+ €D IN BVRG H+ THE CITY OF COUNCIL

Council response to Lothian NHS consultation: Improving Care, Investing in Change 2004

City of Edinburgh Council

11 November 2004

1 Purpose of report 1.I This report seeks the approval of the Council to the attached response to the Lothian NHS (LNHS) consultation document, "Improving Care, investing in Change 2004".

2 Summary

2.1 In August 2004 LNHS distributed a public consultation document on major changes to local health services in three areas: acute services, services to older people and mental health services. The document outlines drivers for change, results of prior consultation and options for addressing the issues. It recommends a significant re-design of all three services to meet future need. The consultation deadline has recently been extended from 5 November to 19 November 2004.

2.2 Responses have been received from five Council departments, from members of the public and from some community councils. A view has also come from the Community Services Scrutiny Panel, which considered this item at its meetings in September and October 2004. The resultant draft response on behalf of the Council is attached as Appendix 1.

3 Main Report

3.1 The consultation document sent out by LNHS in August 2004 outlines far- reaching changes to three major health services in Lothian: acute services, services to older people and mental health services. It is based on a two-year review of these services and seeks to address major drivers, including the following (see pp 8-9 of document):

0 changes to employment law which require the implementation of the European Working Time Directive restricting staff working hours; the national agreement on New Deal for junior doctors which reduces their working hours; a new contracts for consultants and GPs with improved terms and conditions to help attract and keep doctors in NHS;

new Scottish Executive targets on reducing waiting times;

the need to achieve financial balance;

new legislation e.g. Mental Health (Care and Treatment) () Act 2003 which ensures flexible and responsive services to meet the needs of people with mental health problems;

a review of current buildings and facilities in terms of "fitness for purpose";

new Out of Hours provision;

changes in the population, including an increasing number of older people; a the need to provide services more locally, and

the need to modernise health care to match changes in available treatments and expectations.

The review involved consultation with staff of NHS, the Council, other partners, patients and other stakeholders. A series of public meetings is also underway. LNHS gives three options for levels of change for all three services: minimal change, service re-design and substantial change. The second level, Option 2, is the preferred option for all three services. The report makes clear that some change is inevitable, with steps already being taken in some areas of service e.g. the removal of emergency and major elective services from general surgery and orthopaedic services at St John's Hospital, Livingston.

Council Departmental responses

Responses have been received from five departments: Social Work, Finance, Housing, City Development and Corporate Services. Positive comments include the following:

a welcome of the LNHS Board's commitment to improving health care services;

a welcome of the intention to provide services more locally to reduce dependence on hospitals. This is seen to make services more accessible and reduce travel for patients and visitors;

recognition of the imperative to address changes to staff contracts and working hours and the need to balance the LNHS budget; recognition that the shift of some services from St John's to the (WGH) and Royal Infirmary of Edinburgh (RIE) will benefit residents in some areas of Edinburgh, as the shift of other services to St John's will benefit residents living in other areas.

3.4 However, significant concerns raised include the following:

e the risk of focussing services on fewer sites with loss of flexibility and less provision for unplanned emergencies; e budget implications of providing more local services, especially the cost of the double-running of services during the move from hospital to community based provision; e the identified saving of f 1.5 m from older people's services and the impact this may have on services; e the net loss of 41 beds for older people's services that will result from the proposals for closing the Royal Victoria Hospital, which may impinge on joint plans for reducing delayed discharge; e the need for any shift of medical facilities to be the subject of an accessibility audit for affected communities and discussion with transport providers before any decision is taken. If network changes cannot be provided commercially, services may have to be subsidised, which would lead to increased transport costs for the LNHS; e insufficient reference to work with partners (and local authorities in particular), in many aspects of service planning and provision; e the need for LNHS to work more closely with the Older People's Equality Forum, the Council, the voluntary and other providers to ensure the effective engagement of older people in contributing to the development of locally based services; e the complexity of the planning issues raised by development of the sites at the Royal Edinburgh and Astley Ainslie Hospitals such as in the transport and conservation areas. A master plan is required for the Royal Edinburgh Site before planning applications for new development can be considered.

Views of the Community Services Scrutiny Panel

3.5 The Community Services Scrutiny Panel considered the document at its September and October 2004 meetings, taking oral evidence from LNHS and a number of service providers. The Panel made a series of recommendations, which are attached as Part 3 of Appendix 1. It is proposed that these be included in this way as an integral part of the Council's response.

3.6 At the October meeting the representative of the Local Medical Committee expressed the hope that the provision of new local services would precede the loss of hospital-based services.

3.7 In other evidence given to the Panel, the Lothian Health Council representatives voiced a number of concerns regarding the options in the consultation. These included transport links, notably to St John's; community provision for older people; a lack of information about timescales; finance; the shape of community services, and staff recruitment. It also indicated that it was seeking an extension to the consultation period.

3.8 In addition, the Royal College of Nurses (RCN) had concerns about whether training measures would be put in place, especially for specialist nurses; the failure to recognise chronic recruitment and selection difficulties; and the lengthening of journey times for patients and staff, especially relocated staff. The UNISON representative accepted the need for change, but expressed a wish for improved long-term planning in future and was keen to ensure that all possibilities, not just Option 3, were assessed. They endorsed the RCN's concerns regarding workforce-planning issues.

Executive of the Council, 19 October 2004

3.9 The Executive of the Council received a presentation from LNHS on the consultation document at its meeting of 19 October 2004. There followed a question and answer session during which the following points were raised and responded to:

0 proposals for rehabilitation provision 0 re-provisioning of mental health services to

0 crisis response services 0 communication issues relating to the consultation process e.g. people for whom English was a second language provision of respite care 0 clarification of dayhight shift changeover times.

Views of local residents and community councils

3.10 Submissions from these sources raise various concerns, and cover LNHS's tendency for short-term decision-making to meet immediate problems and concern at the closure of the Royal Victoria and the consequent loss of geriatric beds.

3.11 Kirkliston Community Council has sent a letter to the Chair expressing strong opposition to the removal of emergency and major/complex surgery and trauma orthopaedics from St John's to the RIE, due to the lengthy and awkward journeys required from its area.

4 Conclusions

4.1 In general, there is an understanding of the significant factors that are driving change and a cautious welcome of the proposals. If health services in Edinburgh can become more local, with older people and those with mental health services offered community-based provision, this is seen as a positive step, as long as these services are put in place before hospital services are reduced. However, reduction of funding in older people's services, the loss of flexibility by reducing sites, the loss of beds at the Royal Victoria and the transfer of facilities to and from St John's are major areas of concern. Transport and accessibility issues need to be addressed in the planning of such changes. 5 Recommendations 5.1 It is recommended that the Council approves the content of Appendix 1 as the response to this consultation for submission to LNHS.

Jim Inch v@irector of Corporate Services

Appendices One

ContactMEmail Margaret Barbier/ 469 38201 [email protected] k

Wards affected All Background - Report to the Executive of the Council, 19 October 2004: NHS Papers Consultation: “Improving Care, Investing in Change 2004” - Community Services Scrutiny Panel: minutes of meeting, 12 October 2004 Appendix 1

City of Edinburgh Council

Response to Lothian NHS: “Improving Care, Investing in Change 2004”

1.I The City of Edinburgh Council welcomes the opportunity to comment on this far- reaching document and makes the following positive comments:

a welcome of the LNHS Board’s commitment to improving health care services;

a welcome of the intention to provide services more locally to reduce dependence on hospitals. This will make services more accessible and reduce travel for patients and visitors;

a welcome of the improvement in staff terms and conditions and of the reduction in working hours, especially for junior doctors;

recognition of the importance of balancing the LNHS budget;

recognition that the shift of some services from St John’s to the Western General Hospital (WGH) and Royal Infirmary of Edinburgh (RIE) will benefit residents in some areas of Edinburgh, as the shift of other services to St John’s will benefit residents living in other areas.

1.2 The Council also wishes to highlight particular issues.

1.3 Increase in Community based services The commitment to treat as many people as possible locally to reduce dependence on hospitals is welcomed. However, any move to reduce hospital services or capacity most follow the funding. Proven operation performance of the additional / substitute community based services will be needed before the previous service is discontinued. This will require the double running of services with consequential budget implications.

1.4 Drivers for change To a large extent the proposals are being driven by changes in staff conditions, employment law, Scottish Executive targets, etc rather than achieving the “best” health options for Lothian’s population. The position is starkly put in relation to general surgery and orthopaedic services at St John’s (p17)

1.5 Service redesign - Sites The concentration of services on fewer sites will, presumably, allow the sale of existing land / properties to fund new developments, of itself a practical approach. However, the concentration of services on fewer sites and using those sites and services at a higher capacity, reduces the flexibility and overall capacity of the health system to deal with contingencies, for example, emergency incidents, or planned refurbishment, or an incident on the site itself. It will be important to test the proposals against contingency planning assumptions in the NHS and with partner agencies. For example, in the recent past the care of older people in a Council-run home for elderly people, when flooded, was enabled through the use of a ward at the Eastern General Hospital. Clearly, it is nor practicable to retain a site simply for contingency, however the health care system has to plan for, and retain capacity for, unplanned events.

Services to Older People

1.6 Funding The document identifies potential savings of f7.5m: f6m from the changes in BACiL and f 1.5m from older people’s services (page 13). It is widely know that Lothian NHS, like many NHS Boards in Scotland, is experiencing significant budget pressures. While it is important for any public body to balance its budget, it is important that every opportunity is taken to modernise service delivery in the interests of patients. It would be good if some of the savings were re-invested in services for older people.

1.7 Replacing the Royal Victoria Hospital On page 27 LNHS notes that ‘I by improving the way the health care system works”, this will make it possible to “set aside” 30 beds used for delayed discharge. The consultation is not clear on the timing and phasing of the proposed reduction, and whether these are included in, or are additional to, the reduction of 39 in the closure of the RVH. It is critical that any changes in LNHS’s continuing care and delayed discharge capacity dovetails with joint capacity plan for older people and that change is supported by additional resource transfer. The Council is concerned at the possible impact of a reduction of the overall number of beds. Delayed Discharge is a continuing pressure on both Council and NHS Lothian resources and this could prove to be an additional burden.

1.8 Involvement of Older People A presentation of the proposed changes was given to the Strategic Development Group for Older People and the document has also been considered by some members of the Older People’s Equality Forum at the development stage. The Council is delighted to see that older people and particularly members of the Older People’s Equality Forum were involved in the initial consultation. It would be imperative to ensure the continued involvement of older people and particularly that of the Older People’s Equality Forum in future work. Perhaps NHS Lothian could invest in building the capacity of the Forum to ensure its continued engagement in the implementation of the finally agreed changes.

1.9 While these changes may bring about considerable anxiety for some older people, perhaps NHS Lothian and its partners will take this opportunity to allay these anxieties by making a commitment to encourage, facilitate and share best practice examples of how public services are to be organised around older people’s own aspirations and needs. This process will require NHS Lothian working with the Older People’s Equality Forum, the Council, the voluntary and commercial sectors to ensure the effective engagement of older people in using their skills, experience and capacity in contributing to the development of locally based services. Mental health services

1.10 With reference to the mental health strategy, we welcome the emphasis on increasing local community provision. In particular the Council wishes to highlight the need for community-based crisis facilities for mental health.

Partnership

1.11 It is disappointing that the document makes so little mention of local authorities in general, the role they play in the planning and delivery of services, in health improvement etc. The plan makes little mention of the fact that the local Mental Health and Wellbeing strategy has been developed as a joint strategy with the Council. No mention is made of the importance of developing even more positive working partnerships in order to deliver the proposed changes effectively. Despite patient preference for locally based services and a strategic commitment to providing services in the community, there is little explicit recognition of the value of partnership working with local authorities to achieve this.

The Council invites LNHS to take up the offer of increased joint work with the Housing Department to invest in community solutions. Increased joint work with the community alarm service and housing support services would help people to stay in their own homes and also contribute to prevention of admission of people to hospital. The Department could also contribute significantly by the increase of affordable and accessible homes of high standard.

The Council also notes the potential for shared site facilities with LNHS in local areas, for example using schools, GP surgeries, libraries etc.

The Council notes the statement on page 23 on Lothian NHS’s involvement with Public Transport, that “lf is an area in which we have a good record.” Given the subsequent mention of the Royal Infirmary of Edinburgh we feel that, for accuracy, the value of partnership needs to be acknowledged. Commercial bus operators, the City of Edinburgh Council and the predecessors of NHS Lothian were also involved in extensive work on the provision of commercial and supported bus services to the new hospital.

Planning Issues

1.12 The consultation paper raises planning issues, in respect of the future use and development implications of each option e.g. the disposal of the Royal Victoria Hospital (RVH), the disposal of some land at Royal Edinburgh Hospital as new development is progressed on this site, and the prospect of new development at Astley Ainslie (AA). Planning briefs were prepared to guide future development of land at the RVH and AA. At Royal Edinburgh Hospital, CEC was promised a master plan, to be prepared by Lothian Health, to guide new development on the site. The Council stresses that this will be required before planning applications for new development on the site can be considered. Complex planning issues are raised by development of the sites at REH and AA, for example in respect of traffic and conservation issues. In addition there appears to be little space at the Western General to accommodate sianificant new develoDment. 2.0 Travel and Transport Issues

2.1 Congestion The problems of congestion in Edinburgh are expected to worsen over time, affecting supplies, staff, patients, friends and visitors travelling to medical facilities located in Edinburgh. The introduction of the proposed congestion-charging scheme in the city will therefore benefit people who need to travel to these locations by improving public transport links and reducing congestion for other road users.

2.2 The revenue stream from the congestion charging will also be used to improve the Community and Accessible Transport Services available in Edinburgh. A draft Community and Accessible Transport Strategy for Edinburgh is under preparation, involving representatives from NHS Lothian and the Scottish Ambulance Service. Amongst the beneficiaries of this funding will be those who need, to use these services to reach medical facilities. This Strategy will define how the funding from congestion charging will be spent.

2.3 The general concept (p5) of shifting the balance of care from hospitals to improved services in the community is welcomed. The aim to locate facilities as close as possible to people’s homes is likely to increase the attractiveness of sustainable modes, such as walking and cycling, as an alternative to car use. A decentralisation of facilities also assists in discouraging longer distance travel. The Council is pleased to see the document recognise the importance of reducing the amount of travel for patients, helpers and visitors. However, it is critical that the accessibility of locations is taken into account in any relocation decision. Locations that are not on major bus routes should be avoided.

2.4 Acute Hospital Services

In general, the shift of medical services from St John’s Hospital to the Royal Infirmary of Edinburgh and the Western General Hospital should benefit Edinburgh residents, given the greater level of public transport access that Edinburgh residents have to these hospitals. We note that this change is most marked in Option 3 (p21), with St John’s Hospital catchment area being restricted to cover only West Lothian.

2.5 However, access to St John’s Hospital by public transport remains a problem for many Edinburgh residents, for example people from Currie, Balerno and Queensferry. Other negative aspects include the cost of transport and the additional strain that the arrangements may place on people already experiencing health problems, particularly older people, those with mobility problems and their carers. Conversely, it is anticipated that access to the Western General Hospital and the Royal Infirmary of Edinburgh from West Lothian will become an issue, as travel to these hospitals will always require a change of bus for West Lothian residents.

2.6 The Council notes that the consultation raises the issue of how readily patients and visitors can travel to facilities. It is disconcerted that, having raised this concern, the consultation suggests further centralisation of health facilities. For example Appendix 2 does not mention Edenhall Hospital in the future provision of services. This implies closure with patients and visitors having to travel longer distances to reach equivalent facilities, presumably in Edinburgh. In the Mental Health section the Council notes the proposal to concentrate in-patient care on two sites, implying that treatment at Herdmanflat, East Lothian and Rosslynlee, Midlothian will be closed and greater travel distances will be generated for patients and visitors.

Accessibility audit

2.7 The Council recommends that any major shift of medical facilities should be the subject of an accessibility audit. If transport links do not exist to facilitate journeys to a proposed new location, LNHS should undertake consultation with the transport providers on possible network changes before making any decision to relocate. It may be that the network changes required cannot be provided commercially and this should be considered in any option appraisal. The whole cost to the community, including on-going transport costs, of relocating medical facilities needs to be considered. The NHS Lothian budget for relocation of medical facilities should therefore include provision for any additional public transport costs.

2.8 The document asks for feedback on how the public transport companies and the Local Authorities “shoukd’ respond to the proposed changes. Under the Transport Act 1985, bus companies are free to operate those services that they feel are commercially viable. Local Authorities have a power, but not a legal duty, to provide socially necessary bus services. They also have limited budgets for supporting local bus services to work places, shopping and schools as well as medical facilities. The Council would therefore urge that, in planning the location of medical facilities, they be sited as near as possible to established public transport links. This would offer patients and visitors the opportunity to use sustainable transport for longer journeys, as well as offering an alternative to those who are concerned about driving private car due to their condition. It should also be remembered that around 40% of households in Edinburgh do not have access to a private car, or are households with limited access to a car. This would also enhance the viability of commercial public transport services.

2.9 While the focus on local centres to deliver an increasing range of services is generally welcome in transport terms, it is important that these centres are well accessed by public transport. If, for instance, the Astley Ainslie site was to be used to deliver more services for communities in South Edinburgh, this would not be accessible by bus for most people in South Edinburgh. The Council has had recent experience of having to secure a financially bus supported service to provide a link to the Whinpark Medical Centre in West Edinburgh. This facility was established in a location not well served by local buses. Again, it is imperative that an accessibility audit is carried out as part of the relocation process, and that this audit concentrates on the communities that will need to access the relocated facilities. 2.10 Services for Older People We welcome the shift of medical services from the Royal Victoria Hospital to the Western General Hospital, as the latter hospital is much more accessible by public transport. We would urge, though, that as part of the capital works programme associated with this relocation, Lothian Health improve facilities for buses at the Western General Hospital, in order to attract more services off the main road into the site.

3.0 Comments from the Council’s Community Services Scrutiny Panel

3.1 The Scrutiny Panel:

stresses the need for LNHS to actively engage with the local authority and bus companies to seek common approaches to public transport issues. In this context, notes the document’s general failure to highlight existing joint working arrangements with the local authority;

highlights the need for appropriate community health care services to be in place ahead of major development;

expresses concern about the effectiveness of the consultation (e.g. Edinburgh public meetings) and echoes the Health Council’s call for an extension to the consu Ita t ion period ;

highlights the need for adequate workforce planning, including appropriate staff training (e.g. specialist nurses), recruitment and selection, and recognition of the impact of Agenda for Change;

notes the absence of detail in some areas of the paper e.g.:- Provision of community services Timescales for introduction Finance Patient and staff travel

stresses that there should be no presumption about the appropriateness of Option 3 in the longer term, and that all available options for Acute Services should be examined, in the context of the National Framework;

expresses concerns about the impact of the reduction of the local authority Supporting People budget.