Services for Older Adults in Lochaber

Mid Highland Community Health Partnership

DRAFT

Service Plan Proposal

5th DRAFT, 25th January, 2006

Contents

1. Introduction and Background 2. National Context 3. The Need for Change 4. Process to Date 5. Service Plan for the Future 6. Skills for Health 7. Well being and Health Improvement 8. Staff Governance 9. Resources 10.Next Steps

Appendices

1. Rapid Re design methodology 2. Condition of Glencoe Hospital 3. Operational Policy for Intermediate Care 4. Draft Role, Remit and Membership of Implementation Group 5. Draft Action Plan 6. Bibliography

1. Introduction and Background

This paper will describe proposals for changes in service provision for older people in Lochaber, that are in keeping with the „Delivering for Health‟ principles of more emphasis on care in the community, support for self care, anticipatory, proactive care and avoidance of hospital admissions. The building of a modernised community infrastructure will facilitate the shift in the balance of care away from hospital, into local communities and in people‟s own homes. Evidence from elsewhere has demonstrated that through timely interventions and support in the community, hospital admissions can be avoided. This shift has been part of the agenda for NHS and Partner agencies for some years and has been reinvigorated through the work of Professor Kerr, Delivering for Health and the 21st Century Social Work Review. There has been a gradual move to disinvest in NHS continuing care beds and, in Lochaber, there is a need to do so in Glencoe Hospital so that the resource can be re invested in a range of community based services which will provide for many more people than can be accommodated in a hospital building. Very few people now require to be in hospital long term as their needs can be met in other, more homely care settings as residential and nursing homes have progressed and developed the services that they offer. The proposals rely heavily on partnership working with the Local Authority, Voluntary and Independent Sectors and on building community capacity and resilience in order to meet the care demands of the future.

2. National context – Delivering for Health

In November 2005 the Scottish Executive Health Department (SEHD) published “Delivering for Health”, its response to the Kerr report which had been released earlier in the year. “Our vision for the NHS is to reapply its founding principles with vigour to meet the needs of the people of Scotland. Delivering for Health means a fundamental shift in how we work, tackling the causes of ill-health and providing care which is quicker, more personal and closer to home.”

This theme runs throughout the document and is a cornerstone for all Health Boards to review the ways in which they deliver services to their local populations.

The key principles are:- Improving health and well being As local as possible, as specialised as necessary Predominantly community rather than hospital focused Better access to local diagnostic care and treatment Whole systems, integrated care through networks, and use of technology Supported self care Care at home where possible Ambulatory care, day case admissions Team based Enhanced roles of all team members

Existing model Evolving model of care

. Geared towards acute . Geared towards long-term conditions conditions

. Hospital centred . Embedded in communities

. Doctor dependant . Team based

. Episodic care . Continuous care

. Disjointed care . Integrated care

. Reactive care . Preventative care

. Patient as passive recipient . Patient as partner

. Self care infrequent . Self care encouraged and facilitated

. Carers undervalued . Carers supported as partners

. Low tech . High tech

Community Health Partnerships have been given specific actions as part of the implementation of „Delivering for Health‟:-

• Easing access to primary care services • Systematic approach to long term conditions • Anticipatory care • Supporting people at home • Avoiding hospital admission • Local diagnosis and treatment • Enabling appropriate discharge and rehabilitation • Improving health and tackling inequalities • Improving specific health outcomes

These have been taken into account as part of the Review and Planning for new and improved services in Lochaber. This service change proposal demonstrates the implementation of „Delivering for Health‟ in the Lochaber area through shifting the balance of care from hospital to community, adopting a team based, multi disciplinary and multi agency approach. It acknowledges the need for better management of long term conditions, supports self care and carers. When the community infrastructure is in place, supported by the development of rehabilitation services, there will be a reduction in our reliance of hospital and care beds. The proposal is also in keeping with the Review of Nursing in the Community.

21st Century Social Work Review

The 21st Century Review and Implementation Plan reflect the need for change and for all Partners to work together with communities and individuals to promote well being, self care support, engaging people as active participants and to work in new ways to plan and deliver high quality services.

“Doing more of the same won‟t work. Increasing demand, greater complexity and rising expectations mean that the current situation is not sustainable.”

The Review states that tomorrow‟s solutions will:-

“…Involve professionals, services and agencies from across the public, private and voluntary sectors in a concerted and joined-up effort, building new capacity in individuals, families and communities and focusing on preventing problems before they damage people‟s life chances irreparably.”

This is in keeping with the proposals contained in this document.

3. The Need for Change

Building and Health Service Fit for the Future – A National Framework for Service Change in the NHS in Scotland, (Kerr Report) clearly sets out the challenges facing the NHS in Scotland, and, in particular highlights the likely demands of an ageing population unless new and better forms of delivering health care are put in place. The report points out that many of the care needs of frail older people are social rather than medical and that a lack of integrated and preventive care can lead to crises that result in unnecessary hospital admissions. It calls for

“ A proactive and supportive approach to the care of frailer older people, based on „whole system‟ re design of health and social care…”

There is an overwhelming need to establish multi disciplinary, multi agency teams with the ability to respond within 24 hours and provide coordinated packages of care and rehabilitation so that older people can remain in their own homes. The population of Lochaber is ageing, and there is a projected significant increase in those over the age of 65 in the next 20 years (see table below). This is compounded by a lower birth rate. The consequences of this are that there will be more people in the community who have complex needs and who will require care, but fewer younger carers, both formal and informal. There will be fewer tax payers and therefore reduced ability to invest in health services at the level currently enjoyed. Lochaber health and social care community services are already stretched and this, inevitably, leads to unnecessary hospital and care home admissions. We know that it is better and safer in many instances for people to be cared for in their own homes, and, indeed, that this is also their preferred site of care. Unless there is a significant change in the way we plan and deliver services, we will be ill prepared and unable to cope with future needs. Lochaber Locality is already well funded, in Highland terms, in that it uses more than its fair share of both Health and Local Authority resource. There is therefore little opportunity to attract new investment and re design is essential. The hospital admission rates and length of stay in Lochaber, standardised for the population, are already higher than the Highland average. There is an overwhelming need to disinvest in buildings and beds and to re invest in services and people. There are opportunities to do this. In the medium term, planning for the future Belford Hospital as a Rural General Hospital, integrated with extended primary care services, and providing an expanding range of specialist services, will be a crucial component of our service development plan. In the shorter term, there is potential to develop Belhaven Unit as a specialised assessment and rehabilitation service for the whole of Lochaber. The physical unsuitability of Glencoe Hospital, its limited access by the Lochaber population, and its high running costs present an immediate opportunity to use the associated resources more effectively and efficiently. This would ensure sustainable community based care in Nether Lochaber but also allow similar services to be extended

to the wider Lochaber population. It would also enable the further development of Belhaven.

Projected* population changes Lochaber 2004-2024

Population % Change

2004 2024 䦋 0-15yrs 3,585 ㌌2,824 -21 ㏒ 16-64yrs 11,999 10,385 -14 䦋 65+yrs 3,205 좈5,264 +64 䦋 75+yrs 1,317 琰2,604 +98 All ages 18,759 茞18,473 -2 䦋䦋 Ü

4. Process to Date

The Lochaber Local Health Partnership, part of the Mid Highland Community Health Partnership, has led a review of services for older people in Lochaber, in partnership with other public, and voluntary sector agencies. The most recent phase of the review, which incorporated extensive public engagement, has been progressing since June 2006. There has been significant community involvement through meetings, workshops, and face to face contact with individuals. There were also focus groups and fireside chats with older people themselves, culminating in a two day whole system planning event that had a wide invitation list and was attended by approximately sixty five people.

Demographic, epidemiological and financial information is contained in the appendices.

The outputs from all of the above were encapsulated in a Consultation Document that has been widely circulated and followed up with community meetings. The Lochaber Area Committee also discussed the document at the November meeting and supported both the process and the proposals.

The key proposals in the document were:-

To start planning for the closure of Glencoe Hospital in order to allow reinvestment of the staff and other resources in new, alternative services. To further develop Belhaven as a „Hub‟ for community based rehabilitation and augmented care at home services. To improve systems for preparing older people for discharge from hospital back to home.

The Mid Highland CHP Committee and Management Team met to discuss the findings and feedback form the Review on 16th November and agreed to propose the closure of Glencoe Hospital after clinically sound and appropriate alternative care could be arranged for the existing patients. It was also agreed that a range of community services should be put in place, together with supported development of Belhaven ward as a rehabilitation „hub‟ and primary care led unit.

The NHS Highland Board, at its meeting on 5th December, unanimously agreed to support the recommendations. This paper will describe the whole system, rapid re design methodology for the consultation process and outline proposals for the range of alternative services including:-

Anticipatory care Support for self care Better management of long term conditions Prevention of hospital admission Early supported discharge Augmented and Intermediate Care at Home Community rehabilitation Hospital at Home Belhaven Ward as Resource Hub for Rehabilitation Enhanced planning for discharge and transfer

Whole System Rapid Re Design

The methodology used to progress this work was Rapid Redesign, whole systems, which engages key stakeholders for a concerted period of time to explore the current situation and plan together for the future shape of services. It also has a basis is action research, which is an approach designed to learn about systems while simultaneously bringing about change. Rapid Re design requires momentum and commitment to progress quickly. It is essential that ground work such as information gathering and analysis and „taking the temperature‟ of local feeling and willingness to change, is done thoroughly and openly in advance of a concerted period of time working together on the issues.

A more detailed description of this approach is contained in appendix 1.

5. Service Plan for the Future This plan takes into account the national direction of travel and local needs. It encompasses both health and social care elements and the funding released will be used across the traditional agency boundaries to ensure that the service requirements are addressed. It must be stressed that there is already a supporting infrastructure in place in that hospital care fro those assessed as requiring it, can be provided locally in Belford Hospital in Fort William, some 15 miles from Glencoe, where there is Consultant led acute care and also in Belhaven Ward, which is undergoing development and modernisation. Closure of Glencoe Hospital There are currently six patients resident in the hospital, none of whom have been assessed as requiring NHS continuing care, that is, their needs can be met in residential or nursing homes, but they have been in hospital for some considerable time. It is obviously of paramount importance that this is taken into account as part of the planning for future care. The hospital has been operating as a long stay unit with the provision for respite care and short term admissions for acute exacerbations of chronic illness. This latter group of patients would be ideal for hospital at home care, thus preventing hospital admission and loss of independence, or in the proposed developed care home. There are no therapy or rehabilitation services available. Arrangements are being put in place for the current patients to transfer to nursing or residential care homes as appropriate to their needs and taking into account their choices. The hospital will not close until suitable alternative accommodation is found and all patients have moved and settled. Admissions to the hospital have been very limited since March, 2006, due to staffing challenges and the need for staff training. Only pre arranged respite care and occasional emergency respite care admissions have been facilitated. It should be noted that respite care is not normally provided in NHS facilities. Even prior to March 2006 the annual number of admissions were small. As an example there were 29 admissions involving 20 patients in 2005. 21 of these were for “acute / semi-acute care” (based on patients staying in hospital less than 30 days and including respite care) and it is estimated that 2 of these patients received palliative care . The average bed use for all 21 admissions was less than one bed per day. This level of demand could thus be managed with far fewer beds and/or enhanced home care. The 90% of the Lochaber population out with Nether Lochaber account for less than 25% of admissions. This suggests that similar local enhancement of community based services in other parts of Lochaber may be a more appropriate response to their need than the current service. Given the considerable recurrent resource currently tied up in the hospital, there is scope for simultaneously maintaining an adequate service in Nether Lochaber, enhancing community services in other areas of Lochaber, and developing

the role of the Belhaven Unit as a specialised assesssment / rehabilitation service for the older population. Staff members have had the opportunity to discuss their future careers on a one to one basis and have been offered experience of other care environments. Training and developmental opportunities will be facilitated and it is envisaged that all will be offered alternative employment in line with NHS Highland Organisational Change Policy. A paper on the current condition of the Glencoe Hospital building is contained in appendix 2.

Abbeyfield (Ballachulish)

The people of Nether Lochaber made it very clear during the pre consultation and consultation periods, that they wanted to retain care services in the area. In addition to building the community service infrastructure, we have also been negotiating with Abbeyfield (Ballachulish) Society, with a view to developing and enhancing the range of services provided there. At present, Abbeyfield, is an 18 bedded residential care home. The building is new, modern, purpose built and has potential for expansion to provide additional services within the existing building. The Trustees have agreed in principle, subject to detailed contract arrangements, to add a further 6 beds and to become dual registered, that is, to provide nursing as well as residential care. In effect, this will mean that there will be 24 beds available for the spectrum of care required and that current residential care clients will be able to remain in Abbeyfield should their needs change. The increased capacity will allow the transfer of patients form Glencoe, and, in future admission from the community. Two of the beds will be used for short term admissions as part of the intermediate care service, palliative, terminal and respite care. The required nursing staff will be seconded, for a two year period initially, from Glencoe and ongoing leadership, support, training and advice will be made available through the Community Health Partnership. Thereafter, nursing staff will be employed directly by Abbeyfield Ballachulish. Day Care and Lunch Club facilities will be expanded and there is potential for lunch clubs else where to have meals catered from the unit. In addition, the community nursing, social work, home care organiser and therapy staff will be based in the building. There will also be a clinical space available to be used by visiting professionals such as Podiatry and Physiotherapy. This will therefore provide a local „resource hub‟ and will bring together key services under one roof.

Working with Other Care Homes There are five other Care Homes in Lochaber, some of which are currently being developed and some are in planning stages for re provisioning. There has been some discussion with all of them to ascertain their vision for the future and to begin to establish a robust health and care network, described as a „virtual campus‟, to ensure that all facilities and resources are used to best effect. The intermediate care service described below will be available to people living in Residential Homes, this preventing disruption to older people who might otherwise have to be admitted to hospital. End of life care will also be supported in these care settings.

Anticipatory Care, Better Management of Long Term Conditions and Support for Self Care A long term condition is broadly defined as one that requires ongoing (medical) care, limits what the person with the condition can do and is likely to last longer than a year. The definition does not relate to any one condition, care group or age category, but includes people with learning disabilities and mental health problems such as dementia. There is a need for us to better understand risk factors and support intervention before these become chronic, leading to illness, reduced quality of life, dependency and hospital admission. Working with our extended primary care teams, which include GPs, Nurses, Allied Healthcare professionals and some specialists, we will seek to identify those older people most at risk and will offer early interventions and support. This may include more regular health checks, support for self monitoring and self care, including the use of technology, group work or appropriate treatment. As the diagram below shows, evidence suggests that the vast majority of patients can be supported to manage their own conditions to improve quality of life and delay deterioration, and we know that we need to get better at offering the necessary support and information. We will also work with Partners to reduce health inequalities and offer health improvement and well being support. Diagram 2, below, demonstrates that 5% of the population accounts for 43% of occupied bed days. By anticipating the risks and early intervention, this can be reduced, thereby saving disruption to the patient and family and also saving on bed usage. It also a fact that 90% of delayed discharges arise from emergency hospital admission of older people. Preventative approaches should help us to reduce this figure.

Diagram 1

Percentage of those admitted as Inpatients by cumulative days spent as Inpatients Scotland. April 2003 to March 2004

100

1% of patients account for 16% of overall inpatient days 90 2% of patients account for 25% of over all inpatient days 3% of patients account for 32% of overall inpatient days 80 4% of patients account for 38% of overall inpatient days

70 5% of inpatients account for 43% of overall inpatient days

50 10% of inpatients account for 59% of overall inpatient days

30 50% of inpatients account for 7% of overall inpatient days Cumulative percentage of Inpatient days Inpatient of Cumulative percentage

0 0 10 20 30 40 50 60 70 80 90 100 Source: SMR01, ISD Scotland Percentage of Inpatients Diagram 2

Self Management

We will offer a range of support and information to patients at lower risk, to take an active role in managing their own condition and improving quality of life. In conjunction with Partnerships for Well being, we will develop and support expert patient programmes to improve patient skills, knowledge and empowerment. We will also work with technology companies to pilot the use of patient held devices to improve monitoring of conditions, to highlight warning symptoms and therefore facilitate early intervention.

Condition Management

We will further develop our multi disciplinary approach to the management of long term conditions through extended primary care team working, closer links to specialists, disease registers, pro active care, networks and the use of shared care protocols and care planning.

Case Management

We will work with all Practices to identify those at highest risk, those with most complex needs and those who are high intensity users of all services, in order to facilitate active management through Case Managers, most likely to be highly skilled Community Nurses. Individual, personalised care plans will be developed to slow the progression of long term conditions, improve quality of life, delay or avoid severe phases of illness and prevent hospital admission.

Intermediate Care at Home

Hospital at home Multi disciplinary Rapid response Community rehabilitation team Shared equipment store

Conditions Appropriate for Intermediate Care

Acute exacerbations of chronic conditions Patients who require medical and/or nursing care beyond the scope of the community teams, which can be provided in their own homes with additional staff and equipment. An example of this might be patient who has a urinary or chest infection, who is feeling very unwell and requires extra care for a few days. Intravenous fluids and antibiotics will be able to be delivered as well as any rehabilitation or therapy input, such a chest physiotherapy or mobility support.

Rehabilitation Admission for rehabilitation necessary to optimise a patient‟s functional abilities. For rehabilitation to be realistic there should be potential for the patient to make and maintain functional improvement. This can happen in the patients own home and there is good evidence to suggest that rehabilitation time is reduced when patients recover in their own environments. It may also be possible for people to visit local clinics or day hospitals, rather than be admitted to hospital if additional equipment or more intensive team approaches are required.

Post-operative and following acute medical admission

Surgical patients and those requiring transfer from the acute services following a medical crisis may be accepted for admission, to allow for early discharge and active rehabilitation at home. The Intermediate Care service will be tailored to the needs of the patient and the programme will gradually reduce as recuperation takes place and other services are put in place as required. The GP providing medical support to the patient must agree the admission to the service.

Palliative Care

This is the care that is delivered when there is no expected cure for a condition, but there is a need to manage and control any symptoms. This period is loosely accepted to be within the last year of life. Support and planning are key elements of this and patients may require different levels of support and treatment at different times. For most people, home is where they want to be at this time. With this service, that will become an option for more people. Our existing primary and community teams already support their patients at home as much as possible, but, they will be able to access the services of a wider range of people including home care, evening and overnight support and flexible respite care.

If care at home becomes difficult, either in the short or longer term, there will be access to beds in care homes as well as in Belhaven and Belford Hospital. Existing services such as Marie Curie, MacMillan Nursing and Hospice support will continue and will be a part of a network of local support. The CHP has appointed a Clinical Lead for Cancer and Palliative Care and there is an agreement with all of our Practices and Primary Care Teams, that they will follow the Gold Standards Framework for Palliative Care. A Facilitator will be appointed to continue education and training required, to continue to support the use of the framework and the development of services.

Terminal care

This is the care and support that is required towards the end of life. Patients needing care and for symptom management have the option of being cared for at home, in preference to being admitted to hospital or hospice. Many people state this as their preferred option and we are building services to allow this to happen for more people. The CHP is supporting the introduction of the Liverpool Care Pathway for End of Life Care in community hospitals and this will be extended, with support and education, to care homes and to the community.

Support and management of long term conditions

As previously mentioned some people who are living with a chronic, long term condition, such as respiratory disease, will sometimes require additiona care and support care. The intermediate care service will be able to care for those for whom multi-disciplinary advice and support will enable them to maximise their self care ability and prevent crisis admissions to in-patient care.

Discharge Planning Plans for discharge will be started as part of the assessment of individual needs at the time of admission and it will be the responsibility of the named professional to co- ordinate. As far as possible a discharge date will be identified as soon as possible after admission and agreed with the patient, multi-disciplinary team and GP. The underlying principle regarding discharges is for early, active, discharge planning, involving the patient, carer, multi-disciplinary team and Social Work services as indicated. Multi-disciplinary assessment must be completed on admission to the Intermediate care service with particular regard to patient‟s home circumstances and situation. Agreement will be reached as to the appropriate discharge needs e.g. onward referral, additional equipment, day hospital Ensure the patients, and with their consent, the relatives or carers, are consulted and informed at every stage of decision making about discharge. Such arrangements should be fully explained to and generally accepted by the patient, and where appropriate, the patient‟s relatives, advocate or carers.

If there is any doubt about the individual‟s capacity to make competent decisions procedures to assess competency should be followed.

Home Care (expand)

The traditional Home Care services in Lochaber have also been reviewed with a view to extending the availability of the service.

Respite Care

Access to respite care is an extremely important part of planning and sustaining community services. The role of family and other Carers, in supporting and maintaining older people in their own homes cannot be underestimated. This must be recognised and their need for regular respite breaks acknowledged. It can be clearly demonstrated that access to appropriate respite, both planned and emergency, enables Carers to care at home for longer. This proposal to invest in home care, intermediate care and to support flexible respite packages, will facilitate access to this facility for a greater number of people across the whole Locality.

Joint Equipment Service

At present, there is no coordinated system for purchase, supply, maintenance and monitoring of equipment. As part of this initiative, a store will be set up jointly by Local Authority and NHS that will include a computerised management system, cleaning and control of infection facilities and dispatch systems. Staffing will include an Administrator and a Driver/Handyman, who will be able to deliver and set up equipment and also fit simple aids such as hand rails, raised toilet seats etc.

Belhaven Unit

The Belhaven ward is currently a step down ward of Belford Hospital, but sited several hundred yards away. It is Consultant led and provides rehabilitation, care of the elderly and recuperative services. It has recently become the focal point for Stroke Care and a Consultant Physician leads that service. A multi disciplinary stroke team is in place as well as a cardiac rehabilitation team and a range of therapy services is available. The unit has the potential to become the Resource Hub for community based intermediate and rehabilitation services and to develop into a primary care led, Consultant supported facility. There is also the potential to develop Day Hospital services. A Development plan is currently being worked on and staff development action plans are in place. One of the key aims will be to reduce hospital stay and increase throughput in order to provide a more responsive needs led service. This will be achievable as part of the whole system plan, with the supporting community infrastructure.

A GP with Special Interest in Rehabilitation will be appointed to work closely with the ward and community teams and the Consultant Physician. This unit also has the potential to function as a Community Hospital as described in the Community Hospital Strategy.

7. Skills for Health

We are working with The Centre for Rural Health, Aberdeen University and Skills for Health on a research project looking at services available, required competencies, gaps, training needs and educational solutions.

8. Well being and Health Improvement

We will continue to work with Partner agencies, including Culture, Leisure and Sport, Lochaber College, UHI and the Voluntary Sector on initiatives to improve health and to encourage and support active citizenship for older adults in Lochaber.

9. Staff Governance

Our greatest resource in this initiative, are our staff. At present there are 28 people, ?? wte, working in Glencoe Hospital. All will be offered suitable alternative employment. There have been several informal staff meetings to explore possible options for the future and these have been supplemented by informal and, more recently, formal one to one opportunities for career counseling and general discussion. A Partnership Group has been established to oversee the process. Staff have also been offered taster sessions and shadowing in other care environments and have been encouraged and facilitated to research alternative models of care delivery.

Possible redeployment opportunities include

Secondment to Abbeyfield (Ballachulish) Community Staff Nurse posts in existing teams Community Staff Nurse posts in Intermediate Care Team Support Workers in Intermediate Care Team Home Carers for Augmented Care at Home Belhaven Rehabilitation Ward Belford Hospital Community Equipment Service

10. Resources (this table is being further developed in the same format as the A&B submission)

The resource to support the proposals will come from closure of Glencoe Hospital. The release of staff as described above, is the biggest reinvestment. However, there are supporting services and investment in Abbeyfield (Ballachulish) and Belhaven that require to be funded.

Finance

Costs & Implementation

NHS Highland in partnership with The Highland Council.

Resource Implications of: Reprovision of Services for Older Adults in Lochaber

Sources Budgets Recurring total Ward Budget Non Recurriing

Resources released from Glencoe Closure 07/08 07/08 £'000 WTE £'000 £'000 Pays: Nursing 20.69 529 Medical Practitioner Pt11 NHS Scotland 78 0.36 23 Total Pays 21.05 552

Non Pays Direct Patient Care Supplies: Drugs dressings 28 continence and Appliances Travel & Subsistance 3 Other hospital supplies 9 Total Non Pays 0.00 40

Facilities Staffing, Healt Light and Power 134

Capital Charges 130

Total Glencoe Sources 21.05 856

Less Health service recurring requirement: Staff protection and excess mileage -50 Continence -6 -56

Net Resource Release 800

Proposed Applications -642 158

Net Resource Release 158 158

Non Recurring B/Down -158

Total 0

Finance

NHS Highland in partnership with The Highland Council.

Resource Implications of: Reprovision of Services for Older Adults in Lochaber

Proposed Applications:

Community Care implementation Plan

Recurring Non Recurring £ £

Abbeyfield 165,000 Secondment of Nurses (4.5wte) Reception & Admin support (.5wte) Rent of Office and Clinical space

Capital Grant 45,000 Temp Use of Vehicle 11,000 Nursing recovery from Abbeyfield -75,000

Community Equipment store 41,000 Driver Handyman (1wte) Admin support (1wte) Rent of Unit Lease Vehicle Shelving 2,000 Power washer 25,000 Equipment 25,000

Belhaven Development 75,000 Nursing costs (2 wte band 5 + 2 wte band A) Capital cost 50,000

Intermediate Care Including, Home care and Rehab team. 274,000 Team co-ordinator (1wte) RGN (1wte) Care assessor (1wte) Home Care Support Workers (5 wte) Physiotherapy (1wte) Speech & Language Therapy (1wte) Occupational Therapy (1wte) Rehab Nurse specialist (1wte)

Premises Development 162,000 New Premises Capital charges costs arising from the Increased CRL released from Sale of Glencoe Asset

Total Cost of Applications 642,000 158,000

11. Next Steps

An Implementation Group has been established to oversee the action plan which is contained in appendix ?? It must however be noted that much of the action plan is dependent on the release of resource from Glencoe Hospital and will therefore not be able to be delivered before final agreement on the closure has been made. Nevertheless, some of the action plan are already being progressed as part of good practice and builds on existing joint working and initiatives. The Group has membership drawn from Patients, Community Councils, Local Councillors, Professionals, Service Providers from statutory, independent and voluntary sectors. Following agreement of this Service Plan by NHS Highland Board, the proposal will be submitted to the Minister for Health and Community Care for his consideration.

Appendix 1

Rapid Re design Process

Although the Local Health Partnership has been exploring options for improving health and care services for Older People for some time, it was agreed that a concerted effort was required to focus attention on the needs and solutions for the future. A suggestion was made to both the Mid Highland CHP and Lochaber Area Committee that a whole system re design methodology be used to bring about rapid and sustainable results. This was proposed due to the fact that there was a willingness from all partners to work together to make sense of a complex and urgent challenge and also because, although there had been much discussion in the past, there had been little progress made. It was clear that, this time, there needed to be evidence of swift results to demonstrate commitment. This method engages all relevant people in planning their own future. Organisations and communities work together to share a vision, to shape the way services are designed and delivered and to discover new possibilities for action (Wheatley in Pratt et al, 2000). The comparison is made with models whereby different stakeholders independently interpret problems or situations and attempt to find individual, partial solutions. Bringing people together to jointly describe and explore the challenge will elicit rich and varied perspectives from which all can learn and therefore achieve a more sustainable, sensible solution. Senge et al (1994) suggest that systems thinking is more than a powerful problem solving tool and is actually a language which changes the way we think and talk about complex issues. They too emphasise interdependence and interrelationships. Success, they believe, is through participation at all levels, which is aligned through a common understanding of a system. It is particularly important that this understanding is both bottom up and top down as the people closest to the issues are best placed to resolve them but senior level commitment is crucial to the success and sustainability of solutions. Rapid Re design requires momentum and commitment to progress quickly. It is essential that ground work such as information gathering and analysis and „taking the temperature‟ of local feeling and willingness to change, is done thoroughly and openly in advance of a concerted period of time working together on the issues. Previously, a comprehensive health and social needs assessment had been carried out in Lochaber and one of the first tasks was to update that. In June, 2006, a Project Leader was appointed to work with local communities, staff and service providers to determine some of the issues and to gauge the state of readiness for change. In parallel, epidemiological, financial and clinical assessments were made and focus groups were held with key stakeholders. Age Concern also facilitated „fireside chats‟ with older people who would not normally have had the opportunity to participate in activities such as this. All of the information gleaned was presented at a two day, protected time event that was

independently facilitated, using „World Café‟ methodology. Basically this is where conversations are facilitated to allow people to explore issues that matter to them, to capitalise on the collected wisdom, to learn from each other and to solve problems. It is founded on the assumption that people have the capacity to work together, no matter who they are (Wheatley in Brown and Isaacs, 2005). The outputs from this event were written up and formed the basis for a consultation paper that was put out more widely in the community on a formal basis in October and November, 2006, thus continuing to make connections to maintain momentum and continuity.

Appendix 2

Current Situation and Condition

1. Glencoe Hospital

Glencoe Hospital is an imposing country house, situated on the edge of Glencoe Village. The building was purchased from a descendent of Lord Strathcona in 1949 by Argyll and Bute County Council and was transferred to the Secretary Of State for Scotland in 1950. It was built over a hundred years ago as a family home and is listed both internally and externally. Any alterations are subject to approval by Historic Scotland, and this has proved to be problematic in the past. At present, Glencoe Hospital is a 12 bedded Care of the Elderly facility, mostly long term, with a respite bed. Some of the patients have been resident in Glencoe for several years and consider it to be their home. It also houses a Day Care facility and a Lunch Club. Community staff are based in spare accommodation on a temporary basis. In March of this year, a temporary closure was averted due to a staffing crisis and the situation remains very fragile. As a result of this, the running of the hospital, the operational policy and sustainability have been closely scrutinised and there are some matters of concern. The staffing situation remains fragile and the hospital has only been able to take admissions occasionally in the intervening periods depending on staffing levels at the time of request from the local GP. There are currently six patients. The care environment is not ideal and there are pressing health and safety and Disability Discrimination Act (DDA) issues that require to be addressed urgently.

2 Care Environment

The building is on four floors, although only the ground and first floors are used for patient care, however, the basement entrance has to be used for wheelchairs, up a non compliant ramp, then using a non compliant lift to the other floors. There is obviously wasted space that is being heated, but the space is not useful for any purpose. Patients are cared for in cramped rooms with no en suite facilities and it is extremely difficult for staff to preserve the dignity and privacy for patients. It must be stressed, however, that the staff work very hard to achieve this and the care provided is of a high standard. The nature of the layout of the rooms present moving and handling hazards for patients and staff. Works have been suggested to make the building as compliant as possible for both health and safety and DDA, but we have been advised that gaining planning permission for these is very unlikely. The NHS Highland Property Strategy states:- „The estimated cost of bringing Glencoe Hospital to Condition Band DDA compliance is £1.01million against a building value of £1.7million. The ability for major reconfiguration to meet modern care standards is even more difficult at Glencoe because the building is listed both internally and externally and extensive amounts of asbestos are present.‟

3. Asbestos

A Type 2 Asbestos Survey was carried out in May 2004. The report demonstrates that asbestos is widely present. Some areas were not surveyed because it would have required significant damage to structures and decorative surfaces. The report states that areas not inspected must be presumed to contain asbestos unless proven otherwise. The recommendations contain a mixture of Priority 1 (immediate) and Priority 3 (no immediate action required). The widespread presence of asbestos makes any building work extremely costly, even relatively minor adaptations. In the event of any adaptations or other building works the asbestos would be disturbed. Specialist tests would have to be carried out, and specialist contractors brought in at greatly increased cost. For example, plans to install a new bath were delayed by over a year whilst awaiting planning permission and approvals by Historic Scotland, and the cost, including asbestos removal, was estimated at about £45,000. Any major works could require the building to be closed for the duration of the works, and the patients to be found alternative care placements

4. Health and Safety A Health and Safety Report last year from the NHS Highland Health and Safety Advisor has highlighted several risks to the safety of patients and staff. These include: Inadequate access for wheelchair users and others with reduced mobility Limited lift access to upper floors; and The associated manual handling risk should a patient or other person upstairs require to be carried downstairs Difficulty in providing the most basic elements of patient care including use of toilets and bathing Risks to staff working with patients in confined spaces. The report states: getting free

access to bed bound patients in order for the staff to undertake personal and clinical procedures.

It concludes by saying: from what is an unsuitable building. There are numerous Health and Safety concerns, some of which have been working very hard to ensure continuity of care in very trying circumstan

5. Costs

Hospital Budget 569,000 Facilities Budget 132,000 Capital Charges 130,000 TOTAL 831,000 Additional to bring staffing 120,000 levels to compliant levels this year

Urgent DDA compliance 140,915 works Urgent H&S compliance 51,000 works TOTAL 191,915

N.B Complete works estimated at £1.1million

Appendix 3

Intermediate Care Service

Draft Operational Policy

The multidisciplinary Intermediate Care Team provides therapy intervention and care to people who would otherwise face hospital admission or inappropriate admission to acute in-patient care, long term residential care or continuing NHS in-patient care. A structured individual care plan involving active therapy, treatment or opportunity for recovery follows a single shared assessment process. The plans address physical, mental and social care needs. The intervention takes place either in the person‟s home or as close to it as is appropriate, and involves inter-agency working and shared protocols. The service is free at the point of delivery in any care setting, including the home or residential homes. However, any ongoing needs will be fully assessed by the multi disciplinary team and this will include a financial assessment if local authority services are required. The service encompasses a number of elements:- Hospital at home Multi disciplinary Rapid response Community rehabilitation team Shared equipment store

The service is available 24 hours a day, 365 days a year, with availability determined by the following criteria:

As far as possible planned admissions should be arranged to fall within working hours Monday to Friday 9-5. Out of hours admissions may be made to the Hospital at Home portion of the service if appropriate up until midnight. Referrals are made to the whole team with the most appropriate professional taking the lead role in the first instance.

The care of individual patients will follow the multi-disciplinary model of care, which forms a crucial part of the philosophy and vision. All professionals, from whatever discipline, involved in a patient‟s care package will have a declared part to play in the process, with the ultimate responsibility for that care being assumed by the lead professional, whose role is pivotal to the patient‟s recovery, maximising health within the

limits of the condition. A shared assessment process will identify patient needs and inform the subsequent plan of care developed. The team comprises: Nursing Physiotherapy Occupational therapy Speech and Language therapy Dietician Social Work Care Assessor Support workers Home Carers Administration support

Who can refer Referral to the Intermediate care service may come from several sources including community integrated teams community hospital teams social services staff Raigmore Hospital GPs within the catchment area. Self-referral/carer/relative referral Out of hours service

Procedure for referral Requests for admission to the service will be made to the Intermediate Care Team Co- ordinator. Admission will then be prioritised taking into account case load, risk assessment, clinical priority and degree of urgency At the time of referral the referrer is required to provide information regarding the patient‟s medical and social situation sufficient to allow the Intermediate Care team to develop an initial management plan. The named lead professional will liaise with any community/hospital/social services staff already involved with the patient.

The multi-disciplinary team will work to a plan of care prescribed and agreed by all those involved with the individual but co-ordinated and organised by the named lead professional. If the referral is deemed by the Intermediate Care team to be unsuitable, this will be communicated to the referrer.

Following admission multi disciplinary team will review the case regularly – at least weekly A list of patients awaiting admission will be retained by the Team Co-ordinator.

The key principles guiding the philosophy for admissions are as follows:

active management of all admissions multi-disciplinary care discharge planning starting at the time of admission

Admission Criteria Patients are eligible for admission to the Interrmediate care service if Intervention will prevent inappropriate admission to hospital. Their condition can be safely managed at home. They require the input of 2 or more services from the ACAH. Discharge can be planned from the service within a finite period. The patient‟s GP is happy to retain/accept medical responsibility.

Patients must meet all of the above criteria to be accepted to the service. The needs of those deemed suitable for admission will fall into the following categories: Acute exacerbations of chronic conditions – patients who require medical and/or nursing care beyond the scope of the community teams, which can be provided in their own homes with additional staff and equipment. Rehabilitation – admission for rehabilitation necessary to optimise a patient‟s functional abilities. For rehabilitation to be realistic there should be potential for the patient to make and maintain functional improvement. Post-operative surgical patients and those requiring transfer from the acute services following a medical crisis may be accepted for admission. The GP providing medical support to the patient must agree the admission to the service. Palliative/terminal care – patients needing care and for symptom management have the option of being cared for at home, in preference to being admitted to hospital or hospice. Support and management of long term conditions – care for those people for whom multi-disciplinary advice and support will enable them to maximise their self care ability and prevent crisis admissions to in-patient care.

Patients not usually considered suitable for admission include: Children – due to the statutory requirements which would be placed on the team concerning staffing, competence and care programmes.

Patients with acute unstable medical conditions who require highly specialised care or special investigations, which are available in Raigmore or other specialist unit e.g. access to multiple, complex or 24 hour laboratory results; access to urgent or serial imaging including endoscopy; access to cardiac monitoring. Patients with challenging behaviour –who may be profoundly confused or have acute psychiatric conditions are not appropriate for admission. . Patients who primarily require social or personal care, rather than medical or nursing care. Patients requiring social respite care only should be referred to Social Work in order to find a suitable placement. Patients from Specialist Services requiring funding or services to allow them to be discharged, but who do not require acute multi disciplinary care will be accepted subject to the clinical priorities

A weekly multi-disciplinary team meeting will be held to facilitate care planning and discharge GPs will be invited to either attend or have prior input as necessary.

Individual case conferences will be held as required.

Care and therapy will be delivered in the most appropriate environment. This may be the patient‟s home, out patients department or other appropriate facility.

Prior to discharge each patient will receive a summary of their care, written information regarding follow-up care or special treatments such as diets, and an evaluation of the Intermediate care service issued in accordance with the NHS Highland‟s quality assurance policy. A copy of the summary discharge note will be sent to the patient‟s own GP immediately. Any necessary information/arrangement is communicated well in advance of discharge, giving at notice to the appropriate services e.g.: General Practitioner Community Nursing Service Day Hospital Day Centre Community Teams Social Services Ambulance Service Voluntary bodies Relatives and carers

Appendix 4

Improving Services for Older Adults

Implementation Group

DRAFT

Role, Remit and Membership

1. The Group will have the following key functions:- To oversee the progress of implementation of the Action Plan and associated work plan. To firm up on the work streams and clarify work in progress To act as an “umbrella” group in order to co-ordinate and link the work of the sub groups. To be responsible for communication and information sharing on all aspects of the initiative To ensure that there is ongoing involvement of patients and community groups To manage expectations and a realistic approach to planning and monitoring. To be clear on those decisions that can be taken locally and those which require to be referred on. To have clear milestones and timescales. The Group will have a defined life span.

2. Membership 3 members of Community Councils (this has been reviewed following discussion with Association of CCs, who suggest 4 members due to the number of CCs represented and the geography) 1 member from Association of Community Councils 2 Patient Representatives 2 Carer Representatives Minister (Presbytery of Lochaber) Lead Allied Healthcare Professional (AHP) AHP Lead Nurse 1 Hospital Nurse 1 Community Nurse Scottish Ambulance Service GP Social Worker Area Social Work Manager Locality General Manager (Health) Housing Officer

Home Care Organiser Abbeyfield Unit Manager Independent Care Sector Staff Partnership member Voluntary Sector Member Consultant Physician Local Councillor

3. Ground Rules Realism Openness and honesty Remain focussed on issues in action plan Corporate shared responsibility for decisions Stand by decisions of the group Majority vote where necessary Mutual respect Everyone has valuable contribution to make Agree relevant publicity and PR work

4. Frequency of Meetings To be decided

Appendix 5

Review of Services for Older Adults in Lochaber

Draft Action Plan (4) – 27/12/06

Implementation Lead – To be confirmed Action How? Lead By when? Status R.A.G Comments

Set up Implementation Agree membership Gill McVicar December, 2006 Initial meeting set Group to oversee the to include CC for 10th January next steps members, patient, Voluntary, Independent and Appoint Chairman Statutory Sector members Populate action plan and report to CHP Management Team and Committee/Area Committee Develop Media Plan David Ritchie December, 2006 Gill McVicar on Communications and Nevis radio Nevis Radio, 19th Information Plan interview Dec Community Press release feedback following Board Clarify alternative meeting service provision Ongoing press options releases e.g Include SHC Abbeyfield agreement and local workshop invites

Carry out holistic health SSA Charge December, 2006 Work in train and social needs Consultant opinion Nurse/GP/Senior Meetings held with assessments for all where necessary Social Worker relatives patients in Glencoe Patient and Family SSAs complete Hospital Involvement Multi disciplinary Team Specialist Opinion as required Offer access to independent advocacy Develop Future Care As above As above January, 2007 In train Plans, options, arrange 1 patient has visits moved to place of choice Continue negotiations Meetings 16th Gill McVicar January, 2007 Offered:- with Abbeyfield November, 7th Jonathan King Capital Grant Ballachulish and December Secondment of develop partnership Assist with nurses agreement planning as Training required between Advice and support meetings Financial feasibility study ongoing Obtained agreement from Trustees to develop contracts and SLAs. Meeting early January Apply for Dual Continue work with Abbeyfield, Initial meeting with Registration Care Commission Ballachulish Care Commission Develop Staffing held schedule Submit application Training Plan

Alterations to Finalise plans Abbeyfield, December 2006 – Architect has Abbeyfield, including car Agree funding Ballachulish June, 2007 visited, initial plans parking Planning drawn up Permission etc

Staff Governance Partnership Group Theresa January, 2007 Regular meetings James/Mairi with staff McKay/APF Rep Project Lead and Personnel Learning and Caroline Matheson Manager attend Development weekly Opportunities Charge Nurse Re deployment involved with opportunities Mairi McKay Abbeyfield Visits discussions Career Counselling 1:1 meetings offered with GM and Project Lead Speakers invited to raise awareness of other models Shadowing opportunities offered Architectural survey Work with Historic John Swatman December, 2006 Scotland on future use of building

Alternative Explore local John Swatman January, 2007 Discussions with accommodation options for SAS Abbeyfield on Community staff, Ian McFadyen Community SAS, Lunch Club, accommodation SW Staff and Lunch Club Involve all key Early discussions stakeholders, with SAS, meeting Keep community planned informed

Reinvigorate Discharge Review role, remit Elaine Lang/Ian December, 2006 Group meeting Planning Group and membership McFadyen and ongoing Regular joint Use feedback from planning meetings consultation to in Belhaven inform future work Low numbers of Develop work plan Delayed Discharge to feed to Implementation Group Develop Belhaven Plan Review existing Caroline December, 2006 Nursing Action development plan Matheson/Mary Plan developed Review staffing and MacLeod/Shahid Additional senior Medical Cover Barlas/Jim Douglas nurse support Training plan Consultant Review space, ? Physician time adaptations increased Review equipment Discussions with needs GPs on different cover arrangements Development event held, Dec, 2006 Develop and Enhance Plan developed Elaine Lang/ Mary January, 2007 Stroke service Community Rehab Agree new posts, MacLeod/Caroline launched Team job descriptions Matheson February, 2007 evaluated Recruitment April, 2007 Training ongoing Set up Learn from Inner Theresa James/Ian December – April, Operational policy Intermediate/Augmented Moray Firth McFadyen 2007 shared Care Service development work Agree job descriptions Evaluate Recruit Train

Explore transport issues Review existing Theresa and link to Community work and local James/John Planning plans Hutchison/ Identify gaps and Strategic relevant Partnership Group stakeholders Wider Service Planning Mapping, scoping, Local Partnership Ongoing to include Sheltered gap anayalsis Specific targets to Housing, Care Home be agreed requirements, including Respite Care

Premises Needs As part of Clinical John Swatman/ March - Clinical Framework Assessment Framework THC/Clinical Lead September Roadshows in planning at local Jan/Feb level Link to Property Strategy Road show community Series of Gill McVicar/Brian Jan - Feb Ongoing engagement events workshops to Devlin community further explore involvement emerging models Date set for first of care using whole workshops – 10th system January methodology Continued involvement of SHC

Lochaber Review Follow Feedback and Gill McVicar/Jon March, 2007 Up Event – Report on workshop session King progress with those who attended September planning event – external Facilitator