1. Health Fit Strategy for Community Hospitals in Cornwall

2. Purpose of Health Fit Exercise To define the role of CHs and 5 year direction of travel for their development in Central & West Cornwall (including Bodmin) Identify the values and design principles that should underpin CHs development thro analysis of forces & drivers for change impacting on the whole health & social care system

3. Scope 9 Community Hospitals relating to the catchment area of RCHT - Total of 338 beds - MIU attendances (70,000 + per year) account for 50% of emergency care contacts in Cornwall - Size of CHs range from 14-76 beds - Mix of GP bed fund or Specialist Eldercare West Cornwall PCT 4 CHs – Penzance, Helston, St Ives, Camborne Central Cornwall PCT 4 CHs – Falmouth, Newquay, St Austell, Fowey North & East PCT - 1 CH at Bodmin relates to RCHT, Other 4 CHs relating to Plymouth & North Devon not included

4. Process Consultation with stakeholders through focus groups and facilitated workshops (over 50 held) Patient Activity and financial analysis Stakeholder 1 day event facilitated by OPM Development of design specifications for each CH

5. What the Public Want from their Community Hospitals CHs well loved, fiercely protected by their communities & fundamental to provision of local inpatient and outpatient health care; people want to receive as much care and treatment in their own home, admission to hospital should be a last resort; history of under investment in community services to maintain people in their own home e.g. district nursing and therapy; CHs vary widely in size and capacity; nurse led MIUs highly valued & effective vehicles for delivery of local emergency services to large numbers of local residents and visitors; fabric and design of a significant number of CHs not fit for the purpose of delivering modern health care;

6. What the Public Want from their Community Hospitals variation in the skills and services on offer to local populations from their CH; inadequate and limited primary care direct access to CH beds as an alternative to acute hospital admission Ideal care setting for delivery of chronic disease management and specialist neuro-rehabilitation (e.g. stroke) lack of access to basic diagnostic services to support direct admission e.g. X-ray, and ultrasound in smaller hospitals; variability in the responsiveness and quantity of medical cover and supervision variability in the skills and quantity of nursing and therapy to support needs more complex than intermediate and slow stream rehabilitation questions around the logic of investment in an independently provided DTC at the expense of developing CHs

7. Background Financial pressures +++ more services than income and growth money can absorb Dobson decision 1998 Unprecedented growth in emergency referrals to RCH & A&E activity 334 CH beds classed as acute bed stock History of little significant investment in CH services and community provider services, workforce redesign and performance management Growing problem of delayed transfers of care

8. Cornwall Profile Rural and maritime county Population circa 500,000 Scattered villages and small towns Areas of high deprivation with objective 1 funding and Health Action Zone status Pockets of wealth and retired money Low salaries Fastest growth in country in property prices on par with outer London suburbs

9. 2001 Census Data Results Growth Age 75 and over - England – 7.54% - South West – 9.25% - Cornwall – 9.77% Households with one pensioner living alone - England – 14.37% - South West – 15.46% - Cornwall – 16.59% People with a Limiting Long Term Illness - England – 17.93% - South West – 18.10% - Cornwall – 21.21%

10. 2001 Census Data Results Health not good - England – 9.03% - South West – 8.51% - Cornwall – 10.25% Persons providing unpaid care - England – 9.93% - South West – 10.05% - Cornwall – 11.13% Carers who Provide Care 50+ hours per week - England – 20.48% - South West – 19.74% - Cornwall – 23.57%

11. Influences on CH Design Specification Nursing Home Quality and Capacity Community Hospital Workforce Reimbursement fund investment in: - Rapid Response Assessment Teams in each district council are - 4 EPIC nurses in each PCT based in GP practices with the highest repeat emergency admission rates for the over 75s. - Increased therapy in the acute trust to facilitate home assessments and direct discharge.

12. Influences on CH Design Specification Acute Care at Home Increased focus on training, monitoring and support to ward teams to proactively manage discharge planning from the time of admission or before. (SHA, MA & CAT support) OSPREY project and Improvement Programme for Hospitals outcomes will facilitate improved patient flows and rapid access to diagnostics Increased day surgery procedures will release bed capacity & commissioning strategies to shorten length of stay for elective orthopaedic patients through increased community post operative support New Out of Hours services

13. Opportunity Most of influencing factors will impact on the acute trust and community hospital bed days Bed capacity will be released in the CHs and a change in patient flow Opportunity to develop more direct primary care access and local chronic disease management expertise with the CH as a focal point for its delivery and a wider range of community services and rehabilitation to maintain people in their own homes.

14. Central Cornwall PCT CH Design Specification More services and more patient care for the same level of investment programme for reform in Central Cornwall will be achieved through health and social care redesign that will reduce unnecessary hospitalisation, provide more care at home and improve chronic disease management. Changes to existing services will be delivered through a proactive approach and radical approach to improve and widen the role of community hospitals and community services within localities within the current level of revenue funding.

15. This design specification will require: fundamental changes to the traditional way of providing medical cover to community hospitals. Embracing new roles such as nurses with advanced skills and GPs with a special interest. Admission policies focused on patient needs allowing for direct primary care access to community hospital beds, diagnostics and specialist advice including domiciliary support to local care homes. redesign of nursing and therapy roles to reflect the increased need for; patient education/expert patients, day assessment and treatment services, specialist inpatient, outpatient and home based chronic disease management programmes that include; stroke, diabetes, respiratory, dermatology, amputee care etc;

16. This design specification will require: more community nurses and more community based rehabilitation therapists to facilitate early postoperative discharge of patients e.g. orthopaedic hips and knees at 5 days and planned increases in day surgery procedures. New provision of a 24 hour 7 day a week Acute Care at Home Service to provide out of hours emergency care and to prevent unnecessary hospital admission. Provision of an integrated maternity service offering more choice to women on place of birth and local access to midwife led care. Provision of a new model of Out of Hours care provision from October 1 2004 that maximises opportunity to develop new roles and builds on the existing skills of a wide range of health professionals.

17. Vision to Reality Central Cornwall PCTs proposals will be developed in the knowledge that there is limited opportunity for financial investment in community services now and in at least the next two years. They will require changes to the configuration of each of our CHs and new ways of working. maintenance of the current number of beds will prevent any other investment in community capacity designed to enable patients to receive more care in their own homes, & develop local CDM services. Maintenance of the status quo within the current financial climate will perpetuate cycle of dependence on sub acute beds in the absence of home based and more patient focused alternative provision.

18. Vision to Reality Our proposals require changes to the configuration of each of our CHs. In the next year we plan to make major redesign changes in South Restormel at St Austell Community Hospital and the development of a mixed economy health and social care facility to replace Fowey Hospital. Significant changes are proposed to Falmouth Hospital with opportunity to establish integrated specialist stroke care beds. Capital Development to improve sexual health services for young people in Newquay is underway

19. Health Fit Specification for St Austell Community Hospital To be achieved through reduction of some beds and reinvestment to: - increase the therapeutic value of the remaining 46 inpatient beds and enhance the range of inpatient care - - enhance the range of diagnostic and day assessment and treatment facilities enhance community rehabilitation capacity provide a 24 hour ACAH service to South Restormel establish specialist stroke beds establish a Falls Clinic establish a Nurse led dermatology service bring nursing and therapy establishments to national average

20. Health Fit Specification for St Austell Community Hospital Estabish an EPIC nurse post in St Austell to support primary care chronic disease management Increase medical capacity to enable: 1. Domicillary visits and support to care homes by Consultant/GPSI/Staff Grade doctors following GP referral 2. Chronic Disease Management Clinics in COPD, diabetes, neurological e.g. stroke etc 3. Increase direct primary care access to CH beds

21. Next Steps April 2004 - Seek endorsement from PCT Executive Committee to proposed direction of travel April 2004 - Seek sign up from the PCT Board to proposed direction of travel May 2004 - Discuss proposals with nursing and medical personnel May 2004 - Commence process of Public Consultation and presentation of plans to the Overview and Scrutiny Committee May 2004 - Appoint Project Manager from within existing PCT management resources May/June 2004 - Produce Detailed project plan & Board Paper June – September 2004 – Staff preparation, training and selection for new roles October – December 2004 - Implement project and achieve service reconfiguration.

22. Role of the Modernisation team in Cornwall to support Health & Social Care Redesign – Tracie North