Review of Community Hospital Services

North East Wales Health Community

8 February 2005

Community Hospital Review

Document Control Sheet

Client North East Wales Health Community

Document Title Review of Community Hospital Services

Version 12

Secta Reference 12794

Author Susan Thomas, Ian Johnston and Elaine Bennett

Date 8 February 2005

Further copies from Email: [email protected] quoting reference and author

Quality Assurance Steve Smurthwaite By:

Document History Version Date Author Comments 1 03 November 2004 Elaine Bennett Framework for the report 2 09 November 2004 Elaine Bennett Initial drafting of report 3 03 December 2004 Susan Thomas Redrafting of report 4 08 December 2004 Ian Johnston Further drafting and additions 5 09 December 2004 Susan Thomas Further drafting and additions 6 13 December 2004 Elaine Bennett QA of draft report Changes from Neil Bradshaw 7 05 December 2004 Elaine Bennett incorporated Changes from NE Wales Health 8 10 January 2005 Elaine Bennett Community incorporated 9 11 January 2005 Susan Thomas Additional revisions Incorporation of Executive agreed 10 18 January 2005 Elaine Bennett changes 11 31 January 2005 Elaine Bennett Incorporation of final agreed changes 12 8 February 2005 Elaine Bennett Incorporation of final agreed changes

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Contents

1 INTRODUCTION...... 1 1.1 Background...... 1 1.2 Objectives of the Review ...... 1 1.3 Scope of the Review...... 2 1.4 The Shape of this Report...... 2 2 CONTEXT ...... 4 2.1 Introduction...... 4 2.2 National Strategic Drivers...... 4 2.3 Local Strategic Drivers ...... 6 3 FINDINGS ...... 8 3.1 Introduction...... 8 3.2 Methodology ...... 8 3.3 Key Findings...... 8 3.4 Point Prevalence Study ...... 9 3.5 Financial Position...... 18 3.6 Summary of Hospital Services and Estate ...... 20 3.7 Hospital Specific Issues...... 20 3.8 Stakeholder Engagement...... 22 4 RECOMMENDATIONS...... 25 4.1 Introduction...... 25 4.2 Key Conclusions...... 25 4.3 Active Bed Management ...... 25 4.4 Flint Hospital...... 27 4.5 Llangollen Hospital ...... 27 4.6 Priority Projects...... 27 5 NEXT STEPS...... 35

APPENDIX A - Stakeholders Interviewed APPENDIX B - Attendees at Strategic Vision Workshop APPENDIX C - Attendees at ‘Think Tank’ Workshop APPENDIX D - Outputs from ‘Think Tank’ Workshop APPENDIX E - Attendees on Options Workshop APPENDIX F - References

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1 INTRODUCTION

1.1 Background

1.1.1 Early in 2004 a decision was made by the North East Wales Health Community to undertake a review of its community hospitals and the services currently provided. Secta was appointed to undertake this work over a three-month period from September to December 2004. The North East Wales Health Community consists of the following organisations:

■ North East Wales NHS Trust ■ Flintshire Local Health Board ■ Wrexham Local Health Board

1.1.2 The review of community hospitals took place within the context of the Welsh Assembly Government review of Health and Social Care in Wales, during 2003 (commonly referred to as the “Wanless Review”).

1.2 Objectives of the Review

1.2.1 The objectives of the Review of Community Hospital Services were to:

■ Enhance understanding of current community hospital service strengths and inefficiencies ■ Increase system capacity by improving the current efficiency and effectiveness of community hospital services ■ Enhance understanding of alternative models of care ■ Consider future models of care that will make most effective use of community hospital facilities and reduce pressures on other parts of the health economy

1.2.2 Secta’s work programme consisted of the following:

■ Determining existing utilisation: current services, activity, admission and discharge patterns and catchment populations ■ Identifying existing capacity and how this may be utilised more effectively to support current pressures ■ Scoping alternative models of care: consideration of how the community hospitals may be utilised differently to support alternative models, identify the potential capacity and assess the impact upon the overall health and social care system (in accordance with the agreed criteria) ■ Estimating future demand and indicate the infrastructure required to support the identified models of care

1.2.3 It became apparent during the review that finalising the role and, therefore, estimating the future demand for community hospital services was dependent on the development of complementary strategies for the transfer of care from acute

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hospital settings to community and primary care settings. As a consequence, the focus of the review was on the first three items above.

1.3 Scope of the Review

1.3.1 This review focused on improving current use and defining future models of care for the five community hospitals listed below:

■ Chirk ■ Deeside ■ Flint ■ Holywell ■ Mold

1.3.2 The review also considered Llangollen community hospital.

1.3.3 The focus of the review was on identification of areas for improvement, in the short and medium to long term. Hence the emphasis of this report is on areas for improvement, rather than on highlighting good practice, which exists.

1.3.4 In addition, the review also took account of the local acute, primary and social care sectors due to the strong interrelationship with the community hospital services.

1.3.5 Over the course of the work undertaken, it became increasingly apparent that this review was, in fact, just one part of a much larger piece of work; namely, the development of a coherent and organised strategy around the future of primary and community services in general. There is a wider set of reviews occurring concurrently, including the work of North Wales Planning Forum. This examination of the configuration of acute and tertiary services will potentially have an impact on community hospital services.

1.3.6 This review therefore contributes to a wider debate about the future configuration of health care delivery in North East Wales.

1.4 The Shape of this Report

1.4.1 This report takes the following form:

■ Context: This will explore the context within which this review sits, on both a national and local level; ■ Findings: This will outline the key findings of the diagnostic review, which is both quantitative and qualitative in nature. This section includes the diagnosis undertaken at visits to the six community hospitals and will also outline the key messages of the various workshops undertaken during this process; ■ Recommendations: This section will outline the recommendations drawn from the diagnostic phase and information from stakeholders. This part of the

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review identified some short and medium term priorities that will require action; ■ Next steps: This section will outline how this discrete review of community hospitals should be viewed within the wider context of primary and community hospitals. In addition, it will help identify ways in which the health community can move towards developing an integrated strategy for its health care provision.

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2 CONTEXT

2.1 Introduction

2.1.1 Community hospitals need to be viewed in the wider picture of primary and community services as a whole. The nature and scale of services that can be delivered in a primary care setting, as opposed to the more traditional acute setting, is undergoing a dramatic, and necessary, change both in Wales, other areas of the UK and, indeed, internationally.

2.1.2 This has largely come about for a number of key reasons:

■ The increasing push to deliver patient-centric services, as outlined in key documents such as the Review of Health and Social Care in Wales (the Wanless Review) ■ The need to increase efficiency and to deliver services that provide value for money ■ An increased understanding of the benefits (both medically and financially) of managing chronic diseases proactively in a community setting, thus avoiding acute exacerbations of illnesses that result in frequent and expensive admissions to an acute setting

2.2 National Strategic Drivers

2.2.1 The key driver for health and social care reform in Wales is the Wanless review, published in 2003. Although this is obviously well known to the health community of North East Wales, it is worth reiterating the key points that relate to community services, and in particular, how these can help achieve a balanced health service in conjunction with acute services.

2.2.2 A key finding of the review was that “Wales does not get as much out its spending as it should; in health, for example, it now places unsustainable pressure on its acute sector. The impact extends into social care. Long hospital waiting lists and assessments without subsequent social service provision are the unacceptable consequences and are symptoms of the deep underlying problems needing to be faced”1.

2.2.3 In order to deal with this over demand on the acute sector, the Wanless review states that a “step-change in individuals’ and communities’ acceptance of responsibility for their health is needed” 2. This will require a definite strategic shift towards prevention and early intervention; this will obviously necessitate changes in how services are configured and delivered with an increasing emphasis on primary and community services. The review talks of a “radical redesign” of health and social care being imperative, along with the need to develop capacity, in terms of skills, infrastructure and workforce, outside of the

1 The review of Health and Social Care in Wales: The Report of the Project Team advised by Derek Wanless, June 2003, foreword 2 The review of Health and Social Care in Wales: The Report of the Project Team advised by Derek Wanless, June 2003, page 2

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acute setting. The report says, “the rebalancing of the acute hospital sector must involve better utilisation wherever practicable and cost-effective of the smaller, community facilities for a wider range of activity”3.

2.2.4 Short term measures to achieve these goals include the following:

■ Efficient bed management and discharge processes ■ More efficient use of community hospitals: Step down Active rehabilitation and intermediate care Resource centre role ■ Development of disease management services in a primary care setting ■ Enhanced working with the independent sector

2.2.5 Longer term measures look to develop a more integrated pattern of health care delivery and include the following:

■ Prevention and public health measures ■ Social care support to allow people to be managed at home as much as is practicable ■ New models of primary care, obviating the need for acute admissions ■ Development of services that will see specialist services, that are currently delivered exclusively in a secondary care setting, also being delivered in primary and community settings ■ “A joined up hospital sector in which different kinds of hospital provide integrated care on a local and regional basis as part of the whole health and social care system”4

2.2.6 So, in summary, the direction of travel under the Wanless review is clear: a move to more patient-centric services, delivered in community and primary care settings that relieve pressure on the acute setting whilst providing value for money.

2.2.7 However, it is important to add that the move to provision of local services has to be undertaken in the context of continuing financial pressure. The development of community and primary care services has to deliver demonstrable improvements in access to acute hospital services. In addition, any associated investment needs to demonstrate the associated financial, as well as access, benefits.

2.2.8 The minimum level of beds in community hospitals, recommended by the Welsh Assembly Government (WAG), is 30.5

3 The review of Health and Social Care in Wales: The Report of the Project Team advised by Derek Wanless, June 2003, page 5 4 The review of Health and Social Care in Wales: The Report of the Project Team advised by Derek Wanless, June 2003, pages 56 and 57 5 A framework of NHS Policies to Inform the Production of Local Action Plans in Wales: Welsh Assembly Government, December 2003, page 14

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2.3 Local Strategic Drivers

2.3.1 The three organisations that make up the North East Wales Health Community have each developed strategies to address local health needs in the ensuing years6.

The Flintshire LHB and County Council Strategy

2.3.2 The vision for Good Health is as follows:

“Our vision is to encourage healthy and caring communities for the benefit of the people of Flintshire, where individuals and communities are encouraged and supported to attain the best possible levels of health and well-being. Services provided must be co-ordinated, responsive, flexible and effective.” 2.3.3 The objectives in meeting this strategy are:

■ Promoting health and well-being in Flintshire ■ Gain a clear understanding of local needs ■ Priority setting ■ Good quality innovative and integrated services ■ Easy access to services ■ Empowering individuals and communities ■ Maximising participation and involvement

The Wrexham LHB Strategy

2.3.4 The aims of the strategy of Wrexham LHB are as follows:

■ Improve health and reduce illness ■ Promote and support independent living ■ Modernise services to support people with chronic diseases within the community

2.3.5 Essentially, the focus is again in line with the Wanless review, with a move to community-based services rather than inpatient services in an acute setting. Development of an integrated Intermediate Care service, along with chronic disease management, is prioritised.

NE Wales NHS Trust Strategy

2.3.6 The strategy paper of the Trust (Facing the Future) – the third in a series of papers - identifies that future services should have the following features and characteristics:

■ Ability to access a full range of services in a timely fashion

6 Good Health: Health, Social Care and Well-being Strategy for Flintshire; Caring for our Health: The Health, Social Care and Well-being Strategy for Wrexham 2005-2008; North East Wales NHS Trust: Shaping the Future

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■ Access via local “gatekeepers” who are able to refer to a full range of health and social care services ■ Services to be provided at home or in the community where possible ■ Services provided through a differentiated model of hospital care so that each health economy provides a full range of services but individual hospitals provide different contributions to the whole system ■ The need to manage organisational boundary issues

Commonalities

2.3.7 As can be seen from the previous section, there are strong themes running through both the Wanless review and the three local strategies. Essentially, the theme of providing services in an appropriate setting (which will often be home or community based) is the key focus.

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3 FINDINGS

3.1 Introduction

3.1.1 The diagnosis phase of the review took during October and November 2004, with the aim of collating a significant amount of quantitative and qualitative information. The key areas examined were as follows:

■ Capacity: This involved understanding what capacity is currently available with respect to in patients, out patient and minor injuries ■ Utilisation: This included examination of current services, activity levels and admission and discharge criteria; in addition, how effectively capacity is being utilised ■ Alternative models of care: Information was gathered from stakeholders as to how community hospitals might be able to contribute to the modernisation of the health service in Wales

3.2 Methodology

3.2.1 The diagnostic phase consisted of a detailed examination of services and information within the community hospital network. The following work was undertaken:

■ Review of a wide range of strategic and operational documents: National and local strategy documents Local operational information ■ Analysis of Trust data and performance reports ■ Site visits to the six community hospitals: Chirk, Mold, Deeside, Flint, Holywell and Llangollen ■ Structured interview programme of key stakeholders for each hospital site ■ A point prevalence audit of inpatient beds in order to understand current usage ■ A snapshot audit of the minor injuries unit at Chirk

3.3 Key Findings

3.3.1 There was a series of key findings that emerged from the diagnostic phase. These findings were as follows:

■ Up to 75% of inpatients could be cared for under alternative models of care (were these to be available) ■ There is some spare capacity with respect to both inpatients and outpatients ■ Utilisation of the minor injuries units varies across the area and tends towards the low side. In addition, the service appears to duplicate either primary care or A&E services but does not have a unique role

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■ There is a high existing nurse skill mix with respect to the current patient population and their clinical need ■ Stakeholders place a strong value on community hospitals

3.3.2 Sections 3.4 to 3.6 below explore the key findings in further detail.

3.4 Point Prevalence Study

3.4.1 A point prevalence study was undertaken of the inpatient beds at the community hospitals. Due to the time available Llangollen was excluded from the formal point prevalence.

3.4.2 A set methodology for the point prevalence was used in order to formalise and validate the information. The ward manager for each hospital site was interviewed about the current inpatient load (on an anonymous basis). The following information was gathered:

■ Patient age and sex ■ Date of admission and location admitted from ■ Diagnosis ■ Current medical, nursing, therapy and social services input required ■ Approximate number of days patient had been medically stable (if available) ■ Reason, if any, for delay in transfer to appropriate setting ■ Identification of the most appropriate setting for each patient. This acknowledges that, in a large number of cases, this location may not currently exist but envisages a “perfect world” scenario ■ Total number of beds, including number empty, per ward

3.4.3 The studies took place on the following dates:

■ Chirk: 19 October 2004 ■ Flint, Holywell, Deeside and Mold: 8 November 2004

3.4.4 The key findings from the point prevalence were as follows:

■ Utilisation on the day of the point prevalence study was just over 80% on average ■ Up to 75% of inpatients could be cared for under alternatives model of care ■ Lengths of stay varied from 1 day to 321 days (N.B. this does not equate to total length of stay, since the discharge dates of the patients were not set) ■ On average, patients were medically stable for 50% of their stay7 ■ The major causes of delayed discharge were: internal hospital delays, social services delays, family issues and placement issues

7 Note: the definition of medically stable used in the study was taken as the point when patients no longer required active medical input. This therefore differed on occasion from the GP entry in the notes certifying the patient fit for discharge. In addition, for patients with longer stays, the stable period had to be approximated and therefore tended to be underestimated to prevent bias

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■ The main models of care required (to avoid an inappropriate stay in a community hospital bed) were home with a package of care, home, residential or nursing home and residential intermediate care

3.4.5 Utilisation of beds at the time of the point prevalence can be seen in Figure 1 below:

Figure 1 - Bed Utilisation

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Up to 75% of patients could be cared for in an alternative setting

3.4.6 As stated earlier, the point prevalence aimed to ascertain the most appropriate location or model of care for the current group of inpatients. It is important to stress again that the reason patients are not currently cared for under these models is that the models either do not exist or do so in a limited form. This figure of 75% is therefore not a criticism of anyone within the system; rather it highlights inadequacies of the system itself.

3.4.7 An analysis of the most appropriate location for patients, given the caveats above, can be seen in Figure 2.

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Figure 2 - Analysis of Appropriate Patient Location

Community hospital Home with package of care Home RH Residential Intermediate care NH Home with DN input Community Alternative Nurse led rehab hospital bed - location more Respite bed best model of appropriate care Home with modifications Home with reablement team Home with rehab Nurse led bed Rapid response Warden controlled housing Rehousing Secondary care

3.4.8 The next two figures analyse the cause for delays in discharge (or reasons for care under the current model) from community hospitals. Figure 3 demonstrates the number of patients who have been delayed by the various causes. Figure 4 converts this into bed days and compares this with the days patients have been stable.

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Figure 3 - Number of Patients Delayed (by cause)8

18 16 14 12 10 Patient number 8 6 4 2 0

y e e r y e y s n y y e a lay ds fe la c a e ds ue a la ut el ssu s e s bed el d de be en del be is issio e de isp l C t i an issu e g t d a S ily issu n tr T d xist g it n m se nt d rn S d I e e O ent n p n th m e i si ad acu o te am ite iat in d es u e f me al n F r ipm r t sp le e I im ace p ly u d Ho e b h L l ro nt q Fun te ck o r a P p E i a d S/ p re opria L Re S a r im pr pi L p In t cu a Ra o In n e ic rv e S

Figure 4 - Bed Days Lost due to Delayed Discharges9

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e y y s e e y y e r u la e u ay ds u la la fe e u s e e ut s d s s p beds iss s t i t del be iss s an ly i n e r SS dela g en e IC OT d mi d spit din e e Fa ternal n em ipm it In u c u F la im Housing ablement /healthd di d r P L ite ropriate t Eq SS Re im L Inapp

3.4.9 As well as the figures ascertained from the point prevalence with respect to bed days lost due to delayed discharges or lack of alternative services, there are Trust figures demonstrating the impact of delayed discharges. The Trust

8 Note: An internal delay is defined as a discharge that is delayed due to internal hospital factors. For instance, a patient who remains in hospital for a review at the next MDT meeting, despite being stable, would be defined as an internal delay

9 Note: A family issue is defined as a discharge that is delayed due to issues between family members and the patient about the appropriate discharge location. This differs from a placement issue where individuals are on a waiting list for a specific nursing home

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definition of a delayed discharge is a patient who remains in a hospital bed after the GP has declared them fit for discharge. This definition is, as explained in footnote 6, going to lessen the impact of delayed discharges compared with the point prevalence study. However, these figures can be seen in Figure 5.

Figure 5 - Delayed Discharges as a Percentage of Total Bed Days

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0% Deeside Chirk Flint Holywell Mold

3.4.10 The delayed discharges demonstrated in the previous two slides appear to be the result of a series of bottlenecks within the system. The key constraints are listed below:

■ Current medical model: Under the existing model, GPs will annotate in a patient’s records that the patient is medically fit for discharge. Until this happens, there is limited intervention by social services and home visits by occupational therapists (OT) do not occur. In addition, there may be delays waiting for the GP to write in the medical notes ■ Admission policies: At certain hospitals, transfers from the acute sector are limited by which days GPs visit the hospital. Under the current model, there is a requirement that patients are clerked by a medical practitioner within a relatively short period following admission; hence, by limiting admissions to certain days GPs are able to limit the number of visits made. In addition, patients can only be admitted to their “home” area; that is, the hospital covered by their GP. This means transfers from the acute sector can be delayed ■ Frequency of GP visits: There is significant variation in the frequency of visits by GPs to the community hospitals. Furthermore, not all GPs admit patients to community hospitals resulting in an inequitable service ■ Limited discharge planning from early stage of admission: There was little evidence of active discharge planning from the time of admission. Setting a potential discharge date on admission has been shown to have two beneficial effects: Reduction in length of stay

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Reduction in variability of length of stay allowing better planning ■ Lack of proactive decision-making: Decisions about patients appear to be taken predominantly at the weekly multi-disciplinary team (MDT) meeting. Although the importance of such meetings should not be underestimated, it did appear that patients’ admissions were thought of in weekly, fortnightly or monthly blocks, coinciding with these meetings. Hence, patients were often staying in hospital longer than necessary ■ Social work intervention: Social services do not get involved in reviewing patients until they have been declared fit for discharge by a doctor. The reasoning for this is understandable: to undertake social care planning, such as arranging a package of care, while the patient is not “fit” runs the risk that the package may be wasted if the patient is not ready. However, the nature of the patients within community hospitals (vis-à-vis the acute sector) makes this an unlikely scenario. This is backed up by the evidence that patients are medically stable for up to 50% of their admission (a conservative estimate). Indeed, increasing the length of stay of patients is known to increase the likelihood of developing a further iatrogenic illness ■ Limited rehabilitation staff and facilities: Provision of therapy services, and the nature of these, varies widely across the hospital sites. The major areas of concern are Flint and Holywell. The current position at Flint is 6 hours of physiotherapy support per week and three hours of OT per week. In addition, there are no dedicated therapy facilities at Flint; hence, therapy is provided on the wards, which are extremely limited in their practicality. Currently at Holywell OT provision is non-existent due to long-term leave; however, under normal circumstances the provision is only 6 hours per week. Physiotherapy is also limited with no outpatient service and inpatient provision of only 6 hours per week. It must be noted that in the plans for the re-provision of Holywell, therapy services will be significantly enhanced ■ Differential service provision across hospitals: There does not appear to be an overarching strategy around what services should be provided at community hospitals. As a consequence, services are provided on what appears to be largely a historical basis ■ Limited intermediate care facilities: There are a number of issues within intermediate care. Predominantly, the service is not well developed and hence community hospitals are being used to provide this service (although they are not appropriately set up to do so). The areas that need developing or enhancing include: Active rehabilitation beds (nurse and therapy led) Rapid response Home based therapy services Respite care

There is some Spare Inpatient and Outpatient Capacity

3.4.11 Annual utilisation of inpatient beds ranged from 58% at Llangollen to 92% at Deeside. These figures can be seen in Figure 6 to follow. The utilisation snapshot of the point prevalence study is also shown on Figure 6 but for information, not comparison purposes. The figure for Llangollen utilisation (PPS) was noted on the day of the hospital visit, as a point prevalence study was not undertaken there.

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Figure 6 - Annual Utilisation of Inpatient Beds (by hospital)

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3.4.12 Compounding this issue of underutilisation of inpatient beds is the excessive length of stay of many patients. As stated earlier, the longest inpatient stay at the point prevalence was 321 days. The average and maximum lengths of stay for the five hospitals can be seen in Figure 7. It is important to bear in mind that 58% of the patients reviewed in the study had been transferred from the acute sector and so would have been inpatients for a longer period than the figures shown below.

Figure 7 - Non-elective Lengths of Stay

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3.4.13 An analysis of outpatient usage shows that there is spare capacity in the community hospital outpatient departments. Spare capacity varies across the sites but all sites are underutilised.

3.4.14 Figure 8 provides the details regarding room availability for outpatients, based on the outpatient schedules in October 2004.

Figure 8: Out Patient Utilisation by Site

Room Type Total Rooms Utilisation of Rooms Available Deeside Consulting rooms 3 72% Interview rooms 1 88% Treatment rooms 2 79% Flint Rooms 1-2 2 79% Room 3 1 8% Holywell Consulting rooms 5 65% Mold Rooms 1-3 3 72% Clwyd 1 10% Delyn 1 46% DH treatment 1 10% Audio 1 25% Chirk Room A 1 62.5% Room B 1 70% Minor Ops 1 50% Utilisation of the Minor Injuries Units Varies across the Area

3.4.15 Utilisation of the 5 minor injuries units (MIU) in the area (Llangollen, Chirk, Mold, Flint and Holywell) is variable. On the whole, however, utilisation tends to be low. In addition, the service appears to duplicate either primary care or A&E services but does not have a unique role.

3.4.16 The MIU at Flint is open 8am to 8pm. The remaining four offered a 24-hour service at the time of this review. The units are covered by local GP practices and are separate to the out-of-hours service provision. The nursing cover varies with some units having dedicated staff and other units using ward staff if necessary. There are no emergency nurse practitioners currently working at any of the MIUs.

3.4.17 Weekly utilisation of the units can be seen in Figure 9. Only Chirk was able to provide a breakdown of daytime versus out of hours attendances, with on average 8% of attendances occurring between 8pm and 8am. All of the units see a peak in activity between the months of June and August.

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Figure 9 - Average Weekly MIU Attendances (2003/04)

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3.4.18 A snapshot audit of Chirk MIU was undertaken on 19 October 2004. Attendances for the 7-day period from 13 to 19 October 2004 were analysed. During this period 20 patients were seen within the MIU. The following facts are pertinent:

■ No patients required a physical consultation with a GP ■ A GP was contacted for 5 of the 20 patients: three of these contacts were for a prescription and the other two were for advice, one regarding a head injury and the other a sebaceous cyst ■ 2 patients were transferred to the A&E department at Wrexham Maelor (one of the transfers was the patient with the head injury mentioned above)

3.4.19 Obviously, with the low number of patients surveyed at a single site, it is not possible to draw significant conclusions from this audit. However it does highlight the need to look at the MIU service and consider a radical reconfiguration of how (and what) services are delivered.

Current Skill Mix is High

3.4.20 Currently, the inpatient units have a relatively high level of trained staff. The number of trained nurses on day shifts can be as high as 3, with either 1 or 2 staff on a night shift.

3.4.21 When looking at the type of patients who are currently at the hospitals, this seems to be a high level of trained nursing staff. By the very nature of the setting, the patients are not acutely unwell. In a large number of cases, the predominant need is for active therapy or for personal care.

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3.4.22 These services could potentially be delivered with a changed skill mix; that is, a lower ratio of trained nursing to untrained staff may be a possibility. This would release trained staff, allowing them to perform more challenging and satisfying roles. Obviously, in order to achieve this, there would be a concurrent requirement to increase the skill level of the untrained staff.

3.4.23 The above comments on skill mix relate to the current type of patients in the community hospitals. Skill mix would need to be reviewed if different patient groups were to be treated in the community hospitals.

Stakeholders place a High Value on Community Hospitals

3.4.24 This fact was extremely clear throughout the diagnostic phase of the work. All the stakeholders interviewed (including staff, patients, League of Friends and managers) valued the service that their local community hospital provided extremely highly. The local aspect was a particularly important point.

3.5 Financial Position

3.5.1 As part of the diagnostic work, a high level analysis of the hospitals financial position was undertaken. This revealed that four of the five hospitals had overspent in 2003/04.

■ Flint hospital had overspent by £89,627 (16.3%). High use of unqualified bank staff appears have been the major contributory factor, at a cost of £56,294 against a budget of £0 ■ Holywell hospital overspent by £58,735 (9.4%). High use of bank staff (both qualified and un-qualified) contributed to this. Inpatient nursing has overspent by £43,089 ■ Chirk hospital had overspent its budget by £77,309 (8.2%). Much of this was due to inpatient nursing costs, which were £69,715 over budget ■ Deeside hospital has overspent by £50,873 (5.7%). No particular area stands out as a cause of this

3.5.2 Mold Hospital has the largest budget (£1.4m of the £4.4m total) and is also the only hospital to under-spend. Figure 10 provides details regarding expenditure against budget for the five community hospitals.

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Figure 10 - Financial Information 2003/04

2003/4 Expenditure vs Budget

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0 800 £0 600 400 200 0 t ll d e k l r n e d i i i w Fl Mo Ch es ly o De H Budget Actual Hospital

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3.6 Summary of Hospital Services and Estate

3.6.1 Table 1 – Summary of Hospital Services and Estate provides an overview of key service areas and estate condition at each community hospital site:

Table 1 – Summary of Hospital Services and Estate Chirk Deeside Flint Holywell Llangollen Mold No Inpatient 31 31 18 18 18 40 beds MIU 24-hr No service 8am to 24-hr service 24-hr 24-hr service 8pm service service service Outpatients √ √ √ √ √ √ Day Hospital 15 places 15 places X X X 13 places Therapy √ √ √ (Very √ (Very √ √ services Limited) Limited) Diagnostics X-ray X-ray, Ultrasound X-ray, X X-ray, Fluoroscopy, Fluoroscopy, Ultrasound Ultrasound, ENT Barium endoscopy Enemas Physical 100% B 100% B 95% B; 65% B; Not 100% B Condition of 5% C 35% C provided Estate10 Functional A A C D Not B Suitability of provided Estate11 Estate 100% B 100 % B 100% C 100% D Not 100% B Energy provided Performance

3.7 Hospital Specific Issues

Chirk Hospital

3.7.1 The existing accommodation for general practice and district nurses in Chirk was reported to be of poor quality.

■ The LHB and Trust are exploring opportunities to develop new accommodation. Consideration should be given to the potential to co-locate

10 Physical Condition / Energy A As new B Adequate C Change required D Major change required

11 Functional Suitability A Ideal "user"satisfied B Acceptable no structural change C The building is below an acceptable standard in terms of functional suitability D The building is very unacceptable for its current use

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these services with the community hospital. This would support the Wanless recommendations around primary care resource centres. ■ It must be noted, however, that concerns were expressed regarding the location and poor access of the community hospital.

3.7.2 An additional concern at Chirk is the limited utilisation of the MIU.

■ This is run on a 24-hour basis, 7 days per week. ■ As outlined earlier in this section, it only has, on average, 17 attendances per week. ■ The unit is fully staffed either with dedicated staff during the day, or with cover from the wards out of hours. However, this requires two trained staff overnight in order to maintain safe levels of staffing on the ward, should someone be required in the MIU.

Deeside Hospital

3.7.3 Two issues have been identified at Deeside Hospital:

■ The out-of-hours service is based at Deeside. However, this hospital is the one centre to not have an MIU. This again leads to inefficiency in the service. ■ A second inefficiency is the provision of consultant led and GP led rehab beds side by side. The therapy provision to these beds will be the same; it seems likely that the patient groups will also be the same. Yet, there will be two distinct doctor groups covering the beds. There is potential for synergies between the two groups. Nurse-led rehabilitation beds could also be an option.

Flint Hospital

3.7.4 There are a series of significant issues affecting Flint Community Hospital. These issues have an impact on the shape of future service provision for this community.

■ The number of beds at this site (18) also falls short of the minimum sustainable number recommended by WAG ■ The layout of the wards as “Florence Nightingale” units results in decreased utilisation (due to the lower number of elderly male admissions but an even split of beds across the male and female wards). Bed utilisation is the lowest of the five hospitals at 74% ■ Facilities are poor, with no dedicated rehabilitation facility; this requires all rehabilitation to be undertaken on the wards ■ The level of therapy resource is extremely limited; the majority of patients transferred to Flint require significant rehabilitation and, indeed, in a significant number of cases this is the reason for admission ■ There are no X-ray or day hospital facilities ■ The hospital stock is old and not suited to modern healthcare. In addition, due to its location there is limited room for further development

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Holywell Hospital

3.7.5 The current facilities at Holywell are extremely poor:

■ The wards are old fashioned and cramped ■ The wards offer little in the way of privacy and dignity to patients.

3.7.6 However, plans are in place for a re-provision of Holywell Hospital, in combination with the local consultant run geriatric rehabilitation unit. This will obviously resolve the issue around facilities and should aid utilisation, as the beds will be in small bays, allowing flexibility with respect to the number of male and female patients. This re-provision is planned to improve the facilities with respect to therapy input, since over half the beds are due to remain consultant run rehabilitation beds.

Llangollen

3.7.7 A range of issues was identified regarding Llangollen Hospital. No apparent progress regarding strategic planning and utilisation have been made at Llangollen Hospital, since the publication of the Community Hospital Services in Denbighshire Report in 2000. Current issues at Llangollen are:

■ The number of inpatient beds (18) falls well short of the minimum level of 30 beds recommended by the Welsh Assembly Government (WAG) for community hospitals12 ■ Current levels of utilisation: only 7 of the 18 inpatient beds were occupied during a visit on 19th October 2004 ■ Average bed occupancy during the 2003/04 financial year was only 58%, equating to an average of 8 empty beds ■ Despite this low utilisation, staffing levels remain at a fully utilised level, with 2 trained and 2 untrained nurses per day shift ■ The utilisation of the MIU, which was open 24 hours per day at the time of the review, is low and therefore requires a more in-depth analysis ■ Outpatient facilities are extremely limited, with only one clinic room available. However, this single room was not fully utilised ■ There is an empty building on the site, adding to overhead costs

3.7.8 Denbighshire LHB confirmed that Wrexham LHB is taking the strategic lead on Llangollen hospital. The current situation of low utilisation, and the consequent high levels of staffing, along with the inefficiencies in utilisation of the estate needs addressing.

3.8 Stakeholder Engagement

3.8.1 During the hospital visits in October and November 2004, a wide range of stakeholders were interviewed regarding their view on the community hospital services. Appendix A provides a list of stakeholders interviewed.

12 A framework of NHS Policies to Inform the Production of Local Action Plans in Wales: Welsh Assembly Government, December 2003, page 14

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3.8.2 During the course of the review, three stakeholder events were held. These were as follows:

■ Strategic visioning workshop: 8 November 2004 ■ Think tank workshop: 12 November 2004 ■ Options workshop: 29 November 2004

Strategic Visioning Workshop

3.8.3 This event was attended by the executive boards of the three organisations involved in the community hospital review (see Appendix B). This workshop identified two key needs:

■ The requirement to set the community hospital review within the wider context of primary and community services in general ■ Potential uses for community hospitals within the current framework

3.8.4 Each organisation accepted the importance of developing a detailed strategy for improving primary and community care and thus decreasing the reliance on the acute sector.

Think Tank

3.8.5 This half-day workshop was attended by 45 stakeholders (see Appendix C), including the local health boards, acute trust, social services and medical practitioners. Two distinct questions were addressed:

■ How could services be reshaped between hospital, community, social and primary care; that is, what services should be delivered outside acute hospital settings in the future? ■ What role could Community Hospitals play in delivering the reshaped service and what should the priorities be now?

3.8.6 With respect to the question about which services should be offered in the community in the future, two broad themes emerged from the think tank. It was felt that community and primary care services should be utilised to avoid attendance at an acute setting. In addition, these services could be used as a step down facility to allow rapid release of capacity in the acute sector, along with more local treatment and care. These outputs can be seen in Figure 11.

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Figure 11 - Key Outputs from Think Tank

Avoidance of Step down facilities acute setting

MIU/Urgent care

Diagnostics Intermediate care Active rehabilitation Respite •Post operative

Health promotion •Stroke Specialist clinics •Geriatric Chronic disease Palliative care

management Social care services

3.8.7 The second stage of the think tank developed a wide range of ideas of how community hospitals could contribute to this vision of community services as a whole. The output from this workshop can be seen in Appendix D.

3.8.8 This output from these workshops was used to develop a series of priority projects for consideration by the health community. These projects have a short to medium term timescale and aimed to help move the health community in the direction of their strategic vision. These priority projects will be discussed in further detail in Section 4.

Options Workshops

3.8.9 This event was attended by the executive boards of the three organisations involved in the community hospital review (see Appendix E).

3.8.10 This event considered specific areas of work, detailed in Section 4, that could be taken forward locally whilst the wider primary and community care strategy is developed.

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4 RECOMMENDATIONS

4.1 Introduction

4.1.1 The diagnostic phase of the work, along with an understanding of the wider context within which this review sits, enabled a series of conclusions and recommendations to be drawn. These vary from short term “quick wins” through to more medium and long term strategic developments.

4.2 Key Conclusions

4.2.1 The key conclusions drawn from the diagnostic phase are as follows:

■ There is a need to institute a programme of active bed management in the short term to increase efficiency and patient care. These measures will need to continue regardless of the eventual nature of the community hospital beds ■ The size, facilities, underutilisation of inpatient and MIU services and lack of adequate rehabilitation facilities at Flint undermine the long term viability of this community hospital, as it is currently configured ■ The size and underutilisation of Llangollen Hospital makes this an expensive and inefficient resource. Even with attempts to improve utilisation, the size of the hospital (18 beds) makes its long term viability an issue ■ There are a number of roles that the community hospitals can usefully play in helping move the health community towards an integrated community and primary care strategy

4.2.2 The Project Initiation Document identified criteria against which options for change might be assessed as follows:

■ Safe practice ■ Long-term sustainability of services ■ Financial viability of services ■ Impact of changes in terms of health gain or loss, effect on staff, financial consequences, effect on infrastructure and public reaction and political acceptability

4.2.3 We have taken these criteria into account in making the following recommendations.

4.3 Active Bed Management

4.3.1 Co-ordinated active bed management needs to be in place in the community hospitals. This will result in reductions in lengths of stay, enhanced ability to effectively plan services, a reduced backlog of patients in the acute sector and improvements in the ability of GPs to admit to the beds as a step-up facility.

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4.3.2 It is important to note that at each of the hospitals, there are areas of best practice and innovation with respect to managing patients actively; however, a lack of coordination across the sites negates the beneficial impact of this.

4.3.3 Regardless of what decisions are taken around implementing the priority projects outlined below or the future direction of community and primary services, we would recommend that the health community make instituting a process of active bed management an imperative.

4.3.4 The measures that we would recommend as necessary include the following:

■ Active discharge planning from day of admission to community hospital Redesign of admission pro forma with expected date of discharge Ensuring no delays in declaring patient medically fit for discharge Referral to social work on admission as opposed to the current system of referral when declared fit for discharge and improved co- ordination of patient care across health and social care professionals. Referral to the appropriate therapy services on admission Ensure proactive decision making so that patients are reviewed in a timely fashion, not just at the weekly MDT meetings ■ Provision of therapy 7 days per week ■ Coordination of access to community hospitals Ensure maximum utilisation Introduce arrangements for cross cover by primary care if admitted out of area Remove the practice of admitting patients only on certain days, depending on which GP they have ■ Review current model of medical management

4.3.5 Benefits from such initiatives include the following:

■ Improved patient care, outcomes and satisfaction ■ Decreased length of stay ■ Decreased variability in length of stay allowing a better planning of services

4.3.6 The investment required to institute this process includes the following:

■ Training and set up costs ■ Change management investment ■ Cost of enhancing the therapy establishment Potential requirement to increase the establishment Cost of training nursing auxiliaries to deliver therapy

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4.4 Flint Hospital

4.4.1 The size, facilities, underutilisation of inpatient and MIU services and lack of adequate rehabilitation facilities at Flint undermine the long term viability of this community hospital, as it is currently configured

4.4.2 The health community should consider how services in Flint can be provided more effectively and efficiently. This should be undertaken within the context of the projects recommended in this report and the strategy for developing primary and community services (to which we refer in Section 5 below).

4.5 Llangollen Hospital

4.5.1 The current size and underutilisation of Llangollen Hospital, in combination with continued high staffing levels, makes this an expensive and inefficient resource. Even if attempts to improve utilisation are successful, the size of the hospital (18 beds) makes its long-term viability an issue.

4.5.2 In the short term, we recommend that, as a matter of urgency, the health community ensures that utilisation of this facility increases. If this cannot be delivered, we would recommend that the staffing levels be brought to an appropriate level for the number of beds occupied.

4.5.3 As with Flint, the health community should consider how alternative and more efficient provision could be made for those patients who use the services of the hospital. Again, this should be undertaken within the context of the projects recommended in this report and the strategy for developing primary and community services (to which we refer in Section 5 below).

4.6 Priority Projects

4.6.1 As outlined previously, a series of priority projects were identified using the output from key stakeholders. It must be emphasised that these projects in themselves do not represent a strategy for community services in the future, nor do they represent the “future” of community hospitals. Rather, they are a set of projects that will contribute a series of valuable outputs, such as:

■ Enable the health community to move towards the development of the community and primary care strategy ■ Improve the services and level of care that is currently being provided by community hospitals ■ Make apparent to the health community the extent of organisational change that will be required in order to move to the Wanless and local visions of an integrated health and social care service that delivers high quality care close to home ■ Allow the community to fully evaluate the impact, including the benefits, risks and consequences, of the alternative models of care

4.6.2 We recommend that the health community make a formal decision about which of these projects to take forward, in which locations and their associated remits.

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Project management arrangements should then be put in place to ensure that the changes are instituted and the benefits delivered.

4.6.3 We believe that the implementation of active bed management, along with the identified priority projects, will lead to increases in capacity. It will be for the health community to decide whether these increases in capacity should be effected as savings or used to improve access and reduce waiting times.

4.6.4 The five identified projects are as follows:

■ Development of urgent care services ■ An actively managed rehabilitation service ■ Development of an inpatient intermediate care service ■ Development of an evidence base for community diagnostics ■ Health promotion and management of long term conditions

Urgent Care Services

4.6.5 The current provision of minor injuries services at the hospital sites is extremely inefficient. We therefore recommend that a coordinated approach to delivering urgent care should be developed and piloted. This should initially include the current minor injuries service with the opportunity for the project to be phased to also consider minor medical services at a later date.

4.6.6 Due to low levels of utilisation, we would recommend that the future viability of the MIUs at Llangollen and Chirk be carefully examined. It does not seem practical, either from a patient care or financial perspective, to maintain these services in the medium to long term.

4.6.7 Details of this project, including benefits, investment and high-level implementation requirements, can be seen in Figure 12.

Active Rehabilitation Service

4.6.8 Although the community hospitals aim to provide rehabilitation for both step down and step up patients, this very much occurs on an ad hoc basis. As a consequence, we recommend that the health community consider developing an actively managed rehabilitation service that is protocol driven. There are a number of requirements for such a service; these include therapy seven days per week and a tightly defined patient group.

4.6.9 The full details can be seen in Figure 13.

Inpatient Intermediate Care Services

4.6.10 Although there are elements of intermediate care already in existence within North East Wales, overall the service is not highly developed. We would recommend that the community hospitals provide a greater level of this service than currently. Two areas we recommend as a starting point would be:

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■ Inpatient intermediate care beds ■ Development of joint working between social and health care: Personal Support Workers

4.6.11 It is also important to note that there is a need to enhance, and potentially augment, the existing rapid response and re-enablement service.

4.6.12 The details of this project can be seen in Figure 14.

Evidence Base for Community Diagnostics

4.6.13 Attempts to move diagnostics out into a community setting are increasingly common across the UK. Indeed, community hospitals have played an integral role in this area.

4.6.14 However, it is important to assess the viability of such a move; hence, we recommend a project that scopes out an evidence base for this provision.

4.6.15 We have recommended two areas: echocardiography and endoscopy. The rationale for this choice was as follows:

■ Extensive waiting lists for both procedures, which are set to increase ■ Expressions of interest by local practitioners about moving these services to a community setting

4.6.16 We recommend that a feasibility study into the practicality of endoscopy as a community-based procedure be undertaken.

4.6.17 Full details of this project can be seen in Figure 15.

Health Promotion and Management of Long-Term Conditions

4.6.18 Our final recommendation is that the health community consider the development of a “primary care resource centre”. This is a key recommendation that arises from the Wanless review; in addition, at the Think Tank it was the most frequently suggested development area.

4.6.19 The details of this project can be seen in Figure 16.

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Figure 12 - Urgent Care Services

Description Improve the provision of urgent care services:

• Coordinated, local emergency care • Integrated emergency and medical service • ENP led • Utilise telemedicine

Benefits Improve patient access and quality of service

Potential cost efficiencies from consolidation of services Provides return on telemedicine capital investment Diverts activity from acute setting

Investment requirements Training and set-up costs Training and salary costs of ENPs Telemedicine running costs Expense of MIU units vs. A&E • Potentially off-set by efficiencies of amalgamated service

High level steps for implementation Establish pilot Collate best practice Resolve clinical governance arrangements Employ already trained ENPs to expedite delivery Train current staff as ENPs Develop telemedicine expertise

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Figure 13 - Active Rehabilitation

Description Managed rehabilitation service • Clearly defined group, e.g. post joint replacement, post stroke • Defined admission and discharge criteria • Protocol driven • Therapy driven

Benefits Improved patient care Acute beds freed up Increased ability to plan services Decreased length of stay Increased throughput of patients (waiting list impact) Cost efficient

Investment requirements Training and set-up costs • Both acute and community hospital sectors Appropriate level and usage of therapy staff

• 7 days per week • Specialist practitioners • New ways of working

High level steps for implementation Nurs e and therapy led beds pilot Develop strict pathways and protocols

• Collat e best practice • Ensure clinician support exists • Patient involvement • Ensure discharge planning occurs as early as possible in the patient pathway Develop clear medical model • Clarify clinical responsibility • Ensure appropriate governance arrangements

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Figure 14 - Intermediate Care Services

Description Development of joint social and health care work ers

Development of inpatient intermediate care beds Enhancement of rapid response service

Benefits Avoidance of admissions to acute sector Increased capacity due to earlier step down Provision of improved and seamless patient care

• Improved patient pathways • Personal support worker follows patient on discharge Increases joint working of the health and social care sectors

Investment requirements Training and set up costs Specific training costs of home care staff or nursing auxiliaries as Personal Support Workers Cross organisational boundary issues • Health and social care • Pooled funding • N.B. Examples of best practice are available

High level steps for implementation Establish pilot Develop admission and discharge protocols Develop fast track training programme for Personal Support Worker role • NAs and Home Care workers • N.B. National competency framework already exists Examine and possibly change ward skill mix

• Intermediate care status may allow a decrease in ratio of trained to untrained staff

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Figure 15 - Developing an Evidence Base for Community Diagnostics

Description Examine two potential areas • Echocardiography • Endoscopy

Benefits Minimise acute waiting lists Prevention of unnecessary consultant referrals Assist with cancer plan times/requirements Allows development of GPwSI role, improving recruitment potential

Investment requirements Capital cost of equipment • Endoscope/echocardiography unit • Sterilisation unit • Facility development Staff training and salary costs • GPwSI • Nurs e endoscopists • Cardiology technicians

High level steps for implementation Clinical Governance • Resolve clinical governance arrangements Echocardiography Pilot • Identify GPs with interest in developing cardiology service • Develop referral protocols Endoscopy Pilot

• Feasibility study o Cost of equipment o Potential utilisation o Training costs of GPs, nurse endoscopists

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Figure 16 - Improve Health Promotion

Description Design and develop community health and social care resource centre

Benefits Promotes Wanless recommendations for future services and focus on prevention and

intervention Local access for patients Single point of access for wide range of information and resourc es

Investment requirements Training and set up costs Infrastructure costs Running costs • Staff • Facilities Public relations management

High level steps for implementation Establish Pilot Resolve clinical governance arrangements Cons olidate a number of services into one location

• Clinics for long term conditions • Carer support • Expert patient programmes • Smoking cessation • Mental Health services • Citizens’ advice bureau • Other services: for community to decide

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5 NEXT STEPS

5.1.1 As we have noted earlier, this review takes place within a context of a number of other reviews of health care delivery in North East Wales. These include the review of orthopaedic services for North Wales and the North Wales review of acute and specialist services.

5.1.2 We recommend that, to complete this wider jigsaw of reviews and to benefit from their recommendations, the following steps should be taken:

■ Establishment of a Programme Management structure from the health economy to formally overview the various reviews and their impact. The Programme Board should understand the overall programme of work, develop further strategies that are needed (see next point), lead public engagement and communication and regularly review the activity and financial impact of service changes as they are proposed. The work will include taking forward recommendations in this Report and establishing the pilots. This role could be taken on by an existing group, if one exists that can fulfil the above function ■ Develop a detailed strategy that sets out the nature and scale of transfer of services out of acute hospital settings into community and primary care settings. This will include assessments of costs and savings, the impact on acute activity and the benefits from improved access ■ Develop a capacity planning and financial model for reviewing the impact of proposed and actual service changes across the health economy

5.1.3 We believe that these next steps will provide a framework for implementing the recommendations for Community Hospitals that we have set out in this report.

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Appendix A

Stakeholders Interviewed

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COMMUNITY HOSPITAL REVIEW

MOLD COMMUNITY HOSPITAL

14 OCTOBER 2004

Time Department Person/s Venue

9.00AM Physiotherapy Pat Venn – Splinting Room, Physiotherapy Occupational Superintendent Therapy Department Liza Mc Cloughlin – Senior Physiotherapist 9.30AM Occupational Vicky Small – Senior Splinting Room, Therapy I Occupational Occupational Therapist Therapy Department 10.00AM Coffee Break Dining Room 10.15AM Day Hospital Written Report Quiet Room – Day Hospital 10.30AM Home Carers Jane Colburn Quiet Room – Day Hospital 11.00AM Social Workers Lynn Hawtin – Social Quiet Room – Day Work and Purchasing Hospital Manager, Adult Social Care Accompanied by a Social Worker 11.30AM Ward Manager Sister Phoebe Laurie Quiet Room – Day Inpatients Hospital 12.00 Noon Senior Staff Nurse – Senior Staff Nurse Quiet Room – Day Nights to discuss Edith Jones Hospital Minor Injury Department 12.30PM Lunch Dining Room 1.00PM Reception – Lynn Tompkin – Quiet Room – Day Outpatient activity Medical Records Hospital Supervisor/ Deputy Administration Manager for Flintshire 1.30PM Hospital Manager/ Shan Warburton – Quiet Room – Day Service Development Hospital Manager Hospital Lead for Wrexham and Flintshire sites 2.00PM General Practitioner Dr Muckle-Jones Quiet Room - Day Pendre Surgery, Hospital Mold and Dr Dymock – Bradleys Practice, Mold 2.30PM onwards 3 hours point prevalence for hospital walkabout

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COMMUNITY HOSPITAL REVIEW

DEESIDE COMMUNITY HOSPITAL

15 OCTOBER 2004

Time Department Person/s Venue

9.00 AM Hospital Manager Dee Begbie SEMINAR ROOM

9.30 AM Flintshire Out of Toni Glavin SEMINAR ROOM Hours Service

10.00 AM Chiropody Clive Cook SEMINAR ROOM

10.30 AM Occupational Alison Ravenscroft SEMINAR ROOM Therapy Kim Gilligan

11.00 AM COFFEE BREAK

11.30 AM

12.00 Noon

12.30 PM GP’s Dr David Morris SEMINAR ROOM Dr Colin Barnard

1.00 PM LUNCH

1.30 PM Executive Nurse Val Doyle SEMINAR ROOM

2.00PM Social Services Lyn Hawtin/Sue SEMINAR ROOM Catherall 2.30 PM Physiotherapy Valerie Fletcher SEMINAR ROOM

3.00 PM Dietetics Penny Cowley SEMINAR ROOM

3.15 PM Speech Therapy Sue Kirk SEMINAR ROOM

3.45 PM League of Friends Kath Fox/Megan SEMINAR ROOM Jolly 4.15 PM

5.00 – 6.00 PM WARD

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COMMUNITY HOSPITAL REVIEW

FLINT & HOLYWELL COMMUNITY HOSPITALS

18 OCTOBER 2004

Time Department Person/s Venue

9.00 AM Social Services Sue Catherall Flint Hospital

9.45 AM Hospital Manager Dee Begbie Flint Hospital

10.30 AM Coffee Break

11.15 AM Ward Manager Penny Gillespie Flint Hospital

12.00 NOON Elderly Mental Health Julie Roberts Flint Hospital

12.30 PM GP DR DANIELS Flint Hospital

1.00PM LUNCH

2.00 PM Hospital Manager Dee Begbie Flint Hospital

2.45PM WARD FLINT Point Prevalence – Flint Hospital Ward sister

3.30 PM Imaging John Collins Flint Hospital

4.00 PM WARD HOLYWELL Point Prevalence – Holywell hospital ward sister

NOTE: Stakeholders to discuss Flint and Holywell hospitals at the Flint venue.

Follow-up interviews held with:

Dr Fernando Consultant Geriatrician NE Wales NHS Trust Dr Major GP Holywell Dr Jones GP Holywell

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Chirk Community Hospital Community Hospital Review by SECTA

Tuesday 19 October 2004

Time Name Service/Department

8.30am Carole Davies Hospital Services Manager, Chirk

Wrexham Team Co-ordinator

9.00am Sr Julie Mackreth Ceiriog Ward (Point Prevalence)

11.00am Fiona Salomonson Occupational Therapy

11.30am Liz Jones Community Midwife

12.00 midday Dr Husain Cefn Mawr GP Practice

12.30pm Dr R Davies Llangollen GP Practice

1.00pm LUNCH

1.30PM Dr R Greaves Chirk GP Practice

2.00pm Annette Green Ruabon Social Services

2.30pm Sr Carolyn Roberts Day Hospital/MIU/OPD

3.00pm Aileen Mills Physiotherapy

3.30pm Sr Julie Mackreth Ceiriog Ward

NB: Morning visit to Llangollen Hospital in parallel to the above

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Appendix B

Attendees at Strategic Vision Workshop

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ATTENDEES AT STRATEGIC VISION WORKSHOP ON 8 NOVEMBER 2004

Hilary Pepler, Chief Executive North East Wales Trust Mark Common, Deputy Chief Executive & Dir of Ops Neil Bradshaw, Director of Planning Peter Rutherford, Medical Director Val Doyle, Executive Nurse Wayne Harris, Director of Finance Richard Tompkins, Director of Human Resources

Geoff Lang, Chief Executive Wrexham Local Health Board John Darlington, Director of Development & Performance Management Sue Willis, Executive Nurse Bob Evans, Director of Finance Mike Gareh, Medical Director

Andrew Gunnion, Chief Executive Flintshire Local Health Board Phil Jennings, Director of Development & Performance Management Nesta Rees, Director of Nursing Colin Jenn, Director of Finance Janette Fells, Medical Director Mary Popplewell, Clinical Governance Manager Mr P Bowker, Primary Care Manager Dr. S Jones, General Practitioner

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Appendix C

Attendees at ‘Think Tank’ Workshop

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NORTH EAST WALES REVIEW OF COMMUNITY HOSPITALS

“Think Tank" 12th November 2004, Attendee list:

Hilary Pepler, Chief Executive North East Wales Trust Linda Fellowes, DGM – SATCH Geraint Owens, Clinical Director CF&C Chris Cefai, Clinical Director for Pathology Dee Begbie, Community Hospitals Manager Peter Billings, Consultant Surgeon Mark Common, Deputy Chief Executive & Dir of Ops Richard Tompkins, Director of Human Resources Jon Falcus, DGM – Medicine Neil Bradshaw, Director of Planning Simon Pyke, DGM – Mental Health Amanda Lonsdale, Asst DGM Mental Health Julie Roberts, Service Manager – Older Persons Mental Health John Harvey, Clinical Director - Medicine Matthew Makin, Trust Clinical Cancer Lead Lloyd Fitzhugh, Chairman Peter Rutherford, Medical Director Carole Condren, Clinical Governance Manager Robin Wiggs, DGM – Clinical Support & Diagnostics Val Doyle, Executive Nurse Andrew Scotson, Corporate Support Manager Mike Lugg, Head of IT Graham Alexander, DGM – Estates and Facilities Mike Prew, Community Sites Manager/Head of Nursing Mark Scriven, Clinical Lead for IM&T Mike Pollard, Clinical Director Pharmacy Carole Davies, Community Hospitals Manager John Darlington, Director of Development Wrexham Local Health Board & Performance Management Dr Peter Saul, GP & Board member Helen Lumb, Primary & Intermediate Care Modernisation Manager Sue Willis, Executive Nurse

Gareth Davies, Commissioning and Performance Manager Flintshire Local Health Board Paul Bowker, Primary Care Manager Andrew Gunnion, Chief Executive Dr Steve Jones, General Practitioner Phil Jennings, Director of Development & Performance Management Dr Tim Davies, General Practitioner Nesta Rees, Director of Nursing

Ian Howard, Director of Planning Conwy & Denbighshire NHS Trust Liz Morgan, General Manager Conwy & Denbighshire NHS Trust Lin Hawtin, Social Work & Purchasing Manager Adult Social Care Flintshire Maureen Mullaney, Asst Director Community Care Flintshire Social Services Yvonne Hughes, Service Manager, Adult & Elderly Care Denbighshire Social Services Jackie James National Public Health Service Sarah Thelwal – rep. Sheila Wentworth Wrexham Social Services Audrey Houghton, Patient Access Manager Countess of Chester Hospital

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Appendix D

Outputs from ‘Think Tank’ Workshop

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Breakout Group Feedback

Group A Session 1

• Need for local service to prevent social exclusion • Need to reshape transport • Public/private initiatives o Treatment centres o Low risk procedures o Day case surgery

• Diagnostic services o e.g. ultrasound, Endoscopy

• Rehabilitation service integrated with social services • Resource centre • Health education o Professional education

• Admission avoidance schemes o Integrated out of hours service o Flexible access to community hospital o Increased integration with other services o 24/7 service at first point of contact o Full range and menu of services o Intermediate care

• Improved admission process and procedures

Session 2

• Intermediate care facilities o Chronic disease o Crisis support

• Increased rehabilitation post-operatively o Increased therapy levels

• Increased diagnostic facilities

• Underpinned by: o Bed management model and specification o Health and social care generic worker/partnership o Improved IT links to support chronic disease

Group B Session 1

• Acute sector should be used for what it alone can deliver, that is, acute and specialist care • If services are to be moved into the community/primary care setting, there is a need to build up the infrastructure o Likely to require pump-priming • Public involvement will be essential

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• Joint working between LHBs, SS and acute sector essential • NB rationing of care may act as constraint

• Services that could be delivered in the community o MIU, minor illness management (including triage from A&E) o Outpatients – consultant outreach services o Diagnostics o Day surgery o Day care services o Mental health services o Learning disabilities services o Health promotion o Long term conditions o Rehabilitation o Equipment services o Intermediate care o Step up and step down facilities o Continuing care o Respite care o Palliative care o Nurse led services including enhanced role development o Carer breakdown services o Pharmacy o Dental services

Top three issues

• CDM • 24/7 crisis support – alternatives to hospital admission • Diagnostics

Session 2

• Integrated health and social care centre o Access point o MIU • Hub for primary care and social care services • Resource centre • Centre of locality networks • Assessment • Admission avoidance • Admission criteria – linked to care pathways • Needs of patient to be central to services delivered • Out patient/day facilities • Telemedicine • Health promotion • Diagnostic facilities • Therapy services • 24/7 service (including OOH)

Top three!

• Review access and referral criteria for health and social care centre • Review roles and responsibilities of professionals • Review role of existing facilities • Develop infrastructure to support service delivery

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• Underpinned by: o Public and staff engagement o Redesign of services o Political cover

Group C Session 1

• Continuum exists from primary to tertiary care o Admission to a bed should occur only when it is clinically required, that is, we should aim to manage as much in primary care as possible

• Need for care pathways/protocols • Secondary care “consultation”

• Single point of access giving rise to full menu of services: o GPwSI o Specialist practitioners o Skill mix appropriate to care o Generic workers o Prevention services (patient MOT type service)

• Barriers o Organisational boundaries o Resources o Professional boundaries o Legal issues o Cultural issues o Risk aversion

• Need board level appointments • Joint leadership and ownership

Top three

• Management of people in community setting • Produce pathways for 75% of conditions • Provision of care in areas such as diagnostics, carer support

Session 2

• Extended and integrated primary care team • Generic worker o RR/re-enablement • Robust care pathways • Locality hub • Differentiated hospitals across the area • Nurse led, protocol driven – pilot in MIU • Orthopaedic step down • Diagnostics – echo • Medical OPD – nurse led • Minor ops – GPwSIs

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Top three

• Mapping out what specialist services could be provided in the community hospital in the future o Not all services in all settings o Focus on non-inpatient specialties first, as more straight forward • Nurse led services o MIU • Step down for orthopaedics • Diagnostics, e.g. echo

Group D Session 1

• Diagnostics and investigations outside of the acute sector • Focus on patient needs o “patient pathway” • Eliminate steps between elements of care • Make individuals aware of existing services • Health resource centres • Active community and inpatient rehabilitation o Intermediate care

Top three

• Reshape primary care, moving from GP focus o Encompass range of professions and therapies o Integration with social care – pooled budgets

• Early prevention of disease o Active management of LTC – admission prevention o Patient empowerment – self management o Secondary care outreach services to support this • Rehabilitation capacity near patients home o Not hospital environment o Re-enablement o May need change in workforce planning

Session 2

• Re-brand/redefine CH as Health and Wellbeing Centres o CAB o Health promotion o LTC • Urgent care services o Single point of access o ENP o Telemedicine o Links to SS/rehab teams • Pilot an actively managed rehab service o e.g. Post joint replacement o Protocol driven o Clearly defined

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Group E Session 1

• Achieve investment in community and primary care • Alter models to deliver care closer to home • Reshape medical model – rehab and re-enablement teams • Resource centres o Range of individuals/professions

Session 2

• Re-commission buildings as combined health and social care facilities o Resource concept with IT links – e.g. telemedicine

• Consider what acute services could be delivered here to avoid admissions • Remodelling of day hospital and day care o Out reach services o Integrated team with beds o Remodel medical provision

• Patient and staff involvement essential

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Think Tank Priorities

Group A

• Intermediate care services o Management of long term condition o Crisis support

• Improvement of post-operative rehabilitation o e.g. orthopaedics

• Increased diagnostic facilities in community

• Bed management model and specification

• Development of Health and Social Care Generic Worker

• Improvement of IT links

Group B

• Integrated health and social care centre o Review access and referral criteria

• Review roles and responsibilities of professionals and facilities working

• Develop infrastructure to support service delivery

• Need for public involvement

Group C

• Map out purpose of CH in each location o General and specialist functions o Initial focus on non-IP functions e.g. dermatology and rheumatology, as more straight forward

• Nurse led MIU/telemedicine

• Step down orthopaedic service

• Diagnostic services – e.g. echocardiography, GPwSI

Group D

• Re-branding of CH as Community Health and Well Being Centres o CAB o Health promotion o Long term conditions

• Change MIUs to Urgent Care Services o Single point of access o ENPs o Telemedicine o Link with SS and rehab teams

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• Pilot of a managed rehabilitation service o Tightly defined areas, e.g. stroke, orthopaedics o Protocol driven o Defined end-point o Compare Wrexham and Flintshire?

Group E

• Re-commission buildings as “Health and Social Care Resource Centres”

• Develop admission avoidance programme o What acute services can be delivered in community to aid this

• Consolidation/remodelling of Day hospital and Day centre services o Develop outreach teams o Integrated team with beds o Remodel medical provision o Diagnostic work around what needs doing

• Public involvement

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Appendix E

Attendees on Options Workshop

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Attendance for Options Workshop on Monday 29th November 2004

1 Hilary Pepler Chief Executive North East Wales Trust Attending 2 Mark Common Deputy Chief Executive & Dir North East Wales Trust Apologies of Ops received 3 Neil Bradshaw Director of Planning North East Wales Trust Attending 4 Peter Medical Director North East Wales Trust Apologies Rutherford received 5 Val Doyle Executive Nurse North East Wales Trust Attending 6 Wayne Harris Director of Finance North East Wales Trust Attending 7 Richard Director of Human North East Wales Trust Attending Tompkins Resources 8 Geoff Lang Chief Executive Wrexham LHB Apologies received 9 John Darlington Director of Development & Wrexham LHB Attending Performance Management 10 Sue Willis Executive Nurse Wrexham LHB Apologies received 11 Bob Evans Director of Finance Wrexham LHB Attending 12 Mike Gareh Medical Director Wrexham LHB Apologies received 13 Andrew Chief Executive Flintshire LHB Apologies Gunnion received 14 Phil Jennings Director of Development & Flintshire LHB Attending Performance Management 15 Nesta Rees Director of Nursing Flintshire LHB Attending 16 Colin Jenn Director of Finance Flintshire LHB Apologies received 17 Janette Fells Medical Director Flintshire LHB Apologies received 18 Mary Clinical Governance Flintshire LHB Apologies Popplewell Manager received 19 Mr P Bowker Primary Care Manager Flintshire LHB Attending 20 Dr. S Jones General Practitioner Flintshire LHB Attending

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Appendix F

References

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Community Hospital Review

The review of Health and Social Care in Wales: The Report of the Project Team advised by Derek Wanless, June 2003

Good Health: Health, Social Care and Well-being Strategy for Flintshire

Caring for our Health; The Health, Social Care and Well-being Strategy for Wrexham 2005- 2008

North East Wales NHS Trust: Shaping the Future

A Framework of NHS Policies to Inform the Production of Local Action Plans in Wales: Welsh Assembly Government, December 2003

Review of Health and Social Care in Wales, Flintshire Wanless Local Action Plan, April 2004

Wrexham Local Wanless Action Plan

Denbighshire Local Health Group, Community Hospital Services in Denbighshire

Good Health – Draft Health, Social Care and Well Being Strategy for Flintshire, Flintshire LHB

An Integrated Healthcare Strategy for Primary Care Premises in Wrexham 2005 – 2015, Prepared for Wrexham Local Health Board, August 2004

Innovations and Best Practice in Community Hospitals 2000

Innovations and Best Practice in Community Hospitals 2001

Innovations and Best Practice in Community Hospitals 2003

Annual Report for the Community Hospitals (Flint, Chirk, Holywell, Deeside and Mold) – 2003/04

North East Wales NHS Trust, Mold Community Hospital, Annual Report 2003/2004

North East Wales NHS Trust, Chirk Community Hospital, Quarterly Report, 2004/2005

North East Wales NHS Trust, Community Directorate, Report and Analysis on Community Hospitals, Staffing/Skill Mix of Inpatient Services

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Community Hospital Review, Mold Community Hospital, October 2004

Welcome to Chirk Community Hospital

Operational Policies for MIU and OPD

Facilities Directorate Level 2, North East Wales NHS Trust, Costs

Care Pathways – North East Wales Community

The NHS Estate in Wales – Estate Condition and Performance Report Supplement 2003/04, Welsh Health Estates

North East Wales NHS Trust, Directorate General Manager’s Report, Inpatients, Daycases and Outpatients as at 31st March 2004, Activity Performance Information, supplied by the Information Department

North East Wales NHS Trust, Estate Strategy, December 2003

North East Wales NHS Trust, Minimum Data Set

North East Wales NHS Trust, Finance Report to Trust Board for period ended 31st July 2004; Month 4, dated 26th August 2004, by Wayne Harris, Finance Director

Llangollen Hospital Bed statistics and MDS 2003/04

Imaging Services Statistics for the Community Hospital 2003/04

Final Draft of North Wales Capacity Project Report, Stuart Wooler, September 2003

Staffing numbers and Sickness Levels, NE Wales

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