Scrutiny briefing on lines of enquiry attached.
Minutes:
The Chief Executive of Powys Teaching Health Board (PTHB) had that morning provided a response to questions asked prior to the meeting which had been circulated to Members. She introduced the Director of Primary Care, Community and Mental Health) who had joined PTHB three months ago and has extensive experience of the NHS in Wales.
The briefing explained that of the £300million/year budget approximately 25% is spent on directly provided services, 25% on primary care and 50% on secondary and tertiary type care. The focus of this session is largely on the directly provided care. PTHB does not have a District General Hospital (DGH) within the area but is able to access approximately 250 beds from neighbouring DGHs.
How can Community Hospitals be used more effectively as a step-down facility and how can the PTHB and local authority work together to achieve this?
It is unusual to have as many Community Hospitals as Powys has, elsewhere Community Hospitals have generally disappeared. However, in Powys outpatient clinics are extremely important so patients do not have to travel long distances. A number of services are provided from Community Hospitals including; outpatient clinics, therapy services, maternity services (including day assessment services and birthing centres), mental health services (including inpatients, outpatients, community intensive support), inpatient beds (rehabilitations beds and some specialist stroke rehabilitation), day surgery (laminar flow theatres in Llandrindod and Brecon), endoscopy (in Llandrindod and Brecon), renal dialysis (in Llandrindod and Welshpool), Minor Injury Units (some in Community Hospitals, some in GP practices) and some dental services.
What is the position regarding improving the estate, for example the planned extension at Ystradgynlais?
The PTHB estate has a high number of buildings dating from before the creation of the NHS in 1948 and has the lowest level of investment largely because other Health Boards have within their estate DGHs. Close working with Welsh Government has resulted in investment for example £6million in Llandrindod Wells for Phase 1 and discussions are in the early stages for Phase 2 of this project. Developments in Machynlleth and Ystradgynlais are planned but it is necessary for capacity reasons to phase projects.
The endoscopy and laminar flow theatres are all located in south Powys. Are there any plans to introduce these services in north Powys?
PTHB and the local authority are working jointly to ascertain if these services can be provided more locally. At present patients travel for endoscopy and there is an increasing demand for this service. Although the exact demand hasn’t been ascertained it appears to support a case for locating endoscopy and theatre provision in north Powys. Work is ongoing to produce an outline business case for the North Powys Well-being Project for submission to Welsh Government.
What is the timeframe for this project?
It is difficult to give a timescale, work is taking place to submit an outline business case and there is an ambition it would be within 5 years but it is necessary to be realistic about how long it will take Welsh Government to provide capital funding. Work is already taking place on service developments which will be in place before any new building will be completed.
What is the situation in Machynlleth?
There is a commitment from the Board to progress matters in Machynlleth. The planning and highways challenges have been resolved and an outline timeframe exists. Additional costs are likely to be incurred and if this is signed off by the Minister it expected that construction will start during 2020 with completion by March 2022.
Welsh Government have a Minister of Health and Social Care demonstrating a political will to work together. How can the Council and Health Board work together more effectively particularly in light of the Health and Social Care (Quality and Engagement) Bill?
The Chief Executive of PTHB explained Powys is the only area that has a joint Health and Care Strategy. The health board and local authority work jointly at a number of levels including strategically where there is a commitment to work together expressed through the joint working at the Regional Partnership Board, at a planning and commissioning level where workforce plans are being developed jointly, a joint digital first strategy has been produced and joint working is taking place for example at Machynlleth hospital. However, there are some difficulties with joint working for example staff in each organisation are on different terms and conditions and it is not that smooth to move between sectors but these barriers are national and so are for Government to help resolve.
The Health and Social Care (Quality and Engagement) Bill went to National Assembly for Wales Committee last week for scrutiny. This considers matters such as a joint approach towards inspection and complaints.
The Corporate Director (Children and Adults) explained that the Health and Care Strategy had been compiled jointly with good governance behind it. Both sectors are working closely on the North Powys Well-being Project, have Section 33 agreements and also come together as joint Executive Team to examine opportunities for joint working.
As a scrutiny committee it will be interesting to examine in the future how the two sides will be working together to get patients home from DGHs.
The PTHB Director explained that the intention was always to get patients ‘Home First’ from DGHs.
The Corporate Director (Children and Adults) agreed the intention was to get patients Home First and explained that the Regional Partnership Board had commissioned a piece of work from John Bolton of the Institute of Care to examine what the two organisations need to do to shift the culture of Home First for residents.
Some groups operating from hospitals such as the garden group in Machynlleth are particularly successful. What is the bed capacity within Powys compared with the rest of Wales?
The PTHB are increasing their aim of helping people connect on a social basis which is known as social prescribing. For example leg clubs, which across Powys 350 people attend each week, mean people travel to a central point to receive leg care and recover more quickly with less pain than previously where a District Nurse would travel to patients homes to provide care.
The Director of Primary Care, Community and Mental Health advised it was difficult to compare the number of beds in Powys with elsewhere as Powys does not have a DGH. Powys have approximately 150-160 beds across 9 hospitals (including Glan Irfon) and can access approximately 250 beds in DGHs. In addition, the Virtual Ward arrangements across Powys give extra capacity. Virtual Wards are used where patients need a range of support services which can be provided in their own home (for example physiotherapy, care support, pharmacy amongst others). Whilst elsewhere in the country hospital admission rates have increased the Virtual Ward arrangements have succeeded in reducing this rate of increase.
The Chief Executive would confirm if Virtual Ward arrangements are in place across Powys.
To what extent has PTHB embraced early intervention and prevention as a principle?
This is central to the work undertaken and is expressed through support for vaccination, healthy weight, exercise, use of green and open space, eating 5 a day and overall helping people make healthy choices. Loneliness and social isolation is a particular problem in a rural area for both young and older people. Access to early support for mental health is being improved with the introduction of Silver Cloud which was started through an EU funded project which is led by PTHB.
What is the criteria for people to live at home in particular when they have dementia?
The Chief Executive from PTHB explained that a multi-disciplinary assessment would be undertaken to understand the level of risk they pose to themselves and others. The team will consider the professional view and balance it with the wishes of the person.
The Corporate Director from PCC added that as part of mitigating risk a Best Interest Decision would be undertaken.
Powys has had additional funding for mental health support but a lack of beds means patients may have to travel long distances to access this service.
Acute mental health services are available at Bronllys together with inpatient beds at Ystradgynlais, Llandrindod and Brecon hospitals for older people. Hywel Dda University Health Board were unable to sustain a ward at Aberystwyth although only a few people from Powys would have used this facility as most patients from North Powys would access provision at the Redwood Centre in Shrewsbury. For the last few years PTHB has had a Crisis Home Treatment Team which although not a 24 hour service does run 7 days a week and into the evening which helps avoid hospital admission. The trends across England have been for an increase in care at home and there has been an increase in availability for this in South Powys. PTHB are also considering introducing a Crisis House which already exist in South Wales. The £700k investment for mental health services has been used to increase access to talking therapies, CBT and the introduction of the Silver Cloud.
Cllr Jenner left 3.45pm
There used to be a ward in Llanidloes Hospital for mental health patients which is now used for palliative care. There has been support in the community to retain 14 beds but from the written answers provided by the Chief Executive bed stock in Llanidloes is shown as 7.
The Chief Executive advised that senior leaders from PTHB would be attending a meeting in Llanidloes the following day. £150k had been received from residents of Llanidloes to support the development of palliative care rooms. There are particular workforce challenges more acutely felt in Llanidloes. The Nurse Staffing Levels (Wales) Act 2016 has to be applied and there will be discussion with the community regarding the commitment to community hospital provision. Discussion will take place regarding therapy led wards and it will be necessary to have a different solution to staffing in the community hospital.
Is bed availability in Llanidloes 7 or 14?
The Director of Primary Care, Community and Mental Health advised that at present there were 10 patients in Llanidloes and there is an ability to ‘flex up or down’. The previous weekend had been challenging for the Health Service across Wales with many admissions to DGHs which would lead in time to patients being stepped down to Community Hospitals.
Earlier in the meeting the policy of Home First (discharge from DGH straight home) had been outlined. The previous answer suggests that a step down from DGH to Community Hospital is taking place. What is the intention for patients waiting to be discharged from a DGH?
The Director for Primary Care, Community and Mental Health advised that the default position when patients are medically stable is Home First however, in some cases it is appropriate for discharge to be a step down to a Community Hospital.
The written response has provided an update on the position regarding historical disputed debts. Has any further progress been made?
The Chief Executive of the PTHB advised that relevant Directors from both organisations are working closely together and it is hoped that matters will be shortly concluded.
The Corporate Director for Transformation confirmed that matters had progressed at an Officer level and it would then be necessary to conclude this matter at Board/Cabinet level.
At an earlier Health and Care Scrutiny Committee it had been reported that between April 2018 and April 2019 there had been a 200% increase in Delayed Transfers of Care. What are the two organisations doing to support early discharge?
The report provided notes that of 144 patients 26 should not be there with a total of approximately 1,000 days delayed an average of almost 40 days delayed. There are some locations with no delays. How are these locations managing to avoid delays in discharge?
The Chief Executive noted that this was a thorny issue. It is not what any one part of the health and social care system is doing but is a whole system issue. The Chief Executive was sorry to note that Powys has one of the poorest performances in this area in Wales and no-one working in this area is content with this position. In 2009 DToC were 59 and much work was undertaken to reduce it to 20. The lowest level has been 15 and it is the aim to reduce it to this level again but there has been an increase over the last few months. There is an impact on the Community Hospital which means that DGHs are unable to step patients down which in turn means the DGHs are full and are unable to admit patients. This is a critical situation and the PTHB and local authority have a joint action plan to tackle this.
The Director of Primary Care, Community and Mental Health advised in November 2018 there were 17 patients delayed for a total time of 400 days but by August 2019 this had increased to 33 patients delayed for around 1,000 days. Welsh Government collect DToC data one day/month with reasons coded. It is known that the local authority are facing a challenge in providing domiciliary care and the PTHB will work jointly with their partners to deal with this. It will be interesting to see the outcome of the work by John Bolton at the Regional Partnership Board.
The Corporate Director – Children and Adults noted that from the local authority perspective there is joint working and it is acknowledged that the current position is not where it should be and improvements are needed. A Discharge Officer has been appointed and a bespoke team is being put in place in hospitals. There are significant issues in recruiting staff and it will be necessary to make the best use of resources. The work with John Bolton will help understand patient flow, looking at the package of care and how to best use equipment to allow for single handling. There is also an aim to increase Direct Payments to allow patients to arrange their own care and to that end the local authority is encouraging the creation of a personal assistant market in Powys.
The Head of Commissioning noted that Community Catalysts had recently been commissioned to work in Powys and in the first instance are focussing on the eastern border where it is hardest to recruit carers.
Recommended that |
Reason for recommendation |
Quarterly reports are received on Delayed Transfers of Care |
For scrutiny to monitor the position on Delayed Transfers of Care to receive assurance that the actions taken are improving the outcomes for patients in Powys |
Cllr R Williams left 4.00pm
What governance arrangements are in place to ensure the efficiency and effectiveness of the Continuing Healthcare assessment to minimise delay for patients?
The Chief Executive explained that she was Lead in Wales for this area. The arrangements for Continuing Healthcare are tightly prescribed by Welsh Government. They have been in place since 2014 and have recently been revised. This is a very emotive area which relates to where the NHS has a duty to fund all the care of an individual and there is a lot of money at stake. Eligibility does not relate solely to disease but is about needs which means the decision is complex. Staff are specifically trained to undertake assessments and each year Health Boards are audited on their Continuing Healthcare arrangements. PTHB have always had positive outcomes to these audits. The Corporate Director of Children’s and Adults has raised concerns and an external person has been commissioned to check if the correct rules are being applied. It is extremely complex and a Supreme Court Case in 2004 provided clarity but resulted in a large number of claims for historic case review to be received. These reviews were undertaken by PTHB for all of Wales with over 2,000 cases for review by a Special Investigator Team which is only just coming to a close. It is expected that the outcome of the additional review will be available shortly.
What is considered the appropriate capacity for hospitals?
The capacity of a DGH should be around 85% but that is regularly exceeded now. The capacity of a Community Hospital should be around 90%. This is higher than a DGH because the throughput is slower however, if a Community Hospital is full it will result in delays at the DGH.
If there are 8 patients in Glan Irfon with a capacity of 12 beds is the local authority and Health Board still paying for 12 beds?
The Director of Primary Care, Community and Mental Health advised there are now 10 patients in Glan Irfon.
The Corporate Director – Children and Adults advised that the 12 beds at Glan Irfron are run by the Shaw Trust paid for under a section 33 agreement between PTHB and the local authority. There have been some problems regarding bed occupancy and a meeting was held approximately 6 weeks ago. The local authority and PTHB are working closely on arrangements for reducing the need for people to receive long term care in a residential setting. There has been a problem with GP coverage at Glan Irfon but it is understood that this has been resolved (it is no longer limited to 2-3 beds). There are 12 beds at Glan Irfron and they need to be used.
Can patients be admitted after 12 midday and at weekends?
The Corporate Director – Children’s and Adults advised that this information would be provided after the meeting.
If Community Hospitals have spare capacity why is this not been used to step down from DGHs?
Not all patients need to be stepped down from a DGH as many patients attend for a specialist procedure and are then able to return home. Community Hospitals are able to provide a range of services other than inpatient beds and the conversation needs to be in respect of what patients need to be treated or re-abled.
Some of the therapies that are being discussed such as hydrotherapy are not available at all Community Hospitals and therefore are only available to patients able to travel or pay privately for such therapy. What plans are there to widen this access?
The Chief Executive explained that since the 1980s there had been a change in approach with procedures no longer needing a lengthy inpatient stay with an increase in day procedures. The longer older people stay in hospital the more likely it is they will need residential care. For every 10 days a person over the age of 80 stays in hospital they will lose 10years of muscle tone. This information needs to be widely known in the community as part of the move towards therapy services. It will be necessary to work with partners such as Freedom Leisure to increase access to short term interventions. The RPB has received funding for early interventions and are keen to de-medicalise exercise.
What arrangements have been put in place for patients since the closure of the Chronic Back Pain Service at the Robert Jones and Agnes Hunt Hospital (RJAH)in Shropshire?
These patients were transferred to the PTHB Pain Management Service but for a small number of patients with complex needs another provider (Inhealth Pain Management) has been secured in Shropshire. The transfer is nearly complete and both the PTHB and RJAH have apologised to the patients who have been affected by the closure of the Chronic Back Pain Service at RJAH.
Are the two organisations working closely to address workforce challenges?
The Chief Executive noted that there was a shortage of approximately 30,000 staff across the NHS in the UK.
The Corporate Director – Transformation explained joint work was ongoing on a Workforce Strategic Framework between the Health Board, the Council and the Third Sector. The intention is to understand the workforce requirements, look for gaps to ‘grow our own’ and look at the possibility of a Rural Academy to train young people. Links with schools are now being made from the age of 14 so that young people can choose appropriate GCSEs.
There are a number of Community Hospitals across Powys. Is the PTHB committed to keeping them open?
There is a commitment to keep Community Hospitals open however, the type of provision within these hospitals might change.
Until work starts on promised projects (for example at Machynlleth Community Hospital) people will be worried.
The Chief Executive gave an absolute commitment that work on this project would start as soon as approved by the Minister. She invited Members at a future meeting to visit Llandrindod Community Hospital to see the improvements that had been made there.
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