorking Healthcare 1,191

Elderly medicine Dorking Healthcare 31

Gastroenterology Dorking Healthcare 508

General medicine Dorking Healthcare 318

General surgery Dorking Healthcare 459

Gynaecology Dorking Healthcare 940

Neurology Dorking Healthcare 747

Orthopaedics Dorking Healthcare 1,740

Paediatrics Dorking Healthcare 737

Pain clinic Dorking Healthcare 1,545

Plastic surgery Dorking Healthcare 105

Rheumatology Dorking Healthcare 535

Ultrasound Dorking Healthcare 1,337

Urology Dorking Healthcare 495

Total outpatient attendances 26,880 Total inpatient attendances 512

 In the last twelve months there were 512 inpatients cared for at the community hospital. This represents 44% of the total patients looked after in the community hospitals during last year. Dorking has 47% of the total community bed capacity in the Surrey Downs area.

 In the same period there were 26,880 outpatient attendances at the hospital. This outpatient activity represents 98% of the total activity conducted at the hospital.

Dorking Hospital has been identified as an initial base for the Dorking Community Hub. Hub GPs now provide a weekday medical service for the inpatient ward.

Leatherhead Hospital

Located close to the town centre, Leatherhead Hospital in its current form was built in the 1940s. The site was managed by Epsom Hospital and by the 1960s the hospital had 52 inpatient beds, an x-ray department and a small A&E department. The hospital also had an operating theatre. By the 1990s the A&E department has been transferred to Epsom and the bed capacity was 36 beds.

By 2014 the hospital had 18 inpatient beds and an outpatient department including x- ray, physiotherapy and a sexual health service. The ward is configured in bays and side rooms. There are 13 female beds and 5 male beds.

In December 2014 the inpatient beds were transferred to Dorking Hospital and the New Epsom and Ewell Community Hospital (NEECH) due to staffing issues within CSH Surrey.

There are a significant number of outpatient services based at Leatherhead Hospital. The majority of these are provided by Epsom and St Helier University Hospitals NHS Trust, with others provided by CSH Surrey and Virgin Care. In terms of numbers of patients treated CSH Surrey provides the largest proportion of care through its Physiotherapy, Continence and Wheelchair Services. The table below details the clinics provided and the numbers of patients seen at each.

Table 5 – Activity at Leatherhead Hospital

Service / clinic type Provider Annual patient volumes Physiotherapy CSH Surrey 17,889 Orthopaedics Epsom and St Helier 3,364 University Hospitals NHS Trust Cardiology Epsom and St Helier 146 University Hospitals NHS Trust Ophthalmology Epsom and St Helier 1,111 University Hospitals NHS Trust Dermatology Epsom and St Helier 2,071 University Hospitals NHS Trust

Gynaecology Epsom and St Helier 168 University Hospitals NHS Trust Colposcopy Epsom and St Helier 2,760 University Hospitals NHS Trust Fertility Epsom and St Helier 99 University Hospitals NHS Trust General surgery Epsom and St Helier 29 University Hospitals NHS Trust Ear, Nose and Throat Epsom and St Helier 244 (ENT) University Hospitals NHS Trust Gastroenterology Epsom and St Helier 653 University Hospitals NHS Trust Urology Epsom and St Helier 531 University Hospitals NHS Trust Renal Epsom and St Helier 403 University Hospitals NHS Trust Radiology Epsom and St Helier 5,060 University Hospitals NHS Trust Continence service CSH Surrey 430 Wheelchair services CSH Surrey 428 Sexual health Virgin Care 1,804

Total outpatient attendances 37,190

Total inpatient attendances 114

 Between April and November 2014, when the ward was open, Leatherhead Hospital treated 114 inpatients. This was 10% of the total patients looked after as inpatients in the community hospitals during last year, however it is noted that the ward was not open for four months of the year.

 In the same period there were 37,190 outpatient attendances at Leatherhead hospital. The outpatient activity represents 99.7% of the total activity conducted at the hospital. Full year activity for inpatients would see 220 patients receiving care. Outpatient activity would be 99.4% of all activity conducted at the hospital.

Molesey Hospital

Situated in the East Elmbridge Locality, Molesey Hospital is the oldest of the five community hospitals. The hospital site was first used in 1891, however the current building dates back to the 1920s. During the 1970s and 1980s the hospital had an operating theatre and 28 inpatient beds. By 2005, when the hospital came under the management of Surrey Primary Care Trust (PCT) this had reduced to 18 beds. This was further reduced to 15 beds in 2012 and today the hospital is commissioned to provide 12 inpatient beds.

The current inpatient bed capacity is split into:

 Four male beds  Six female beds  Four side rooms - used flexibly as part of the 12 bed total

Molesey has 20% of the total community bed capacity across Surrey Downs.

There are a number of outpatient services based at Molesey Hospital. These are provided by CSH Surrey, Surrey Medical Limited and Kingston Hospital NHS Trust. The table below details the clinics provided and the numbers of patients seen at each.

Table 6 – Activity at Molesey Hospital

Service / clinic type Provider Annual patient volumes

Physiotherapy CSH Surrey 4,908

Urology Surrey Medical 151

General surgery Surrey Medical 86

Colorectal Surrey Medical 62

Elderly medicine Surrey Medical 46

Total outpatient attendances 5,253

Total inpatient attendances 200

 In the last twelve months there have been 200 inpatients cared for at the hospital. This equates to 17% of the total inpatients looked after across the community hospitals.

 In the same period there have been 5,253 outpatient attendances at the hospital. This outpatient activity represents 96% of the total activity conducted at the hospital.

Molesey Hospital has a non-functioning x-ray machine which is now obsolete. The machine ceased working over 12 months ago and cannot be repaired. Patients attending for outpatient clinics are currently referred to Kingston Hospital, Surbiton Health Centre or Cobham Hospital if radiological investigations are required.

Molesey Hospital has been identified as an initial base for the East Elmbridge Community Hub. Hub GPs are now providing medical cover for the inpatient service as well as support for patients based in the community.

New Epsom and Ewell Community Hospital (NEECH)

The New Epsom and Ewell Community Hospital (NEECH) is located on the West Park Estate on the outskirts of Epsom. The current hospital was opened in 1990, although the original Cottage Hospital dates back to 1873 when it opened with eight beds in Epsom town centre.

When it first opened NEECH had a 20 bedded inpatient ward, outpatient services and a physiotherapy gym.

In 2012 the hospital opened four neurological rehabilitation inpatient beds and an outpatient physiotherapy service for patients with neurological conditions.

Today NEECH retains the 20-bedded ward, which provides both general and neurological rehabilitation services. The outpatient physiotherapy department also provides care for patients requiring general and neurological rehabilitation. A small number of outpatient services are also provided from the site.

The current inpatient configuration is as follows:

 3 x 6-bedded bays  2 side rooms

The ward has one dedicated male bay and one dedicated female bay. The third bay can be used flexibly, depending on demand. The ward was refurbished in 2014 at a cost of £380,000. During the refurbishment process the ward was transferred to the Epsom Hospital site (Croft ward).

NEECH has 33% of the total community bed capacity across Surrey Downs.

There are a small number of Outpatient Services based at the NEECH site. These are provided by CSH Surrey. The table below details the clinics provided and the numbers of patients seen at each.

Table 7 – Activity at NEECH

Service / clinic type Provider Annual patient volumes Physiotherapy CSH 5,916 Inpatient Ward CSH 325

In the last twelve months NEECH has cared for 325 inpatients. This includes the period where the NEECH ward was relocated to Croft Ward at Epsom Hospital whilst the ward area underwent refurbishment. This equates to 29% of the total inpatients looked after in the community hospitals. In the same period there were 5,916 outpatient attendances at the hospital. This outpatient activity represents 95% of the total activity conducted at the hospital.

NEECH has been identified as an initial base for the Epsom Locality Community Hub. The East Elmbridge Hub GPs are at present providing the medical input for the inpatient service. The Community patient support programme has not yet started in the Epsom Locality

Key themes emerging from this section

 The five community hospitals provide a range of services to local communities. The majority of the care provided is through hospital outpatient services, with

three of the hospitals currently providing inpatient services (bedded care).

Section 3

Inpatient services

Section summary

This section describes how inpatient (bedded) care is delivered across the community hospital sites with inpatient beds. It includes information on how many patients are admitted, referral patterns and workforce profiles.

How inpatient care is currently delivered

Three of the five community hospitals are currently providing in-patient rehabilitation care. All three hospitals deliver inpatient care in the same way (how care is delivered is also known as a model of care). Leatherhead Hospital also used the same operating model prior to the beds being transferred in December 2014.

The patient journey

Under the current model of care, larger acute hospitals (such as Epsom Hospital, East Surrey Hospital and Kingston Hospital) identify patients who have rehabilitation potential and are therefore considered suitable for transfer to a community hospital. This is based on an assessment criteria provided by CSH Surrey, who run the inpatient service (see Appendix 1). The acute ward staff refer the patient to the CSH Surrey Referral Management Centre (RMC) service, a telephone triage service which verifies the patient’s suitability for transfer.

Once accepted by the Referral Management Centre, the patient is placed on the waiting list for a community bed. Nursing staff in the acute hospitals discuss rehabilitation options with patients and currently, patients can state a preference for the community hospital they would prefer to stay in (the preference is usually to stay at the hospital closest to where they live). Historically, patients have been given the option to turn down a place in the rehabilitation unit if it is not at their preferred community hospital. As a result, patients can wait a number of days for a place at their chosen hospital when rehabilitation beds are readily available elsewhere in other community hospitals. This approach causes delays in discharging patients who are ready to move on from acute care and start their rehabilitation journey. Because of the relatively low turnover – a bed of the correct gender in a twelve-bedded site with a 23 day length of stay will become available on average once every 3.5 days – this creates a significant challenge in terms of system-wide capacity management when bed capacity is at a premium. As well as delaying the start of the rehabilitation process, it is also means that an acute hospital bed is not available for an acutely unwell patient.

Historically, the community hospitals have been nurse‐led, with the ward manager acting as Senior Clinician. However, following the introduction of the new Community Medical Team, medical support is now provided by local GPs in a clinical lead role. On admission patients are assessed by nursing, medical and therapy staff to determine the patients’ rehabilitation potential and expected length of stay.

The nursing, medical and therapy teams have regular multi-disciplinary team meetings to discuss each patient’s rehabilitation and their progress. There is a weekly Discharge Planning Meeting attended by nursing, therapy and social work teams to discuss each patient’s care plan in detail.

For patients admitted from home, the Ward Manager or Community Medical Team GP determines the suitability of the patient for admission through a discussion with the referring clinician.

CSH Surrey is currently commissioned to provide just under one hour of physiotherapy per patient per week. We have compared this with ten community hospitals across the UK of a similar size and serving a similar population and this has indicated an average of 1.6 hours per week in other areas.

Nurse staffing levels are high at the community hospitals, particularly in comparison to staffing levels in the acute sector, but they are on a par with the benchmark hospital sites with one registered nurse per 6.6 patients. Benchmarking this with the other areas, staffing levels at the sites ranged from one registered nurse for 5.5 patients to one registered nurse for 7 patients.

Table 8 - Staff ratios

Workforce Molesey Dorking NEECH Leatherhead Cobham

Registered 1 per 6 1 per 7 beds 1 per Not Not Nurse ratio beds 6.6 applicable applicable beds Healthcare 1 per 6 1 per 7 beds 1 per Not Not Assistant ratio beds 6.6 applicable applicable beds Qualified 0.52 0.52 hours per 0.52 Not Not physiotherapy hours per patient hours applicable applicable hours per week patient per patient

Social work 5 4 3 Not Not hours per week applicable applicable

Discharge Co- No Yes – 1 whole No Not Not Ordinator time equivalent applicable applicable registered nurse

Cost per bed £420 £350 £310 Not Not day applicable applicable

Across all four sites, between July 2014 and June 2015 the average length of stay in hospital for in-patients was 23 days. This was above the benchmark data obtained from other hospitals in the country, which reported an average length of stay of 15 days.

Length of stay in the four community hospitals (including data from the Leatherhead ward) has ranged from 15 to 39 days. In recent months the general trend has been an improvement in length of stay, with most hospitals now achieving below 20 days.

Bed occupancy has followed a similar trend to the average length of stay. Smaller units such as Molesey Hospital have difficulty maintaining full occupancy as, due to the layout of the ward, it has limited ability to reconfigure the space to be able to accommodate male and female beds in line with single sex accommodation standards.

Occupancy rates for the ward at Leatherhead Hospital were significantly affected by the improved length of stay at the New Epsom and Ewell Community Hospital (NEECH) when it relocated to Croft Ward at Epsom Hospital in July 2014. During this period, occupancy fell to below 75% as a result of improved throughput of patients at Croft Ward effectively increasing its bed capacity. With more patients able to receive their rehabilitation at Croft Ward the demand for inpatient beds at Leatherhead fell. NEECH sustained some of its Length of Stay improvement following its return to the NEECH site in November 2014, increasing to 18 days which was lower than the starting point of 30 days prior to the transfer to Croft.

Current patient profile

As part of the review process a census of current users of the inpatient rehabilitation service was undertaken. The census sought information relating to age, presenting condition, point of referral and home postcode.

From this data, at the time of the census the average patient age was 78 years. The youngest patient was 51 years and this was the only patient under the age of 65 staying at one of the community hospitals at this time. The oldest patient was 99 years. The snapshot indicated a slightly higher number of female patients – 55% female, compared to 45% male.

The most common presenting conditions were:

 Post-surgery rehabilitation following bone fracture from a fall  Exacerbation of a chronic disease such as heart failure  Chest infection or urine infection  Stroke rehabilitation  Falls management

Admission profiles

The table below shows the number of patients admitted to each hospital site over the last 12 months. Dorking admissions have steadily increased from December as its bed stock increased. Overall bed numbers have not changed significantly over the 12 month period. However, as each hospital improves occupancy and length of stay, the number of patients treated per month has increased. This is clearly demonstrated by the trend graph below.

Table 9 - Patient admissions by month

Dorking NEECH/ Croft pilot Leatherhead Molesey Total June 2014 17 23 15 13 68 July 2014 18 30 20 13 81 August 2014 17 27 17 12 73 September 2014 24 32 27 13 96 October 2014 17 31 25 12 85 November 2014 27 13 10 14 64 December 2014 43 21 0 19 83 January 2015 43 22 0 18 83 February 2015 47 26 0 18 91 March 2015 62 23 0 17 102 April 2015 67 24 0 18 109 May 15 63 27 0 10 100 June 2015 67 26 0 23 116 Total 512 325 114 200 1151

Graph 1 – Admissions to community hospitals June 2014 to June 2015

Patient Admissions per month 150

100

50 Total

Nov…

Jan-…

Jun-… Jun-…

Mar…

Oct-…

Apr-…

May…

Sep-… Feb-…

Dec-… Aug-… Jul-14

Source of admissions

Data on community hospital admissions from the last twelve months has been reviewed to determine the source of each admission and any trends that have emerged. The graphs below give a breakdown of where admissions came from for each hospital.

Most patients admitted to the community hospitals are being transferred from the acute sector. Epsom and St Helier Hospitals are by far the largest source of referrals. Patients from these sites are generally transferred to the New Epsom and Ewell Community Hospital (NEECH) and Dorking Hospitals. Dorking Hospital also receives patients from East Surrey Hospital. Molesey hospital inpatients are mostly referred from Kingston Hospital.

Graph 2 – Dorking Hospital – source of admissions

0% Dorking Hospital A & E EGH A&E ESH 0% 2% 4% 1% Acute Hospital EGH 2% 11% Acute Hospital ESH Acute Hospital Kingston Acute Hospital Other 32% 17% Other Community From Molesey 8% From NEECH Home 22% LA Residential Home 1% MAU ESH

Graph 3 – Molesey Hospital – source of admissions

Molesey Hospital A & E EGH

1% 5% 3% A&E Kingston 1% Acute Hospital EGH 11% 12% 15% Acute Hospital Kingston Acute Hospital Other

From Leatherhead

Other Source

52% Home

MAU EGH

Graph 4 – Leatherhead Hospital – source of admissions

Leatherhead Hospital A & E EGH 2% 1% 9% Acute Hospital EGH 11% Acute Hospital ESH

Acute Hospital Kingston 36% Acute Hospital Other 34% Home

6% MAU EGH

1% MAU ESH

Graph 5 – New Epsom and Ewell Community Hospitals (NEECH) – source of admissions

0% NEECH A&E EGH 2% 1% Acute Hospital EGH 1% Acute Hospital ESH 8% 9% Acute Hospital Kingston Acute Hospital Other 18% Home MAU EGH 1% Other Source 6% 54% Leatherhead CAU SWELEOC

The data shows 80% of patients in the community hospitals are transferred from acute care. Only 10% of patients are being admitted from home. The introduction of the Community Hubs is expected to increase the number of admissions from home. It is interesting to note that each community hospital has received patients from all the acute hospitals. This is contrary to the public understanding gleaned from the workshops. It was believed that the community hospitals only treated patients from their immediate locality. For example it was thought that that Molesey Hospital accommodated all patients referred from Kingston Hospital.

The table below provides a breakdown of the admissions by category:

Table 10 – Community hospitals – source of admissions

Source % of Total A&E / MAU 8% Acute ward 72% Community Hospitals* 10% Home 10%

*Assumed to be hospital to hospital transfers during transition of sites

The review has highlighted inconsistencies in the process for admitting patients to, and discharging patients from, the community hospitals. The census also identified a number of patients at each hospital that was not appropriate for rehabilitation. Discussions with nursing and medical staff indicate this is a common problem. Support from community and social work services in facilitating discharge can also be variable, with some patients waiting a number of weeks for care packages to be arranged. To address this, as part of ongoing work to establish the new community hubs, social care have reviewed, and are increasing, their input into community hospitals, which will help ensure assessments happen as quickly as possible.

Key themes emerging from this section

 This section has highlighted opportunities to improve efficiency in how care is delivered, through closer working with local partners and improved processes.

 Social care are working with us on the development of community hubs and have increased social care input into community hospitals, which will help ensure assessments are timely

Section 4

Research and best practice models

Section summary

This section of the report provides a summary of research into best practice in community hospitals and considers bed capacity, comparing bed numbers in Surrey Downs with other parts of the country.

Best practice in in-patient rehabilitation care

The available literature on community inpatient services contains a number of common themes. These included:

 Setting an expected date of discharge for patients on admission  The development of a key worker role to coordinate patients care through to discharge  Adopting a target length of stay for each condition or profile  Implementing the NHS Institute’s Productive Community Hospitals initiative (a series of recommended working practices to improve efficiency and patient care in community hospitals)

The NHS Benchmarking Network, the in-house benchmarking service of the NHS which exists to identify and share good practice across the Health and Social Care sector, published a report in 2011 detailing the national picture of community hospitals. Although the data is not recent it is still relevant and applies to elements of this review.

Importantly, this benchmarking report stated that there is no clear link with a higher number of community bed days equating to a lower number of acute bed days. Equally, a longer average length of stay in the community setting does not equate to a shorter average length of stay in acute care. This view is supported by research By Cook & Porter (1998) which states that there is a weak correlation between community bed usage and decreasing usage of acute beds.

Community hospitals in England have few equivalent models in other countries. (Tucker, 2006) and the Scottish Executive (2006) refers to the lack of research‐ based evidence on the safety and effectiveness of services in community hospitals.

Furthermore, there is limited information regarding benchmarking in Optimum Length of Stay for specific care pathways.

The table on the following page demonstrates how services have changed over the last eight years. The table shows benchmarking data from 2008 compared with the information obtained through a literature search and direct contact with the community hospitals listed. The 2008 data was obtained from the Good Practice Guide (Care Services Improvement Partnership 2008).

Table 11 – Patient profile definitions

Patient Profile Description Optimum length Optimum length of stay 2008 of stay 2015

Intensive Admitted for rehab 21 days 14 days rehabilitation following a fall or episode of illness

Specialist stroke Admitted for rehab 28 days 35 days care following stroke

Sub-acute care Admitted for medical 5 days 3 days or nursing need. Not complex

Complex elderly A frail elderly patient 42 days 21 days with co- admitted for medical morbidities / nursing / therapy input and diagnosis

End of Life care Admitted for 5 days No evidence Palliative / End of available on Life Care optimum LoS

Neuro Admitted for rehab 42 days 42 days rehabilitation following moderate brain injury

It is interesting to note that the perceived optimum length of stay for stroke has increased, whilst the length of stay for neuro-rehabilitation has remained the same. The increase in length of stay for stroke is understood to be a result of the developments in rehabilitation techniques and better understanding of the needs of patients who have suffered a stroke-related brain injury.

Comparing community hospital capacity

Because of the fluid nature of the development of services, multiple configurations and the difficulty in identifying a true comparator, there is limited high quality research literature on community hospitals. Some literature is available for community hospital configuration but the majority was produced before 2010 and is therefore outdated.

To identify how the current community hospitals are performing, ten community hospitals, mostly of a similar size and providing similar services, were identified in

36 order to compare and benchmark performance. Each site was contacted regarding their activity and performance. The information supplied (below) has been used to give a comparator for the community hospital services in Surrey Downs.

Table 12 – Comparing community hospital bed capacity

Hospital Bed capacity Potters Bar Hospital 30 Clacton Hospital 15 Bolsover Hospital 51 Halstead Hospital 20 Haywood Hospital 77 Sir Robert Peel Hospital 24 Sutton Cottage Hospital 28 East Riding Hospital 30 Fryatt Hospital 21 Malton Hospital 30

All hospitals provide general rehabilitation services, similar to those in Surrey Downs. Additionally, two sites provide rehabilitation for patients who have suffered stroke, which is helpful in considering the neuro-rehabilitation services currently provided at NEECH. Larger hospitals like Haywood and Bolsover have more than one ward.

Key themes emerging from this section

 This section looked at best practice in rehabilitation care and how bed capacity in Surrey Downs compares with other parts of the country

Section 5

Mapping future demand for services

Section summary

This section gives details of the current Surrey Downs population and explores how predicted population changes over the next ten years will impact on demand for inpatient community rehabilitation beds.

Population demographics

Population projections by the Office of National Statistics (ONS) anticipate a 2% growth in the over 65 year old population year on year over the next 10 years in the Surrey Downs catchment. Table 1 below gives a breakdown of this growth.

Table 13. Population changes in the over 65 year old age group in the Surrey Downs area

The graphs below show how the five age categories in the age bracket 65 years and above are expected to change over the next 10 years.

Graphs 7a, 7b, 7c, 7d and 7e – Changes in population volumes over time by age category

The graphs demonstrate that the population groups are not increasing at the rate first anticipated. For example, some categories show a decline before beginning a gradual increase in population numbers. Regardless of this, the growth will need to be taken into account as part of this review, particularly when considering inpatient bed capacity requirements.

The change in patient numbers is not the only key factor that must be accounted for in determining inpatient capacity. The ageing population brings an increase in the incidence of chronic disease and multiple conditions. This increase is likely to be greater than the 2% increase demonstrated in the population volumes and will increase the demand for rehabilitation services. The expected increase in demand for rehabilitation, observed from historical trends in risk stratification data, is approximately 6%.

During the last twelve months the community hospitals treated 1,166 inpatients. This is approximately 2% of the population over 65 years of age. On the basis of a 6% growth rate as outlined above, this would suggest that the service would require the capacity to treat 1,500 patients per year by 2025 if nothing else were to change.

Population geography

The information provided above gives a breakdown of the population changes in the entirety of the Surrey Downs area. It is important to look more closely at where the population is located to ensure services are provided to meet the demands of the population. Using risk stratification data supplied by the CCG’s Business Information team it was possible to see how each individual practice population is made up. This data was then broken down into the four localities that were in place when the CCG was first established (MEDLinC and Mid-Surrey have now merged to form the Epsom locality) to show the health of the population by locality.

Graph 6 – Population of each locality split by health risk

45%

40%

35%

30% East Elmbridge 25% MEDLinC 20% Mid Surrey 15% Dorking

10%

0% Non-users Healthy Low Moderate High Very High

The community hospital inpatient services are accessed by those patients in ‘high’ and ‘very high’ risk categories. Given that the Medlinc and Mid Surrey localities (which both refer to Epsom Hospital) have the highest number of ‘high’ and ‘very high’ users, it is logical to assume that a large percentage of the community hospital inpatient provision should be located within reach of the Epsom locality. At present the population is served by both the New Epsom and Ewell Community Hospital

(NEECH) and Dorking Hospital.

Historically the hospitals have served the localities in which they are based. For example, Molesey Hospital inpatient beds have mostly been occupied by residents from the East Elmbridge locality, with the majority of admissions coming from Kingston Hospital. The hospitals at Leatherhead, Dorking and Epsom have followed similar patterns. However, with Leatherhead’s beds being transferred to Dorking, the nearest community hospital for patients in the south of the Epsom catchment is now Dorking.

The map below illustrates how the population of patients in various age groups are spread across Surrey Downs.

Map - Percentage of at risk users with access to hospitals within a reasonable time by public transport/ walking

Key issues emerging from this section

 Surrey Downs has an ageing population that is on the increase and this needs to be taken onto account when considering future inpatient bed capacity

 Risk stratification tools are helpful in identifying levels of health need in specific populations and this provides an insight into where the ‘higher risk’ health users live. This information also needs to be considered when planning future services to ensure inpatient beds can be easily accessed by these groups.

Section 6

Modelling future community bed

requirements

Section summary

This section considers projected population changes and how this, and other factors, will impact on future community hospital bed requirements. It also looks at current operating models and these could be enhanced to reduce length of stay and increase bed capacity.

Community bed capacity requirements

At present the CCG commissions sixty beds from CSH Surrey, who deliver community inpatient rehabilitation services. In the last twelve months there have been 1,166 admissions to the community hospitals.

Table 16 below outlines the potential bed requirements over the next ten years, based on a 6% increase demand per year. This assumes everything else remains the same (i.e. this does not take account of any potential changes in service delivery which could reduce demand or reductions in average length of stay which could further increase bed capacity).

Table 14 - Beds capacity requirement based on 6% increase

Assumed Projected average Annual Maximum patient length of bed Occupancy beds Year admissions stay days (%) required 2016 1262 22 27,774 84% 91 2017 1284 22 28,257 84% 92 2018 1307 22 28,762 84% 94 2019 1328 22 29,214 84% 95 2020 1351 22 29,717 84% 97 2021 1375 22 30,251 84% 99 2022 1402 22 30,841 84% 101 2023 1430 22 31,459 84% 103 2024 1461 22 32,141 84% 105 2025 1494 22 32,866 84% 107

This modelling suggests that the maximum community bed requirement over the next 10 years is 107 beds.

However, there is a significant inconsistency in both the length of stay and occupancy at the four hospital sites, which suggests opportunities to improve efficiency and therefore increase capacity.

The graphs on the following page illustrate the variance in average length of stay for each hospital.

Graphs 8a, 8b, 8c and 8d – Average length of stay

The data shows Dorking performing well with an average length of stay in June at around 13 days. NEECH patients are staying an average of 16 days whilst Molesey patients stayed an average of 19 days in July. Since the introduction of the new Community Medical Teams in July 2015 Molesey has seen a reduction in length of stay; this is currently 17 days. Leatherhead patients were having stays of around 21 days prior to the beds being relocated.

It is interesting to note that the Dorking length of stay has been dropping most significantly since the end of 2014, following the transfer of the additional beds from Leatherhead. This has coincided with the appointment of a dedicated Discharge Planning Nurse at the site. The hospital has also benefited from the input of a consistent, experienced medical team, who have established a clear working pattern to support the nursing staff. This has been demonstrated in Molesey Hospital with the new CMT already having a positive impact on the length of stay.

Using the average length of stay data, activity from 2014 and expected activity of 2015 is shown below:

Table 15 – 2014 patient activity data

Average Annual bed length Patient Site Beds Occupancy Days of stay volumes Dorking 22 87% 6986 20 349 Molesey 12 87% 3811 25 152 NEECH 11 87% 3493 20 175 Leatherhead 15 83% 4544 20 227

Total 60 904

Table 16 – 2015 patient activity data

Average Annual bed length of Patient Site Beds Occupancy days stay volumes Dorking 28 95% 9709 15 647 Molesey 12 87% 3811 22 173 NEECH 20 85% 6205 22 282 Leatherhead 0 14 0 Total 60 1103

The data shows that improving (reducing) length of stay can increase the volume of patients able to be seen. In the last twelve months Dorking Hospital has achieved an average length of stay of less than 14 days.

If this average length of stay was achieved by all sites capacity and therefore patient volumes would be expected to increase as demonstrated in table 17 on the following page.

Table 17 – Potential capacity increases as a result of reduced length of stay Average Annual bed length of Patient Site Beds Occupancy days stay volumes Dorking 28 95% 9709 14 694 Molesey 12 87% 3811 14 272 NEECH 20 85% 6205 14 443 Leatherhead 0 14 0 Total 60 1409

Having a target of 14 days for the average length of stay will increase the bed capacity by 27%. The volume of patients able to be seen within current bed capacity is equivalent to the 6% increase in demand per annum for the next ten years. Table 16 above has patient volumes at a maximum of 1,494 in 2024. This may indicate that an improvement and standardisation of average length of stay may lead to excess capacity in community beds in the intervening years. The impact of the new community medical teams, and how they affect bed capacity, also needs to be considered.

As well as variances in the average length of stay between the hospitals there is also a marked difference in the occupancy levels at each unit. The occupancy data for the four sites is shown below.

Graphs 9a, 9b, 9c and 9d - Occupancy data for community hospitals

From the graphs we can again see that Dorking achieves maximum occupancy almost all of the time. The maximum occupancy standard for an acute hospital is acknowledged to be 85%. This is predominantly driven by the need to have escalation beds that can be opened as necessary and increased risk of infection associated with higher levels of occupancy, and therefore patient throughput.

There are at present no published standards of occupancy specifically for community hospitals. Due to the acuity of the patients they treat, the incidence of infection is considerably lower than acute hospitals and the average length of stay for community wards is generally higher than that of an acute ward setting, due to their focus on rehabilitation. This suggests that community hospitals can absorb more patients without compromising quality of care.

Dorking Hospital has not experienced an increase in the incidence of hospital acquired infections when compared with the other hospitals. Patient satisfaction also remains high and so there is no evidence that has been seen by the review that higher occupancy is creating a patient safety or quality challenge at Dorking. If the community sites were to operate at 95% occupancy, bed capacity would increase further.

The table below shows the impact on capacity of improved length of stay and increased levels of occupancy.

Table 18 - Increased occupancy - decreased average length of stay Average Annual Patient Site Beds Occupancy length bed days volumes of stay Dorking 28 95% 9709 14 694 Molesey 12 95% 4161 14 297 NEECH 20 95% 6935 14 495 Leatherhead 0 14 0 Total 60 1486

If the hopsitals were to achieve and maintain an average occupancy of 95% and an average length of stay of 14 days, 60% more patients could be seen within the current bed capacity. This increase in capacity as a result of improved efficiency would potentially absorb the 6% increase in demand for community rehabilitation year on year for the next ten years.

The table on the following page provides details of the total community hospital inpatient bed requirements per year for the next ten years based on the above analysis

Table 19 – 10 year bed requirments

Average Annual Year Patients length of stay bed days Occupancy Beds 2016 1262 14 17,043 95% 51 2017 1284 14 17,340 95% 52 2018 1307 14 17,649 95% 53 2019 1328 14 17,926 95% 54 2020 1351 14 18,236 95% 55 2021 1375 14 18,563 95% 56 2022 1402 14 18,925 95% 57 2023 1430 14 19,304 95% 58 2024 1461 14 19,723 95% 59 2025 1494 14 20,168 95% 61

The bed requirement can be separated into the three GP locality areas using the percentage of the total population over 65 years of age within Surrey Downs.

Table 20 – East Elmbridge locality – 16% of patients over 65 years

Average Annual Year Patients length of stay bed days Occupancy Beds 2016 202 14 2,828 95% 8 2017 206 14 2,877 95% 8 2018 209 14 2,928 95% 8 2019 212 14 2,974 95% 9 2020 216 14 3,026 95% 9 2021 220 14 3,080 95% 9 2022 224 14 3,140 95% 9 2023 229 14 3,203 95% 9 2024 234 14 3,273 95% 9 2025 239 14 3,346 95% 10

Table 21 – Dorking Locality – 16% of patients over 65 years

Table 22 - Epsom Locality – 68% of patients over 65 years

Average Annual Year Patients length of stay bed days Occupancy Beds 2016 858 14 12,019 95% 35 2017 873 14 12,228 95% 35 2018 889 14 12,446 95% 36 2019 903 14 12,641 95% 36 2020 919 14 12,859 95% 37 2021 935 14 13,091 95% 38 2022 953 14 13,346 95% 38 2023 972 14 13,613 95% 39 2024 993 14 13,908 95% 40 2025 1016 14 14,222 95% 41

The graph on the following page demonstrates the impact of reduced length of stay on the number of inpatient beds needed over the next 10 years. However, this does not take into account any impact from the community hubs, which may affect future bed requirements. The focus on managing patients better within the community will most likely bring an increase in the number of patients admitted directly from home for what is commonly known as ‘step up’ care. At present only 10% of patients admitted to the community hospital beds come directly from their home or care home.

Graph 10 - Inpatient bed numbers based on average length of stay

Bed Requirements from Improved AvLoS

22 days 20 days 17 day 14 days

110 100

90 80 70

No of Beds of No 60 50 40 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

If the average length of stay and occupancy rates are standardised across all community hospital sites, and capacity increases as a result, based on current activity and future assumptions the current commissioned capacity of 60 beds will not be required in its entirity until 2025. This assumption is based on the 6% increase in demand each year for the next ten years.Changes to acute services and the evolving community medical teams and community hubs are likely to have some impact on the bed demand but at present this is assumed as a neutral position; with neither increased or decreased demand for community beds.

Section 7

Estates and the quality of the buildings

Section summary

This section of the report provides a summary of the condition of the current hospital buildings and the costs involved with delivering improvements

Estates review

Under the previous NHS management structures which were in place until April 2012, Primary Care Trusts owned and managed community estate such as community hospitals. The CCG does not own estate in the same way. Instead, NHS Property Services manages, maintains and improves the current community hospital estate and the wider estate portfolio that the CCG holds.

As part of this review process, the CCG has been working with NHS Property Services to undertake a review of all estates used to deliver services commissioned by the CCG. This review has included reviewing the current community hospital sites, as well as clinics in the Surrey Downs area.

The estates review is nearing completion, but has already identified a series of property maintenance issues at each of the hospitals.

The table below is a summary of the estates review to date in relation to the use and condition of the five community hospital sites. The hospital sites have been graded on a scale of A to D, depending on their current condition.

Table 23 – Estates review of community hospital by NHS Property Services

Property Physical Invest to B Comments condition (cost of returning property to ‘sound’ condition

Cobham B N/A Building has 3 floors. Hospital and Health B = Sound Ground Floor is held by Superior Centre Operationally safe. Landlord (and is location of Only minor Community Ward space deterioration 1st Floor (NHS PS)

Dorking C £2.5M Wards require investment and Hospital have a number of maintenance C = Operationally issues. Means of escape needs safe but major to be improved to the rear of the repair needed soon premises

Epsom and B(C) £3.0m Plenty of space for expansion. Ewell Community B(C) = Currently £380k invested 2014 Hospital sound but will fall (NEECH) into C in 5 years and the Poplars

Leatherhead B(C) £3.9m Hospital B(C) = Currently sound but will fall into C in 5 years

Molesey C £2m estimate Hospital Operationally safe but major repair is needed soon

The Physical Condition Column Key

A = As New

B = Sound – operationally safe. Only minor deterioration

B(C) = As B but will fall to C in 5 years

C = Operationally safe but major repair is needed soon

D = Inoperable or serious risk of failure/breakdown

‘Invest to B’

The ‘Invest to B’ column is an estimated cost to return the property to Category B for current use. It does not include total costs to re-engineer space for new purposes (i.e. change use to clinic space).

Work is ongoing to fully survey each sites but as can be seen above, information so far suggests the need for substantial investment in the Dorking and Molesey hospital sites.

Dorking Hospital will require investment of up to £2.5m to bring the facility to the desired (B) classification. Molesey Hospital will require a minimum spend of £2m to bring the facility to the desired B classification

Table 11 below provides a per square metre cost comparison between the five hospital sites, based on the data currently available. Cobham Hospital is the most expensive site per square metre, being almost double the cost of Dorking Hospital.

Table 24 – Cost of community hospital estate (excluding clinical and housekeeping costs)

Site Building Utilities* m2 Building Utilities Total Invest to Cost Total cost cost m2 cost B m2 m2 (£) m2

Cobham 574,286 50,988 2,072 277.17 24.61 301.77 - - 301.77

Dorking 180,772 71,991 2,646 68.32 27.21 95.53 2,500,000 47.24 142.77 NEECH +Poplars 142,225 19,740 1,732 82.12 11.40 93.51 3,000,000 86.61 180.12

Leatherhead 304,785 35,247 2,720 112.05 12.96 125.01 3,900,000 71.69 196.70

Molesey 78,269 25,718 1,102 71.02 23.34 94.36 2,000,000 90.74 185.11

* Estimated based on current data available

NHS Property Services are presently undertaking their review of the hospital sites and will provide more accurate financial information during September 2015.

Estates considerations for outpatient and diagnostic services

As described in previous sections, the five community hospitals currently provide a range of outpatient and diagnostic services. In addition, the CCG commissions a range of outpatient services that are delivered from clinical sites (such as GP practices and clinics) across the Surrey Downs area. Part of this review process has focused on how these would be affected if the inpatient model and/or estates were reconfigured.

Section 3 of this report contains a detailed breakdown of the services provided across the community hospital sites. Dorking and Leatherhead Hospitals have a significant number of outpatient services delivered from the site, including physiotherapy, medical outpatient services and radiography. The review process has identified that relocation of these services would prove extremely difficult if the sites were reconfigured following the review process. Furthermore Epsom and St Helier University Hospitals NHS Trust has advised that the services they provide from Leatherhead Hospital would be almost impossible to re-house on the acute hospital site in Epsom as the space required to accommodate the services on the Epsom site is not available and cannot easily be created.

In terms of other outpatient services, Molesey Hospital and NEECH provide less outpatient clinics and are limited by space. East Elmbridge has capacity in the Emberbrook Clinic for additional services.

Cobham Hospital has a comprehensive range of services including a day surgery unit. Like the other sites, relocation of services would prove extremely difficult. There are a very limited number of sites within the locality which would be suitable to deliver the services available at Cobham..

The review has highlighted the potential for consolidation of community-based outpatient services onto the hospital sites under some of the options being explored. Leatherhead Hospital in particular has capacity to host additional services with some alterations to the current layout. In addition to benefits for patients in co-locating services, consolidation would result in savings in property costs for the CCG.

Key issues emerging from this section

 Dorking and Leatherhead Hospitals provide a range of outpatient services. Following discussions with the organisations that run these services, it is clear that it would be very difficult to re-locate these services to other sites if reconfiguration is recommended following this review

 Following the estates review, there may be opportunities to re-locate some outpatient services from community clinics to other sites within the CCG estate where space is available. Co-locating and consolidating services could offer benefits to patients and lead to savings on rent for the CCG if some smaller sites become redundant.

Section 8

Service developments influencing community hospital bed requirements

Section summary

This section explores planned service developments within Surrey Downs which

are likely to impact on the community hospital inpatient bed capacity needed in future. The section provides details of the services and how they may influence capacity and future bed use.

Impact of the Community Hub programme

On 1 July the CCG launched three new Community Hubs, with one operating in each of the three localities (Dorking, Epsom and East Elmbridge). The hubs are a new locality-based GP service put in place to better manage frail elderly patients in the community. The hub teams focus on patients over the age of 75 years who have one or more chronic illness. These are the patients most at risk of admission to an acute hospital. This is also the group of patients who most frequently use inpatient beds at the community hospital.

The community hubs consist of both GPs and multi-disciplinary teams of care professionals. The teams are locality-specific and include GPs, nursing services, physiotherapy, occupational therapy, social work and domiciliary care.

The teams work together to better manage frail elderly patients in community and have already taken over the medical management of patients within the community hospitals. Once fully established, the teams will work closely with care homes, managing patients better in the community to prevent admissions to acute care.

It is anticipated that the community hubs will increase the number of patients directly admitted to the community beds from their home. At present around 10% of patients are admitted to a community hospital from home, with the majority transferred from an acute hospital following an inpatient stay.

As the hubs only started in July 2015 there is currently very little evidence to indicate the volume of patients that will be admitted to community beds through the hubs. However, it is clear that many of the patients managed by the team will be following a recurring pathway whereby their health or medical condition deteriorates to a point where they are unable to maintain their personal safely at home. At the current time these patients are generally admitted to the acute hospital for treatment following which they may be discharged home, or transferred to the community hospital for rehabilitation. Early intervention by the hub teams will in some cases prevent the patient’s condition from deteriorating to a point where admission to acute hospital is required. The patient may be safely managed at home with support from the hub team.

It is expected that there will be a cohort of patients whose medical condition will warrant their admission to the community hospital for close medical management and nursing intervention. Such patients are likely to require an average of seven days of treatment. Some patients will require a shorter length of stay but it is anticipated that there will be patients whose stay exceeds the seven days.

During the first six to twelve months of the hubs being established it is unlikely they will have a significant impact on demand for bed capacity in the community hospitals.

It is vital, however, that the activity of the teams is reviewed regularly to ensure capacity is available if needed.

Planned care service redeisgn

The CCG has work underway to look at the commissioned pathway for planned care services. This work may lead to changes, for example in how outpatient care is provided, or the order in which patients are referred to hospital doctors, diagnostic testing and other healthcare professionals.

One of the key objectives of this work is ensuring that as much of a patient’s care is as close to home and based in local communities as possible. In this context, sites with significant diagnostic services and which are some distance from the nearest hospital outpatients department, such as Dorking and Leatherhead, will continue to have an extremely important role.

Key issues emerging from this section

 The new community hub service will help support older people living with long- term health conditions. As this is the same group of people who use community hospital in-patient beds, the impact of this new service will need to be closely monitored and once further data is available this will need to feed into any final options that are developed

Section 9

Conclusions, recommendations and options

Section summary

This section is in two parts. The first summarises a number of general conclusions and recommendations relating to the community hopsitals and how they operate. The second part considers options for change and possible options to reconfiture how services are provided across the community hospital sites.

General conclusions and recommendations

The review identified a number of opportunities to deliver improvements in how care is provided at the community hospitals by making changes to the current operating model, thereby increasing efficiency. The review also identified opportunities to improve patient care in some areas. This section summarises these general conclusions in more detail.

Key outcomes of the review

Following extensive public and stakeholder engagement, a comprehensive review of each hospital site and an examination of best practice models, the Programme Board identified a number of key service configuration issues for the Community Hospital Services. These four factors underpin the final recommendations and options made within the outcome paper:

Three Ward Model

The Programme Board recommends delivering inpatient care from three sites.

Dorking Hospital

The inpatient services provided from Dorking Hospital have proven to be operating very effectively. The increase in bed numbers in December 2014 from 18 beds to 28 beds (including 6 winter funded beds), led to a significant reduction in average length of stay and a corresponding increase in occupancy levels. The increased bed capacity and combined workforce from Dorking and Leatherhead gave the provider the opportunity to develop innovative care models including the appointment of a dedicated discharge planning nurse.

62 may reduce the efficiency of the services provided and potentially impact on clinical outcomes.

The Programme Board recommends Dorking inpatient and outpatient services remain in their current site and configuration.

Leatherhead Hospital Inpatient Ward

The inpatient services at Leatherhead hospital were transferred to Dorking Hospital and NEECH in December 2014. The transfer of the beds allowed CSH Surrey to introduce new innovative practices such as the introduction of a dedicated discharge planning nurse at Dorking Hospital, achieved in part through the economies of more beds per site. The Programme Board recommendation of a three site model prompted a close examination of which community hospital sites best served the needs of the population. It was concluded that each of the three localities (Dorking, East Elmbridge and Epsom) require inpatient beds, however, only Epsom has two recently functioning inpatient sites. The three site model led to a straight choice between the Leatherhead and NEECH inpatient wards as a preferred site for the Epsom locality. NEECH inpatient ward was refurbished at a cost of £380,000 in 2014. Leatherhead inpatient ward requires upgrading and investment. NEECH provides both inpatient and outpatient neurological rehabilitation services. The Poplars unit has been specified to support the outpatient rehabilitation service. Leatherhead would require significant investment to accommodate the neurological rehabilitation function, particularly the outpatient service.

The Programme Board recommends the permanent closure of the inpatient ward at Leatherhead Hospital

Leatherhead Hospital Outpatient Services

The Programme Board recommends that Leatherhead Hospital is developed as a Planned Care hub, which includes diagnostic services.

Specific recommendations

The following recommendations have been made:

1. Localised versus CCG-wide bed management

In the past patients requiring rehabilitation have “waited” in the acute hospitals for a bed to become vacant in their local community hospital. This has clearly impacted on the bed capacity within the acute trust and reduced occupancy levels at the community sites, with available beds left vacant. Whilst there is a view that patients may be isolated from family if they are placed in a community hospital a number of miles from their home (a view that was discussed at a number of the community workshops), in order to achieve efficient occupancy levels of 95%, the hospitals need to achieve, and mainain, optimum use of all community beds and this is not happening currently.

The concerns raised about patients potentially feeling isolated and relatives not being able to travel to other locations to visit them is recognised, particularly in terms of the impact this could have on an individual’s rehabilitation journey. Taking this feedback into account, these transport issues could be addressed through innovative use of voluntary services and public transport. In discussions at one of the public workshops it was suggested that a daily taxi service is commissioned to take relatives to and from the hospital to visit. If the average length of stay for the patient is 14 days and the transport costs are £20 per day, the total cost of this service would be £280 per patient. This is less than the cost of one bed day at an acute hospital and would therefore offer a cost effective solution. The transport would be available to relatives who live beyond an agreed distance from the community hospital and have difficuly travelling.The model for delivery could be incorporated into the current Patient Transport Service with a modified Eligibility Criteria used to ensure the service is deployed approriately.

Recommendation 1: Introduce/confirm a single Surrey Downs community bed approach where patients are placed in the first available, suitable rehabilitation bed regardless of which hospital the bed is available in.

2. Neurological rehabilitation services

Surrey Downs has both inpatient and outpatient rehabilitation services for patients who have suffered neurological problems including stroke and acquired brain injury (ABI). The services are based at the New Epsom and Ewell Community Hospital

(NEECH) site, with the outpatient function in the Poplars unit and the four bed inpatient unit on the ward.

There is some debate as to whether there is a need to increase the capacity of the inpatient neuro-rehabilitation service. Much research has been undertaken into the outcomes of patients who have suffered from stroke or acquired brain injury. Rehabilitation services haven proven most effective when delivered from dedicated specialist units which are typically located within acute hospitals, with staff trained in the care and management of patients with neurological conditions.

NEECH ward has four beds specifically for patients requiring neurological rehabilitation. These beds are part of the 20 bed ward, with the other 16 beds being used for general rehabilitation. The neurological beds have a separate team of therapists specifically trained in neurological rehab.

Between July 2014 and June 2015 NEECH provided neurological rehabilitation for 28 patients. Of these, 18 patients have been under 65 years with the remaining ten being over 65 years. The rehabilitation unit receives patients from a number of referring sources. The majority of patients are referred from Epsom Hospital (17) with others referred from Kingston Hospital (6), Royal Surrey County Hospital (3), St George’s (1) and St Peter’s (1).

The four beds are almost always full, with over 90% occupancy. The average length of stay for patients receiving neurological rehabilitaton is 59 days, compared to 22 days for the general rehabilitation services in NEECH. The majority of patients are discharged to their home from the rehabilitation service with only three of the 28 patients being placed in long term care.

In reviewing wider bed capacity the waiting list for the neurological rehabilitation service was also reviewed. The average waiting list for the services is three patients, although it has increased to five patients at times. Conversely, it has been as low as one patient waiting. As of the week commencing 15th June there were three patient’s waiting; two were from Epsom Hospital and one from Kingston Hospital. The average wait for a bed is 15 days with the longest wait to date being 28 days. Patients are referred during the acute phase of their treatment. Delays in transfering patients from acute care to rehabilitation care is linked to neuro-rehabilitation bed availability.

A review of services provided through St George’s gives similar, or in some cases, longer waiting times. Increasing capacity in the neurological inpatient service would significantly reduce, if not eliminate, the current waiting list. However, community inpatient rehabilitation is now an atypical model for stroke patients following acute discharge, with recent developments in stroke services preferring home-based early supported discharge care. The future model and capacity requirement for this service will therefore be heavily influenced by the outcome of the Surrey-wide stroke review programme, which is currently underway.

Recommendation 2: Review the scope and capacity of the NEECH neurological rehabilitation beds in the context of both current and future demand for services and the outcome of the Surrey-wide stroke review.

3. Patients not requiring rehabilitation

The review process has highlighted a group of patients whose care is not managed consistently, highlighting the need for clarity on the appropriate care pathway for these individuals. These are patients who are in acute hospitals and who have been identified as requiring long-term care. Typically these patients are being assessed for Continuing Healthcare (CHC) or social care funding. The assessment process can take time, with patients waiting a minimum of two weeks for a decision and placement. In some cases the patients remain in the acute hospital. In other cases patients are transferred to a community hospital with the suggestion they would benefit from some level of rehabilitation care. However, following this review it has been identified that rehabilitation potential for this group is limited.

At times of increased demand, the acute hospitals need to find alternative placement for these patients and, at present, the community hospitals are the only available option. A report of Medically Fit for Discharge patients is provided by Epsom Hospital on a daily basis. This report includes patients identified for placement and patients involved in the assessment process. A review of data from the last six months indicates that the acute hospital has between six and ten patients per week whose discharge is delayed whilst the assessment process is undertaken. Typically higher numbers are reported by Kingston Hospital and East Surrey Hospital.

In January 2015 Epsom Hospital experienced increased admissions and a number of delays in discharges. This created a significant capacity issue for the hospital. Working with the trust, Surrey Downs CCG purchased a number of nursing home beds in the form of two week placements for patients awaiting long-term care. This period allowed funding arrangements to be confirmed and freed up capacity for acute admissions. The programme proved extremely successful with 50% of the patients choosing to remain at the care home in which they were initially placed. The majority of the other patients moved to their home of choice within the two week period and one patient was discharged home.

The project demonstrated that patients awaiting long-term care placements could safely be managed in a low level care environment. The beds were purchased at a cost of between £700 and £800 per week; this is considerably less than the bed day cost of both acute and community hospitals.

The pilot was focused on solving a specific problem of increased demand for acute beds but continuing healthcare patients are always present in the acute hospital.

Facilitating their discharge to a transition bed in a low level care environment will reduce bed day costs to the CCG and free up capacity in the acute sector.

While care home capacity exists within the Surrey Downs area it has been suggested that consideration is given to using empty community hospital ward space for this group of patients. The proposed model would provide services for those needing social rehabilitation or interim care, which may arise following a brief period of illness, a fall resulting in a fracture or elective surgery, for example.

Recommendation 3: Consider the requirement for a distinct type of community inpatient service, separate from the current rehabilitation beds, that can accommodate patients who are awaiting long-term placement but not acutely unwell. Whilst this could be part of a community hospital model, other settings of care may be more appropriate and cost-effective. Patient care is paramount so it is vital the type of care required is identified early on and that a suitable care environment is commissioned to meet these patient’s needs.

4. Ambulatory Rehabilitation Centre – ARC

At present the clinical model in the community hospital only has patients receiving rehabilitation as inpatients. This model is driven predominantly by the need to maintain patient safety, particularly in the overnight period. There are patients, however, who are admitted to the community hospital for rehabilitation who are mobile and have support at home to maintain their safety. These patients still require rehabilitation with input from nursing, medical and therapy teams. It is possible to have the patients at home overnight and attending the community hospital for rehabilitation during the day.

This idea has been discussed with staff at the community hospitals. There is general consensus that the number of patients who would be suitable for such a service would not be more than or three or four per site. However, it was agreed that such a service would free up bed capacity and allow for better utilisation of therapy services.

Patients would require assessment to confirm their suitability to be safely managed in their home at night. The patient would remain a patient of the community hospital but as a day case only.

An Ambulatory Rehabilitation Centre would require a dedicated transport service to bring patients to and from the service. Reliance on patient transport services may compromise the efficiency of the ARC and this would need to be explored further. The ARC would also require a domiciliary carer workforce to assist patient to prepare for coming to the service and to settle the patient back home. As with the patient transport it may prove problematic to rely on the current domiciliary care providers as these patients would need to be managed as part of their extensive workload. While

67 a domiciliary therapy service is in place at present it has a waiting time of up to six weeks from referral to treatment. Additionally, the home care therapist team provide hands on care for around 40% of their time. This is common with many home care services as time is lost through travelling and administration. Centre-based services offer greater efficiency by maximising the time clinicians have to deliver hands on care. Centre-based therapists can spend up to 80% of their time delivering physical care.

The total annual cost of the service would be around £270,000, factoring training time and travel costs. This works out at around £70 per patient per day, based on ten patients using the service, five days per week. Increasing the service to seven days a week increases the cost to £105 per patient, based on ten patients using the service each day. This is considerably lower than the current cost of a community hospital bed for one day. The costs include food and domestic services.

The Ambulatory Rehabilitation Centre would create a facility which would evolve into an assessment and ambulatory treatment centre, with the continued development and input of the community hubs. The hospital teams have expressed interest in acquiring new skills which would facilitate the transition.

Recommendation 4: Work with the new community hub teams to consider the case for introducing ambulatory rehabilitation services, both to complement the hubs, but also to manage some of the future demand which may otherwise fall on inpatient rehabilitation care.

5. Minimum scale for effective operation of services

We have seen during the review that sites with a larger number of beds have a lower length of stay, whilst admitting patients with similar presenting conditions. We have identified specific factors that are available at the sites with lower lengths of stay. Specifically these are:

 Higher resilience and continuity within the nursing and therapies workforce  Ability to flexibly manage therapies input  The use of specific staff with specific skills i.e. discharge nurses  Ability to secure more time from partner agencies i.e. social services  Strong clinical leadership

Each of these factors is linked to having a larger bed base in a specific population and this is demonstrated by the fact that our current site with the longest length of stay has the lowest number of beds (Molesey) and vice versa (Dorking). At the same time, we have also observed that sites with 20 beds have a similar bed day cost (NEECH and Dorking) whereas the site with a smaller number of beds (Molesey) has a significantly higher bed day cost, driven by the inherent inefficiencies in safely

68 managing a smaller unit of this type. It should also be noted that currently Dorking hospital is the only site to benefit from a dedicated Discharge Planning Nurse, which contributes to the reduced length of stay at the hospital.

Additionally, the strong clinical leadership now being provided at Molesey Hospital through the new community hub has already demonstrated its effectiveness through a reduced length of stay. However, lack of capacity at the site will continue to affect occupancy and financial efficiency.

This would suggest a case for having larger numbers of beds on any bedded site, and by inference a smaller number of sites with inpatient beds given that the overall need for bedded care is set to only increase by a small amount. This could be delivered either solely within the current Surrey Downs community bed base, or by working with neighbouring areas. However, this needs to be balanced against the requirement to align services to the levels of need in each locality and with the service delivery model of the community hubs.

The commissioned levels of physiotherapy input to patients on the wards is lower than the benchmark figure from the ten hospitals surveyed. Consideration should be given to a review of the therapy input provided to patients during their stay in the community hospitals and whether this is sufficient. Consolidation of the bed base would support this.

The review identified problems with patients not suitable for rehabilitation being transferred to community beds. Communication between the acute and community hospitals needs to be improved to ensure all organisations share a common understanding of the service provided by the community inpatient teams.

Recommendation 5: Operate a model where no fewer than 16, and ideally 18 – 20 beds, are typically open in an inpatient rehabilitation facility at any time. Ensure the standard admission criteria is reviewed and clarified with providers and fully applied, with common and appropriate levels of support to patients on admission, during their stay and at discharge to maximise the benefits of this model. In addition, specific consideration needs to be given to levels of inpatient physiotherapy and occupational therapy.

Options for future configuration of community hospital services

The review process has identified a considerable number of options for the future configuration and development of services delivered from the community hospitals in the Surrey Downs area. Every option being explored has advantages and disadvantages, with operational implications and financial considerations for each.

This report contains a detailed review of the inpatient bed requirements, based on projected changes in population and demand for care over the next ten years. For clarity, the table below outlines the anticipated bed requirements until 2025

Table 26 – Community inpatient bed requirements 2016 to 2025

Average length of Annual bed Year Patients stay days Occupancy Beds 2016 1262 14 17,043 95% 51 2017 1284 14 17,340 95% 52 2018 1307 14 17,649 95% 53 2019 1328 14 17,926 95% 54 2020 1351 14 18,236 95% 55 2021 1375 14 18,563 95% 56 2022 1402 14 18,925 95% 57 2023 1430 14 19,304 95% 58 2024 1461 14 19,723 95% 59 2025 1494 14 20,168 95% 61

These requirements are based on achieving a standard length of stay across all units and an occupancy level of 95%. We believe that this efficiency can be achieved through the implementation of recommendation (5) above.

The table clearly shows that the improved efficiency reduces the number of beds required to deliver the service. Taking this into account, the current capacity of 60 beds would not be required in its entirety until 2025.

Further reductions in the bed capacity required could be achieved by introducing an assessment bed model and an ambulatory rehabilitation centre as previously described.

These are shown below.

Table 27 - Bed requirements with operational Ambulatory Rehabilitation Centre and assessment beds

Average Annual Year Patients length of stay bed days Occupancy Beds 2016 1262 10 12,625 95% 38 2017 1284 10 12,844 95% 39 2018 1307 10 13,073 95% 39 2019 1328 10 13,279 95% 40

2020 1351 10 13,508 95% 41 2021 1375 10 13,751 95% 41 2022 1402 10 14,019 95% 42 2023 1430 10 14,299 95% 43 2024 1461 10 14,609 95% 44 2025 1494 10 14,939 95% 45

The options review for the community hospitals have been based on how best to structure services to achieve, not only the inpatient bed requirements but also facilitate the development of both outpatient services and the community hub teams.

Estate options and flexibilities

Noting recommendation 5 above, it is important to consider the estate which is available for potential future configuration of services. Two key conclusions have been reached:

 In the light of future capacity requirements, it is clear that the Dorking site is a fixed point in inpatient and outpatient provision. The site offers a high volume of high quality inpatient care estate. The outpatient services are comprehensive and any attempt to relocate them would most likely have a negative impact on the quality of care and require significant extra service provision at East Surrey Hospital, some distance from the Dorking locality population. Dorking Hospital currently represents good value with a cost per bed day of £350. This is broadly comparable with NEECH (£310) and significantly cheaper than Molesey Hospital (£420).  Leatherhead Hospital poses a similar issue in that its broad outpatient service portfolio cannot feasibly be relocated and is required to maintain appropriate diagnostic and outpatient capacity and services to the population in the south of the Epsom Hospital catchment i.e. Ashtead, Leatherhead and Fetcham.

With the option to develop Leatherhead Hospital as a planned care hub being strongly supported by the Programme Board, the inpatient ward area could be re- developed for other uses. The review has confirmed that the relocation of the beds to Dorking did not negatively impact on patient care and may in broad terms have had a positive impact, fostering innovation and allowing the Dorking site to improve efficiency through economies of scale. Investing in the Leatherhead Hospital site would allow the development of a planned care hub which can provide additional outpatient and diagnostic services to the locality population. There is an opportunity to consolidate outpatient services, currently delivered in a number of locations, onto the Leatherhead Hospital site. Furthermore, the planned care hub development would allow greater flexibility for outpatient and diagnostic service delivery as the

71 local population grows. The hub would develop in parallel with the planned Transform Leatherhead Programme.

The primary options left are focused around the NEECH, Molesey and Cobham sites. The options for NEECH are either retaining the service at the NEECH site or relocation to the Epsom Hospital site, with full closure of the community hospital. The relocation option is supported by good evidence from the Croft pilot in 2014.

In East Elmbridge the options can be summarised into whether Molesey hospital is retained and developed, closed (and the inpatient beds located to Dorking / NEECH), or closed and the beds relocated to Cobham. Closure of the hospital need not necessarily mean the loss of healthcare facilities at the site. There is an option to develop the site and create a primary care hub, offering GP, outpatient and diagnostic services. This would require the building of a new facility on the current hospital site.

Summary of Programme Board options appraisal process

The review process identified 17 separate options for the future configuration of services delivered from the community hospitals. Each option was explored, examining the impact on patients, staff, and the public. The initial appraisal of the options focused on the feasibility of each in the context of the estate considerations above and their likely impact on the clinical outcomes for patients. This appraisal was undertaken by the Programme Board convened to oversee the Community Hospital Review.

From the original list of 17 options, the programme board excluded 8 options. The remaining options were further examined and consolidated around the three localities to produce a list of six options.

The Programme Board was keen to consider all proposals and suggestions put forward from engagement events. However, some of these represented variants or suggestions around individual hospitals rather than comprehensive options.

Each supported option for further consideration included permanently closing the inpatient ward at Leatherhead and develop the site for outpatient service delivery as a planned care hub. This is because of the excessive costs and unsuitability of the Leatherhead site for reinstating inpatient bed services; and the availability of other suitable sites (NEECH, Epsom and Cobham) in the Epsom locality.

The table below is divided into two sections: firstly, options that partly or wholly address the requirements of recommendation (5) above; and secondly, potential further developments to the future service model.

Detailed descriptions of each option, including the advantages and disadvantages of each and why options were forwarded for further consideration or discarded, can be found on the following pages.

Table 28 – Summary of full list of options considered by Programme Board

Inpatient bed configuration options Forwarded Rejected for review Option 1 - Maintain the current three-ward model with X inpatient wards at Dorking, Molesey and NEECH. Develop Leatherhead planned care services (Leatherhead in-patient services remain closed).

Option 2 - Transfer NEECH inpatient services to the X Epsom Hospital site and transfer outpatient services elsewhere in the locality. Develop Leatherhead planned care services (Leatherhead in-patient services remain closed).

Option 3 – Transfer Molesey inpatient services to X Cobham Hospital and transfer outpatient services to suitable location(s) within East Elmbridge locality. Develop Leatherhead planned care services (Leatherhead in-patient services remain closed).

Option 4 – Both options 2 and 3 above X Return to the previous inpatient model with an open X inpatient ward at all four of the community hospital sites. Close Leatherhead Hospital and relocate all X outpatients’ services to other sites.

Relocate the inpatient and outpatient neurological X rehabilitation services from NEECH to Leatherhead Hospital

Close Dorking Hospital - relocate all inpatient services X to Epsom Hospital and relocate outpatients services to other sites in the Dorking locality.

Further development options Forwarded Rejected for review Increase number of neurological rehabilitation beds at X NEECH by opening new unit

Develop the Ambulatory Rehabilitation Centre model X

Build a new community hospital on the Molesey X Hospital site

Open Leatherhead Hospital as a continuing healthcare X transition bed unit Develop Molesey outpatients department by providing X X-ray The below table shows the configurations based on the currently commissioned overall bed numbers. The assumption is made based on maintaining the currently commissioned beds including the System Resilience Group (winter) beds.

Inpatient bed capacity in east Elmbridge As part of the review process, the CCG had considered the relocation of inpatient beds from Molesey Hospital to Kingston Hospital. However, following discussions with Kingston Clinical Commissioning Group, it has become clear that there are currently no plans to increase bed capacity at Kingston. In view of this, this option is no longer viable.

Table 29 – Bed configuration options

Options Bed numbers Cobham Molesey Dorking NEECH Epsom Total Beds Total Beds Hospital (excluding (including NEECH Neuro beds) Neuro beds) Option 1 0 12 22 + 6* 16 0 56 60 Option 2 12 22 + 6* 16 56 60 Option 3 18 0 22 16 56 60 Option 4 18 0 22 0 16 56 60

* The CCG currently commissions 60 community beds across all the community hospitals. This includes 4 neuro-rehabilitation beds at NEECH and six additional rehabilitation beds at Dorking that are currently funded until September 2015 through winter pressures funding. Under all four options, bed numbers remain the same, although the additional six beds will be continually reviewed and only commissioned if additional capacity is needed.

Full options list

Option description and source Maintain the current three-ward model with wards at Dorking, Molesey and NEECH. This option emerged from discussions at both the Programme Board and from internal discussions within the CCG Strengths / Opportunities This option describes the model currently in use. There has been an improvement is length of stay and occupancy at the three sites since the model was adopted. The patient quality indicators have remained constantly good, pointing to an effective service.

The option has allowed the adoption of best practice such as the introduction of a dedicated Discharge Planning Nurse

The three-site model gives sufficient bed capacity for Surrey Downs during the winter period

Leaving this model in place would cause no disruption to the Community Hospital Care Services.

Maintaining inpatient services at NEECH would see rehabilitation care continuing to be provided in a community environment, which following feedback, local people feel is important and should be reflected as a strength.

Weaknesses / Threats The model provides 60 beds; this is more capacity than is required in the short to medium term

Smaller units such as Molesey Hospital may not be able to achieve the targeted occupancy level of 95% due to the reduced ability to flex male and female bed numbers

The bed locations do not match the population profile or demand profile within the localities

As the Community Hubs become more active the three-ward model may result in three separate, differently run units. Programme Board recommendations The board agreed that the current model has allowed the development of good practice within the service, particularly at Dorking

The patient care quality measures have remained consistently high in the units indicating a safe, effective model.

The model would offer minimal disruption to patients and service providers.

Leatherhead residents may feel let down if the ward remains unoccupied.

The board agreed this option should go forward for further public consideration and review Rationale for recommendation The rational for the programme board recommendation was primarily the evidence of the efficacy of the current model and the opportunity is has provided to develop innovative care solutions such as the Discharge Nurse. The three wards are working

75 towards improving their current length of stay and are sharing good practice. The board agreed that the model should operate at least over the winter period to provide stability and to allow further evidence of the Community Hub function and impact to be gathered.

Option source and description Transfer NEECH inpatient services to the Epsom Hospital site and transfer outpatient services elsewhere in the locality This option was discussed internally within the CCG following the NEECH / Croft move in 2014. This was also discussed within the public meetings

Strengths / Opportunities The programme board discussed the precedence for this option; NEECH moved to the Epsom site in 2014 during refurbishment. The move facilitated an improvement in both occupancy and length of stay for the patients.

Such a move would provide additional capacity for the community hospital service as most wards at Epsom have a larger number of beds when compared to NEECH

The inpatient service would operate independently and run as a separate community ward, located within Epsom Hospital. The move would facilitate better integration between the community and acute hospital providers, improving access to medical support and diagnostics.

Weaknesses / Threats NEECH was refurbished 12 months ago to upgrade the facility. The cost benefit of this work would not be realised

The neurological services may be compromised, particularly if the move results in the separation of the inpatient and outpatient neurological services.

The move would reduce the capacity of escalation beds within Epsom Hospital. This will have an impact on care during the winter pressure period.

The community hospital unit may have to be used as escalation beds if demand for acute services becomes too great.

Programme Board recommendations The programme board accepted that the NEECH / Croft relocation in 2014 provides good evidence for supporting this option. Occupancy and length of stay both improved dramatically when NEECH ward was on the Epsom site. Inpatient clinical outcomes would be improved with better access to medical and diagnostic services

Conversely the neurological services may be compromised by such a move. It is unlikely the acute site could accommodate the Outpatient neurological rehabilitation service. Both inpatient and outpatient services are linked

The board agreed this option should go forward for further public consideration and review

Rationale for recommendation The programme board agreed that the arguments for and against this option are evenly balanced. Patient outcomes for the inpatient service would be improved by relocating. However, inpatient and outpatient neurological rehabilitation services may be severely compromised.

Option Description and Source Transfer Molesey inpatient and outpatient services to Cobham Hospital and transfer outpatient services to suitable location(s) within the East Elmbridge locality This option came through “what if” discussions held in the first of the public workshops and in staff meetings with the hospital teams.

Strengths / Opportunities Molesey is the oldest and smallest of the community hospitals, offering the least capacity.

The building is in need of significant upgrade and repair work at present. Transferring services to Cobham may be a more cost effective solution longer term.

The outpatient services are limited with little room to add more services to the site

Weaknesses / Threats Molesey Hospital is well supported by the newly formed Community Hub in east Elmbridge

Closure of the hospital would remove the inpatient bed facility for the Community Hub

There is significant public support for Molesey Hospital and full closure would not be well received, particularly if improved clinical outcomes cannot be demonstrated

Cobham Hospital is an expensive site to deliver care from due to rental and site costs.

Potential loss of staff if services transferred to Cobham due to transport issues.

Programme Board Recommendations The board discussed the argument both for and against this option. It was agreed that there was a requirement for a bedded care option to service the population of East Elmbridge but, if a better alternative as not available, Molesey Hospital should remain.

The programme board agreed that the fluidity of the bed situation at Kingston Hospital made it impossible to discard this option.

The programme board agreed this option should go forward for further public consideration and review

Rationale for Recommendation The changing situation in the Kingston locality and the recent implementation of the Community Hubs makes it difficult at his time to determine the best clinical option for the Molesey site. It was therefore agreed that the option would go forward giving more time to gather more data.

Option description and source Permanently close the inpatient ward at Leatherhead and develop the site for outpatient service delivery This option was raised at the public meetings held in Leatherhead.

Strengths / Opportunities The programme board discussed the impact of the relocation of the inpatient services from Leatherhead in December 2014. Patient care has not been compromised by the move.

Leatherhead provides a large number of outpatient services, More services could be delivered through utilisation of the existing building and the land that surrounds it.

The ward activity is less than 5% of the overall care activity delivered at Leatherhead Hospital

Weaknesses / Threats

There is strong public support for the re-opening of Leach ward. This was demonstrated through a petition signed by local residents.

Leatherhead is a costly site in terms of the rental costs incurred by the CCG

Increasing the outpatient services may further increase costs to the CCG, particularly of unnecessary care

Enlarging the Outpatient capacity may further exacerbate the parking issue at the site

Programme Board recommendations The programme board discussed the activity at the hospital and capacity of inpatient beds required. It was agreed that the Outpatient Services constituted the majority of activity and that the relocation of the beds had not had an impact on the patient care or the wider hospital services

The programme board agreed this option should go forward.

Rationale for recommendation The programme board decision was based on the improved patient pathway which resulted from the relocation of the beds to Dorking also a factor was the lack of a credible and suitable alternative location for the outpatient services at Leatherhead. The changing population makes having outpatient services on the site vital.

Option description and source Return to the previous inpatient model with an open ward at each of the community hospital sites.

This option was discussed at the early public workshops. There is much public support for the ward services at each site.

Strengths / Opportunities The option would be well supported by the public. The local model offers patients more convenient access to rehabilitation services. Relatives would find it much easier to visit and support patients.

The 4 site model would give additional bed capacity for Surrey Downs, giving a total of 81 beds available for use.

The additional capacity would allow the potential development of new inpatient services at each site

The model would enhance the public support for the hospitals, particularly from organisations such as League of Friends

Weaknesses / Threats The four hospital model would have small capacity units. Larger units such as Dorking are able to achieve greater flexibility and therefore offer better occupancy rates and length of stay.

The analysis of the changing population in Surrey Downs indicates that 60 beds may not be required before 2020. With four sites, a small number of beds may be occupied at times of lower demand. This will reduce the economy of scale achieved by those wards with 20 or more beds. This will make the inpatient model more expensive than it is today.

The estate costs to the CCG will continue to remain high on the four site option.

Programme Board recommendations The programme board discussed the options and agreed that the experience and data gathered since the move of the Leatherhead beds to Dorking indicates that there is no efficiency to be had in going back to the old four-ward model.

Patient care and outcomes would not be improved in such a model when compared to the current service. Patient satisfaction has remained constantly high since the consolidation of beds in December 2014.

The four-ward model would increase the number of nursing and therapy staff required by the provider. There remains a national shortage of clinical staff and increasing the staff numbers would prove challenging

The board recommended that this option be discarded

Rationale for recommendation The primary rational for rejection was the likely lack of any improvement in patient

79 outcomes associated with returning to the four-ward model. The option would introduce further costs as staffing profiles would require adjustment and the efficiency of the service would be compromised.

Option source and description Close Leatherhead Hospital and relocate all outpatients services to other sites.

This option came through ”what if” discussions held in the first of the public workshops and in staff meetings with the hospital teams.

Strengths / Opportunities The board discussed the impact on inpatient care of the relocation of the beds from Leatherhead in December 2014. There has been no reduction in quality of care or quality indicators from moving the service.

The option would allow the ongoing development of innovation and best practice at the three remaining inpatient sites

The current three-site model gives sufficient bed capacity for Surrey Downs during the winter period

Adopting this model in place would cause no disruption to the Community Hospital inpatient services Weaknesses / Threats Leatherhead provides a significant volume of outpatient and radiology services which would be extremely difficult to place elsewhere in the Epsom locality

Relocation of the outpatient services would prove a costly exercise and would provide no short term improvement to patient care. Such a move may compromise care though reduced attendances.

There is significant public support for the Leatherhead Hospital and full closure would not be well received, particularly if improved clinical outcomes cannot be demonstrated

Many providers using the site have contracts which contain exit penalties. The CCG may face a large, unexpected cost if the clauses are invoked.

Programme Board recommendations The board discussed the clinical outcomes of this option, particularly for the outpatient services and agreed that there were no strong arguments to support the option going forward.

The financial cost to the CCG may be large and closure would not be well received by the public.

The programme board recommended this option be discarded Rationale for recommendation The lack of improvements in clinical outcome and the potential to compromise care

80 were the key reasons behind the programme board recommendation.

The financial and public implications were also a factor in the decision.

Option description and source Relocate the inpatient and outpatient neurological rehabilitation services from NEECH to Leatherhead Hospital This option was raised at the Leatherhead public workshop Strengths / Opportunities Leatherhead Hospital has the inpatient bed capacity to take the neurological rehabilitation beds currently at NEECH

Moving the beds would provide an additional four beds for general rehabilitation at NEECH.

The move would keep the inpatient and outpatient services together. During the NEECH / Croft relocation the Outpatient Neurological services were transferred to Leatherhead.

The move would allow the inpatient bed capacity to be increased as the ward has a large number of beds

Weaknesses / Threats The Leatherhead hospital physiotherapy department in poor condition and would need substantial work to allow it to be a permanent home for the neurological outpatient service.

Extensive work has already been performed on the Poplars unit at NEECH to upgrade it for the Neurological services.

There is a question about what alternative use could be found for the Poplars, given the investment made by the CCG to upgrade the building in 2014.

Programme Board recommendations The programme board discussed the implications of moving the inpatient services. It was agreed that, whilst the Leatherhead Hospital ward had capacity, the four bed ward would be non-viable as a standalone option.

There was much discussion about the clinical safety of such a ward. Staffing levels would be one nurse for two patients because of minimum requirements. This would make the service prohibitively expensive

The programme board recommended this option be discarded

Rationale for recommendation The primary rationale for the recommendation was patient safety. The 4 or 6 bed neurological rehabilitation ward would not work as a standalone unit. Staffing levels for nurses would have to be extremely high; the ward cannot have less than two nurses. With four patients this option is unrealistic.

Option description and source Close Dorking Hospital and relocate all inpatient services to Epsom Hospital and the outpatients services to other sites in the Dorking locality. This option came through ”what if” discussions held in the first of the public workshops and in staff meetings with the hospital teams.

The move would facilitate better integration between the community and acute hospital providers, improving access to medical support and diagnostics.

The move would potentially allow for improvement to the service efficiencies already achieved at Dorking Hospital

Weaknesses / Threats Dorking Hospital provides a significant volume of outpatient and radiology services which would be extremely difficult to place elsewhere in the Dorking locality

Relocation of the Outpatient services would prove a costly exercise and would provide no short term improvement to patient care. Such a move may compromise care though reduced attendances.

There is significant public support for the Dorking Hospital and full closure would not be well received, particularly if improved clinical outcomes cannot be demonstrated

Additionally, the move of the inpatient would not offer additional capacity as Dorking has 28 beds. The clinical outcomes for patient would be unlikely to improve further with the move.

The programme board recommended this option be discarded

Rationale for recommendation The lack of improvements in clinical outcome and the potential to compromise care were the key reasons behind the programme board recommendation.

The financial and public implications were also a factor in the decision.

Option description and source Increase number of neurological rehabilitation beds at NEECH by opening new unit This option came from discussions held in the public meetings in Epsom

Strengths / Opportunities Evidence indicates that there is always a waiting list for inpatient neurological rehabilitation services. The list always has at least two people waiting.

Opening a specialist unit would allow the development of a centre of excellence for neurological rehabilitation

The new unit would free up four beds on the NEECH ward for general rehabilitation patients.

Weaknesses / Threats There is a question over the viability of a 6 bedded standalone unit. Staffing cost would be high.

Extending the existing ward would be costly with limited improvement in clinical outcomes for the investment

The emerging pathways for the management of patients with Stroke may reduce demand for the beds long term (following the Surrey-wide Stroke review)

Programme Board recommendations The programme board discussed the arguments for and against this option. The arguments are evenly balanced. The development of a larger, specialist unit would improve patient outcomes but the cost may outweigh the benefits.

Patient safety / minimum staffing requirements are a serious concern on a standalone unit

The programme board agreed this option should go forward for further public consideration and review

Rationale for recommendation The decision to put the option forward was based on the current and potential future need for the rehabilitation services, and the potential to further improve the clinical outcome for patients.

Option description and source Develop the Ambulatory Rehabilitation Centre (ARC) Model This option came from discussions with staff in the community hospitals

Strengths / Opportunities The ARC model could increase capacity for rehab at hospital sites by offering both inpatient and day case functions

The ARC model is less expensive than inpatient service, costing £105 per patient

83 per day

The ARC model could be development into day treatment centres with input from the Community Hubs

Weaknesses / Threats There may be limited need for the service – patients may not be suitable

The ARC would require the recruitment of new staff, particularly therapists

The existing hospitals may lack the space to accommodate the ARC

Programme Board Recommendations The programme board discussed this option and feel there is potential in exploring it further. There are concerns that not enough patients may be suitable for day case rehabilitation but the centre may be used to support the domiciliary therapy teams

The programme board agreed this option should go forward for further public consideration and review

Rationale for Recommendation The decision was based on the need to explore new ways to deliver rehabilitation services and maximise the efficiency of the current estates.

Option description and source Build a new community hospital at Molesey Hospital site This option was put forward by the public at the East Elmbridge meetings

Strengths / Opportunities The current Molesey Hospital site has sufficient land to allow a new community hospital to be build

The local GPs would support the new build, particularly if the site included a GP surgery option

The hospital League of Friends would provide significant funds towards the build

Weaknesses / Threats There is a question as to whether a new hospital is needed. The locality needs a maximum of 10 beds and a new hospital would have at least 20 beds.

Cobham Hospital could be used as an alternative. Cobham offers 18 inpatient beds as well as x-ray services

There is a risk of repeating the Cobham mistake again – a hospital is built when capacity isn’t required and the site quickly closes

Programme Board Recommendations The programme board discussed the option. While it is agreed that the patients of

East Elmbridge would benefit from a community inpatient unit, it does not necessarily need to be at the Molesey site in a new build. Alternatives are available, not least is upgrading the existing building

The programme board recommended this option be discarded

Rationale for Recommendation The programme board decision was based on the availability of resources in the locality which can be used to service the needs of the patient without the need for a new hospital.

Option description and source Open Leatherhead Hospital as a CHC / transition bed unit This option came from a review of CHC patients medically fit for discharge at Epsom Hospital

Strengths / Opportunities The transition beds would free capacity in the acute hospitals

Having the beds on a single site would help build the necessary skill set in the ward staff around the CHC process

Patients can be acclimatised to the care home model before being transferred to their place of residence

Weaknesses / Threats The bed cost will be expensive as a result of the high property costs

Care home beds can be purchased and provide a similar service

Moving elderly patients too many times may result in increased confusion and distress for them

Programme Board recommendations The programme board accepts the need to look at the transition bed model but do not believe Leatherhead is the correct environment. The ward has limited male capacity and may be better used for other services.

The programme board recommended this option be discarded

Rationale for recommendation The primary reason for the decision was patient safety. Moving patients too many times will have a negative impact on their mental state.

Transition beds need to be examined but the Leatherhead site is not suitable

Option description and source Develop Molesey outpatients department with an X-ray service This option came from discussions at the East Elmbridge public meetings

Strengths / Opportunities The current x-ray system in Molesey Hospital is offline. A new machine would need to be purchased

A new machine would increase capacity for the East Elmbridge locality

It would support the develop of the Molesey hospital site into a day treatment centre

A new machine would give easier access for local patient attending outpatient clinics at the Molesey site

Weaknesses / Threats There is a question as to whether a new machine is needed. Patients currently attend Surbiton or Kingston for x-rays

Staffing the new service may prove difficult

The ongoing running cost may outweigh the clinical effectiveness of having a new machine

Programme Board Recommendations The programme board agreed that the current services provided at Surbiton and Kingston are sufficient for the patient needs within the East Elmbridge locality.

Outpatient clinics are not dependant on having an x-ray machine on site.

The Community Hub have stated that having an x-ray is not an essential part of their hub model

The programme board recommended this option be discarded

Rationale for Recommendation The rationale for the decision was based on clinical need. While the siting of a new machine would offer convenience to the locality population, the existing services at Surbiton and Kingston are sufficient and accessible

Evaluation criteria

The previous section summarised a number of options for consideration and discussion relating to the future configuration of community hospital services. It is therefore essential to determine the most suitable criteria by which to assess each option. This will allow the remaining options to be ranked according to the best outcome for both patients and commissioners.

The evaluation criteria has been developed as part of the public engagement workshops, with co-design sessions to understand the factors people feel are most important when evaluating any potential options.

The general evaluation themes coming to the fore in the public workshops have been:

1. Clinical outcomes – ensuring the service model maintains the current high standards and improves the longer-term care for the patient

2. Patient centred – ensuring the service is designed around the patient with their needs at the centre of all decisions

3. Access to services – providing a comprehensive range of services at a site which can be reached and has good accessibility for patients and the public

4. Estates – ensuring the building is fit for purpose or can be upgraded / developed to provide space for current and new services

5. Travel time – ensure the sites are well served from other locations to ensure patients, relatives and staff can get there

6. Staff – attracting and retaining the staff with the right skills for the job

7. Costs – ensuring the site offers best value within the confines of the health economy

The criteria above have been listed in the order of importance, or weighting, identified in the public meetings, with clinical outcomes being seen as most important, and cost being ranked least important (attendees felt it was more important to get the right service model, although it was acknowledged that affordability was an issue that needed to be considered). The criteria will be further refined to allow their application to the various options for community hospital services being discussed.

Next steps

Following publication of this report (20 August 2015) the CCG led a further period of engagement with local people, patients, staff, GPs, healthcare providers and partner organisations to seek feedback on the options that have emerged.

This feedback will be considered by the CCG Governing Body in September and will form part of the evaluation process, where final options for consultation will be confirmed.

If major changes are proposed, these would be subject to public consultation.

Local people and stakeholders can share their comments on the options that have emerged by emailing [email protected] or writing to Surrey Downs Clinical Commissioning Group, Cedar Court, Guildford Road, Leatherhead, Surrey KT22 9AE.

People will also be able attend a series of public workshops and events to find out more and have their say as part of a public consultation. Details will be advertised in due course.

For the latest updates see www.surreydownsccg.nhs.uk

Section 10

Appendices

Appendix 1 – Accessibility

Table 30 - Distance between hospitals in miles

Site Molesey Dorking NEECH Leatherhead Cobham

Molesey 0 19 10 12 6

Dorking 19 0 12 6.4 12

NEECH 10 12 0 5.7 12

Leatherhead 12 6.4 5.7 0 6.2

Cobham 6 12 12 6.2 0

Table 31 - Road travel times between hospitals in minutes

Site Molesey Dorking NEECH Leatherhead Cobham

Molesey 0 40 35 30 20

Dorking 40 0 30 15 30

NEECH 35 30 0 6 30

Leatherhead 30 15 6 0 13

Cobham 20 30 30 13 0

Table 32 - Public transport times between hospitals

Site Molesey Dorking NEECH Leatherh Cobham ead

Molesey 0 1hr 40 1 hour 30 1 hour 30 1 hour mins mins mins

Dorking 1hr 40 0 40 mins 23 mins 1 hour mins

NEECH 1 hour 30 40 0 34 mins 1 hour mins minutes

Leatherhead 1 hour 30 23 mins 34 mins 0 30 mins minutes

Cobham 1 hour 1 hour 1 hour 30 0

minutes

The travel times listed above are based on journeys undertaken during non-peak periods. The public transport times reflect both bus and train transport. It is recognised, however, that further work is required to model travel times at both peak and non peak times and this work will be undertaken following further engagement over the summer and once the list of potential options has been refined further.

Appendix 2

Community Hospital Admission Criteria for Central Surrey Health

Locations covered:

 Dorking Community Hospital  Leatherhead Community Hospital  Molesey Community Hospital  New Epsom and Ewell Community Hospital

Aim:  To promote independent living for adults registered with GP’s within the locally agreed catchment area  To provide nursing care and rehabilitation for criteria specific patients  To prevent unnecessary hospital admission to secondary care by receiving direct community referrals  To promote appropriate transfers from Secondary and Tertiary care to ensure effective and efficient use of hospital beds.

Inclusion Criteria:

1. Patient from an acute hospital is medically stable, documented by discharging doctor and is not awaiting any imminent medical intervention or investigation.

2. Patient and/or next of kin are aware of, and agree to the transfer/admission.

3. Patient is over 18.

4. Patient is registered with a G.P. within the locally agreed catchment area.

5. Patient is assessed as requiring access to 24 hour nurse led care, rehabilitation and palliative care accessing MDT if appropriate.

6. Patients will be admitted with specific outcome in mind (the length of stay will be the minimum required to achieve this).

7. Patient has a clear rehabilitation goal

8. The Referral should be made by fully completing a “Community Hospital referral form”

a. From an acute hospital via the RMC: the form needs to be accompanied by a Physiotherapy /Occupational Therapy reports and the latest blood results. b. From the community/A&E/CAU etc. (i.e. where the patient is not in a place of safety) directly to the ward.

9. Transport arrangements to CSH Community Hospitals will be arranged and funded by the referrer.

Exclusion Criteria

1. Patient’s condition is unstable and beyond resources/care/treatment that a Community Hospital can offer.

2. Patients whose behaviour may cause distress or harm to existing patients or who require one to one supervision and/or has acute psychiatric needs.

3. Patients who have purely social needs or are awaiting funding for placement to residential/nursing home or commencement of domiciliary care package.

4. Patients with minimal or no expected rehabilitation potential due to a physical or cognitive reason.

5. Patients more appropriately supported in an alternative environment e.g.: within their own home supported by community teams or within a nursing/residential home.

6. Those requiring access to 24 hour medical support on site or patient requiring highly specialised care or special investigations unavailable on site.

7. Patients purely requiring respite or convalescence.

Under normal circumstances the ultimate decision to admit/decline patients must rest with the Modern Matron/Ward Manager.

Under exceptional circumstances the final decision to admit lies with the Clinical Manager for In-patients or the appropriate director, in consultation with the Modern Matron/Ward Manager.

These criteria for admission will be reviewed as required in consultation with stakeholders.

Appendix 3 – community hospitals and clinics

Appendix 4

Summary of main changes to Outcome report following feedback received during engagement period (August to September 2015)

Feedback Change in document The narrative relating to the length of This section has now been amended, stay data for stroke and neuro- with a clearer explanation provided (p36). rehabilitation, and how this had changed, required clarification.

Feedback from social care: This is now reflected in the report on page 33. Social care are working with the CCG to establish new community hubs and have increased social care input into community hospitals.

The axis on the ‘length of stay’ graphs This has been amended and the graphs used different values. updated (Section 6).

It was felt it should be explained that This has been added on P67. Dorking hospital is the only hospital to currently benefit from a Discharge Planning Nurse and that this contributes to a reduced length of stay.

If NEECH in-patient services were This point has been clarified in the transferred to Epsom Hospital, the ward rationale section for this option (p72). would be run separately, co-located on the Epsom site. It was felt this was not clear in the original draft.

Kingston CCG do not currently have Reference to this option has been plans to increase bed capacity on the removed from this version. Kingston Hospital site so the possible option to transfer inpatient services from Molesey Hospital to Kingston Hospital is no longer viable.

CSH staff have raised concerns about This has been noted in the ‘weaknesses’ being able to travel to Cobham if section of the rationale for this option services transferred from Molesey (p74)

It has been queried why cost has been Cost was considered to be the least ranked least important in the evaluation important factor at the public workshops. criteria An explanation has been added in the

evaluation criteria section on page 84.

Leatherhead residents have asked for This has now been included in the the public support for the re-opening of rationale on page 75. Leach ward to be noted.

East Elmbridge residents and Molesey This has now been added to the rationale League of Friends wanted it noted that on page 77. they were disappointed an option had been included that could see the potential transfer of services out of Molesey Hospital

Leatherhead hospital is part of a large This has now been included in the estate so opportunities to extend should rationale on page 75. be noted.

Chapter 9 also includes options, which The chapter heading for section 9 has is not reflected in the chapter heading. been amended to reflect that the chapter also includes options (along with recommendations and conclusions).

Comments received from Kingston Hospital NHS Foundation Trust:

1. Review admission criteria to allow This has now been reflected on page transfer of more complex patients to P69. community hospitals

2. Clarification on the suitability of Assurance is being provided to the trust Cobham Hospital for outpatient services on this issue. The wording for ‘option 3’ and consideration of other locations has been amended to reflect this within east Elmbridge comment and feedback about considering other east Elmbridge locations for outpatients services

In table 2 it is not clear if the out of This has now been amended. hours medical cover provided by Care UK is in addition to the service provided by the community hub.

The background information relating to This has now been included the New Epsom and Ewell Community Hospital does not mention that the hospital was refurbished last year

Table 22 relating to improvements in This has now been added length of stay needs to make reference to the impact of community hubs and the impact this is likely to have on acute

97 bed provision and ‘step up’ beds

No explanation had been given on why A new section explaining the rationale for Dorking Hospital was a fixed point (ie. this has been added prior to the options no changes proposed), why NEECH being explained. was the preferred option for in-patient services over Leatherhead and why Leatherhead Hospital is recommended as a planned care hub.

Feedback from CSH Surrey: This feedback has been incorporated and the relevant sections updated. Points of accuracy were highlighted relating to changes in bed capacity.

It was also suggested that further information on the innovative practices introduced at Dorking Hospital was included.

Inpatient occupational therapy levels This has now been included as part of also need to be reviewed, alongside recommendation 5. inpatient physiotherapy services

Are we speaking your language?

If you would like a copy of this report in large print, on audio tape or translated into your own language please call us on 01372 201721.

We welcome your feedback

If you have any comments about this report we would very much like to hear from you.

You can call us on 01372 201721, email us at [email protected] or you can write to us:

NHS Surrey Downs Clinical Commissioning Group Cedar Court Guildford Road Leatherhead Surrey KT22 9AE

www.surreydownsccg.nhs.uk

Appendix 2 Community hospital services review: Engagement Log

Type Stakeholders Event/Engagement activity CCG Representative (e.g. meeting, stall, Subject Date Location (e.g. patient reps, GPs Numbers of people survey, consultation) etc.) engaged (non CCG) Leatherhead Resident Director of Presentation followed by Q Leatherhead hospital/community 02/02/2015 Leatherhead Members of the public 103 Association public meeting on Commissioning and & A hospital services review Institute and other interested community hospital services Strategy, Project lead, stakeholders review Communications lead, Engagement manager Health and Scrutiny Committee Director of Meeting – Bill Chapman, Review process. HOS involvement 26/2/2015 Cedar court Health and scrutiny 5 Commissioning and Chair, Tim Hall, Louise and individuals to attend committee, SCC Strategy, Project lead, Botting, Ross Pike plus one programme board Communications lead Ewell Community hospital Director of Public meeting Community hospital services review 02/03/2015 Bourne Hall, Ewell Members of the public 40 services launch Commissioning and and other interested Strategy, Project lead, stakeholders, including Communications lead, local MPS, current and Engagement manager former patients and community groups Esher Community hospital Director of Public meeting Community hospital services review 04/03/2015 Elmbridge Civic Members of the public 26 services launch Commissioning and Centre, Esher and other interested Strategy, Project lead, stakeholders, including Director of Operations, local MPS, current and Engagement manager former patients and community groups Dorking Community hospital Director of Public meeting Community hospital services review 05/03/2015 Burford Bridge Members of the public 25 services launch Commissioning and Hotel, Dorking and other interested Strategy, Project lead, stakeholders, including Communications lead, local MPS, current and Director of Operations former patients and community groups Disability Alliance Network Communications lead, group meeting Community hospital services review 09/03/2015 Park House Disability services users 10 (DAN) Engagement manager – item on agenda Derby Medical Practice PPG Engagement manager PPG meeting Patient engagement in the CCG, 17/03/2015 Derby Medical PPG members - patients 14 meeting including the community hospital Practice - Ebbisham services review Centre League/Guild of Friends (for Director of Meeting Engagement in community hospital 18/03/2015 Cedar Court League of Friends reps 6 community hospitals) Commissioning and services review introductions Strategy, Project lead, Communications lead, Engagement manager Mole Valley Access Group Engagement manager Group meeting Community hospital services review 08/04/2015 Park House MVAG members 15

Cobham and District Residents Director of Public meeting Community hospital services review 09/04/2015 Cobham Resident Association 80 Association Commissioning and members Strategy, Project lead, February – September 2015

Event/Engagement activity CCG Representative Type Subject Date Location Stakeholders Communications lead

Workshop 1 - Molesey Project lead, Workshop What is your ideal community 13/04/2015 King George’s Hall Patients 7 Communications lead, hospital? Members of the public Engagement manager Staff drop-in session 1 – Molesey Project lead, Engagement Drop-in session An overview of the review, how this 13/04/2015 Molesey Provider staff on site Not counted manager will affect staff, staff input Community (mainly CSH Surrey) opportunities and any questions Hospital Workshop 1 - Epsom/Ewell Project lead, Workshop What is your ideal community 14/04/2015 St Barnabas Church Patients 9 Communications lead, hospital? Members of the public Engagement manager Staff drop-in session 1 – NEECH Project lead, Drop-in session An overview of the review, how this 14/04/2015 NEECH Provider staff on site Not counted Communications lead will affect staff, staff input (mainly CSH Surrey) opportunities and any questions Project group meeting Director of High level meeting Review progress Every two weeks Cedar Court CCG, provider n/a Commissioning and from 14/04/2015 organisations, Elected Strategy, Project lead Members Workshop 1 - Leatherhead Project lead, Workshop What is your ideal community 15/04/2015 CAU Room Patients 20 Communications lead, hospital? Leatherhead Members of the public Engagement manager Hospital Staff drop-in session 1 – Project lead, Drop-in session An overview of the review, how this 15/04/2015 Leatherhead Provider staff on site Not counted Leatherhead Communications lead will affect staff, staff input Community (including CSH Surrey, opportunities and any questions Hospital ESHT and Virgin Care) Workshop 1 - Dorking Project lead, Workshop What is your ideal community 16/04/2015 Dorking United Patients 11 Communications lead, hospital? Reformed Church Members of the public Engagement manager Staff drop-in session 1 - Dorking Project lead, Engagement Drop-in session An overview of the review, how this 16/04/2015 Dorking Community Provider staff on site Not counted manager will affect staff, staff input Hospital (including CSH Surrey and opportunities and any questions Dorking Healthcare) Service Redesign group Project lead, Meeting Developing/redesigning service Monthly from Cedar Court CCG service redesign 3 Patient representatives Communications lead, pathways 23/04/2015 teams, provider Engagement manager organisations, 3 patient representatives Friends of Dorking Hospital AGM Project lead, Public meeting Community hospital services review 29/04/2015 St Paul’s, Dorking Patients, members of the 25 Communications lead as an agenda item public, Friends group

Staff drop-in session 2 – Project lead Drop-in session Update on review process and Q&As 5/05/2015 Leatherhead Provider staff on site Not counted Leatherhead with staff Community (including CSH Surrey, Hospital ESHT and Virgin Care) Staff drop-in session 2 – NEECH Project lead Drop-in session Update on review process and Q&As 6/05/2015 NEECH Provider staff on site Not counted with staff (mainly CSH Surrey)

Staff drop-in session 2 – Dorking Project lead Drop-in session Update on review process and Q&As 7/05/2015 Dorking Community Provider staff on site Not counted with staff Hospital (including CSH Surrey and Dorking Healthcare)

February – September 2015

Event/Engagement activity CCG Representative Type Subject Date Location Stakeholders Staff drop-in session 2 – Molesey Project lead Drop-in session Update on review process and Q&As 8/05/2015 Molesey Provider staff on site Not counted with staff Community (mainly CSH Surrey) Hospital Workshop 2 – Cobham Project lead, Workshop Community hospital services review 11/05/2015 St Andrew’s Patients 7 Communications manager Church, Cobham Members of the public

Workshop 2 - Dorking Project lead, Workshop Community hospital services review 12/05/2015 United Reform Patients 8 Communications lead Church, Dorking Members of the public

Workshop 2 – Leatherhead Project lead, Workshop Community hospital services review 13/05/2015 Leatherhead Patients 15 Communications manager Hospital Members of the public

Transform Leatherhead Team Project lead Meeting with local Community hospital services review 13/05/2015 Cedar Court, CCG Leatherhead local 3 Meeting councillors (Paul Brook, Jack and the Transform teams future councillors Straw, Nick Gray) plans for /Leatherhead Workshop 2 – Epsom Project lead, Workshop Community hospital services review 14/05/2015 St Martin of Tours Patients 9 Communications manager Church, Epsom Members of the public

Friends of Thames Ditton Project lead Public meeting Community hospital services review 19/05/2015 Embercourt, Patients 15 Hospital Thames Ditton Members of the public

BBC Surrey media coverage Project lead Media Community hospital services review 21/05/2015 N/A Patients N/a – Surrey-wide public Members of the public coverage

Staff drop-in session 3 – Molesey Project lead Drop-in session Update on review process and Q&As 1/06/2015 Molesey Provider staff on site Not counted with staff Community (mainly CSH Surrey) Hospital Staff drop-in session 3 – Project lead Drop-in session Update on review process and Q&As 2/06/2015 Leatherhead Provider staff on site Not counted Leatherhead with staff Community (including CSH Surrey, Hospital ESHT and Virgin Care) Staff drop-in session 3 – Dorking Project lead Drop-in session Update on review process and Q&As 3/06/2015 Dorking Community Provider staff on site Not counted with staff Hospital (including CSH Surrey and Dorking Healthcare) Team Brief update Director of Staff briefing Update on review and signposting 3/06/2015 Cedar Court and Staff based at Cedar Court Emailed to all CCG and Commissioning and for staff to patients/public Email follow-up – CCG and SE CSU CSU staff (approx. 191) Strategy, Project lead, Communications lead Staff drop-in session 3 – NEECH Project lead Drop-in session Update on review process and Q&As 4/06/2015 NEECH Provider staff on site Not counted with staff (mainly CSH Surrey)

Workshop 3 - East Elmbridge Project lead, Workshop How services are provided and best 8/06/2015 King George’s Hall, Patients 11 Communications manager practice in community care Esher Members of the public

Workshop 3 – Dorking Project lead, Workshop How services are provided and best 9/06/2015 Dorking United Patients 3 Communications manager practice in community care Reformed Church Members of the public

February – September 2015

Event/Engagement activity CCG Representative Type Subject Date Location Stakeholders Workshop 3 – Leatherhead Project lead, Workshop How services are provided and best 10/06/2015 Leatherhead Patients 29 Communications lead practice in community care Hospital Members of the public

Workshop 3 - Epsom Project lead, Workshop How services are provided and best 11/06/2015 St Joseph's Church, Patients 6 Communications manager practice in community care Epsom Members of the public

Additional staff team meetings: Project lead Meetings with service Discussions over the review specific 17/06/2015 Leatherhead Virgin Care and ESHT staff 6 Sexual Health Service (Virgin providers to these staff groups, to ensure full Community Care) and Colposcopy Service engagement Hospital (ESHT) at Leatherhead Emberbrook site visit Project lead Site visit and meeting To look at Emberbrook site and 19/06/2015 Emberbrook Local councillors/Save Our 2 plus providers on site discuss past and present services Community Centre Surrey Community and local population needs for Health Hospitals and providers East Elmbridge facing local Project lead Meeting To discuss East Elmbridge needs and 22/06/2015 Off site Local and county 2 meeting Molesey and Emberbrook sites. To councillors, including give assurance over CHSR process HOSC member for this population. Your Local Guardian – media Project lead, Programme Media coverage Findings to date and signposting to 5/06/2015 Online and East Patients and members of Local coverage coverage Board Clinical Chair engagement Elmbridge print the public

Surrey Independent Living Day shared amongst Fair – SILC support Stand for CCG – speaking to 25/06/2015 Epsom Racecourse Interested public Over 1,000 at event. Council (SILC) Fair communications and individuals with disabilities. individuals about local concerns and attendees Direct engagement on engagement team gaining feedback on the review review = 3 process as well as individual issues. Direct engagement total = 27 Staff Drop-in session 4 – Project lead Drop in session Update on review process and Q&As 6/07/2015 Molesey hospital All staff based at Molesey Not counted Molesey with staff (mainly CSH Surrey)

Staff Drop-in session 4 – Project lead Drop in session Update on review process and Q&As 7/07/2015 Leatherhead All staff based at Not counted Leatherhead with staff Hospital Leatherhead, including CSH Surrey, Virgin Care and ESHT Staff Drop-in session 4 – Dorking Project lead Drop in session Update on review process and Q&As 8/07/2015 Dorking hospital All staff based at Dorking Not counted with staff Hospital (mainly CSH Surrey) Staff Drop-in session 4 - NEECH Project lead Drop in session Update on review process and Q&As 9/07/2015 NEECH All staff based at NEECH Not counted with staff (mainly CSH Surrey)

Workshop 4 – Esher Project lead Workshop Community hospital services review 13/07/2015 Imber Court, Esher Patients 10 Members of the public

Workshop 4 - Dorking Project lead Workshop Community hospital services review 14/07/2015 United Reform Patients 6 Church, Dorking Members of the public

Workshop 4 - Leatherhead Project lead Workshop Community hospital services review 15/07/2015 Leatherhead Patients 20 Hospital Members of the public

February – September 2015

Event/Engagement activity CCG Representative Type Subject Date Location Stakeholders Workshop 4 - Epsom Project lead Workshop Community hospital services review 16/07/2015 St Martin of Tours Patients 5 Church, Epsom Members of the public

Healthwatch update Director of Commissioning Meeting Two-way overview and update of 22/07/2015 Cedar Court, Healthwatch Surrey (x2) 2 and Strategy, on-going projects and engagement Leatherhead Communications lead, work, including review Head of Quality PPG Chairs and Representatives Communications lead and Meeting Two-way overview and update of 27/07/2015 Cedar Court, PPG Chairs and 15 meeting communications manager on-going projects and engagement Leatherhead representatives, Practice work, including review managers Extraordinary PAG meeting Project lead Meeting Discussion over the draft report and 10/08/2015 Cedar Court, Patient representatives 2 feedback on emerging options, Leatherhead who sit on service evidence, readability, presentation, redesign group etc. Informal Well-being and Health Director of Meeting Informal discussion to update on the 11/08/2015 Cedar Court, Well-being and Health 4 Scrutiny Board update Commissioning and development of the review and final Leatherhead Scrutiny Board members; Strategy, Project lead, emerging options, including role of Chair, Secretary and 2 x Communications manager the programme board and councillors engagement activities. Discussion of information required for formal meeting on 16 September 2015. Extraordinary PAG meeting Project lead, Meeting Discussion over the draft report and 17/08/2015 Cedar Court, Patient representative 1 Communications manager feedback on emerging options, Leatherhead who sits on service design evidence, readability, presentation, group etc. Provider Staff Meetings (x4) Project lead 4x staff sessions held within Organised with CSH Surrey leading, 19/8/2015 Community Staff on all sites, inc. CSH Not counted each community hospital however all other provider staff hospital sites: Surrey, ESHT, and Virgin site invited. Recommendations and Molesey, Healthcare emerging options from the draft Leatherhead, paper (going live the next day) Dorking and NEECH presented and a chance for questions and answers to employers and CCG. Leatherhead League of Friends Director of Meeting Discussion over the publication of 21/08/2015 Leatherhead Chair and Secretary of 4 Commissioning and the draft outcome report, inc. hospital Leatherhead Lofs, CSH Strategy, Project lead, inpatient and outpatient services Surrey staff members Communications manager and the future acquisition of a new x-ray at Leatherhead, which the LoF have funds to procure. Friends of Dorking Hospital Project lead, Meeting Discussion over the publication of 24/08/2015 Dorking hospital Members of the Friends 4 Communications lead the draft outcome report, inc. of Dorking Hospital, CSH inpatient and outpatient services Surrey ward manager Molesey League of Friends Director of Meeting Discussion over the publication of 26/08/2015 Molesey hospital Members of Molesey 6 Commissioning and the draft outcome report, inc. Hospital League of Strategy, Project lead, inpatient and outpatient services. Friends, CSH Surrey ward Communications manager manager Workshop 5 - Cobham Project lead, Workshop Draft outcome report feedback and 01/08/2015 St Andrew’s Patents, Members of the 7 Communications manager next steps Church, Cobham public and interested stakeholders

February – September 2015

Event/Engagement activity CCG Representative Type Subject Date Location Stakeholders Workshop 5 - Leatherhead Project lead, Workshop Draft outcome report feedback and 02/08/2015 Leatherhead Patents, Members of the 21 Communications lead, next steps Institute, public and interested Communications manager Leatherhead stakeholders Workshop 5 – Dorking Project lead, Workshop Draft outcome report feedback and 02/08/2015 United Reformed Patents, Members of the TBC Communications lead next steps Church, Dorking public and interested stakeholders Workshop 5 – Epsom Director of Workshop Draft outcome report feedback and 03/08/2015 St Joseph’s Church, Patents, Members of the 8 Commissioning and next steps Cobham public and interested Strategy, Project lead, stakeholders Communications manager, Engagement manager Staff Session – Dorking Project lead Two-way session FAQs with staff 07/09/2015 Staff room, Dorking Provider staff at all sites, Not counted hospital organised by CSH Surrey

Staff Session – Molesey Project lead Two-way session FAQs with staff 08/09/2015 Meeting room, Provider staff at all sites, Not counted Molesey hospital organised by CSH Surrey

Staff Session – Leatherhead Project lead Two-way session FAQs with staff 10/09/2015 Day room, Provider staff at all sites, Not counted Leatherhead organised by CSH Surrey hospital Staff Session – NEECH Project lead Two-way session FAQs with staff 11/09/2015 Seminar room, Provider staff at all sites, Not counted NEECH organised by CSH Surrey

Staff walk around TBC Site visit Organised visit for staff who wish to TBC Cobham Hospital CSH Surrey staff TBC visit Cobham hospital

Formal Wellbeing and Health CCG Clinical Chair, Public Board meeting Presentation of review process and 16/09/2015 Surrey County Wellbeing and Health Not counted Scrutiny Board Director of draft outcome report. Discussion Council offices, Scrutiny Board and public Commissioning and and scrutiny over process, inc. Kingston attendees Strategy, and engagement Communications lead

CCG Governing Body CCG Governing Body and Public Governing Body Presentation of final outcome 25/09/2015 King George’s Hall, CCG Governing Body and TBC appropriate meeting report, inc. scrutiny and Esher public/stakeholder representatives of the engagement. Next steps attendees review, including communications team

In addition, the following regular items:

 Bi-weekly Programme Board – GP Chair, CCG Programme Leads, Communications, Estates, Providers and Health and Scrutiny Committee Representation  Monthly Service Design Groups – Programme Lead, Communications, Providers and 3 x Expert Patient Representatives  Regular provider meetings – Programme Lead and relevant representatives, with others invited as required  Team brief – bi-weekly meeting and email, providing updates as required – CCG/CSU staff based at Cedar Court  Start the week – Weekly GP update as required

February – September 2015