Notice

Responses from local groups to statement of issues

Updated 26 August 2015

Applies to England

1. Responses from the public

1.1 Member of public 1

We are residents of the Tiverton area who have lived here for well over 30 years. Although retired, we have very committed and busy lives within our community and follow local issues with considerable interest. Although we have not been directly involved with any of the local groups contributing to the debate on the provision of local health services we have talked regularly with members of such groups. We have been pleased to note the level of local involvement in decision-making and the strenuous attempts to involve as many members of the community as possible in any recommendations made.

We are, therefore, very concerned to read that there is a potentially costly and time-consuming challenge being made to the local Clinical Commissioning Group’s (CCG) decision in favour of services being provided by the Royal Devon & Exeter Health Trust. It is our view that this evidence-based decision is the correct one for our area and would hate to see monies and time that should be used for patient care being used to pursue this unnecessary challenge.

1.2 Member of public 2

I am writing, as a resident of Tiverton, to express my strong support for NEW Devon CCG’s decision to select Royal Devon and Exeter NHS Foundation Trust as the provider of Community Services, specifically community services for adults with complex care needs, in the Eastern Locality.

My reasons for supporting the CCG’s decision are:

• the evidence I have read confirms this as being the best way of providing high quality, integrated, effective and efficient healthcare.
• the evidence concerning provision of healthcare by Northern Devon Healthcare Trust since April 2011 indicates that this current provider is not able to provide adequate or satisfactory healthcare in the Eastern Locality; and in particular, this current provider has failed to utilise Tiverton Hospital adequately, appropriately or satisfactorily
• the evidence of the past indicates that prior to April 2011, and prior to the involvement of Northern Devon Healthcare Trust, healthcare in the Eastern Locality was good in general; and, in particular, Tiverton Hospital was utilised to a significantly greater and more effective extent
• NEW Devon CCG’s replacement of the Minor Injuries Unit at Tiverton Hospital, and elsewhere, by an Urgent Care Centre has resulted in a much needed, much better, more effective and very successful service; thus demonstrating NEW Devon CCG’s commitment and ability to improve local health services; and confirming NEW Devon CCG’s decision-making abilities
• personal experience as a local resident, patient and user of healthcare services and facilities in the Eastern Locality during a period of 40 years is consistent with all 4 of the above points

1.3 Member of public 3

I would like to express my support for the decision by the NEW Devon Clinical Commissioning Group to award preferred provider status to the Royal Devon and Exeter NHS Foundation Trust (RDEFT) for the new contract for Community Services commencing in October 2015.

1.4 Member of public 4

As a resident of East Devon I strongly support the decision by NEW Devon CCG to commission the provision of community health services in Exeter and East Devon to the RDEFT. It has never made sense to me that these services in our area have been provided by the Northern Devon Healthcare Trust. I understand the RDEFT is already working closely with the social services and other providers in the Exeter area in order to establish a much more seamless pathway of care for people from the community, to hospital and back into the community, as well as working to prevent unnecessary hospital admissions and promote more care in people’s own homes.

The proposal by NEW Devon firmly puts patients and their needs at the centre of the care process, and I sincerely hope that it will be accepted and put into operation.

1.5 Member of public 5

Thank you for the opportunity to input into your enquiry. Over the last 18 months we (in the Eastern area of Devon) have seen a gradual withdrawal of hospital in-patient beds in our community hospitals. What little and it has been little, information has been available from NDHT about why they have withdrawn these, has been put down to “safety” and lack of staff. I’m not in a position to dispute this but whatever the cause it’s hardly surprising that NEW Devon CCG is looking for a provider that can deliver the five year plan. Whilst now with the level of technology available certain things can be run at a distance, the geography of the area means that staff from NDHT main hospital cannot easily be diverted to community hospitals in the East on an emergency or temporary basis. There was no logic in selecting NDHT to run the services on a temporary basis, only Hobson’s choice.

These hospitals are the hub of the community services in each locality. Staff working in and from these hospitals provide services to rural communities. The staff are dedicated to their patients whether in the hospital or in their homes. The staff deserve competent leadership and to know they have a secure job not one that will disappear at the first “management” difficulty.

The Eastern community, coastal and market towns and the hinterland want their community services and community hospitals to survive and flourish, after all in most cases it was these communities, pre-NHS, that started these services. These communities have no faith at all that the existing services and the expansion of these they wish to see, could be provided by NDHT.

I must say in conclusion that I have found NEW Devon CCG’s approach to consulting/engaging with the public refreshing. They have made great strides since being set up. Any new organisation is going to struggle initially with communications and there was little of value that could be learned from its predecessor, the PCT, who in my experience regarded the public more as an impediment to progress. However NEW Devon CCG do appear to genuinely want to consult in a meaningful way with patients/public.

1.6 Member of public 6

I write as an individual but represent a practice in the Mid Devon area on the local patient panel covered by the proposal.[…]

I write in support of the proposal to appoint the RD and E Foundation Trust as the preferred supplier because it is likely to produce a well integrated, seamless service along the patient pathway from primary to secondary care as needed and has the resources to form a stable base for the further development of services in line with “Five years Forward”

Member of public 7

I was a member of the reference group involved in the consultation and design process for the Transforming Community Services process in Devon. The consultation was of very high quality, extensive in its reach and did, I feel, genuinely engage with the public and stakeholders on the future design of services without any preconceived ideas of how the eventual service would look . There was overwhelming support from the consultation events I attended for services to remain within the NHS, and for closer integration of health and other services to be a key outcome to be achieved by the holder of the new contract for community services.

2. Responses from local councils

2.1 Axminster Town Council

Axminster Town Council has historically been heavily involved in the provision of health services in its area, and continues to be so. We have organised or been involved with 4 recent meetings concerning the CCG’s plans, (Transforming Community Services) and the temporary transfer of inpatient beds to Seaton Hospital by the NDHT for safety reasons. These meetings were well attended (700, 500, 50 and 450) by local citizens.

At every one of these meetings the unanimous response as to who should be responsible for the running of our community services including our hospital was “Royal Devon & Exeter Foundation Healthcare Trust”.

The clear view of this town, and of Axminster Town Council is that, other things being equal, the Royal Devon & Exeter Foundation Healthcare Trust (RD&E) is best placed to provide continuing and integrated care for those people with complex needs.

Current situation

At present NDHT runs the community nurses operation, and within the hospital is responsible for provision of inpatient services, X ray, physiotherapy, mental health assessment services and medical outpatient facilities. RD&E use the hospital for day case surgery and surgical outpatient appointments across several disciplines. This has on several occasions resulted in surgery day case patients who are deemed not well enough to go home being taken down to Exeter by ambulance when there is a perfectly good bed and staffing only yards away!

It has to be said that it is very difficult having to explain to patients and their relatives the way that healthcare fragmentation has given rise to things like this in a service which is supposed to be ‘National’ Patients and their relatives deplore this lack of common sense or “joined up” thinking demonstrated by such situations.

Finances

Clearly, with no financial assessment given as part of the decision making process, we are unable to comment. It should be noted that during recent discussions with both the CCG and NDHT, those figures which have been forthcoming have been open to much question, and alternative analysis, and we are not certain all the figures have been available. This common opacity has been frustrating to us as stakeholders.

There is, however, an important issue of ‘double charging’. If a patient has treatment at Exeter, paid for by the CCG on ‘payment by results’, and is released to a community hospital prior to recommended tariff deadline, the CCG is charged again by NDHT for the stay. The money does not follow the patient, as it would do if RD&E were running the community hospital. This would offer far better value for money and may well be a significant factor in budgetary overspend.

History

The transfer of responsibility for community services to NDHT in April 2011 was handled with no public consultation at all. The only consultees were the Gps who, we suspect were offered a Hobson’s choice. This transfer was against all common sense, especially as under the previous PCT governance, the services were fully and properly integrated. One is left with the impression that this transfer was made solely because it enhanced the NDHT’s financial viability, and had little to do with patient care, wellbeing or choice.

Competition

It is the view of Axminster Town Council, that despite the requirement in the Health and Social Care Act for contracts to be put out to competition to get best value for money, this contract should be exempt from such a process. This is the overwhelming view too expressed by the people of Axminster in all the meetings we have had. Whatever one’s political persuasion, there is deep unease at the prospect of a private provider being allowed to run our community services. That the tendering process should involve the CCG in expenditure of c£100K, and the potential providers in similar costs at a time of financial austerity seems wasteful to say the least. There are better and more fruitful ways of saving money.

It is Axminster Town Council’s opinion that by awarding the contract to RD&E, we would gain a more integrated and cohesive service for our increasing and ageing population. We have, within our community many experienced individuals who would be willing to give their time, pro bono publico, in order to identify cost savings in areas such as procurement, recruitment and retention of staff, and training, just to give 3 examples.

Transparency and bias

We are unable to comment on this issue, as we have no facts on which to base an opinion.

Conflict of Interest

This is a difficult issue to asses objectively. One of the objections to GP commissioning in the first place is because of conflict of interest; and removing Primary Care commissioning away from the CCG does not remove this objection. One has to rely on the integrity of the individuals involved to make evidence based decisions. As scientists this should present them with few problems, we believe. There is the issue that some of the Gps are and would be employed by the provider. Our understanding is that in fact the medical practices, of which the doctors are partners, are contracted to provide daytime GP cover. It is our view that whoever is the provider, these practices are likely to be contracted for this cover, and that within this context, there is unlikely to be any conflict of interest.

Conclusion.

Axminster Town Council believes that in order for this contract to be objectively viewed, it must consider the 4 NHS England tests:

• be based on a clear evidence base. In this we have to rely on the views of our medical practitioners, as they are properly qualified and experienced to make such a judgement - as they support this move, we concur with them.
• be supported by patients and public. As stated above, this move has unambiguous public support
• have a positive impact on current and prospective patient choice: as the proposal means that patients will be able to move from Exeter to their community hospital ‘under a common umbrella’, it is clear that such a move is likely to offer a more integrated and comprehensive service - this must be the choice of all involved
• must have the support of GP commissioners - if it didn’t we wouldn’t be here today!

It should also be noted that the Town Council fully agrees with and supports the submission to Monitor of Dr Phil Taylor of Axminster Medical Practice.

Jeremy Walden, Axminster Town Mayor, on behalf of: Axminster Town Council Agreed at the Town Council meeting 9 February 2015

2.2 Exeter City Council

The health and wellbeing of Exeter residents is a key priority for the council, which has taken a leading role in the formation of the Exeter Health and Wellbeing Board of which I am a member. The board is a unique place-based partnership that mirrors the statutory equivalents.

As you will see from the Terms of Reference, integration, effective partnership working and meeting citizens’ needs are central to the Board’s aims. In this context, the council fully supports the Integrated Care Exeter Programme, which has been endorsed recently by the board.

In assessing whether the process used by NEW Devon CCG enabled it to assure itself of the quality, efficiency and value for money of service provision, it is important that Monitor recognises the CCG undertook extensive public engagement to inform its Community Services Strategy. The decision to select the RD&E therefore reflects the priorities and needs of Exeter’s communities and residents and it is fully supported by the City Council.

In addition, I would emphasise that, in my view, fully integrated care and an optimum patient experience within a locality demands the integration of acute and community care services within a geographic region. Furthermore, as a leading organisation in the city, the RD&E is central to the engagement of key partners in the city and their contribution to integrated care through shared aspirations, pooled budgets and asset realisation. This contribution is critical for achieving maximum benefits from fully integrated care and, ultimately, delivering the high-quality services demanded by the residents of Exeter.

Yours sincerely

Cllr Peter Edwards Leader, Exeter City Council

3. Plymouth City Council

Plymouth City Council (PCC) is one of the two local authorities which is linked to NEW Devon CCG. We are a Unitary Authority serving a population of circa 261,000 within the city of Plymouth.

Plymouth Hospitals NHS Trust is the acute provider in the city and Plymouth Community Healthcare is the community health provider for adults, children and mental health. We work closely with NEW Devon CCG and our local health providers to deliver services across the city.

In relation to the Transforming Community Services (TCS), there has been extensive involvement of Plymouth City Council and many other partners in the TCS process. This has included officers attending several multi agency workshops, as well as more detailed design meetings. Officers from Plymouth City Council have also been part of the TCS Steering Group and as a result are fully engaged and supportive of the process. I have personally been given the opportunity to present at major stakeholder events including representatives from across the CCG area.

We are also aware that the TCS process was built on solid and extensive service user engagement. Again PCC and crucially elected members were part of this process. The messages coming out of the process were clear and consistent- organisational boundaries cannot be an obstacle to providing seamless care that is wrapped around the person.

The five year strategy which underpins the TCS process is also the result of an extensive co-design process. This document is now feeding into and driving our integrated commissioning plans, and was clearly reflected in our Better Care Submission. This again has been through an extensive consultation process including going to our Health and Wellbeing Board, where the document was warmly welcomed. The outcome of this is that we are now using this document as one of the cornerstones of the CCG and PCC commissioning activity and feeds into our four integrated commissioning strategies. Specifically it is driving service design and service improvement, around health and social care integration and indeed by April 2014 we will have an integrated health and social care provider. This is significant as we believe it will deliver efficiencies, seamless care, improved outcomes and crucially it delivers what service users told us they wanted through the Transforming Community services process.

The TCS process has been clear, transparent and focussed on delivering seamless care and the best outcomes for people.

4. Responses from local GPs

4.1 GP 1

I support the decision to move community services to The RD&E Foundation Trust from Northern Devon Healthcare.

It is common sense that the less Health and Social Care organisations a patient has to go through on their care pathway, the better for the patient. It is not unknown for a patient with some conditions to have contact with 5 different organisations during a period of care:

• primary care
• community services (North Devon)
• secondary care (RD&E)
• mental health (Partnership Trust)
• social care Devon County Council

This arrangement does not work well especially at a time of austerity. For a patient it can be confusing and often wastes their time. For a clinician it can be frustrating with different organisations having different ways of doing things.

From a commissioning perspective too many organisations wastes time, effort, and money in planning patient care and dilutes the opportunities to effect change quickly.

Too many organisational cultures and agendas do not make for sensitive patient care and often hinder it. So one less organisation will be better.

I think the RDE will provide a more seamless service for our patients in Exeter. It should make the Exeter Healthcare system more efficient. If the secondary care provider also provides community services there is a great opportunity especially when the NHS is under such great pressure to improve the care of our patients. Why would you want an organisation based in Barnstaple running Exeter community services? The RD&E is our local hospital, it is an excellent hospital and understands our local needs.

I have not been party to the decision making process so can not comment on it. I was involved in the PCT board decision to park services with North Devon. This was a mistake for patient care in Exeter and there is now an opportunity rectify this.

I am willing to provide examples if helpful to evidence my comments.

I think this decision is good for patients.

4.2 GP 2

Awarding the contract to North Devon Trust was clearly a mistake. They have been pretty unsatisfactory, [RESPONSE REDACTED].

The RD&E is at least slap in the middle of the patch they are to be asked to administer.

I have experience of each Trust. The RD&E is significantly better managed.

4.3 GP 3

I should like to comment on this investigation.

I am a GP in Axminster […]

Firstly with regard to services for the frail elderly, it has been clear for some time that our pathway for this group of patients is fragmented. Having two trusts running Acute and Community beds respectively means that patients are often not in the best location for them. A unified governance structure tasked with ensuring that this crucial group of patients are always looked after by appropriate clinicians in the closest location to, or in, their own homes is vital.

Devon is a very widely scattered community with significant communities far from a central hospital served by community hospitals yet the current structure of care where one part of the pathway is resourced by PbR (payment by results) whilst another is a block contract is not conducive to the aim of ensuring top quality local care. Communities such as my own, 26 miles from our acute hospital have expressed the huge importance to them of their local hospitals and are outraged that beds are closing.

Monitor must look at its own role in developing acute trusts and backing them in their absolute entitlement to PbR funding, regardless of the health communities’ ability to pay, because this leaves community resources to diminish or at best remain static despite rapidly rising demand. Under NEW Devon’s current arrangements Acute Trusts can transfer patients to community hospitals without transferring the funding which they have earned under PbR. The public is astonished to learn that funding doesn’t follow patients.

Many local colleagues have concluded that the only way in which we can ensure that the whole pathway for frail older people is properly resourced is for it to be organised by one organisation accountable for ensuring that resources are spent where they are needed and where people wish - as close to home as is possible. This means an integrated pathway which includes acute beds for this group, community beds and non-bed based community services.

Northern Devon Healthcare Trust has been an award-winning provider for community services and many GPs like myself are very proud to work with that part of the trust. It would be a shame to lose the integrated approach of complex care teams where social care and health staff work together. We have outstandingly low levels of acute admissions to hospital for older people and we wish this to continue.

Unfortunately many GPs are very unhappy with NDHT’s tenure of community hospitals. As clinicians working in the hospitals there has been (until recently) a lack of training ,a failure to involve us in the introduction of new systems and procedures and as commissioners on behalf of our patients a lack of engagement. NDHT has reduced bed numbers and most recently “consolidated” beds, removing them from, for example, Axminster yet has failed to persuade GPs or the wider public that there isn’t sufficient demand for beds. It has failed to persuade us that adequate resourcing can be provided to look after more frail older people in the community, however desirable that may be in theory. Large numbers of people at public meetings have asked for financial details in support of bed reductions and have produced evidence of family members and friends spending long periods far from home, in our case in Exeter.

NDHT has not demonstrated a significant financial case and has simply denied that there is unmet demand for community hospital beds without producing evidence contradicting the communities’ case. NDHT has also frequently closed minor injuries units at short notice causing many patients to make long journeys to closed units. These views are not exclusive to communities whose community hospitals are threatened but are much more widely held.

There is no doubt in my mind that some of the problems which I have described result from a lack of incentive to encourage community hospitals to flourish. I believe that had there been a PbR system for community beds there might have been a different scenario now. However, this is not likely to be introduced and therefore we have no alternative but to have both sets of beds in our pathway run by one organization. I am concerned about community services outside of hospitals but as this is a key part of the pathway I believe that there is no alternative but for RD&E to become the host of the whole pathway. It should then be up to Monitor to ensure that as a foundation trust RD&E invests resources to provide the localness of care to which the NSH aspires, and which communities are rightly demanding.

5. Responses from local groups

5.1 East Devon Campaign to Protect Rural England (CPRE)

The CPRE objects clause sets out, in terms, the aim to protect the countryside of England, and ensure the better development of its towns and villages. We are therefore interested in housing and roads and railways, and other necessary infrastructure, which must include a vibrant Health Service. The population of East Devon is set to increase by around 30,000 over the next 15 years, and is an ageing population.

We have therefore considered the local community hospitals existing in East Devon and the General Practitioner structure. We see these 7 local hospitals as an important support for the local community and the excellent major hospital by the Royal Devon and Exeter Hospital (RD&E), inter alia providing beds for RD&E to use to discharge appropriate recuperating patients. The Minor Injuries Units are also important to reduce the queues at A&E at RD&E.

During the tenure of Northern Devon Healthcare Trust (NDHT) as the provider of East Devon community hospital services, there has been steady mandate to reduce East Devon facilities and beds. We are clear that it is now appropriate to assess NDHT’s performance, and consider a new administrator.

Concerns about NDHT include:

• breach of Statutory Duty to Consult – now trying to rush it through in a 4-week period (vice 12 weeks) over Christmas/New Year
• not approved to proceed re Axminster Hospital to close beds by Devon CC Scrutiny Committee – just going ahead anyhow on very flimsy basis
• costings produced very superficial and incomplete, so unreliable and unprofessional
• seek prevent disclosure of info. inter alia by forbidding staff in Axminster to speak to Axminster residents including League of Friends
• NDHT appear to wish to hang reason for Bed Closures/Moves at Axminster on Safety
  • Robert Francis QC (Stafford Hospital) report seeks No Registered Nurse Alone on ward
  • NICE guidelines of July 2014 state this applies to District Hospitals, but not apply to Community Hospitals
  • it seems NDHT did not nominate Nurse for night shift, claiming none available, whereas in Axminster 20 recruits willing to do such work
  • NDHT have advertised, but only generic, and not mention Axminster – yet locally Axminster League of Friends have found 20 recruits
• the Axminster proceedings (Judicial Review) are due for rolled-up hearing on February 17/18:
• it is unlikely to be done in 2 days
  • the cost for each party, with leader (QC) plus junior counsel plus solicitors is likely to be circa £250,000 each (3 parties), which costs are irrecoverable NDHT should never have permitted this situation to arise
  • serious lack of competence and lack of accountability is in question
• the RD&E has good relations with East Devon local hospitals, and direct contacts - NDHT is remote physically and otherwise - the result is no confidence in NDHT, whilst RD&E is known to be entirely competent, and indeed appropriate as administrator from 1 October 2015

5.2 CHOICE Group Tiverton

The Choice Group was formed to represent the public and interested parties specifically in regard to services at Tiverton Hospital, in response to public dissatisfaction with the way certain services were being run by the North Devon Healthcare Trust. The consensus was that the hospital was under-utilised and there were significant staffing problems resulting in bed closures and the frequent non-availability of the Minor Injuries Unit, resulting in loss of public confidence in the unit and increased pressure on emergency services at the RD&E. As a result of this pressure, the CCG held a competitive procurement process for the MIU services, with which Choice Group had a significant involvement. That contract was won by South Western Ambulance Service Foundation Trust.

In the Tiverton area patients look towards the Royal Devon & Exeter hospital for services which cannot be provided at Tiverton, and public consultations have demonstrated that the local community would prefer that the hospital was under the single governance of the RD&E, and this view has been communicated clearly through the many public consultation meetings held by the CCG (and attended by members of Choice) prior to arriving at its decision to nominate RD&E as its preferred bidder. The Choice group is therefore dismayed by the complaint made by the NDHT which we consider unjustified and a waste of money and resources which would be better spent on patient care. An additional concern is that, if this procurement must be opened to competition, it could result in the contract being won by an organisation with no ties to the area and no knowledge of local conditions, which would be very disruptive and inefficient. Choice Group applauds the CCG’s desire to create properly integrated services and considers that they have followed the wishes of the community, showing patient-centred care.

We recently sent a letter to the Mid Devon Gazette, regarding the investigation into the NEW Devon CCG (Eastern Locality) Procurement process for Community Services:

Members of the Tiverton Hospital CHOICE group are disappointed and frustrated to learn of the complaint raised by the Northern Devon Healthcare NHS Trust against the decision by the NEW Devon Clinical Commissioning Group to award preferred provider status to the Royal Devon and Exeter NHS Foundation Trust for the new contract for Community Services commencing in October 2015.

We are informed that this complaint procedure could cost the NEW Devon CCG many hundreds of thousands of pounds which would otherwise be spent on patient care. The people in East Devon have made it absolutely clear throughout the public consultation period of this procurement process that THEIR preferred provider IS the Royal Devon and Exeter NHS Foundation Trust. Patients in this area look to the RD&E for healthcare and their experience of being on the periphery of the Northern Devon NHS arrangements, has not been a success and has resulted in the under-utilisation of Tiverton hospital.

We understand that this complaint will be regarded by NHS England as a test case for the whole country, but for which the cost will fall on the NEW Devon CCG. If this complaint is upheld, it will mean that competitive bids must be obtained, for this and many NHS contracts in other areas for other services. This process is likely to draw in bids from commercial “for profit” service providers as well as internal NHS providers. The procurement process will be hugely expensive, is likely to delay the start of the new contract and could result in services at the hospital and local community services being in the hands of a private company. Choice believes that this is not what our community wants, and fully supports the decision of NEW Devon CCG to name RD&E at the preferred supplier.

There may be a further consequence of this additional financial burden on the NEW Devon CCG; the current contract with the South Western Ambulance Service Foundation Trust (SWASFT) to provide the new “doctor led” Urgent Care service at Tiverton Hospital runs out in October 2015. CHOICE is concerned that there will not be enough money left in the system by this complaint process to maintain this flagship service. People across East Devon can make a difference by making sure that they, their families and their friends use it for all their urgent health needs and particularly those which require a doctor. There are encouraging signs that this is happening and that as a result attendances at A&E at the Royal Devon and Exeter NHS Foundation Trust by patients from the Tiverton area and beyond are falling. In this target and data led environment we all live in, we must “use it or lose it”.

Yours sincerely

Councillor Dennis Knowles

Acting Chairman

5.3 Tiverton Hospital League of Friends

We should start by saying that we agree in principle with the CCG’s proposal to select the Royal Devon and Exeter NHS Foundation Trust as the provider of certain community services for the Eastern Locality. This is based to a great extent on the fact that referrals by local GP’s are mainly made to the RD& E, and in addition we consider any reduction in the number of providers for Tiverton Hospital can only be of benefit.

We feel strongly that at this time of change, when appointing the new provider of community services, serious consideration should be given to their willingness to take on the responsibility for the management of the Urgent Care Centre/Minor Injuries Unit. The RD& E. are currently responsible for The Tiverton Day Case Unit and the Maternity Unit, and should they ultimately be selected, this would result in a further reduction in providers at our hospital. It is our opinion that this would result in a more ‘joined up’ approach, and a less fragmented service, as is currently the case for Tiverton Hospital, caused mainly by several different providers often using the same premises and equipment, which can sometimes lead to disagreement.

We are aware that considerable expense was incurred when the Northern Devon Healthcare NHS Trust took control of the provision of community services at Tiverton Hospital 3 years ago. Our understanding is that there has been significant improvement during this period in the running of this department, which is well received and respected. A further change will inevitably involve more expense in areas such as staff contracts, IT etc.

We appreciate in today’s financial climate, savings have to be made. However, we strongly feel that for a hospital the size of Tiverton, some consideration should be given to establishing a group of interested parties such as the Matron, representatives from G.P. practices and providers. This group should be involved in the decision making regarding the services and facilities available and their use at the Tiverton Hospital, rather than judgements being made, not always with local consultation or agreement.

Reducing the number of providers at Tiverton Hospital would hopefully avoid some of the difficulties encountered by us as volunteers, in the financial support we have given since its opening, amounting to approximately £1.2 million. These include:

• at least 2 pieces of equipment purchased at a cost of about £24,000, no longer being used due to no qualified staff being made available by the provider
• the termination of maternity ultra sound scans, apparently without any known consultation, and despite the request for a specific ultra sound scanner to enable these scans to take place and costing £60,000 only 2 or 3 years ago
• the closure of the Maternity Unit for a period of 8 months
• the difficulties we have recently encountered in providing equipment requested for the Day Case Unit and the Maternity Unit

We strongly believe that one main provider would feel encouraged to use our hospital to its full potential, which would inevitably lead to an increase in the use of the Day Case and Maternity Units, both of which are currently under used despite having excellent facilities and equipment.

I trust our comments will be helpful in the decision making process and if we can be of any further help, please do not hesitate to contact us.

5.4 Devon Health and Social Care Forum

The Forum welcomes the opportunity to respond, and comment, to the above investigation.

Individual members of the Forum, a wholly independent group of volunteers, are active as lay members in a number of NEW Devon Eastern Locality CCG Reference - and C2C – Groups, Fora and Stakeholder groups in addition to voluntary public involvement in member’s respective local area. This wide-ranging and longstanding involvement within NHS and local authority structures gives us confidence to respond to your investigation.

Individual members of the Forum reside in the areas covered by your investigation and declare, therefore, also an ‘interest’ as existing or future service users.

We note the very short time-span from notification (5 February 2015, received by the Forum from NEW Devon CCG) of the opportunity to respond (by 11 February 2015).

The Forum wrote to Monitor, the TDA (Trust Development Authority) and CQC (Care Quality Commission) regarding the Northern Devon NHS Healthcare Trust (NDHT) on 12 November 2013. We believe that the letter is pertinent to your investigation.

The Forum understands that a previous intervention by the TDA had to be sought to arbiter between the Commissioners and NDHT.

The Forum understands that Monitor has been asked, and intends, to investigate the complaint received from NDHT (a Foundation Trust applicant) that: ‘NEW Devon CCG (Eastern Locality) acted in breach of various provisions of the Procurement , Patient Choice and Competition Regulations’ .

The Forum notes that Monitor, in addition to investigating the procurement process will take the opportunity to seek understanding …’about the best way to achieve better integration of care.

The Forum noted from the minutes of the January NEW Devon Governing Board minutes that the following ‘preferred providers’ have been agreed, eg

• Northern Locality of the NEW Devon CCG: NDHT
• Eastern Locality of the NEW Devon CCG: RD& E (FT)
• Western Locality of the NEW Devon CCG: Plymouth Community Healthcare (CIC)

which would indicate that attention to ‘local/geographical’ criteria are being employed in the choice of providers for Community Services.

Whilst Monitor ’s investigation has a prescribed process and method to deal with the complainant’s submission – and that of the defending Commissioner(s) - the Forum takes the liberty to comment from the view as informed lay members and, of course, members of the public and as patients.

The Forum wish to draw attention to the fact that, under the current community services contract, and for the purpose of this letter in the Eastern Locality, all community hospitals (sites, buildings) are, until the end of the contract (or any extension of this) in ownership of the NDHT.

Exploratory and pro-active work is being undertaken by the CCG, incl. members of this Forum, supported by MPs, with NHS Property Services Ltd, NHS England and the Secretary of State for Health, to explore possible options following the end of the contract and ownership currently held by NDHT.

In this context, the ongoing TCS strategy work/ process towards ‘integrated community services’ - the integration of community hospitals - including NHS/community ownership of - and continued use as community hospitals - within this - is sought.

This is the most challenged aspect of the TCS strategy, by the public.

It appears that data used in the TCS strategy assessing the viability of community hospitals is based on the outcome and data arising from NDHT’s management of the in-patient facilities/beds in the respective Community Hospitals (in the Eastern Locality) during the period of their community services contract.

During the period (from April 2011) of NDHT’s contract erosion of in-patient facilities, often/always at short/no consultation/notice – sometimes for a short period and sometimes, permanently – but always without public consultation, took place. The reasons given were always due to ‘operational/managerial reasons. This, to the point that bed/ward ‘costs’ are now seen as unaffordable and ‘unsustainable’… including claims by NDHT of inability to recruit staff (safe staffing ratio). This, in turn, leading to ever-more rounds of closures and, assumedly, staff redundancies.

Following are some instances - over the contract period - which, due to ‘timing’ - or lack of prior consultation/information …. or manner … in which matters were dealt with or imposed by NDHT … were noted ‘with concern’:

• a surprising purchase of new beds for, we understand, all community hospitals under NDHT’s contract (for reasons of uniformity and benefit for health considerations of the staff) was made despite the number of beds planned to/ being reduced, including (some almost ) new beds, donated by respective League of Friends
• an entirely unexpected situation emerged when ‘stroke in-patient facilities’ (for intermediary and rehabilitation patients following acute care ) had to be moved into an unplanned location as the planned/intended location in one of the NDHT controlled community hospitals – had been converted to - offices
• an extra-ordinary situation was observed (by a member of this Forum in a lay member role within a CCG structure) where a strategic decision had to be taken but which was made subject to a notice served by NDHT of ‘consequences’ if the decision was other than– assumedly –that preferred by the NDHT - was served by NDHT to a group of stakeholders

Monitor may be aware of a recently granted Judicial Review against NDHT by people in Axminster in the face of a ‘temporary’ closure of the last 10 beds in Axminster’s community hospital. MIU service provision in the community hospitals experienced the same, erratic and relentless erosion and confusion for the public.

Forum members attending an ‘inspection’ meeting by the CQC on the 26th June 2014 regarding the NDHT’s FT status re-application noted that questions about the applicant related only to nursing and PEAT issues (patient satisfaction/quality) but entirely ignored to look at compliance to deliver the services as per the contract (volume).

The Forum’s letter to Monitor, TDA and CQC - already mentioned - may serve as an example of concerns the public and some health professionals hold.

In conclusion we have come to the view that there is an inherent contradiction between the ’Procurement, Patient Choice and Competition regulations’ and the need to put patients first, well expressed in ‘The quality of care provided to patients should never be compromised by the ambitions or management pressures of the organizations commissioning or providing services. Organisations need to look beyond their organizational boundaries and concerns about their autonomy and always consider the needs of the patient first’’.

(Quality in the new health system – Maintaining and improving quality from April 2013 – from a draft report of the National Quality Board).

We trust that the Forum’s considered comments may contribute to the inquiry and assist with it’s views ‘from the grass-roots’.

Devon Health and Social Care Forum letter 12 November 2013

Dear Sirs,

On behalf of the Devon Health and Social Care Forum we are writing to you out of concern over the North Devon Healthcare NHS Trust, which is reportedly seeking Foundation Trust status and prioritizing some decisions with this in mind, which may be affecting some of its obligations for the wellbeing of the community services and community hospitals which it is contracted to sustain.

A number of members of staff and of the general public have been able to share their concerns with us in confidence. We would draw your attention to the Wakley sub-locality report of September 2013 to the Eastern Locality Board of the NEW Devon CCG. These concerns are in line with the comments made to us.

We are writing again bearing in mind Monitor’s helpful response to our earlier enquiry to the effect that any member of the public may write directly in the context of a full consultation with the wider public in relation to Foundation Trust applications. We have been guided by Monito’s own review entitled ‘A fair playing field for the benefit of NHS patients’ and other relevant publications from a number of sources.

The Forum’s standing in this matter is that of an independent group of interested members of the public and patients. We are all voluntary and enclose a copy of our Terms of Reference.

We should be pleased to know that Monitor will note and respond, accordingly.

Yours faithfully,

Ian McKintosh

Chairman, Devon Health and Social Care Forum

c.c. Prof. Sir Mike Richards, CQC NHS Trust Development Authority Independent Reconfiguration Panel

Devon Health and Social Care Forum Terms of Reference

The aim of the Devon Health and Social Care Forum is, through co-operation with other groups, to contribute to the improvement of health and social care services in Devon. In particular, the Forum will monitor provision in those two sectors, and it will act as a central point of reference for the exchange of information and experience amongst its members and the Public. It will feed concerns about provision of services to the appropriate body for comment and, if necessary action and resolution, citing appropriate evidence.

The terms of reference were approved unanimously by the Forum at its inaugural meeting on 25 June 2008.