Meeting documents

Purpose:

In February 2017, the Committee first reviewed the Hospital Trust’s plans for developing care closer to home which included developing community hubs.  Since April 2017, Marlow and Thame Community Hospitals have been piloting the hub model by providing day health services in a community setting.  The pilot was initially for 6 months but it was extended to 12 months to allow more services to be introduced.  The Committee set-up a Task & Finish Group after the 6 month report was presented to the Committee in September.  The Task & Finish Group put forward a number of recommendations for the Trust to consider as part of its final report.

The Committee will now review the community hubs in light of the paper submitted by Bucks Healthcare Trust.

Attendees:

Dr T Kenny, Medical Director, Bucks Healthcare Trust

Dr M Thornton, GP Partner Unity Health and Clinical Lead, FedBucks

Mr N Macdonald, Chief Executive, Bucks Healthcare Trust

Ms L Patten, Accountable Officer, Bucks Clinical Commissioning Groups

Papers:

Report attached

Intended outcome:

For Members to evaluate the community hubs pilot and to consider the future plans put forward by Bucks Healthcare Trust.

The Chairman welcomed Ms C Morrice, BHT;

Dr M Thornton, GP Partner Unity Health and Clinical Lead, FedBucks; Mr N Macdonald, Chief Executive, BHT and Ms L Patten, Accountable Officer, Bucks CCGs.

Mr Macdonald advised it was important to review the pilot as part of the jigsaw of the STP and ICS in trying to pull together to solve the growing issue of effectively managing emergency demand and dealing with some of the issues of an increasingly frail and elderly population   Mr Macdonald also thanked the members of the Thame and Marlow stakeholder groups.

Ms Morrice said the purpose of the presentation was to provide an overview of the full paper contained in the agenda pack.  The aim of the presentation was to share the results, explain how the pilot fitted into the wider communications strategy and outline the next steps.  The following points were highlighted:

• 600,000 contacts cared for outside of hospital annually.
• Working with partners to ensure safe services were provided.
• Invested over £1m to expand community services.
• Delivering what patients and clinicians had asked for.
• Creating a health and social care environment to reduce pressure on the GPs and hospitals.
• Developing locality teams, rapid response intermediate care teams and community care co-ordinators.
• There had been a 12 month pilot at Marlow and Thame hospitals which had provided a new community assessment and treatment service (CATS), more outpatient clinics and more diagnostic services.
• The pilot was run with a strong governance structure by an operational group. 
• Dr Thornton advised that The Clinical Innovation Group had been looking at how to develop the service further.  Frailty was an emerging area and clinicians had been looking at the next steps of development to try to predict who may need to use the service. 
• Ms Morrice said she worked with the Stakeholder Engagement Group and had received a lot of challenge on the key performance indicators.  Stakeholders had provided a wealth of information on the population.
• Over 300% more patients had been seen in CATS than in the inpatient service in 2016/17 at Marlow and Thame.
• 92 people were followed up on in their own homes.
• Less than 1% of patients seen by CATS were subsequently referred to A&E.
• The number of Community Care Co-ordinator referrals of 6,063 included families.
• Patients felt the clinicians had the time to listen and understand care needs. 
• Patients thought the new model should have been better communicated.
• Transport was a consistent issue; there had been some progress with looking at using transport hubs and having staggered appointment times.
• Stakeholder views on the hubs were obtained by a variety of means.
• Recommendations from the stakeholders were to raise awareness, increase the service to five days a week, consider expanding the process to self-referral, more outpatients and voluntary sector involvement.
• Dr Thornton showed an example of what the model of care might look like which showed input onto self-management with more support.  GPs had started to work together and were empowering people to look after themselves.
• The proposed next steps over the next two years were as follows:  Phase 1; to continue with the community hubs in Marlow and Thame.  Phase 2; April-June 2018 – to review the out of hospital care model.  Phase 3; June 2018-2019 - to increase the scale of delivery of the hubs and integrated teams across the county. Phase 4; to roll out the full care model by March 2020.

A short video was shown.

In response to questions from Members, the following key points were made:

• There were no negative comments in the report as no formal complaints had been received.  The staff tried to resolve issues at the time but acknowledged there had been issues around transport. However, nothing had been hidden and Ms Morrice reiterated that there had not been any specific complaints about the hubs themselves.
• Feedback had been received to say that more could be done and Ms Morrice agreed that the service needed to be taken up a notch to get to the harder to reach communities.  Ms L Jones, Director of Communications, BHT, said the stakeholder engagement had been focussed on Thame and Marlow.  In Buckingham there was a group looking at how to develop a joined up approach to bring different work streams together. 
• Ms Patten said a key area was to provide information and work on prevention at the national STP level in order to educate people and change their behaviour.  Dr Thornton acknowledged that behaviour change was a major challenge and advised that a programme called care and support planning had been implemented to try and achieve behaviour change in those people that were ready for it.  The challenge was to find out the barriers that prevented people living independently
• Mr Macdonald said there had been eight beds in Thame and 12 in Marlow and the starting theory was that resources could be invested in different models of care to reach out and treat more patients and prevent people coming into hospital.  Mr Macdonald thought if beds were built at the rate that the population changes in traditional healthcare required it would not be affordable; another limiting factor was the shortage of nurses.
• The stakeholder groups did not want the beds to be re-opened; they wanted a better use of resources.  Rather than waiting for a GP to send a patient to the community hub; the hub should be getting the data out of the GP system and targeting those individuals who were at risk and likely to be healthcare users and proactively bringing them into the hubs to develop bespoke care plans that were beyond what a GP could provide.
• The Buckingham situation would be decided jointly with the residents of Buckingham.  Mr Macdonald offered to find out the cost of a bed outside of the meeting.

Action:  Mr Macdonald

• £0.5m worth of community care in terms of care packages and domiciliary care were put in place over the winter period to support people coming out of hospital sooner which had worked well considering the extraordinary levels of demand this winter. It would be an ongoing challenge and the key would be to reduce the number of people turning up in the A&E department.  Mr Macdonald said he supported the GP cluster scheme and the building of community hubs that could spend more time, particularly with the frail elderly, or providing more outpatient care and then connecting to the hospital only when required.
• Dr Thornton said the project was massive; and agreed that mental health patients need the right services in place; the pilot was one small cog in a much bigger wheel.  As a GP he could see much more clearly how the system could connect together. 
• Dr Thornton explained that the big agenda was to identify patients who were housebound.  If transport was provided; housebound patients could often get to appointments but were put off psychologically.  It was more time consuming for various clinicians to go out to people’s houses and it would be a better use of resources for transport to be provided to get people to the hubs. 
• The ideal would be to expand opening times at Thame.
• Access to be hubs had been through GPs but it could become a self-referral process. 
• Volunteers could make the hubs more sustainable e.g. by running exercise programmes.  It was felt there were a lot of retired people in Buckinghamshire who could contribute. 
• Ms Jervis, from Healthwatch Bucks, asked for reassurance that BHT would work with BCC to consider building plans and the existing transport infrastructure.  Ms Jervis felt transport needed to be a priority and that there were opportunities for strategic working to support community transport and the flow of patients to and from appointments.
• It was suggested that a lot of people in Buckinghamshire were keen to be involved in the clinical intervention group.
• Transitional beds had been in place since the autumn 2017.  Patients were assessed as to whether they needed a transitional bed rather than an acute bed.  The aim was to move people out of hospital more quickly.  The outcome had remained the same in that the patients were no more or less likely to be re-admitted to hospital.  Mr Macdonald said there had not been enough volume to ascertain if it cost less to run.
• In response to a query on the funding situation if the community hubs were to open five days a week; Ms Morrice said the early evidence showed that reduced duplication would release funding to be re-invested into care outside of a hospital setting.
• Ms Morrice added that the community hubs provided the opportunity to do something different; often an occupational therapist could give a better outcome than a nurse; releasing nurses to deal with those with more complex needs.
• The data on page 43 was queried and the Committee asked for defining terms, baselines and clinical outcomes to be provided.  Mr Macdonald offered to produce a data fact sheet.

Action:  Mr Macdonald

• Mr Macdonald clarified that intermediate care was the reablement and community based services.  MUDAS was the original service based in Wycombe and similar to the CATS service.  A single point of access had been introduced for GPs to refer to.
• A committee member raised concern that early discharge would have an impact on carers particularly as carers’ respite was not as readily available.  Ms Morrice agreed it was necessary to monitor the impact on carers and to look at the health support network for the person.

It was agreed that more time was needed to be dedicated to this important subject and that the Committee would ask more questions at the next meeting on 22 May 2018. The Chairman thanked the presenters for attending.