Independent report

IRP advice to the Secretary of State for Health and Social Care on Teignmouth and Dawlish community services (accessible version)

Published 17 March 2022

Applies to England

1. Referral to the Secretary of State - Modernising health and care services in the Teignmouth and Dawlish area

Rt Hon Sajid Javid MP
Secretary of State for Health and Social Care
39 Victoria Street
London
SW1H 0EU

23 December 2021

Dear Secretary of State,

Thank you for forwarding copies of the referral letter and supporting evidence from Councillor Hilary Ackland, Vice Chair of the Devon County Council Health and Adult Care Scrutiny Committee, along with the Independent Reconfiguration Panel (IRP) information template completed by NHS Devon Clinical Commissioning Group and NHS England and NHS Improvement. The IRP has also received and considered further correspondence from interested individuals and a list of all the documents we have received is included in Appendix A.

The IRP provides this advice in accordance with our agreed protocol for handling contested proposals for the reconfiguration of NHS services. In considering any proposal for a substantial development or variation to health services, the Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013 require NHS bodies and local authorities to fulfil certain requirements before a referral to the Secretary of State may be made. The IRP provides the advice below on the basis that the Department of Health and Social Care is satisfied the referral meets the requirements of the regulations.

The Panel has considered the referral on its merits and concluded that NHS Devon Clinical Commissioning Group consulted adequately with Devon County Council’s Health and Adult Care Scrutiny Committee on its proposal.

The Panel has provided its view on the impact of the proposal on equality issues and also considered the effects of the COVID-19 pandemic as requested.

A series of recommendations are set out within the body of the letter below for your consideration.

2. Background

2.1 The local health and care system

The NHS Devon Clinical Commissioning Group (CCG), part of the Integrated Care System for Devon, commissions healthcare services for nearly 1.2 million people with a budget of more than £1.8 billion. It was formed in 2019 as a result of a merger between NHS Northern, Eastern and Western Devon CCG and NHS South Devon and Torbay CCG.

The Coastal Locality, on the south coast of Devon, includes the towns of Teignmouth and Dawlish, which combined have an estimated patient population of around 36,000 people. Around 40% are over the age of 60 and about half of the population have at least one long-term health condition, with these numbers expected to rise as people live longer. The area of Teignmouth town centre and sea front has the highest score of multiple deprivation in the locality (a score of 38 against an overall score for Devon of 17 from a 2017 survey).

NHS services for the area are provided by one GP practice in Dawlish and two in Teignmouth, with secondary care provided by Torbay and South Devon NHS Foundation Trust, who in 2015 became one of the first NHS trusts in England to join up hospital, community, and social care together into one integrated organisation. The trust provides acute healthcare and a full emergency department service from Torbay Hospital in Torquay, along with five community hospitals, including Teignmouth Community Hospital and Dawlish Community Hospital, which are approximately four miles apart.

Teignmouth Community Hospital, built in 1954, provides outpatient clinics, specialist clinics, and minor day case procedures for people from across south Devon and Torbay. Dawlish Community Hospital is a purpose-built hospital opened in 1999 and acts as a clinical hub for the locality, providing outpatient clinics, an X-ray service, minor operations and 16 beds on a medical inpatient ward.

2.2 History of proposal

Since 2013, there have been ongoing local discussions about how best to integrate health and care services in Teignmouth and Dawlish. A public consultation in 2014/15 led to a decision to implement a model of community care made up of integrated health and wellbeing teams supporting people to receive care closer to home, including 12 rehabilitation beds proposed to open at Teignmouth Community Hospital.

In 2017, due to the success of the health and wellbeing teams in providing out-of-hospital care which had been recognised nationally, the CCG’s Governing Body decided to review the need for the 12 rehabilitation beds in Teignmouth which were yet to be implemented.

In 2018, the CCG undertook public and stakeholder engagement about further integrating health and care services in the area. The CCG sought people’s views about bringing primary care and other services together into a new building in Teignmouth, including where the new building should be located, and asked for feedback on the view that the 12 rehabilitation beds at Teignmouth Community Hospital were no longer needed.

In June 2018, councillors from Devon County Council’s Health and Adult Care Scrutiny Committee (HACSC) visited Teignmouth Community Hospital to broaden their understanding of the model of care provided.

The HACSC then received a report from the CCG in November 2018 describing the public and stakeholder engagement, the vision and rationale for further integration of services in the Coastal Locality, and the case for not opening the 12 rehabilitation beds in Teignmouth. The CCG outlined to the HACSC its plan to move to public consultation on the relocation of services to a new Health and Wellbeing Centre in Teignmouth and to Dawlish Community Hospital, resulting in the closure of Teignmouth Community Hospital.

2.3 Pre-consultation business case

NHS England’s South West Clinical Senate (a panel of independent expert clinicians) undertook a review in early 2019 to consider the clinical evidence for reconfiguring services in Teignmouth and Dawlish. The Clinical Senate supported taking the proposal to public consultation, noting that:

It seems very clear that they do not need the 12 rehabilitation beds that were proposed for Teignmouth hospital in 2015, but which have never been implemented. The impact of the Integrated Care Team has reduced the need for beds despite the demographic and demand.

Further stakeholder involvement took place towards the end of 2019 with the Coastal Engagement Group, comprising representatives from patient participation groups, Teignmouth and Dawlish Community Hospitals’ Leagues of Friends, voluntary sector groups, Devon County Council, Torbay and South Devon NHS Foundation Trust, and the CCG to develop a list of options.

An options evaluation stakeholder group was formed by the CCG to review this with support from Teignbridge Community and Voluntary Services. This identified the following as viable options to take to public consultation:

• move community clinics to the Health and Wellbeing Centre
• move specialist outpatient clinics and day case procedures to Dawlish Community Hospital
• continue with a model of community-based intermediate care, reversing the decision to establish 12 rehabilitation beds in Teignmouth

In December 2019, Healthwatch Torbay (an independent body) conducted a month-long survey to understand the experiences of people travelling to Teignmouth Community Hospital and the potential impact on them if clinics were moved. This survey was used to inform the CCG’s quality and equality impact assessment, which indicated that overall, the impact of the proposal on people using the services was neutral or of benefit.

In January 2020, the South West Regional Director in NHS England and NHS Improvement gave approval for the CCG to move to public consultation, and in February 2020, the CCG verbally briefed councillors from Devon County Council and Teignbridge District Council on the proposal, with members from the HACSC invited to attend.

The final pre-consultation business case entitled ‘Modernising health and care services in the Teignmouth and Dawlish area’ was presented to the CCG’s Governing Body on 27 February 2020, who approved the public consultation to start in March 2020. The launch was subsequently postponed due to the COVID-19 pandemic which the HACSC was informed of on 12 March 2020.

Further updates on progress were provided when the CCG met with the HACSC Chair on 17 August 2020 and HACSC members were provided with a briefing document on 18 August 2020 to explain the rationale and the process for the public consultation.

2.4 Public consultation

A formal public consultation took place from 1 September to 26 October 2020, with the consultation document and feedback survey available online and paper copies posted to 16,000 households in the Teignmouth and Dawlish area. Six public consultation meetings also took place online with the opportunity for local people to ask questions.

The proposal consulted on consisted of one option with four elements:

1. Move high-use community clinics from Teignmouth Community Hospital to a new Health and Wellbeing Centre in Teignmouth.
2. Move specialist outpatient clinics from Teignmouth Community Hospital to Dawlish Community Hospital, four miles away.
3. Move day case procedures from Teignmouth Community Hospital to Dawlish Community Hospital.
4. Continue with the model of community-based intermediate care, reversing the decision to establish 12 rehabilitations beds at Teignmouth Community Hospital.

The consultation document also stated that:

If the proposal is approved, Teignmouth Community Hospital would no longer be needed for NHS services and would be likely to be sold to generate funds for reinvestment in the NHS.

Healthwatch in Devon, Plymouth and Torbay were commissioned to take an independent administrative and oversight role in the consultation and to analyse and report on the responses submitted.

The CCG circulated a briefing on the launch of the public consultation to HACSC members on 1 September 2020, with a further update report submitted for review at the HACSC meeting with the CCG present on 10 September 2020. HACSC members requested that the CCG provide an update report at the next meeting in November, noting that the full analysis of the consultation outcome by Healthwatch would not be available until after this date.

2.5 Post-consultation evaluation

At the HACSC meeting on 12 November 2020, members received an update from the CCG which confirmed that over 1,000 people had taken part in the public consultation and that a decision on the proposal was expected to be made at the CCG’s Governing Body meeting on 17 December 2020. HACSC members resolved that a ‘spotlight review’ meeting be arranged to evaluate the evidence and consultation process before a decision was made by the CCG.

The CCG had also invited the submission of alternative proposals as part of the public consultation. These were compiled by Healthwatch and 18 alternative options were evaluated on 25 November 2020 by a stakeholder panel observed by the Chair and Vice Chair of the HACSC. This evaluation was then reviewed by a steering group who recommended to the CCG Governing Body that the four elements of the proposal should proceed and that specialist ear, nose and throat clinics, along with specialist orthopaedic clinics, should move to the new Health and Wellbeing Centre rather than Dawlish Community Hospital.

Healthwatch published its independent report on the consultation on 10 December 2020 which found that overall, 61.3% of respondents supported the proposal. The HACSC then held a spotlight review on 14 December 2020, meeting with Healthwatch and the CCG separately to discuss the report, resulting in HACSC members agreeing to submit a short statement to the CCG’s Governing Body meeting in December.

2.6 The CCG Governing Body’s decision

A paper with feedback from the HACSC’s spotlight review was submitted to the CCG’s Governing Body meeting on 17 December 2020, in which HACSC members raised issues about the public consultation process and concluded that they did not believe that the proposed changes were in the best interests of the local area.

During the meeting, the final decision-making business case was presented to the Governing Body, who approved the four elements of the proposal with a series of recommendations.

2.7 Efforts to seek agreement

At the HACSC meeting on 26 January 2021, CCG members gave an update on what had been agreed at the Governing Body meeting on 17 December 2020. Based on support for the retention of Teignmouth Community Hospital, the HACSC agreed to make an informal approach for advice to the IRP.

A letter from the HACSC Chair was sent to the IRP on 5 February 2021, to which the IRP Secretary replied to advise that at this advanced stage in the process it would not be appropriate to offer informal advice but encouraged the HACSC and CCG to continue working together for the future of local services.

The CCG’s Clinical Chair wrote to the Chair of the HACSC on 9 February 2021 welcoming the challenge around processes and conclusions but raised concerns that some of it had been directed at the personal and corporate motives behind the decision. The HACSC Chair replied on 11 February 2021 to agree to work constructively with the CCG.

On 25 February 2021, the Clinical Chair of the CCG wrote to the IRP responding to points raised by the HACSC in its request for informal advice and expressing his disappointment that the HACSC had questioned the veracity of the consultation and engagement process.

2.8 The referral to the Secretary of State

At the HACSC meeting on 18 March 2021, the CCG provided a progress update and confirmed that a planning application for the Health and Wellbeing Centre had been submitted to Teignbridge District Council on 25 January 2021 with construction due to be completed in 2022.

Councillors discussed the proposal again and agreed to refer the issue to the Secretary of State with a letter sent to the Department of Health and Social Care (DHSC) on 25 March 2021. A pre-election period of sensitivity began on 15 April 2021 ahead of local government elections on 6 May 2021. The DHSC then sought clarification on the grounds for referral, which the HACSC sent on 21 May and 2 August 2021, and the case was subsequently referred to the IRP to consider on 8 November 2021.

3. The grounds for referral

The letter of 25 March 2021 from Hilary Ackland, Vice Chair of the Health and Adult Care Scrutiny Committee, states that:

…as no consultation process has been undertaken or even suggested by the Trust with respect to the future of Teignmouth Community Hospital this part of the substantial change has been referred on the grounds that Scrutiny is not satisfied with the adequacy of the consultation, this Scrutiny Committee has not been consulted, and it is not satisfied that the reasons given for not carrying out consultation are adequate.

This was later clarified by Dan Looker, Scrutiny Officer, in an email dated 21 May 2021 which confirmed that the referral was made using regulation 23(9)(a) of the Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013 – that the Scrutiny Committee is not satisfied that consultation between the CCG and themselves has been adequate in relation to content or time allowed.

In your referral letter to the IRP of 8 November 2021, you also requested that the Panel considers:

• the impact of these proposals on groups with protected characteristics under the Equality Act (2010) in light of you duties around health inequalities and the Public Sector Equality Duty

• current system resilience and the impact of the COVID-19 pandemic

4. Consultation with the Scrutiny Committee

4.1 Background

The HACSC Vice Chair complains, in her referral letter of 25 March 2021, that the CCG did not consult with the Scrutiny Committee on the future of the Teignmouth Community Hospital building and site which would become empty should the proposal that was consulted on be implemented.

In response, the CCG argues that its responsibility is only to consult on changes to healthcare services and not the hospital estate, therefore any decisions about the future of the Teignmouth Community Hospital building are for Torbay and South Devon NHS Foundation Trust (TSDFT) to make because they own the site.

The CCG go on to explain that there is currently a public involvement programme ongoing in nearby Dartmouth to discuss the future of an empty community hospital there and TSDFT will ensure a similar approach is taken in Teignmouth to engage with the local community on the future of the building and site at the appropriate time.

The CCG has also recognised the local community’s strong sense of attachment to Teignmouth Community Hospital and point out that Teignbridge District Council has approved the site to be given status as an ‘asset of community value’, meaning that the local community will have the right to bid for the building should it be put up for sale.

4.2 The IRP’s view

The Panel notes that the CCG has carried out extensive engagement and consultation since 2013 using a variety of methods based on strong clinical evidence with scrutiny from the South West Clinical Senate and others.

With regard to the specific complaint of the HACSC, it is significant that the CCG first submitted a report to the HACSC meeting in November 2018 which announced the intention to move to public consultation on the proposal and confirmed the consequences for Teignmouth Community Hospital. This was reiterated to the HACSC in a series of regular updates and on pages 2 and 17 of the public consultation document which stated:

If the proposal is approved, Teignmouth Community Hospital would no longer be needed for NHS services and would be likely to be sold to generate funds for reinvestment in the NHS.

Taken with the evident interest of local people, captured and reported in successive engagement exercises and the public consultation, it is clear to the Panel that the future of Teignmouth Community Hospital under the proposal has been in plain sight for everyone and open for discussion with the NHS since 2018.

The minutes of the HACSC meeting on 10 September 2020 record that HACSC members commended the ‘quality and clarity of the consultation material’ and the Panel considers that at that point the HACSC appear to be content with the CCG’s process.

The CCG attended a subsequent HACSC meeting on 12 November 2020 to present a paper with initial findings on the public consultation, along with an outline of how the alternative options received during the consultation would be evaluated. This paper explained that the Healthwatch report would be submitted to the CCG by the end of November, that the evaluation of alternative options would also take place at the end of November, and that the CCG’s Governing Body would make a final decision on the proposal at its meeting on 17 December 2020.

It appears to the Panel that it was after the publication of Healthwatch’s consultation report on 10 December 2020, and the subsequent spotlight review on 14 December 2020, that the HACSC first raised concerns to the CCG by submitting a paper to the Governing Body meeting on 17 December 2020.

Guidance for local authorities on health scrutiny published by the Department of Health states that timescales for scrutiny bodies to respond to NHS bodies should be ‘realistic and achievable’ and that it is sensible for scrutiny bodies to receive details of the outcome of a public consultation before it makes its response.

Although the two parties in this case jointly agreed the scope of the spotlight review and collaborated in delivering it, the time available to complete the review severely limited the opportunity for due consideration and discussion of the findings by either party before the CCG’s decision-making meeting on 17 December. In the Panel’s view, this is not in keeping with good practice and left both parties exposed to potential criticism of their processes and decisions.

The Panel acknowledges that the hospital is highly valued by sections of the local community who cherish the history of the building and wish to see it continuing to serve the town. With hindsight, and given the sensitivities around this, the Panel feels that the CCG perhaps could have been more explicit in its communication with the public about how they would be involved in determining the hospital’s future, should the proposal be implemented. In this regard, for example, the public consultation document was a missed opportunity.

The Panel also believes that it would have been helpful to have a clearer and more concise financial summary of the options presented in the supporting evidence to the public consultation, including the capital costs and financing from the sale of community sites. This would clarify both the evident financial advantages of the proposal compared to options that retain the hospital, and the contribution from the sales of community sites to financing the new Health and Wellbeing Centre.

Overall, the Panel considers that the CCG did consult adequately with the Scrutiny Committee in terms of content and time allowed. There are lessons to be learned for both parties about timing and process which should be the subject of a joint review to prevent similar issues happening again in future.

Drawing on the example of engagement in Dartmouth, and innovative examples of repurposing community hospitals elsewhere, the NHS must engage the local community and interested parties, such as the local authority, in a programme to determine the future of the Teignmouth Community Hospital site. It is for the HACSC and the relevant NHS body to discuss how they wish to be involved and whether the remedy of being consulted, as requested in the referral letter, is taken up.

5. The impact on equality and protected characteristics

5.1 Background

Clinical commissioning groups have legal duties to consider equality matters and the need to reduce health inequalities under the Public Sector Equality Duty, the Equality Act (2010), and the National Health Service Act (2006, as amended by the Health and Social Care Act, 2012).

The CCG demonstrated evidence of this by carrying out a quality and equality impact assessment to consider the impact of its proposal on people with protected characteristics. This was completed originally in 2018, updated as part of the pre-consultation business case in January 2020, which was assured by NHS England and NHS Improvement, and reviewed again after the public consultation ended in October 2020.

Healthwatch in Devon, Plymouth and Torbay were commissioned by the CCG to ensure that all areas of the local community had the opportunity to provide feedback during the public consultation. Healthwatch directly contacted over 200 community support groups and voluntary organisations in the Teignmouth, Dawlish and surrounding areas, including many organisations who work with ‘harder-to-reach’ groups of people with protected characteristics under the Equality Act.

In addition, the CCG contacted local primary and secondary schools to raise awareness of the consultation to both students and parents, and the consultation was shared with local church groups and the care home network. Healthwatch Torbay also carried out a travel survey in December 2019 and January 2020, the results of which fed into the CCG’s impact assessment. This found that some respondents were concerned about parking at the new Health and Wellbeing Centre in Teignmouth, as well as the cost and accessibility of transport to Dawlish Community Hospital.

The final version of the quality and equality impact assessment, updated in December 2020 after the public consultation, indicates that across the 17 equality groups identified, the impact of the proposal would be of benefit to seven groups and neutral to the other 10 groups.

The CCG acknowledged the issues raised around transport during its Governing Body meeting on 17 December 2020 and agreed to act by working with Teignbridge District Council and Torbay and South Devon NHS Foundation Trust to mitigate parking issues for staff and patients and to continue discussions with community transport organisations to improve access to services, with a written commitment already agreed.

5.2 The IRP’s view

The Panel has reviewed the quality and equality impact assessment and the travel impact assessment in full and considers that the CCG has properly assessed the impact of the proposal on people with protected characteristics. The Panel also notes the involvement of various stakeholders to provide feedback on the proposal, including the independent expertise of Healthwatch.

The Panel understands that the centre of Teignmouth has the highest deprivation levels in terms of health and disability and agrees with the CCG that moving services into this area as part of the new Health and Wellbeing Centre, with multi-disciplinary teams working together under one roof, would be of positive benefit to patients. The Panel is mindful of the issues raised about parking in the town centre, particularly during the summer, but also notes that all public transport routes go via Teignmouth town centre where the new Health and Wellbeing Centre will be situated.

The Panel considers that the proposal to move services to Dawlish Community Hospital, although it is four miles away from Teignmouth, demonstrates positive benefits for equality because it is on a level site with good car parking and would improve disability access when compared to Teignmouth Community Hospital which is sited at the top of a steep hill with limited parking.

The Panel acknowledges the concerns raised about public transport but notes that Dawlish is accessible from Teignmouth by car, bus or train. There is around a ten minute walk from the main bus stop or train station in Dawlish to Dawlish Community Hospital along relatively level ground, compared to an eight minute walk uphill from the nearest main bus stop in Teignmouth to Teignmouth Community Hospital, which also has a less regular bus stopping outside the hospital on Mill Lane.

The Panel recognises the challenges that people with disabilities have in travelling to healthcare appointments, but also notes that some people will be eligible for support via patient transport services which the CCG states would absorb the cost of any additional miles to Dawlish.

It is also important to note that the services being proposed to move to Dawlish from Teignmouth are used in high proportion by people living outside of the area, with 86% of patients who have day case procedures, and 70% who attend specialist clinics, living outside the Coastal Locality and will already need to travel some distance to Teignmouth to attend their appointments.

The Panel therefore feels that it is reasonable for patients to travel a further four miles to Dawlish under the proposal but agrees that there are still some legitimate concerns around public transport.

Overall, the Panel considers that the proposal as described would not disadvantage groups with protected characteristics under the Equality Act (2010).

Although no services have moved at the current time, and the application for the Health and Wellbeing Centre remains at the planning application stage, there are important mitigations to be pursued with regard to travel, access and transport for some groups, particularly in relation to Dawlish.

The Panel understands that Devon CCG and Torbay and South Devon NHS Foundation Trust (TSDFT) will work with Teignbridge District Council to explore transport options, especially for the most vulnerable people. The CCG will also engage with Dawlish Community Transport and Volunteering in Health to support the further development of community transport options. As part of the planning application process, TSDFT has been working with Teignbridge District Council to mitigate the impact on parking at the Health and Wellbeing Centre, particularly for disabled people and staff.

The IRP strongly supports these actions and recommends the establishment of a specific time-limited standing group of stakeholders, including patient representatives, transport providers, and planning authorities, to scope out the work required and the time frame for each action.

6. The impact of COVID-19 and system resilience

6.1 Background

The CCG completed a review of the impact of COVID-19 on services in July 2020 to analyse the need for beds in case of a future surge of COVID-19 cases and in line with an assumption that a second wave would be similar in size to the first wave which peaked in April 2020. The review also considered the impact on rehabilitation services and the delivery of primary care and outpatient services. This was presented in the public consultation document and as a separate attachment in the supporting documents.

The review concluded that the 12 rehabilitation beds at Teignmouth Community Hospital would not be required as there was adequate bed capacity across the Devon and Cornwall system, supported by additional beds available within the NHS Nightingale Hospital in Exeter.

Teignmouth Community Hospital was considered unsuitable to care for patients with COVID-19 because it would require significant investment in the estate to bring it up to the required standards for infection prevention and control, with constraints around the entrance and exit to the ward meaning that it would not be possible to introduce the necessary one-way system.

In October 2020, Torbay and South Devon NHS Foundation Trust (TSDFT) reviewed its community hospital capacity and designated Brixham and Totnes community hospitals to be used to care for patients with, or recovering from, COVID-19, with Brixham being used for this purpose in November 2020.

On the delivery of rehabilitation services, the Panel notes that the local community and their elected representatives have regularly raised concerns about the ability of local services to cope with COVID-19 and the effects of long COVID if there are no beds available at Teignmouth Community Hospital.

The CCG analysed nationally defined “discharge to assess” pathways (numbered from zero to three) and found that from April to July 2020, 77% of patients discharged from TSDFT were able to go home with additional support (pathway one) , 8% were discharged to a short-term bed placement (pathway two) and 15% were discharged to 24-hour bed-based care (pathway three).

The CCG found that care homes in the area had been able to meet the demand for pathway two patients during the first wave and submitted to the Panel that there are 118 care home beds with nursing, and 493 care home beds without nursing, registered within a 10-mile radius of Teignmouth.

The CCG also stated that the proposed Health and Wellbeing Centre in Teignmouth will ensure the safe separation of staff and patients to comply with social distancing and infection control requirements. The Centre will have fully functioning digital technology to allow for telephone and video consultations which have increased during the pandemic, with TSDFT aiming for 50% of all outpatient consultations to be carried out virtually by September 2021.

6.2 The IRP’s view

The Panel has considered the CCG’s review of the impact of COVID-19 and acknowledges the difficulties in planning services around future COVID-19 prevalence as the situation is constantly evolving.

On the issue of surge capacity, the Panel understands that the Nightingale Hospital in Exeter has been decommissioned for COVID-19 patients and now provides diagnostic and specialist services for people across Devon. In this context, the Panel was concerned about whether adequate scenario planning on system resilience was being undertaken, including an assessment of pathway two capacity and bed capacity across the five community hospitals in the area, to ensure that there are sufficient numbers of beds available to prepare for future waves of COVID-19.

The CCG has responded to the Panel to confirm that projected COVID-19 bed requirements, including community beds, have recently been remodelled for the Devon Integrated Care System. Demand for beds in the current third wave is expected to peak at a level below that seen in the first two waves, at about 160 against capacity of 200 COVID beds available. These projections remain under review, not least subject to an analysis of the potential impact of the Omicron variant.

On the issue of rehabilitation beds in Teignmouth, the Panel acknowledges the CCG’s evidence on reducing hospital admissions and that the integrated care model is able to care for around four times as many patients at home when compared to caring for patients on a ward at Teignmouth Community Hospital. This model of care was evaluated by researchers from the University of Plymouth over a two-year case study published in 2019.

The Panel recognises the Devon system as a national exemplar of providing integrated care which highlights the importance of admission avoidance and supports emerging national evidence on people staying well out of hospital.

During the first wave of the pandemic, the 12 rehabilitation beds were not in place at Teignmouth Community Hospital and the Devon health and care system had sufficient capacity without them. Current modelling, the effectiveness of the model of care in place, and the continuing availability of more suitable and cost-effective alternative facilities, all support the view that opening beds at Teignmouth Community Hospital is not a viable option to consider for providing additional COVID-19 capacity in the future.

The Panel considers that in the current context of COVID-19, workforce availability is the main constraint on the capacity and resilience of health services, noting for example that staff have already been redeployed from a local minor injuries unit to Torbay Hospital in support of emergency care.

The Panel understands that the CCG’s proposal involves moving the location of existing services with minimal impact for the current workforce and agrees that the improved facilities of the new Health and Wellbeing Centre are likely to improve recruitment and retention, particularly among GPs and the local integrated health and wellbeing team.

Given the critical contribution of the integrated care model in keeping people out of hospital beds, its sustainability depends on the resilience of the wider community workforce, including domiciliary care and those working in residential and nursing homes. Therefore, as with many parts of the NHS, the Panel feels it is important to flag the potential staffing risks to the service arising from vacancies, sickness absence and redeployment.

The Panel also notes that during the pandemic there has been a shift to clinicians providing telephone or virtual consultations which may be adopted permanently as a feature of the new Health and Wellbeing Centre. In this context, the Panel highlights the need for the NHS to examine digital inclusion to ensure the local population are able to access consultations remotely to minimise the potential impact on health inequalities and ensure no patient groups are disadvantaged.

After examining the impact of COVID-19, the Panel recommends that the NHS keeps its scenario planning and risk analysis of bed and workforce capacity under close review.

It is also important to recognise that COVID-19 is having a huge impact on mental health. The Panel notes that the South West Clinical Senate’s review in 2019 queried how mental health services would be delivered via the Health and Wellbeing Centre. The CCG’s decision-making business case suggested that mental health services may be provided via drop-in clinics integrated with mental health support provided by the GP practice.

The Panel encourages the CCG to explore the options and ensure that mental health services are included in the integrated care model of the Health and Wellbeing Centre in Teignmouth.

6.3 Conclusion

After a thorough review of the evidence in this case, the Panel understands how the proposal will deliver the vision of patient-centred and integrated local services by modernising and making the best use of health and care facilities and staff resources in the Teignmouth and Dawlish area. The history and contribution of Teignmouth Community Hospital is cherished by some of the local community and they need to be involved in its future possibilities.

Although the Panel finds that the CCG’s consultation with the Scrutiny Committee was adequate, there are lessons to be learned for both parties, particularly around engagement with Scrutiny Committee members to resolve issues and agree reasonable timescales for discussion before a final decision on a proposal is made. The evidence also highlights the importance of NHS commissioners working with local authorities and community organisations outside of health and care to consider equality issues, such as travel, in order to provide an integrated and joined-up service for people to access the care they need.

This case demonstrates how challenging it can be to develop proposals for service change in a fast-moving situation such as the COVID-19 pandemic. However, health and care systems must adapt and learn from this experience and use COVID-19 as an accelerator for change to improve the safety, sustainability, and quality of services for all.

Yours sincerely,

Professor Sir Norman Williams, Chair of the Independent Reconfiguration Panel

7. Appendix A - list of documents received

7.1 Devon County Council Health and Adult Care Scrutiny Committee

Informal advice letter sent to the IRP by Councillor Sara Randall Johnson, Chair of the Scrutiny Committee, 05.02.2021.

Referral letter to the Secretary of State from Councillor Hilary Ackland, Vice Chair of the Scrutiny Committee, with evidence bundle attached, 25.03.21:

• timeline of Scrutiny Committee’s involvement in the proposal
• minutes of the Scrutiny Committee’s meetings, 10.09.20, 12.11.20, 26.01.21, 18.03.21
• CCG reports submitted to the Scrutiny Committee, 18.08.20, 01.09.20, 10.09.20, 03.11.20, and 18.03.21
• Scrutiny Committee’s notes from the Spotlight Review meeting with the CCG, 14.12.20
• correspondence between the Scrutiny Committee and IRP, 05.02.21, 04.03.21, 05.03.21, and 09.03.21
• letter with supporting evidence from the CCG Chair to the IRP setting out the CCG’s position, 25.02.21

Clarification of referral grounds sent via email to the Department of Health and Social Care from Dan Looker, Scrutiny Officer, 21.05.21 and 02.08.21.

Email from Dan Looker in response to IRP questions on 18.11.21 with attachments:

• letter from the CCG Chair to Scrutiny Committee Chair, 09.02.21
• response from Scrutiny Committee Chair to CCG Chair, 11.02.21

Further emails from Dan Looker in response to IRP questions, 23.11.21 and 29.11.21.

7.2 NHS Devon Clinical Commissioning Group

Letter with supporting evidence from Dr Paul Johnson, CCG Chair, to the IRP setting out the CCG’s position, 25.02.21.

IRP evidence template completed by the CCG and NHS England and NHS Improvement with supporting evidence attached, 25.11.21:

• South West Clinical Senate report, January 2019
• pre-consultation business case and supporting documents, February 2020
• consultation document, feedback survey, and supporting documents
• Healthwatch’s consultation report, December 2020
• evaluation of alternative options report, December 2020
• quality and equality impact assessment, December 2020
• decision-making business case, 17.12.20
• letter from NHS England and NHS Improvement’s South West Regional Director, 14.01.20
• minutes of the CCG Governing Body’s meetings, 27.02.20 and 17.12.20
• engagement approach for the Dartmouth health and wellbeing centre

Further evidence submitted to the IRP with attachments, 02.12.21:

• terms of reference of the Coastal Locality Engagement Group
• email from CCG Chair to Anne Marie Morris, MP for Newton Abbot, 17.09.20 following a meeting with the CCG Chair on 07.09.20
• column by Anne Marie Morris MP in the Teignmouth Post newspaper, 24.09.20 and the CCG response, 01.10.20
• letter from Anne Marie Morris MP, 28.09.20, and CCG response, 15.10.20
• letter from Anne Marie Morris MP, 29.10.20 and CCG response, 17.11.20

Further evidence in response to IRP questions with attachments, 10.12.21:

• additional information document to clarify points
• Scrutiny Committee’s Spotlight Review report to the CCG Governing Body, 14.12.20
• Scrutiny Committee’s Spotlight Review scoping document
• CCG’s evaluation of alternative options report, December 2020

Further evidence in response to IRP questions with attachments, 16.12.21:

• CCG’s presentation slides presented at the Scrutiny Committee’s Spotlight Review meeting, 14.12.20
• draft notes from the Scrutiny Committee sent to the CCG on 24.12.20 after the Spotlight Review of 14.12.20
• CCG’s update paper submitted to the Scrutiny Committee meeting, 26.01.21

7.3 Other correspondence received by the IRP

Email from Pauline Constantine, local resident, 14.11.21.

Email from Brenda Banks, local resident, 16.11.21.

Email from Julia Brown, local resident, 16.11.21.

Emails and documents submitted by Viv Wilson MBE, local historian and resident, 17.11.21, 18.11.21, 21.11.21, 29.11.21, 30.11.21 and 05.12.21.

Emails and documents submitted by Geralyn Arthurs, local resident and campaign co-ordinator, 29.11.21, 30.11.21 and 03.12.21.

Email from John N. Smith, local resident, 30.11.21.