Minutes:
Context:
To receive an update by Aneurin Bevan University Health Board (ABUHB) regarding Chepstow Hospital. In particular, dementia services, inpatient and outpatient services, capacity in terms of wards and beds. Similarly, the position for Nevill Hall and Royal Gwent Hospitals in line with the future services that will be provided by Llanfrechfa Grange.
Key Issues:
To provide updates in respect of:
· The provision of health services within the Chepstow area.
· Service provision for Older Adult Mental Health.
· The Clinical Futures Programme and the development of the Grange University Hospital, which is within budget and on schedule to open in March 2021.
The Chepstow Site
· The shop at the main entrance has been converted into a multi-use information / discussion area. The facility will be co-ordinated by Monmouthshire County Council’s Community Wellbeing Coordinator. This facility will open in May 2019. The following organisations have committed to having a presence in the information point, namely: Gwent Association of Voluntary Organisations (GAVO), MIND, the Community Connections Befriending and Community Car Scheme, Pace, Volunteering for Wellbeing, Building Bridges, Monmouthshire Housing Association, Social Inclusion and Housing and Wellbeing.
· A series of enabling works to allow the two wards on the ground floor to move upstairs are being undertaken. The idea being to move the in-patients upstairs which will create a private environment with the wards being linked via a centralised nursing station allowing the wards to operate as one unit whilst still being two separate areas. There will be no bed closures. The transfer of the services will allow for more capacity on the ground floor for the creation of the wellbeing hub.
· With regard to the ward move, a section of the ward will be converted to create a six bed frailty assessment area.
· Aneurin Bevan University Health Board (ABUHB) has sought further funding from this year’s Integrated Care fund allocation. In order to create the new wards upstairs, the older Adults CMHT base needs to be relocated to the ground floor. Alterations to the IT infrastructure is being undertaken before the move can be undertaken.
· The outpatients department is almost full which has resulted in expansion into the former minor injuries unit. Health visitor and midwifery clinics have been moved to the former MIU which is a more suitable environment for them. The Older Adult Mental Health Clinic has been moved to the former Day Hospital.
· When the capacity has been created on the ground floor, it is proposed that a Children’s unit be created.
· Increased space will be required on the site to accommodate the Integrated Health and Social Care Team.
· The alteration will provide capacity on the ground floor to provide a fully integrated Health and Wellbeing Hub.
· A new Perinatal and Mental Health Clinic had commenced in November 2018 and is operating from the new unit.
· Patient education group sessions are being held to manage osteoarthritis of the knee and low back pain which takes place every six weeks at Chepstow Hospital.
· Adult weight management clinics commenced in March 2019.
· The Frailty Assessment Unit will result in new staff being appointed. A consultant in frailty will cover the whole of Monmouthshire and will run clinics in Chepstow, Abergavenny and Monmouth.
· A monthly gastroenterology clinic has been requested and ABUHB is keen to further develop this.
· Expert patient education sessions are being run from the hospital which will alternate between Chepstow and Caldicot.
· The Care of the Elderly Clinic has not yet commenced. There have been some operational difficulties in the Care of the Elderly Directorate based at St. Woolos Hospital, Newport. However, this matter is being pursued.
· Chepstow Hospital is producing a new integrated newsletter which is circulated throughout Monmouthshire.
· A public engagement exercise is being undertaken in Chepstow Hospital whereby, visitors are asked for their views on services, going forward.
· Late funding approval has been received from Welsh Government for the improvements to be undertaken at Caldicot Health Centre. A receptionist has been recruited. Approval is awaited via the ICF process for this year.
Member Scrutiny:
· Welsh Government has provided designated funding for improving intermediate care services. This is managed via the Regional Partnership Board. The funding approved last year equated to £200,000, which has funded the enabling works for the ward and the alterations to the shop. This has not been fully spent. Therefore, a request has been made for the remainder to be carried forward into the current financial year to enable the ward element and the move of the Older Adult Mental Health Team to the ground floor. The remaining schemes are to go forward this year but have yet to be costed.
· In terms of consultant led clinics, a number of the clinics that ABUHB have introduced and are proposing to introduce are consultant led clinics and a number of the others are members of the consultant team who see patients within their scope of practice.
· With regard to ‘bed blocking’ at Chepstow Hospital and at the Royal Gwent Hosptial, the waiting time for patients who are appropriate for transfer to Chepstow Hospital, based on their clinical condition being suitable for management at the hospital, is generally not an issue and are usually transferred quickly to hospital. However, there are patients who are unable to move on to the next phase of their care and in some cases can wait longer at Chepstow Hospital. Also, patients at the Royal Gwent Hospital who are not suitable to go to Chepstow Hospital, because they are not there to undergo rehabilitation, can wait in the Royal Gwent Hospital for packages to be developed or for them to move onto their next phase of care. However, this did not occur that often in Monmouthshire.
· In Chepstow, Ebbw Vale and Newport, ABUHB is developing a graduated care model where patients can receive their required secondary care but without having to go into the acute hospital. By bringing patients into the community hospital, their length of stay is being shortened, they are being seen by the integrated team to provide support to allow patients to return home as quickly as possible.
· With regard to outpatients, ABUHB has a development group for both the north and south of Monmouthshire. Additional services are being sought and work is being undertaken to provide more services locally. One of these services is audiology. ABUHB is trying to move Audiology, ophthalmology and audio visual services out of secondary care hospitals. A trial regarding audiology services in Blaenau Gwent has resulted in this service being provided by different service providers other than hospitals in the community for all of the lower level hearing issues. This has proved to be very successful. In terms of ophthalmology, ABUHB, over the last two years, has moved in the region of 7000 patient appointments into optometry provision in the community.
· Representatives of ABUHB agreed to attend a future meeting of the Severnside Area Committee to discuss issues specific to that area.
· In response to a question raised regarding the need for a document to be produced outlining ABUHBs plans for Chepstow Hospital, it was noted that the newsletter being produced informs and advises patients, visitors and the general public regarding the services that are available. Representatives of ABUHB regularly liaise with local Members in terms of particular issues centred locally around Chepstow and the Lower Wye Valley. The partnership with the local Authority is key.
· In terms of the provision of staff, the challenge of recruitment and retention of medical staff and healthcare providers is an issue across Wales and the UK. However, ABUHB is confident that it will be able to recruit to the consultant post within the Frailty provision and to the Rapid Response team.
· The Local Authority needs to monitor timescales on the proposals that have been identified in respect of Chepstow Hospital. It was noted that ABUHB has an action plan and timetable of delivering the proposed changes to the hospital. This information can be shared with the local Authority. The Select Committee will liaise with the Chief Officer for Social Care Safeguarding and Health with a view to establishing the required data sets needed from ABUHB to be monitored by the Authority.
· In response to a question raised, regarding the Gastroenterology clinic and whether there is a link with the Gwent Drug and Alcohol Service, it was noted that currently, there has been a request for a monthly outpatient follow up clinic. It was considered that strong links exist between the Gastroenterology clinic and the Gwent Drug and Alcohol Service. However, this specific clinic is intended to stop local patients having to travel to Newport for follow up appointments.
· The Minor Injuries provision that was at Chepstow Hospital is no longer a part of ABUHBs Clinical Futures Plan. ABUHB will retain a minor injuries unit at the Royal Gwent and Nevill Hall Hospitals when the Grange University Hospital opens. The provision of the minor injuries units at both Nevill Hall and The Royal Gwent Hospitals will most likely be improved as the major element of the Accident and Emergency units will move to the Grange University Hospital with the service provision likely to improve at the two sites. As Lydney Hospital is being closed, including its Minor Injuries Unit, due to the rebuild of a new facility in South Gloucestershire, it is understood that there will be some minor injuries unit provision at Cinderford.
· ABUHB has a contract where it pays South Gloucestershire for services that it provides for residents of Monmouthshire for the use of Lydney Hospital’s Minor Injuries Unit. However, the numbers in question are very small on an annual basis. Therefore, the relocation of this provision to Cinderford will likely lead to even fewer Monmouthshire residents going across the border to utilise this service.
· With regard to GP services, ABUHB has recently established a new neighbourhood care network lead in South Monmouthshire from the Town Gate practice in the hospital. The former NCN lead for South Monmouthshire is working on the provision of Frailty services for the whole of Gwent.
· In terms of minor injuries, it has been identified that in certain areas of Gwent the Health Board has had to intervene and manage a number of GP practices. There are three relatively large practices in south Monmouthshire (two in Chepstow Hospital and one in Caldicot) which could utilise space to introduce a multi-disciplinary approach. The pharmacy service has already been introduced into those practices, which was funded centrally from a budget that was allocated to general medical services in the previous financial year.
· As services were commissioned in general practice and because they are independent contractors, it is sometimes more difficult for ABUHB to tell them what to do rather than encourage them what to do. Therefore, money is made available for certain enhanced services and certain local services that if they sign up to, they can gain access to and then provide the service. However, ABUHB cannot insist that they must have a particular type of health professional unless ABUHB is running the practice. Therefore, this is a model that ABUHB does not want to pursue. However, ABUHB has a very good relationship with the lead officers across Monmouthshire.
· As ABUHB begins to see general medical services, in particular GP services, consolidate into larger practices which will result in a wider, multi-disciplinary workforce that offers a wider range of services going forward. Chepstow and Caldicot is seen as being well placed to deliver those services over time.
· ABUHB was asked as part of the development of the Neighbourhood Care Networks (NCN) of the clusters of GP practices to allocate budget to each of the individual clusters which was undertaken. That budget was for them to spend on service provision and service enhancement that they considered was going to improve what was provided. Around 12 to 18 months ago, 15 pharmacists were recruited across the 12 NCNs to provide a pharmacy service. ABUHB will look to roll out this model across Gwent with potentially looking at providing a further 10 – 12 pharmacists across its area. This would be funded via ABUHB and its development money would be given back so that something else might be tried in the next 12 months. ABUHB will be meeting with them in May 2019 to discuss how to take this matter forward.
· Concern had been expressed regarding the delay in receiving diagnostics information, such as x ray results. It was noted that the results of an x ray, taken seven weeks ago, had not yet been received. It had been acknowledged by ABUHB that a seven week wait was unacceptable and would be investigated.
· With ABUHB investing in services like x ray staff, further provision of MRI and CT scanning machines, diagnostic waits have been lowered. 99.9% of people waiting for a diagnostic get seen within six weeks. The biggest challenge is the interpretation and the reporting of the results. In terms of x ray, plain film reporting has been quite lengthy. ABUHB is aware that this is currently taking too long and is working to reduce the reporting of the diagnostic.
· Nationally, reporting of diagnostic information is a problem. Therefore, Wales has created an academy that looks at training more radiologists and radiographers to address this issue.
· In response to a question raised, it was noted that ABUHB has an agreement with Gloucestershire in that any patient from Monmouthshire or Wales who accesses services at Lydney Hospital for minor injuries, ABUHB has a contract to pay for that service. Similarly, a patient who is from Gloucestershire goes to a hospital in ABUHBs area, that Health Board has a contract with ABUHB to pay for that service. It is therefore a reciprocal contract.
· In certain areas within Chepstow Hospital, it is close to capacity, particularly around outpatients. The space exists within the hospital which has led to the proposed capital plan going forward for a range of schemes that will enable ABUHB to address the capacity issues over the next two years to ensure that the hospital is fit for future purpose. However, it was noted that capital finding would be required in order to undertake the work.
Older Persons with a Mental Health Need
ABUHB approved a number of recommendations in the spring of 2018 in order to redesign its specialist services for older adults with a mental health need. There are a number of key elements to the redesign, namely:
· Enhance and strengthen its specialist community services for older people with a mental health need.
· To consolidate the number of inpatient services to move to three inpatient dementia wards and one inpatient ward for older people with a functional mental health difficulty.
· ABUHB had approved these recommendations and had also approved an additional investment of £200,000 specifically for Monmouthshire for the Health Board to work with partners within Monmouthshire in relation to enhancing community services for older people with a mental health need.
· Community Services – A considerable amount of work has been undertaken over the previous 12 months. Significant benefits are being identified for residents within Monmouthshire.
· With regard to support to care homes, ABUHB has introduced a new Behavioural Support Team that is able to provide advice and support and work alongside care homes in Monmouthshire for them to work with individuals with complex behaviours.
· The nursing In-reach service has also been increased into care homes. There is an in-reach worker working with the care homes in the north of the County and likewise in the south of the County.
· Improvements have been made in improving access to psychological support for older people with a mental health need with average waiting times having reduced significantly.
· With regard to memory assessment services, a number of changes have been made. This service is delivered form three centres within Monmouthshire, namely, Mardy Park, Monnow Vale and Chepstow Hospital. ABUHB has been able to increase the number of dementia support workers available across Gwent, including Monmouthshire.
· Cognitive Stimulation Therapy has also been implemented. A 12 week programme has been established which provides that therapy in all three places across Monmouthshire.
· In November 2017 within Monmouthshire, 75% of individual who were being referred to the Memory Assessment Service were accessing their first assessment within 28 days. In November 2018, 100% of individuals were seen for their first appointment within 28 days.
· Changes in in-patient services – There are now three in-patient wards for people with dementia and one ward for older people with functional mental health difficulties on the County Hospital site.
· Bed numbers have reduced from 72 beds across Gwent to 67.
· St Pierre Ward closed in April 2018. Since that time within Monmouthshire, 21 individuals with dementia have required admission. The majority of the individuals living within the North of Monmouthshire have gone to the hospital in Ebbw Vale. The majority of individuals from the south on Monmouthshire have gone to St. Wollos Hospital in Newport.
· Work force and recruitment of registered nurses has continued to be a challenge across Wales and the UK. However, there has been significant improvements. Figures have dropped resulting in there now only being five vacancies within ABUHBs in-patient services. The number of agency staff being used has also been reduced.
· Strengthening leadership within in-patient services has enabled ABUHB to invest in and enhance the number of deputy ward mangers.
· Strengthening multi-disciplinary teams within wards has been slower than in other areas. Therefore, the focus is to improve speech and language therapy provision and pharmacy provision within in-patient wards. Plans are in place to increase these services by July 2019.
· £200,000 has been allocated to the Integrated Services Partnership Board for Monmouthshire to investigate piloting new ways of providing community support for people with dementia.
· The Bridges Community Transport Scheme commenced in January 2019. Of the 524 passengers that are registered with the car scheme, 48 of those have a diagnosis of dementia. This is a Monmouthshire wide service. The cost of running this scheme for the financial year 2019/20 equates to £40,000.
· The Living with Dementia Exercise and Education Programme was run in partnership between the National Exercise Referral Scheme out of Chepstow and Caldicot leisure centres and the County Council. A pilot was established providing an exercise and wellbeing programme which initially supported 10 recruits plus their carers. The criteria is being revised with regard to admissions in order to allow more people to gain access to this programme, going forward. The intention is to roll out the programme to people in other parts of Monmouthshire. The cost of running the programme for the 2019/20 financial year equates to £13,700.
· A pilot has been established for the Creative Lives Active Lives project which initially operated from the Shire Hall, Monmouth. The project provided opportunities for participation in arts and culture. A lottery bid is being prepared for this scheme. ABUHB is going to consider at the May meeting of the ISPB meeting whether it should continue to fund that initiative just for the remainder of this year pending the outcome of the lottery bid. In order to do this, the cost equates to £13,940.
· With regard to the development of a respite bed option, this has been managed via the County Council’s Social Services Department. The scheme commenced on 11th January 2019. Five people have been through the scheme. The period of respite is for up to two weeks. An increase in the use of the bed is anticipated. So far, the bed has been occupied for 58 out of a possible 98 bed days between January and the present day. Provisional allocation for this scheme equates to £47,500 for the full year.
· With regard to respite options for day services for people with complex dementia who were not able to access voluntary sector dementia day support, ABUHB has not been able to access this service via any of the voluntary organisations because they are unable to cater for people with very complex demands.
· ABUHB is now looking at options for managing the staff via the Council structure. However, this has led to a delay in implementing the scheme. The full year cost for this respite option equates to £62,000.
· The residual allocation from the £200,000 for all of the schemes if they run for the full year has resulted in a residue of £17,700. Further gaps have been identified in ABUHBs Community Services provision. Therefore, a proposal will be presented to the Integrated Services Partnership Board for options in which to utilise this money.
· With regard to the data captured via the pilots, it was noted that in respect of Bridges, everyone who attended the living with dementia exercise and education programme was from south Monmouthshire. Everyone who attended the Creative Lives Active Lives Project was from North Monmouthshire. With regard to the Respite Bed option, two were from the North of the County, one was from Usk and two were from the South of the County.
Member Scrutiny:
· Across Gwent, ABUHB has provided a piecemeal service in terms of in reach service into care homes. Monmouthshire only had one worker providing support into care homes across the County. However, via the reconfiguration of services, ABUHB has been able to strengthen the provision to care homes across Gwent.
· In response to a question raised, ABUHB stated that it could investigate the support being provided to Monmouthshire residents that are placed outside of Gwent.
· Through the redesign of the service, ABUHB is investing its resources within the community services and is able to support far more individuals than if they were put into beds. Therefore, a part of the model relates to how ABUHB strengthens community services. In relation to bed occupancy, ABUHB had been mindful of even a small number of reductions beds and wanted to see what impact that would have. Occupancy is monitored frequently in terms of all in-patient services. ABUHB identified that occupancy has reduced even further.
· With regard to the Dementia facilities, over the last 12 months only 65% of those beds have been occupied. Work is being undertaken to establish why this is happening.
· Current bed capacity is sufficient. ABUHB Older Adult Mental Health bed numbers are in the upper quartile compared to the rest of the UK.
· A part of developing the Clinical Futures model in Gwent is to address the challenges facing the ABUHB workforce. ABUHB has recognised that by ‘growing its own’ staff, it tends to have a better record of retaining staff.
· An area of work that ABUHB is focussing on is widening access with a view to helping people into health careers that are not necessarily via the traditional route of obtaining A level qualifications and University degrees. ABUHB is developing its healthcare support worker workforce via direct recruitment providing training on the job. This can lead to alternative access into nursing careers. This system could also apply to medical staff with a view to ABUHB ‘growing’ its own staff, going forward.
Clinical Futures
This has been a long standing strategy of ABUHB which is a whole system approach. The three main areas of the Clinical Future Strategy are:
· Providing as much care as close at home as possible.
· Developing a network of hospitals.
· Agreement by Welsh Government of the business case for the Grange University Hospital, which had been approved in October 2016.
· ABUHB delivers over 3,000,000 GP appointments per year in Gwent. This compares to 1600 critical care admissions. Therefore, there is a differing scale of activity and service delivery for each of the varying elements of the service.
· The three main levers for change are that the demographics are changing, people are getting older and their needs are becoming more complex. Workforce supply is becoming challenging. Therefore, ABUHB needs to be innovative, going forward.
· In 2018 ABUHB assessed 47 clinical models. ABUHB now has a better understanding of how the services can be configured.
· There will be 560 beds, cots and trolleys at the Grange University Hospital. There will also be a 24/7 emergency department located here with a helicopter pad located at this site.
· All emergency surgery and trauma will be delivered from the Grange University Hospital.
· Elective patients that require backup of intensive care beds will be delivered for the Grange University Hospital.
· There is space for 30 critical care beds which is a significant improvement.
· Cardiology will be delivered from the Grange University Hospital. As will the hyper acute stroke unit.
· The Grange University Hospital will house all consultant led obstetric in-patient services.
· Consultant and midwife led out-patient services will continue to be delivered from all of the other sites as currently provided.
· The neo-natal unit will be delivered from the Grange University Hospital. As will paediatric inpatient and paediatric inpatient surgery.
· The Grange University Hospital will have wards consisting of 32 beds with 75% being single rooms.
· The development of the site is ahead of schedule and ahead of budget. The planned opening date is March 2021.
· Both Nevill Hall and Royal Gwent Hospitals will have access to urgent services and both sites will have a 24/7 Minor Injuries Unit. There will be no emergency department at either of these sites.
· ABUHB has a well-developed plan in terms of its emergency patient transport system with regard to acute emergency transfers.
· Nevill Hall and the Royal Gwent Hospitals will have a Medical admissions Unit that will operate on an 8.00am to 8.00pm basis accepting GP referrals.
· Pre-hospital streaming will be established which will ensure that patients will be routed to the correct place, providing a better assessment process.
· The Nevill Hall site will differ slightly in some respects to the Royal Gwent site. Nevill Hall Hospital will have a Surgical Day Care Unit allowing significant elective surgery to be undertaken at the Nevill Hall site.
· A satellite radio therapy unit will be provided from the Nevill Hall site. As a part of this development, a case is being developed to create a local cancer centre, whereby, chemotherapy treatments would continue to be provided.
· Nevill Hall and Royal Gwent Hospitals will have an emergency Frailty Unit.
· The Royal Gwent Hospital will host a Post Anaesthetic Recovery Unit allowing for the majority of elective surgical treatment for in-patients to be undertaken.
· Last year over 1500 elective patients were cancelled due to the lack of bed provision, as these had been taken due to emergency pressures. However, the reconfiguration of ABUHBs services means that the elective work can be protected at the Royal Gwent with the provision of the Post Anaesthetic Recovery Unit.
· Approximately 6000 staff will be affected by the changes.
· Women and Children’s Services are currently being challenged. However, this service is monitored weekly and is providing a safe service, albeit a fragile service. It is intended that Women and Children’s Services will centralise on the Grange Site. However, it might be difficult for these services to operate from two sites. Therefore, there might be a need to centralise these services in advance of the move to the Grange site.
Member Scrutiny
· With regard to hip fracture data, the current mortality rate at the Royal Gwent Hospital is 7.6%. This has been a focus of the ABUHB for some time and the Health Board, in partnership with the partnership boards had invested £500,000 from the Integrated Care Fund in developing orthogeriatrician support in the hospital as this allows for patients to return to their homes more quickly. In the Royal Gwent Hospital there was no dedicated orthogeriatrician support. However, ABUHB now has a dedicated consultant located on the Royal Gwent site and he is currently undertaking regular multi-disciplinary ward rounds.
· Prevention work has also been undertaken, in particular around falls.
· Though the mortality rate has reduced, it remains an area of work within ABUHB that is high on its priority list from a clinical futures perspective about ensuring that the new system of care that will be in place when the Grange University Hospital opens in particular and in the lead up to the opening, continues to be progressed and enhanced with the orthogeriatrician support and the multi-disciplinary way of working.
· Originally, there were to be 177 beds for Nevill Hall Hospital. However, with the shift from in-patient to day case beds, that reduces the bed base down to 118 beds. However, these numbers are changing continuously, as services are modifying their models.
· In terms of Maindiff Court, alongside the Clinical Futures Programme, there is also a strategic stream of work that looks at all of ABUHBs estates. There are plans that are currently being worked through at this site with a view to there being some changes to some of the community facilities, going forward.
· The centralisation of some services to the Grange University Hospital will mean that there will be fewer people either at the Royal Gwent or Nevill Hall Hospitals than there are now which will provide more space in the current configuration of both of those sites. In terms of the Grange University Hospital, parking provision will be ample.
· ABUHB welcomed the opportunity to work with Members with regard to providing an update on Nevill Hall Hospital for Members’ individual newsletters that are directed to local residents.
· ABUHB is engaging with public transport bodies with a view to connecting all of its hospitals, going forward.
· In terms of the Welsh Ambulance Services NHS Trust (WAST) regarding the emergency transfer model, ABUHB has a number of options. WAST has been involved in the numbers modelling that has been undertaken, which is continuing to be refined. It is intended that in the summer of 2019 ABUHB will provide specifications for the volumes of the patients that it considers will need to be transferred.
· The numbers for major trauma are very small. In terms of vascular work, it is intended that this service will be taken into the Grange University Hospital until told differently from a regional perspective.
· ABUHB is in discussion with Newport City Council regarding the provision of park and ride transportation at the Royal Gwent Hospital. A similar conversation could be undertaken with Monmouthshire County Council regarding provision at Nevill Hall Hospital. Mostly, feedback regarding hospital food is very positive.
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Committee’s Conclusion:
· In terms of capital development and service re-provision in Chepstow Hospital, reference was made to an action plan regarding the development, details of timescales and the need to monitor progress on a quarterly basis.
· Adult Older Mental Health Care – The Select Committee would benefit from viewing the data sets that underpin the various pilots and initiatives.
· Clinical Futures – ABUHB to forward an update to the Scrutiny Manager with a view to this information being made available to Members.
· To receive from ABUHB a higher level action plan so that the Select Committee can monitor the timescales leading up to 2021.
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