Ymddiriedolaeth GIG Hywel Dda NHS Trust

Review of the Alignment of Services between the Proposals for the Development of new Health facilities at , Cardigan and Tregaron and services provided from Bronglais Hospital,

May 2008

Contents

Page

1. Terms of Reference 3

2. Introduction and Background 3

3. Aberaeron Hospital 3

4. Tregaron Hospital 7

5. Cardigan Hospital 8

6. Local Health Board - Consultation on Community Services 10

7. What can appropriately be undertaken or devolved to these community hospitals? 10

8. Supporting Early Discharge 11

9. Governance Arrangements 11

10. Benefits of a Nurse-led Service 12

11. Shared Care Model for Continuing Care 12

12. Sustainability 12

13. Conclusion and Recommendations 13

Appendix A

Models of Care in and Elsewhere 17

2 Ymddiriedolaeth GIG Hywel Dda NHS Trust

Review of the Alignment of Services between the Proposals for the Development of new Community Health facilities at Aberaeron, Cardigan and Tregaron and Services provided from Bronglais Hospital, Aberystwyth

Terms of Reference

1. In the light of services currently provided at Bronglais Hospital, Aberystwyth and proposals for the development of new community health facilities at Aberaeron, Cardigan and Tregaron, to assess and report on: i) What can appropriately be undertaken or devolved to these community hospitals from Bronglais Hospital, in a cost effective and sustainable way, across the spectrum of care of diagnostics, therapies, inpatients and outpatients; ii) What model should be used, with reference to the models in place and being developed in other parts of Wales and further afield (South Pembrokeshire Hospital, Tenby and the emerging model in Builth Wells).

2. In relation to the model, to take into account work already undertaken in relation to the role of the three facilities and the intentions of the local authority, with regard to the development of local community services and consider: i) How could these facilities be used to support early discharge from Bronglais Hospital; ii) If there are to be beds, what should the governance arrangements be; iii) The potential benefits of a nurse-led service/unit; and iv) The most appropriate shared care model for Continuing Health Care.

1. Introduction and Background

The purpose of this paper is to consider the current proposals for the development of new community health facilities in Ceredigion and to assess what services can appropriately be undertaken or devolved to these hospitals from Bronglais, in a cost effective and sustainable way, across the spectrum of care of diagnostics, therapies, inpatients and outpatients.

Details of the three Community Hospitals within Ceredigion, situated in Aberaeron, Tregaron and Cardigan, are shown in sections 2, 3 and 4 below.

2. Aberaeron Hospital

• 17 Miles from Aberystwyth. • Outpatient facility only (no inpatient beds). • Base for health and social care staff. • Contract let for 3rd party developer to create integrated community resource centre.

Aberaeron Hospital was established in 1916, funded from public subscriptions. Until 1999, it operated as an inpatient community hospital for local residents, but because of clinical governance and cost effectiveness issues, the beds closed and the site became a base for the provision of outpatient and community health services, as well as providing accommodation for multi-agency and multi-professional teams.

The fabric of the current hospital building is dilapidated and whilst the in-patient beds have been closed for some time, the existing hospital building has since remained open and the use of the

3 hospital as a base for community health and social services staff has been maintained since that time, with additional clinics provided on site.

When the inpatient beds were closed, the Health Authority announced a review of provision and gave a commitment to the development of a multi-agency integrated centre to replace the old building. A Project Management Board was set up and it was agreed that the project should proceed as a primary care development via the primary care funding route, led by Ceredigion LHB.

The principles underpinning the model of care were that:

• People should be able to access care as safely and as locally as possible utilising both primary care services and secondary care services based in community settings. • The provision of appropriate care in local settings maximises the ability of people to remain in their own homes rather than relying on inpatient, residential or nursing home services. • By working together, service providers can ensure that appropriate care is delivered by appropriate people at the appropriate time. • Modern service provision is not about one service working in isolation, but about all services which an individual needs including services offered for health, social care, housing, education, recreation, benefits and the wide range of services offered by voluntary organisations. • The strategic goals of Designed for Life and the Wanless Report would be incorporated into future service provision.

The proposed model of care in the original business case documentation (1998) was to provide an integrated response service as first contact point for new clients and a support and resource centre for patients with chronic and complex needs. The objective was to draw on available services within Ceredigion health, social and voluntary services, to provide a rapid, holistic response to keep clients safe in their own homes. The final model of care was developed by the Clinical Services Operational Development Group and adopted by the Project Management Board. The focus is the principle of local care delivered at a local level and has identified the following enablers as the basis for the development of successful and sustainable health services:

• Access – this refers to better access to services that are currently oversubscribed or under- resourced which typically results in long waiting lists, along with improving access to advice and information and to services by extending the hours that they are available, and creating access to multi-functional space within the new facility. • Communication – better communication and information sharing is envisaged to ensure that everyone involved with the care and treatment of an individual will have timely access to relevant information. This will come about through a range of developments such as co- location, multi-disciplinary team meetings, video conferencing, and improved/compatible IT systems fully acknowledging the requirements of the data protection act. • Skills-sharing – co-location, improved integration and information sharing will provide an environment for increased learning and skills sharing within and across teams and disciplines. • Flexibility – the design of the facility must include multi-functional space and as many shared facilities as possible, plus must have the capacity to accommodate evolving patterns of health and social care delivery into the future. Flexibility also refers to the willingness to explore and commit to different ways of working to make the best use of resources in the area. • Integration – this is more than simply co-locating services within the new facility and refers to the changes in work practice that will bring services and information together to provide improved holistic, user-centred services. Mental health services is an area where improved integration between primary and secondary health care, social care and voluntary sector providers can result in significant improvements in the speed and quality of the services provided to users. • Prevention – this crucial element to healthy living and avoiding crisis health and social care intervention is manifested through encouraging and harnessing the enterprising expertise of the voluntary sector, recognising the importance of early, low level health and social care

4 interventions, providing joined up advice and information, and exploiting the benefits of new technologies in video conferencing, streaming diagnostic test results, telecare and telemedicine services. The role of primary health care providers is central to the success of the prevention strategies and long term health improvement of the population to reduce some avoidable causes of ill health. • Maintaining independence – by providing services as close to people’s homes as possible, integrating the care provided across disciplines and promoting preventative health and social care measures, people will be able to maintain their independence for as long as possible. • Sustainability - an environmentally sensitive approach to building design, materials, construction and management constitutes one aspect of sustainability, but this also refers to the flexibility agenda of creating spaces that retain their viability as service provision changes over time as well as acknowledging the need to ensure effective use of the resources allocated to the area.

The preferred site for the integrated facility is adjacent to the Local Authority offices in Aberaeron. One of the local GP practices will be accommodated within the building and the other GP practice in the town wishes to develop links with the facility for training, telemedicine and intermediate chronic disease management purposes. In addition members of the adult social care team and the Sure Start team will be relocating and community mental health services intend to use the facility on a sessional basis. It is also envisaged that a dental practice and pharmacy services will be developed in the facility. There will also be a range of flexible space that may be utilised by voluntary groups and the local community. This provides the Trust with the opportunity to develop good working relationships and links with these teams and services by co- locating within this development.

The services to be provided in the new centre are set out below. GP Practice - using the new GMS contract provision of enhanced services to provide services locally. Nurse Led Services (2 room) Including: leg ulcer management, health care assessments, ECGs, phlebotomy, pre- operative assessments, field of vision measurement and ante-natal assessments. Consultant Led Clinics (3 rooms) It is envisaged that there will be full utilisation of the 3 rooms on a timetabled basis. The clinics to be provided are: Ophthalmology, Orthoptist and Diabetic Retinopathy Screening. There are many developments to be taken forward in Ophthalmology by the Service Group of the Three Counties Planning Forum. These developments include; • Establishment of Lucentis Macular Service for the region • Teleophthalmology in Community hospitals. • Development of Ophthalmology Electronic Patient Record (EPR) system as part of the Welsh Clinical Portal • Shared care with optometrists for long term glaucoma follow ups in light of increased workload from the Lucertis Service Aberaeron is geographically well located to take additional macular referrals from South Ceredigion, Pembrokeshire and Carmarthenshire. The new building plans include: • a consulting room • a room for OCT/fundus imaging • a room for telemedicine/ teleophthalmology/ GP training for ophthalmic emergencies • Provision for EPR/Welsh Clinical Portal with appropriate computer screens in clinic with links to GP’s and Optometrists. General Medicine and Movement Disorder Clinics The integrated service will incorporate chronic disease management which will include involvement of the specialist nurse for Parkinson’s Disease, Incontinence Advisory Nurse, Dietician, Physiotherapist and Occupational Therapist (N.B. funding required) and will ensure local access and excellence.

5 The new facilities will increase the clinic usage through development of telemedicine neurology clinics and nurse led muscular sclerosis clinics, which are an under-developed and much needed service in this area. Gynaecology The gynaecology service has recently been enhanced through the purchase of a portable TVS ultrasound scanner. This allows the consultant to provide a one stop service which includes diagnostic investigations and fitting of IUCD’s for complex reasons and HRT implants. Waiting list initiative clinics can also be booked here. The service would benefit if the Continence advisory nurse could be scheduled at the same time, which up until now has not been possible from lack of room availability. Paediatrics The benefit of holding paediatric clinics is the on site accessibility of the school nurse and health visitor e.g. investigating DNA’s and the children have less time away from their education. Family planning This service is under utilised due to the inflexibility of the clinics and the incumbent skill mix of the staff. The sexual health team are currently addressing the situation through training of nursing staff with a view to set up a weekly nurse led regular service to include well women assessment and all aspects of sexual health. This will expand the Genito- Urinary Medicine service to ensure clients’ ability to access advice within 48 hrs in line with Annual Operating Framework (AOF) Targets. Diabetes The management of diabetes as a chronic disease needs to be monitored and treated locally in line with current WAG strategy. These patients are seen in numerous clinics at Aberaeron, for example ophthalmology, podiatry, dietetics, diabetic nurse specialist and leg ulcer clinics. Co-ordinated patient management would ensure quality care and improved efficiency in terms of transport and cost effectiveness. A one stop service would lead to better use of consultant time. Physiotherapy services (1 room) Including assessment and treatment – 3 treatment beds. Better use of these facilities would also include pre-operative assessment for arthroplasty. Stroke assessment and rehabilitation would also then be possible because of the presence of an OT. Podiatry services (1 room, including storage) Dedicated room with I chair, allowing for a full range of podiatry services, including nail surgery, orthotic services i.e. specialised shoes and raises Audiology services (1 suite) Specialist paediatric audiology services for the whole of Ceredigion are currently provided from Aberaeron Hospital along with new born screening. Adult audiology services include hearing assessments, hearing aid repairs and fittings. The expansion of the DR service is also planned, which initially will be based at Aberaeron to facilitate travelling for staff members. Counselling Room (1 room – non-clinical) This is used by speech and language therapists, dieticians, specialist nurses, clinical supervision. Reablement Team/Occupational Therapy A base for the Reablement Team/Occupational Therapy staff. Supporting Space Requirements As well as the above, the facility will provide space for the following: • Patient/waiting/reception/public WC services • Meeting rooms/staff/kitchen/lockers • Office accommodation for Head of Podiatry, 3 district nurses, 3 health visitors + 1 student, 1 Macmillan nurse, 2 school nurses + 1 student, 3 outpatient nurses, 3 community midwives, 1 audiologist, 1 outpatient/site manager, Reablement Team/Occupational Therapy and Community Mental Health staff

6 • Utility space, plant & stores.

There is a significant opportunity to expand the services provided in the facility in order to support the Trust’s attainment of waiting times targets. This could be by the provision of additional consultant sessions in the evenings or by innovative services such as nurse led treatment and discharge, chronic disease management and with more diagnostic resources being provided in local settings.

Approval has been agreed for the development of the new building and the contract has been let for a third party developer to construct the new centre. Discussion is currently taking place about the revenue consequences of the scheme, which has delayed the start of the construction programme.

Project Team members have raised concerns that the new building has been designed as a direct replacement for existing services and that there is little potential for expansion and ‘future- proofing’. This is due to the funding route via a third party developer, which means that the revenue costs of the scheme will increase if additional floor space is required. It is recognised that costs have to be contained within the existing financial envelope.

3. Tregaron Hospital

• 18 miles from Aberystwyth. • 29 inpatient beds (mainly accepting discharges from Bronglais General Hospital). • Minimal outpatient activity (Physiotherapy and baby clinic). • Base for health and social care staff.

Health services in Tregaron originally developed from a Victorian Workhouse that was established at the end of the Drover’s line. The workhouse building is still in existence and houses some support services, although the main ward block is a 1980’s build and in reasonable condition. As part of a Strategic Outline Case presented to WAG several years ago, plans were established to demolish the old building and co-locate the local GP surgery (currently housed in very poor accommodation) plus a Local Authority Residential Home with the potential for extra-care housing on the Tregaron Hospital site. The old building is in a significant state of disrepair and remedial arrangements are in place to secure the safety of users of the site.

The standard of patient care provided at Tregaron is good, the majority of which is Nurse and Therapist-led, with medical input from three Clinical Assistants from the Tregaron GP Practice. One of the issues from a governance perspective is that the GPs are not clinically attached to a specific Consultant and there is some debate about where clinical responsibility lies.

Over the past 3 years there has been considerable discussion with staff and within the community regarding the future of services in Tregaron and the need for inpatient beds in particular. Bed occupancy is high and the beds are used for step up/step down, rehabilitation (orthopaedics and general medicine patients) palliative care and end of life care.

There are several key factors underpinning the need for local health and social services provision in Tregaron as follows:

• The GP practice premises in Tregaron are totally unsuitable for modern healthcare needs with Disability Discrimination Act (DDA) compliance constraints • The Local Authority Residential Home in Tregaron is also in need of modernisation to meet compliance standards • There is no supported housing in the Tregaron area (where much of the local housing stock is significantly sub-standard) • The hospital is used for rehabilitation with most patients being discharged from Bronglais. • The majority of residents of the Tregaron area access acute health care and outpatient services from Bronglais Hospital 18 miles away in Aberystwyth, so there are strong clinical links in existence.

7

3.1 Outline Business Case

An Outline Business Case was under development, but was put on hold pending the outcome of the Community Services Review.

4. Cardigan Hospital

• 40 Miles from Aberystwyth, 31 Miles from Carmarthen and 34 miles from Haverfordwest. • 21 Inpatient GP Medicine beds, accepting admissions of patients who are registered with the GP Practices in the Bed Fund arrangement; • X-Ray, Outpatient and Diagnostic services. • Minor Injuries Unit and base for GP Out of Hours service • Base for health and social care staff. • Deals mainly with discharges from West Wales General Hospital and Withybush Hospital, with extremely few patients from Bronglais Hospital.

4.1 Outline Business Case

An Outline Business Case is under development for an integrated health and social care centre, with a preferred site identified. The proposal is to replace the existing Community hospital with a new facility for a number of reasons. The environment and fabric of the building is very poor and there are few single rooms, which makes it difficult to accommodate patients being transferred from other hospitals and results in inability to isolate patients with infection.

Significant delays have been caused by site access issues and until these have been resolved, the Outline Business Case cannot be resubmitted. This represents a significant risk to the project.

4.2 Model of Care

In order to determine the model of care, a formal option appraisal workshop was held on 18 April 2007 at which it was agreed that the following essential components should be provided in the new development:

• GP Practice co-located or adjacent, using the new GMS contract provision of enhanced services to provide services locally. • Day Hospital • Minor Injury Unit • Outpatients • X-Ray • Therapies o Physiotherapy o Occupational Therapy o Speech and Language Therapy o Podiatry o Dietetics • Telemedicine o Videoconferencing o Image transfer o PACS • Office base for integrated health and social care teams, including mental health • Inpatient Beds o “Step-up/Step-down” care o Palliative care/End of life care o Rehabilitation o Reablement/Intermediate Care o Joint health and social care assessment

8 Considerable debate took place about the need for inpatient beds and the number of beds required in the new development and a range of options were costed, including an integrated centre with a) no beds, b) 8-10 beds, c) 22 beds, and d) with 30 beds.

4.3 Medical Input

An essential component of the integrated health and social care development is the inclusion of the Cardigan Health Centre General Practice. However, the GPs are currently considering alternative sites for a new health centre, due to delays in securing the site. Discussions with the GPs are continuing with the aim of ensuring that the new GP Practice premises are located directly adjacent to the new building, if they cannot be integrated into the new development.

Medical input to the inpatient beds at Cardigan Hospital is in the form of a GP bed fund arrangement at present. Admission to the beds is only permissible if the patient is registered with one of the GP practices in the bed fund, which are Cardigan Health Centre; Ashleigh Surgery, Cardigan; Meddygfa Emlyn, Newcastle Emlyn; Crymych Surgery; Newport Surgery.

Admission criteria for the new facility would need to ensure equity of access for all patients who meet the criteria irrespective of their GP practice registration in order to meet the fundamental principles agreed for the new facility and to meet the requirements of the Community Services Strategy.

The total budget for the Bed Fund is circa £45,000 per annum. It is assumed that any alternative models of medical staffing would need to be contained within this existing financial envelope. Other alternative models of care could be nurse-led or therapy-led.

4.4 Nursing Input

Although a decision has not yet been made about the number of inpatient beds required on site, the nurse staffing profile would be based on the following principles:

• A requirement for a minimum of two qualified staff on every shift. • A Band 7 nurse on site between the hours of 9am to 5pm Monday to Friday, to act as Site Coordinator. • A Band 6 ward-based nurse working early and late shifts. • A Band 6 ward-based nurse to coordinate out of hours. • A Band 6 nurse in the Minor Injury Unit from 9am to 6pm Monday to Friday and 9am to 12 noon on Saturdays. • A cohort of band 5 nurses to coordinate day-to-day care, supported by Band 2/3 Healthcare Support Workers.

Account has to be taken of the geographical isolation of the building and the nurse staffing levels should be based on the assumption that there will be no medical staff based permanently on site to provide support/clinical opinion to the nursing staff.

Norms for skill mix at ward level are not available in the UK. Mix and Match (DHSS 1986) avoided making recommendations about staffing levels or staffing mix and advised that these should be determined ‘systematically’ in relation to the dependency of the patients and the objectives of wards or units in each specialty. RCN guidance indicates that a stand-alone community hospital should have a staffing ratio of 60:40 qualified nurses to Healthcare Support Workers. Dependency levels and the designation of beds also need to be taken into account.

Nurse staffing levels should also be based on the assumption that all rooms provided in the new development will be single, en-suite rooms, to maintain privacy and dignity, to meet infection control standards and to future proof the facility for evolving models of care.

9 5. Ceredigion Local Health Board – Consultation on Community Services

There have been a number of reviews undertaken in the last 5 years within the NHS in Ceredigion which concluded that the need for community hospital beds would be much less if the appropriate community infrastructure (health and social services) was in place to enable elderly people to be cared for more effectively at home. The key questions are as follows:

• How many community hospital beds would be needed within Ceredigion if the requisite health and social services infrastructure was in place to support people in their own homes? • Would it be best to have just one community inpatient facility for Ceredigion? • Where should the community beds be situated according to patient need and accessibility?

The Ceredigion Local Health Board (LHB) discussion paper on the future development and delivery of community based services in Ceredigion, ‘Your Community Services’ (September 2007) suggested that only 22 community hospital beds would be needed for the whole of Ceredigion if a full range of intermediate care services were available, as this would reduce delayed transfers of care and enable patients to be cared for in their own homes instead of being admitted to hospital. This equates to a reduction of 28 beds, or 56%. However, at the end of the consultation and engagement process, the formal report entitled ‘The Model for the Provision of Community Care in Ceredigion’, which was released by the Community Services Change Programme Project Team in March 2008, identified the need to build up community services and facilities in Ceredigion before reducing the number of beds in acute or community hospitals. The document proposes that ‘future bed provision would make use of a range of options within the private and statutory sector and be flexible, multi-purpose, multi-functional facilities easily accessible to the north, mid and south of Ceredigion’. The public engagement process supported the need for beds with 24 hour care in the community and accepted that the beds should be available for intermediate care, ‘slow stream’ rehabilitation, palliative care and end of life care.

The document confirms the strategic importance of Cardigan Hospital to the three counties of Ceredigion, Carmarthenshire and Pembrokeshire and states that ‘an integrated health and social care facility with inpatient beds is supported by this review’. However, it does not specify the number of beds.

In terms of Tregaron, the document states that more consideration needs to be given to determine the future health and social care facilities in Tregaron. The LHB confirms their continued commitment to develop the community infrastructure by working closely with the Tregaron community and partner organisations and recommends the establishment of a Project Group to develop the principles as set out in the paper.

For Aberaeron, the document states that the new Aberaeron facility will continue to be developed as an integrated facility with the emphasis on community care services and maintaining people at home.

The document states clearly that community hospital services or acute services cannot be reduced until the requisite community infrastructure is in place.

6. What can appropriately be undertaken or devolved to these community hospitals from Bronglais Hospital, in a cost effective and sustainable way, across the spectrum of care of diagnostics, therapies, inpatients and outpatients?

6.1 Range of services currently planned in Aberaeron, Cardigan and Tregaron

Details of the model of care and the range of services that are planned to be provided at the three community hospitals in Ceredigion are detailed in sections 2, 3 and 4 above. Examples of models in place and being developed elsewhere are detailed in Appendix A.

10 7. Supporting Early Discharge

The Model for the Provision of Community Care in Ceredigion, which was produced by the Community Services Change Programme Project Team for Ceredigion LHB proposes the following model of care:

• Networked Primary Care in two zones, north and south Ceredigion;

• Localities within the zones, which are coterminous with groups of GP practices.

• Multi-agency health and social care teams in the two zones, with one overarching Integrated Management Structure, comprising of:

• District nurses • Home Care recognising that some elements are provided in house within Social Services and some is within the Private Sector • Social Workers • Reablement Team • Therapies • Community based Chronic Disease/Specialist Nurses and Therapists • Voluntary Sector • Specialist Community Public Health Nurses • Community based staff working for the mental health and learning disability services.

The teams will provide a 24 hour a day 7 day a week service but between the hours of 10pm and 8am will be integrated with the Out of Hours Service in Ceredigion.

Access to out-patient clinics will be developed allowing access to out-patient consultations from the community where clinically safe and appropriate. The use of Telecare and Information Technology will be integral to the further development of this service.

Access to out-patient rehabilitation will be increased on a number of sites in Ceredigion. Further work will need to be done on the cost effectiveness of providing a community based rehabilitation service able to visit people in their own homes.

Community based mental health services will be integrated into the already integrated health and social care teams and be provided from the three community health and social care sites in Aberaeron, Cardigan and Tregaron.

The model for integrated day hospital/day care facilities will be developed to allow access to day assessment and treatment facilities for chronic conditions on a number of sites in Ceredigion.

Emphasis will be placed on designing safe and appropriate access to diagnostic services within the community.

The development of an integrated community equipment store will ensure multi-agency access to equipment for use in the community, allowing people to live in their own homes or as close to home as possible in the community.

8. Governance Arrangements

Clarity is required around the clinical accountabilities of the medical staff in the future model of care. The merger of Ceredigion & NHS Trust with Carmarthenshire and Pembrokeshire and Derwen NHS Trust should refine the clinical governance arrangements and clinical accountabilities around community hospitals and their relationship with acute hospitals.

11 9. Benefits of a Nurse-led Service

Currently, the inpatient services at Aberaeron, Cardigan and Tregaron are provided by nursing and therapy staff based on site, with medical input from GPs acting as Clinical Assistants or working in a Bed Fund arrangement.

For Outpatient services at all three sites, there are visiting Consultants in a wide range of specialties, supported by on-site nursing staff.

For the Minor Injury Unit at Cardigan Hospital, the service is nurse-led and the nursing staff can access clinical opinion via a video link with the Accident and Emergency Department at Bronglais.

There are clear financial benefits to developing nurse-led services, using telemedicine to ensure that nurses can seek access to a medical opinion if necessary.

10. Shared Care Model for Continuing Care

The Model for the Provision of Community Care in Ceredigion paper refers to the 177 beds that are currently commissioned by Ceredigion LHB through continuing care and NHS funded care in nursing homes and confirms the LHB’s commitment to develop beds across Ceredigion that can be developed for flexible, multi-agency use, which will allow equality of access to local care.

Continuing care or long term care is a general term that describes care which people need over an extended period of time as a result of a disability, accident or illness. It may require the services of the NHS and/or health and social care services provided by local authorities, private and voluntary organisations. The final draft of the National Framework for Continuing NHS Health Care, states that continuing NHS Health Care does not have to be provided in an NHS hospital and can be provided in a care home with nursing, hospice or the individual’s own home. However, where there is primarily a health need and an individual has been assessed as eligible for continuing NHS health care, the NHS has full responsibility for funding the full package of health and personal care. Continuing NHS health care encompasses primary care, rehabilitation, respite, palliative care, equipment and transport.

In Ceredigion, there is a shortage of private sector nursing and residential beds and pressures on the home care service. Although the reablement service and joint care beds have been established there is a need to significantly strengthen the community infrastructure across the Health and Social care economy. Particularly for example that termed “intermediate care” and a need to extend hours of community nursing and home care/health support arrangements. The paucity of these services has impacted upon delayed transfers of care and upon inappropriate admissions to the acute sector. As a solution, a number of beds at Tregaron Hospital have been designated as Continuing Care and have been used for continuing NHS health care patients for up to six months. This has enabled patients to be cared for in a more appropriate setting whilst waiting for their long term package of care to be put into place.

11. Sustainability

People, Places, Futures, the Wales Spatial Plan, 2004, sets out an agenda for the sustainable development of Wales over the next twenty years. It is intended for use by both policy makers and those involved in operational delivery, to guide their work, whether locally, regionally or nationally. It is based on five national themes: ‘Building Sustainable Communities’; ‘Promoting a Sustainable Economy’; ‘Valuing our Environment’; ‘Achieving Sustainable Accessibility’; and ‘Respecting Distinctiveness’.

The first of the five national themes of People Places Futures is ‘Building Sustainable Communities’, which states that ‘Our future depends on the vitality of our communities as attractive places to live and work.’ The vision for central Wales is for ‘High-quality living and working in smaller scale settlements set within a superb environment, providing dynamic models of rural sustainable development, moving all sectors to higher value added activities’. One of the

12 key priorities is to ‘prioritise the cluster/hub approach to the sustainable development of settlements and the sustainable delivery and accessibility of services in a rural context to include all aspects of education provision and health services’.

To achieve this vision, it is important to understand the potential impact that a reduction in health services would have in a rural community like Tregaron, Cardigan or Aberaeron, in terms of access to services and the potential effect on the local economy. Any change in service profile or skills requirements would have a direct effect on the local economy and the health and wellbeing of local residents.

12. Conclusion and Recommendations

12.1 A*C*T

(Aberaeron*Cardigan*Tregaron)

There is clear evidence from examples of community health and social care developments elsewhere in Wales that a wide range of services can be devolved from secondary care into the community in a cost effective and sustainable way. The transformation of the service from its current form to the new model of care will depend on the development of multi-agency health and social care services in the community. In the paper produced by the Community Services Change Programme Project Team for Ceredigion LHB regarding the proposed Model for the Provision of Community Care in Ceredigion, it is stated that ‘the engagement process strongly identified the need to build up community services and facilities in Ceredigion before committing changes to bed stock in acute or community hospitals’ and that ‘there can be no reduction in the number of beds until the community infrastructure has been built up’. This position is fully supported from a healthcare governance perspective.

Conditional upon the development of community services, the following proposals are recommended.

12.2 Aberaeron

The current proposals for Aberaeron should proceed as planned, with an integrated health and social care centre adjacent to the County Council offices and residential care home, comprising a GP Practice, Outpatient department, diagnostics and a base for a multi-disciplinary team of health and social care staff. The success of the facility will be based upon the design of the building and the introduction of new ways of working, with extended days, the potential for weekend working and fully integrated management structures to reduce management costs, underpinned by the use of Telemedicine/Tele-care/Assistive Technology.

The recommended model is as follows: • GP Practice Using the new GMS contract provision of enhanced services to provide services locally. • Nurse Led Services (2 treatment rooms) Including: leg ulcer management, health care assessments, ECGs, phlebotomy, pre- operative assessments, field of vision measurement and ante-natal assessments. • Consultant Led Clinics (3 rooms) It is envisaged that there will be full utilisation of the 3 rooms on a timetabled basis. The clinics to be provided are: o Ophthalmology, Orthoptist and Diabetic Retinopathy Screening. o General Medicine and Movement Disorder Clinics o Gynaecology o Paediatrics o Family planning

13 o Diabetes • Physiotherapy services • Podiatry services • Audiology services • Counselling Room • Base for Reablement Team/Occupational Therapy Services • Base for integrated health and social care staff who are currently co-located and mental health team staff

The current discussion regarding the revenue consequences relating to the future proofing of the scheme should be brought to a conclusion to allow the construction phase to commence. There is no need for additional floor space to accommodate the services proposed if staff can work together and modernise working practices.

12.3 Cardigan

Cardigan is different in terms of its location in the new Hywel Dda Trust. It is strategically positioned on the borders of Carmarthenshire, Ceredigion and Pembrokeshire and has a close relationship with West Wales General and Withybush Hospitals in particular.

There is consensus that inpatient beds are required in Cardigan and the number of beds has been subject to lengthy debate, but twenty two beds would be the minimum to ensure financial viability. The recommended model is as follows:

• GP Practice (co-located or adjacent), using the new GMS contract provision of enhanced services to provide services locally. • Day Hospital/Rehabilitation service • Minor Injury Unit • Outpatient Department • X-Ray • Therapies o Physiotherapy o Occupational Therapy o Speech and Language Therapy o Podiatry o Dietetics • Telemedicine o Videoconferencing o Image transfer o PACS • Office base for integrated health and social care teams o District nurses o Home Care o Social Workers o Reablement Team o Therapies o Community based Chronic Disease/Specialist Nurses and Therapists o Voluntary Sector o Specialist Community Public Health Nurses o Community based staff working for the mental health and learning disability services • Inpatient Beds o “Step-up/Step-down” care o Palliative care/End of life care o Rehabilitation o Reablement/Intermediate Care o Joint health and social care assessment

14

The limiting factor in Cardigan is the delay in planning approval for access to the proposed site and there is growing public opposition from one sector of the community who would prefer the hospital and associated commercial development to be located elsewhere. The deadline for consideration of the planning approval is August 2008 and if the access route is deemed inappropriate and approval is not agreed, it is unlikely that an alternative site will be identified within the Cardigan area. A new site would then need to be selected, which would have to be strategically placed as an alternative location and would need to be acceptable by and accessible to local residents.

If the alternative site were to be identified in the /Felinfach area, which has been put forward on several occasions and where developmental opportunities are available, this would have a direct impact on the Tregaron locality, as there would be no requirement for inpatient beds in Tregaron if an integrated health and social care centre were to be developed in close proximity. However, transferring the Cardigan development to Lampeter, with the inclusion of inpatient beds would provide Bronglais Hospital and West Wales General Hospital with step down/intermediate care/palliative care beds, but would disadvantage Withybush Hospital, leaving a gap in the centre of the new Trust. Therefore the preferred option is to develop the service in Cardigan.

12.4 Tregaron

Based on the assumption that the planning issues associated with Cardigan will be resolved and the proposed development in Cardigan with inpatient beds will be approved, there will still be a need for an integrated health and social care facility in Tregaron. The following model is proposed:

• GP Practice - using the new GMS contract provision of enhanced services to provide services locally. • Day Hospital/Rehabilitation service • Minor Injury Unit • Outpatient Department • X-Ray • Therapies o Physiotherapy o Occupational Therapy o Speech and Language Therapy o Podiatry o Dietetics • Telemedicine o Videoconferencing o Image transfer o PACS • Office base for integrated health and social care teams o District nurses o Home Care o Social Workers o Reablement Team o Therapies o Community based Chronic Disease/Specialist Nurses and Therapists o Voluntary Sector o Specialist Community Public Health Nurses o Community based staff working for the mental health and learning disability services

It is therefore recommended that:

15 • There is no reduction in community hospital beds in Tregaron until the integrated community health and social care teams are established, at which point it will be possible to correctly identify whether a need for beds still exists; • A Project Team is set up to define what the new facilities for Tregaron should include. The Project Team will be responsible for: o Defining whether there should be beds in the facility and who should provide them; o Developing the Business Case for Tregaron.

These recommendations would have the support of Ceredigion Local Board and, it is anticipated, the Local Authority.

Bro Ddyfi Community Hospital, Machynlleth

Although not within the terms of reference of this Report, reference needs to be made to the historic links and potential future use of the Community Hospital at Machynlleth, which is 18 miles north of Bronglais Hospital and only 30 minutes away by road.

The Machynlleth site currently provides the following:

• 24 in-patient beds • a 5 day OT and physiotherapy service • a 5 day 8.00 am to 8.00 pm Minor Injuries Unit • excellent out patient facilities with five consulting rooms • day hospital facilities • radiology facilities

Several Bronglais based clinicians undertake out patient activity at Machynlleth, but have no responsibility for the in-patient activity. The resources at Machynlleth are under utilised, and some clinical governance concerns have been expressed.

Historically, the hospital at Machynlleth, which in the past was referred to as Machynlleth Chest Hospital, had very close links with Bronglais. Two Physicians at Bronglais throughout the 1980s and early 1990s shared responsibility for the use of 30 beds at this site and were able to transfer patients from Bronglais to Machynlleth, whilst retaining clinical responsibility for their care. Regular ward rounds were undertaken and out patient consultations were held for new and follow up patients. In recent years, these services were withdrawn by Powys Health Authority and, since that time, the hospital has been used mainly to provide a Care of the Elderly and Rehabilitation service for Powys residents only. This has resulted in North Ceredigion patients experiencing a longer than necessary length of stay in acute hospital beds at Bronglais.

Machynlleth is strategically very well placed for patients residing in North Ceredigion and South Meirionydd in addition to North Powys. A model of care, similar to that proposed for Cardigan, should be considered. Unlike Cardigan, the infrastructure at Machynlleth is in excellent order and fit for purpose. It would be a positive development to restore the close links between Bronglais and Machynlleth for the benefit of patients residing in South Meirionydd, North Ceredigion and North Powys for active rehabilitation/intermediate care.

Dr Alan Axford, Medical Director, Hywel Dda NHS Trust – Ceredigion & Mid Wales

15th May 2008

16 APPENDIX A Models of Care in Wales and Elsewhere

1. South Pembrokeshire Health and Social Care Resource Centre

In Pembrokeshire, the South Pembrokeshire Health and Social Care Resource Centre has been designed to deliver modern health and social care services closer to home and provides a single point of access to the following services:

• Day Care • Minor Injury Unit with Telemedicine links to Withybush Hospital • Outpatient Department • 35 inpatient beds (Single en-suite inpatient rooms and four bed wards) for rehabilitation, intermediate and palliative care • 5 Community Care Reablement beds • Physiotherapy Gymnasium • Computer and Craft Activity rooms • Library • Sensory garden • Outside steps/rails for OT assessments.

It provides services in radiology, audiology, podiatry, dietetics, speech and language therapy, Physiotherapy, Occupational Therapy, complementary therapies and is a base for Macmillan Nurses, Out of hours District Nurses, Pembrokeshire ‘Care on Call’ Out of Hours GP services, Home Care administration and the Acute Care at Home service.

The facility has taken many years to redesign the way in which health and social care services are provided across Pembrokeshire and the reason for this working so effectively is the vision and values on which the new development was based, the philosophy of which is to provide an environment that enables people to achieve maximum independence. It was developed through a fully-collaborative partnership including Pembrokeshire and Derwen NHS Trust, Pembrokeshire County Council Social Care and Housing Directorate, Pembrokeshire Local Health Board and Pembrokeshire Association of Voluntary Services. The new resource Centre combines the services previously provided at South Pembrokeshire Hospital, Hawkstone Road Day Centre and Riverside Residential Home.

2. Builth Wells

The new model for health and social care services in Builth Wells proposes that a new nursing home should be commissioned and that some of the present general practitioner beds currently provided in the hospital should be moved into the nursing home as extended nursing care beds for the treatment of chronic conditions, under the medical management of the General Practitioners. This will also provide an opportunity to co-locate other hospital services, Residential care, and GP Practice services, Minor Injury Unit, Day Hospital/Day Centre and Reablement Service onto the same site, to provide a single point of access. It is possible that other services will wish to relocate to the site, including dental, pharmacy and Optometrist.

3. Neath Port Talbot

In Neath Port Talbot, the closure of a community hospital was accepted by the local population as it was to be replaced with alternative services, including private sector beds, additional NHS community hospital beds in adjacent community hospitals and enhanced intermediate care services. An Integrated Working Project is now in progress, which is bringing multi-agency staff into one team to deliver services together. This may require staff to be co-located and details of the project plan are awaited.

17

4. Monnow Vale Health & Social Care Facility, Monmouth.

Monnow Vale Health & Social Care Facility is a unique collaborative project, which is a partnership between Monmouthshire County Council Social Services, Monmouthshire Local Health Board, and Gwent Healthcare NHS Trust. It will integrate primary, intermediate, community care and nursing services to provide whole system health and social care for the people of Monmouth and surrounding area.

It is a new building procured under a Private Finance Initiative (PFI) for which Gwent Healthcare NHS Trust is a signatory with Monmouth Facilities Limited and replaces a number of outdated or separate facilities scattered throughout Monmouth.

Monnow Vale brings together people with a wide range of expertise in both health and social care and is a partnership that will deliver a model that holds the citizen at its centre.

The facility provides inpatient, outpatient and day activities that will focus on a seamless, co- ordinated approach to people who have medical, social, community or rehabilitation needs and will promote well being, optimise independence and provide a timely and appropriate response to crisis.

Having everything in one building enables health and social care teams to meet quickly and easily, to discuss the needs of the patient following discharge. As this model of care is developed much stronger links are being forged with statutory bodies and the voluntary sector.

Description of the services available from Monnow Vale. • 25 Inpatient beds • Minor Injuries • Community Care Team • Reablement (Healthy At Home Scheme) • Day Hospital • Day services • Older people Mental Health Day Hospital • Physiotherapy Outpatients (10 sessions per week) • Occupational Therapy (for hospital and community) • District Nursing Teams (Chippenham and Wye Valley Practices) • Catering and housekeeping provision for the facility • Administration

A range of outpatient/community health clinic services sessions will also be provided from Monnow Vale. These include consultant outpatient clinics in the following specialties: • General surgery (one session per month) • Trauma & Orthopaedic surgery (Back Pain clinic) one session per month • General Medicine (two sessions per month) • Rheumatology (Two sessions per month) • Gynaecology (one session per week) • Psychiatry (EMI) (one session per week) • Psychiatry (two sessions per week) • Consultant Podiatrist (One session per week) • Ophthalmologist (one session per week)

In addition there are community clinics for: • Podiatry (10 sessions per week) • Audiology (one adult and one paediatric session per week) • Speech therapy for adults and children, (four adults and two paediatrics per week) • Dietetics (one session per week and weight management once per month) • Orthoptics (three sessions per week) • Baby milk sales, (one per week)

18 • Health visitor led baby clinics (one per week) • District Nurse clinics Plus: • Nurse led clinics (one per week) • Citizen Advice Service (Better Health Better Wales scheme) one session per week • Community Pharmacist (one session per week) • Occupational Health Team (one session per month)

There is also potential for the provision of mobile community dentistry as water and electricity supplies to which the dental vehicle can be connected are available. (One session per month)

The partners in the project have entered into an agreement under Section 31 of the Health Act 1999 to integrate the management of the provision of the Services from the Facility and to introduce a pooled fund for the services provided.

5. Kaiser Permanente at Torbay PCT

Torbay Primary Care Trust (PCT) has been using a model of care (the Kaiser model) that focuses on improving the management of long-term disease to reduce hospital stays by providing a wider range of specialist medical services in the community. Their approach includes supporting and encouraging patients to have greater involvement in their own care, enabling them to receive more treatment at home and so avoid admission to hospital.

A strong focus on the management of people with long-term diseases, such as asthma, bronchitis, and improvements in integrating primary and secondary care is encouraged by the Kaiser model. More care is delivered in a community setting and when hospital admissions are unavoidable, early discharges are facilitated by the ready availability of intermediate care. This has helped organisations to cut the number of days patients stay in hospital to around a third of those currently used in the NHS. Patients are also taught how to self-manage their conditions and families are encouraged to help provide their care.

One of only eight Kaiser Permanente pilot sites in England, Torbay PCT has been developing ways to deliver the Kaiser model including:

1. The North Torquay Programme - this involves integrating three big GP practices into one large care centre that can offer a wider range of services that would normally be only be offered in an acute hospital

2. Increasing nurse therapy led care at Paignton Hospital - the model of care used has been changed to a nurse therapy led model offering more intermediate care, rather than the traditional medical model

3. Long-term disease management - based in the community, the PCT is working to provide a wider range of specialist medical services in the community.

The PCT has also identified a number of patient groups who have the greatest potential to benefit from the increased use of intermediate care, home care and self care, including patients who have:

• had two or more emergency admissions in the previous 12 months • long-term lung conditions, chronic obstructive pulmonary disease (COPD) • heart failure • been discharged from hospital with inadequate access to rehabilitation • been admitted because of poor access to clinical or care planning information • been living in care homes; and

• older people who have fallen or collapsed, who require social support in an emergency or who do not take their medication regularly

19 • older people with mental health problems.

With effective care plans it is expected that as many as 15% of these admissions can be avoided.

6. Eldercare project in Cornwall (EPIC)

Eldercare Project In Cornwall (EPIC) is one of several modernisation team projects being run in Cornwall to reduce unplanned hospitalisation and increase capacity in community services. The principal objective of the project is to manage proactively the health of people aged over 75 who have a chronic disease and repeated, unplanned hospital admissions. The aims are to:

• Improve the quality of life for patients, their carers and families, • Reduce unplanned hospital admissions, • Minimise time spent in hospital when a stay in necessary or unavoidable, • Review medication and improve the quality of prescribing, • Strengthen the interfaces of care.

The advanced primary care nurses undertook a 5 week intensive training course. The purpose of the training was to equip the nurses with advanced clinical examination and diagnostic skills. The nurses are building up case loads over the next year with the intention of taking on a maximum of 60 patients each.

The nurses use a comprehensive toolkit to carry out thorough assessment of patients. The majority of these tools are already in use in the community. The main assessment document signposts the nurse to further interventions or referrals to other services. A significant benefit of this assessment process is the nurses’ ability to make high quality, direct referrals.

The nurses work with the patients to enable them to spot the early signs of deterioration or exacerbation of their chronic disease. The nurses liaise with the GP to assess whether hospital admission is required; in the majority of cases it is not. The nurses have a menu of options, many of which are accessed through the central referral system, to support the patient safely at home, acting as care coordinator.

The nurses have found that in many cases, relatively simple interventions have made significant impact on the patient’s ability to manage chronic disease; for example, proper use of inhalers by patients with COPD. A key role for the nurses is to educate patients, their carers and families about signs and symptoms of exacerbation and how to manage chronic disease. As the service develops, nurses will identify common problems and provide advice about chronic disease management to patients and health/social care professionals.

The majority of EPIC patients live at home, although there are also a significant number of care home residents on the caseload and some patients were in an acute or community hospital at the time of referral to EPIC.

7. Sir Alfred Jones Community Hospital, Liverpool

The main purpose of the service, which is led by nurse practitioners, is to offer nurse-led inpatient care. Patients are accepted from both the acute Trust and the community against well defined but flexible admission criteria. If the team think they can make a difference to the quality of life for any patient ‘in transition’ then they will accept them. The unit also offers a primary care treatment centre to complement the work of the GPs which is also led by nurse practitioners. A range of minor injuries is treated against well developed protocols with an aim of providing local service while diverting some pressure from the acute A&E departments.

The hospital development was part of a wider initiative supported by the Health Authority, who were seeking a package of schemes which would help to bridge between acute and primary care. In addition to the community hospital there is a home rehabilitation service to provide alternative

20 treatment for people with an exacerbation of a chronic chest problem and a range of other admission prevention schemes.

There is no on site medical cover, but the rich skill mix allows for expert nursing cover over the 24 hour period. Admissions and discharges, including length of stay are managed by the nurse practitioners who have negotiated agreement to refer directly back to the acute Trust, by-passing A&E, should the need arise. The data show these referrals to be around 11% of the total number receiving care in the unit. Medical cover is provided by a local GP with dedicated time for the unit. He has been instrumental in helping the nurse practitioners to recognise their own skills, as well as developing new ones, and to extend the willingness and ability to take responsibility for their own actions. Over time they have felt able to extend the range of decision making which they make independently, as evidenced by the changes in records of the messages left for the medical colleague’s advice since the unit opened.

An ‘in house’ needs driven development program, managed by the occupational therapist, is offered to the support workers who have developed a generic range of nursing and therapy support skills. Thus while the OT and physiotherapist are managed by the senior nurse there are times when they, in turn, manage the nursing support workers. This flexible cross boundary working typifies the way in which the team work together.

8. The Coppice Model – South Staffordshire

The drivers for change in the provision of rehabilitation services were variable standards of care, lengths of stay, poor management information, outmoded skill mix and the rising costs of care.

Features of the new service provision are to: • Radically change an out-dated approach to care; • Create robust audit data for systems change; • All patients admitted would be as medically stable as patients attending their GP; • No routine medical surveillance: staff physicians available to treat patients in an emergency; • Each Registered Nurse on the unit would be a supplementary or independent prescriber; • Unit staffed by those with skills in reablement; • All patients would undergo a range of standardised functional ability assessment on admission and every 3 days thereafter; • Length of stay would be determined by functional ability.

The major achievements of the model are as follows:

• Average length of stay halved for many conditions including stroke and hip replacement; • Staff morale increased, turnover, sickness and absence reduced; • The Unit ran at a cost of £450000 per annum, including drugs ( a substantial cost saving); • The rehabilitation assistant workforce demonstrated their ability to plan, implement and evaluate care provision based on standardised functional ability assessment.

9. Windsor, Ascot and Maidenhead Intermediate Care Service

The objectives of this project were to ensure the appropriate provision of services which • Prevent inappropriate acute hospital admission • Ensure safe and timely supportive discharge • Provide rehabilitation in community settings • Prevent premature admission to long term care

The Intermediate Care Services to be provided are as follows:

• Day hospital, providing short term rehabilitation for over 60s, with a capacity of 25 patients per each weekday. Ambulance transport is provided as needed. Parkinson’s Disease clinics and nail clinics are held.

21 • Rapid response and rehabilitation service, which provides social care crisis intervention and/or rehabilitation in people’s homes. It is operational 24 hours per day and also provides end of life palliative care at home. Referrals from primary and secondary care professionals and from social services are accepted. • Intermediate care flats, within an Extra Care housing scheme, supported by rapid response and rehabilitation services. The accommodation is used for the assessment of mobility and daily living skills when it is considered unsafe to do so in a person’s own home. • In-patient community units, (24 and 20 beds) with patients admitted from Trust and community settings. • Community and intermediate care liaison nursing team, with liaison nurses appointed specifically to facilitate early identification and the pro-active discharge planning of appropriate patients for all intermediate care services within the area. • Nurse Consultant for Intermediate Care and Older People, providing expert nursing advice and practical support for the whole of the intermediate care service. • Additional therapy support (Speech and Language and Dietetics) available for the whole of intermediate care with direct referral from any of the settings.

22