What are the purposes and functions of Community Hospital beds?
Dr Ben Titford presented a paper on this subject-
Proposals for the future of community health and social care services Update briefing – September 2014 Moor to Sea Locality
Ashburton and Buckfastleigh
“Engagement in the town will start later in September. It is the view of the locality GP lead, Dr Ben Titford, and of other GPs in both towns, that this rural area with poor transport links needs bed-based care for patients. This would be at the existing community hospital in Ashburton.”
1. Beds for those who are very unwell, requiring complex and increasingly specialist medical care, outside the acute hospitals – possibly fewer
2. Beds for those who no longer need to be in the acute hospital, but need to recuperate before they are well enough to go home – possibly more
3. Beds for those who are not so seriously ill they need to be in the acute hospital, but who are nevertheless too unwell to be at home, especially if they would be alone – possibly more
Integrated community care within each town, including GP services, so that the best use is made of existing resources
The question of beds and how they should be designated will be looked at on a town-by- town basis. However, the wider locality – and whole CCG – pattern of services will need to be taken into account. (And the services available in one town may well have a bearing on what will be needed in another nearby.)”
This paper was discussed at a meeting with local people and with those representing bodies such as Ashburton Town Council in December. I offered to convene a small group in order to answer his question and to provide some context for a further meeting. We have not been able to meet over Christmas but this will be shown to Mrs Elaine Baker. It will be edited as necessary. It is no exaggeration to say OUR NHS is in crisis. Thus it is hoped to define at least some of the soluble log jams and deficiencies, define priorities and point a way
forwards. This is offered in humility and in the public interest.
It is best to start at the DGH where there is tremendous pressure to discharge patients quickly and safely. This is being written with at least a dozen hospitals in the UK having declared 'Major Incidents' with A&E departments overwhelmed. The major reason is the inability to discharge the many frail elderly people because there is no prompt care in the home, or no available Community Hospitals (CH), Nursing Home or Care Home bed as relevant. Note – at present, there is no ice but instead mild weather, and no 'flu epidemic, the usual causes of winter 'bed alerts'. 'Social care' and DN nursing is sparse. The former relates to funding and organisation. The latter relates to shortage of specialist nurses.
Snapshot - Royal Devon & Exeter - Princess Elizabeth Orthopaedic Unit Exeter Friday 2nd January 2015
80-90 medical cases admitted today. A feeling there is no money for projects that would help efficiency.
Since September, overwhelming pressure – as usual.
2 FULL days of elective operating – Saturday and Sunday cancelled because of 'overflows' from medical wards. Three theatres of the five theatres would be running. One of the three would be for trauma cases. Agency nursing staff employed. 8 replacement 'joints' would have been done.
No ice, no 'flu but norovirus in hospital. 'At the current time the hospital has closed Lowman ward and isolated areas in three other wards – Torridge, Okement and Mere - where Norovirus is either confirmed or suspected' 2-01-15
The orthopaedic and trauma unit has 23 consultants and expertise of wide renown eg hip replacement, spinal surgery with 4 surgeons. The Princess Elizabeth Orthopaedic Hospital, which I trained and worked in, had 120 beds with NO overflows from the DGH because it was separate. It was demolished in the 90's. An upmarket housing estate replaced it where once patients were pushed out on their beds for sun and air. TB was treated there much earlier. There was a very modern Ward 2, a modern theatre with 4 operating rooms and the hospital had been re-engineered fully. The OPD was very roomy, being purpose designed by one of the senior surgeons.
When the substitute Princess Elizabeth Orthopaedic Centre was built on to the RD&E there were 4 wards. At present they are not managing with 1 1⁄4 but could with 1 1⁄2 !
They succeed in this by energetic application of the most modern methods and with first class surgical, anaesthetic,nursing, physiotherapy etc practice. Many patients who have knee and hip replacements are discharged home or to CHs as appropriate on the third day. (David Halpin – many THR and TKRs at 5 days to CHs 25 years ago)
A friend with a very severe disc protrusion affecting his sacral nerve roots was admitted on a Monday >immediate MRI scan >theatre for microdiscectomy. Home next day pain free with no neural deficit. The unit is doing exactly what is required of it by our population.
Medical secretaries – downgraded. Big re-organisation 2 years ago. Morale and efficiency suffered. Now being reversed.
Miss Pedder CE of the RD&E at Health and Wellbeing Scrutiny Committee County Hall - when closure of CH beds in Ottery, Axminster, and Crediton were being looked at. Budleigh already closed. She said that on average there were 60 people waiting to be discharged ie 'delayed discharges'. She did not make plain whether this included patients in the 2 new wards built 2 years ago – 44 beds. She agreed with the proposed closures. RD&E attempting to liaise better with 'social' care etc - Mr Chinnock Divisional Manager Corporate Affairs & Communications! (Announced tonight 6-01-15 that 10 beds at Axminster will close.)
NURSING – as relevant to DGHs and CHs: Pat McDonagh MA RGN RMN kindly gave me his time and intimate knowledge in this. I am indebted to him for his generosity and straight forwardness. 12 December 2014
(Nursing. Why am I interested? Happy times – great respect for the profession. I want to see everything thriving.)
All the eggs in the university basket - wrong
Should be another stream of essentially practical, apprenticeship training as SENs underwent. 'SENs' now called assistant practitioners
Not enough trained nurses for the population of England
Morale – generally
South Devon Care Trust nursing in top 3 nationally. Measured at c. 90% using CARE criteria. 'Would you recommend this hospital, ward, CH to your family' etc. Torbay Hospital not far behind. RD&E behind that
Too small a pool
Neglected for far too long (as it was in late 70s – 'austerity' then too. I recall big cuts in recruitment for training at Torbay with shortages to follow a few years later – as I predicted when I protested)
67% would leave the profession if they could - Unison poll of 10,000 a year ago.
1.2 RGNs per bed in Torbay ICU.
Studio school for nurses, radiographers etc on Torbay DGH site going well. 40 16 yr olds
In the CHs – you infer particular problems in recruitment and you said the problem had been neglected for far too long.
General problems – every 3 years RGNs have to re-register, presenting a portfolio of duties and experience. Less easy in a CH post.
Can they rotate – say through CHs? Some opportunities and more could be done. PMcD would like to see – rotation through General Practice, Sub-acute practice – say stroke ward at NA, and acute at Torbay
Any problems recruiting and retaining nurses in the DGHs?
DSH - What factors are there which militate against recruitment and retention of nurses in CHs? I can imagine some. Perceived as backwater perhaps and not enough contact with other nurses professionally? A lack of buzz but some good compensations like getting to know some patients well, and their relatives.
I recall this from discussions after in-patient beds were first threatened:-
The number of RGNs on each shift is usually down to just one.
Nurses were tutored so they could assess each other's competence. Difficult due to :-
a. pressure of duties
b. shift time altered with working day reduced to 7 hours
c. and new policies like the need for RGNs to check the CD stock daily- taking up to 45 minutes
I recall the nurses were keen to rotate if it meant retaining skills and keeping the hospital open. Furthermore, I learned that the skills the CH RGNs developed probably went unrecognised. The ability in assessing the sick patient or with a worsening condition, arranging timely transfer to an acute hospital, juggling an unpredictable workload and managing more patients with dementia and with limited staff, are skills that are vital in our CHs, though difficult to measure.
Recruitment was said to be slow with posts not being advertised until a nurse has left That resulted in poor morale and often in those 'hours' disappearing.
Nurses who applied for posts were often put off when they learnt they would be in sole charge of the ward with no other trained nurse as back up, particularly since an MIU nurse was not in post. The lack of trained staff also meant the CH was no longer suitable for newly qualified RGNs.
Discharges from DGH's
Who records the 'delayed discharges'? (I tried to find this in last Torbay 'Trust' Board minutes – 257 pages – tons of stuff, much irrelevant)
There is a 'discharge team'? Yes. At Torbay a team of 5 in the 'Control Room'. Very efficient.
NB The delayed discharge figures at Torbay (see NHS England web site) are exemplary especially given the population profile – the elderly and the poor, and given that Torbay has removed c. 30 beds ** in the determination that there will be close working with community services – 'Integrated Care'. This has been the subject of several papers funded by the King's Fund.
** But note – many of the 31 beds at the private Mount Stuart hospital are used by the NHS. Ramsay Health derives 79% of its income in Mount Stuart from the NHS.
PMcD – final comment. The hospital has not been able to concentrate on the numbers of humans coming through the doors of the A&E department. The other evening/night there were 220, and 100 discharged (to where? - DSH).
Care package/care in the home/hospital in the home/social care
Gained from experience of carer in a distant county. Variations are likely of course. Difficult to obtain details. Carers and superiors seem to be frightened for their jobs. This included a senior person in Torbay where things are said to work well.
Some background. Today programme 6-01-15 220,000 carers receiving LESS than the minimum wage. A Mrs Claridge spoke up clearly about her attempt at redress. Her alleged treatment by HMRC and then by the Department for Business Innovation & Skills was frankly evil.
Carers provide their own clothing and 'sensible' shoes, and motor transport. At least a year ago many were told that the mileage allowance of 25p per mile would only be paid for that mileage to the client. There was also a restriction re. mileage allowance in travelling to other clients on a circle of visits. Some visits arranged to last 15 minutes only.
The Care 'companies' charge Social Services (SS) etc about double the carers hourly wage.
No pension. Zero hours 'contract'. Carers require NO qualifications. Training given but no professional development generally available. Therefore is great 'churning' – carers leave suddenly and then there is panic to find replacements. Some take NVQs.
So what happens when the 'Control Room' at Torbay hospital or the sister and houseman at the RD&E decide that the famous Mrs Smith is fit to leave the acute hospital to a CH, half way house or to her home?
A Care Plan is sought and a Care Package
When the patient is leaving hospital, either the discharge team or social worker will contact all the relevant agencies in the area stating the needs. Up to six weeks of care will be asked for. Agencies will then see if they have carers available and then they will visit the patient at home. The latter does not always happen.
Social services or NHS 'continuing care' will fund the arrangement for up to six weeks depending on the patient's means.
A senior carer then visits the patient at home with masses of forms – eg care plan, cost assessment of the care required, risk assessment. The latter is very detailed. Notes of bleach and other chemicals under the sink, loose rugs, loose wires – extension leads, pets – to be put away in case the carer is allergic to dog dander etc, whether a neighbour is perhaps too attentive – a demented patient/client might accuse the carer of stealing when another person might be responsible for actual theft. Lighting at night is assessed and a torch mandatory if poor.
The senior carer returns to the office and enters information on the computer and puts care in place. The process is intensely bureaucratic; the folders on each patient will be up to 11/2 inches thick. These are what the CQC look at. Great attention and time is applied to making sure that all is right.
Some may only require care limited to one day. An assessment is not made in those cases.
Contracts are arranged via Social Services (SS) or privately with client. Brokerage forms received from SS to say whether and how much they will fund. Petrol allowance for a 'package' from SS – but no guarantee.
Learned tonight that there was no more experienced carer to be with a tetraplegic patient in his home. So the agency arranged for a carer to travel by train to the person. She had to rise at 4.30. Travelled for 4 hours, then home by train at the end of the day. This emphasises the scarcity of carers in some or many areas, and especially those with more knowledge.
NB I recall speaking with a lady who had been a senior supervisor of care in the home for Devon County Council. What she described was an organisation with constancy and nous. I think she knew the carers, many of whom were in post for a long time. Has 'privatization' been of any benefit in the sphere?
Further information :-
From: Mcdonagh Pat (TORBAY AND SOUTHERN DEVON HEALTH AND CARE NHS TRUST)
Sent: 14 November 2014 16:54
Cc: Payne Janine (LEATSIDE SURGERY); Titford Benjamin (ASHBURTON SURGERY)
Subject: CCG meeting
1. I understand you want to know how many patients are in Torbay Hospital waiting to be transferred to Community Hospitals?
The answer I’m afraid changes daily but to give you some idea, I attach the enclosed data (and graph) to show you our Community hospital Bed occupancy rates and number of admissions per unit (specifically for one week as well as some weekly data back til early September).
2. Additionally, I have checked our admissions today. These are as follows:-
Brixham 1 bed - Torbay admission
Paignton 1 bed – GP admission
Ashburton no beds available today
Bovey Tracey 1 bed - Torbay admission
Newton Abbot 5 beds – 4 Torbay admissions & 1 GP admission
Dawlish - 1 bed - Torbay admission
Teignmouth 1 bed - GP admission
Dartmouth 2 beds - Torbay admission
Totnes 1 bed - GP admission
Kingsbridge 1 bed – Derriford admission
Total 14, of which 10 are patients transferring from the Acute Hospitals and 4 GP admissions (this reflects the general picture of “60-70% Acute admissions vs 20-30% GP admissions”
3. I also attach the ‘home areas and hospital placements’ audit that was done in 2012. I’m sorry that this is not more current but it would take a lot of time to do this and my gut feeling is that it wouldn’t be much different anyway.
I hope this is helpful? Please don’t hesitate to contact me if you have any further questions about this.
Assistant Director for Community Hospitals
Attachments to this letter from Pat McDonagh
a. Weekly admissions to 12 CHs
b. Ashburton and Bovey placements, including 'end of life care' > death in CH – c. 20%
Two bulletins received today 7-01-15
Political row deepens over A&E problems.
The government has "betrayed patients", Labour leader Ed Miliband says, as the political row over the problems facing A& E units deepens. Data for the last three months showed waiting times in England had dropped to their worst levels for a decade. In the first prime minister's questions of 2015, Mr Miliband said the government's policies were the cause. The row surfaced as a number of trusts have declared major incidents in recent days, with cases emerging of patients being treated in corridors and ambulances queuing outside A& E. Addenbrooke's Hospital in Cambridge is the latest big hospital to have declared a major incident. Dr Keith McNeil, chief executive of Cambridge University Hospitals NHS Foundation Trust, said the hospital had been under "extreme pressure" since New Year's Eve. The hospital had nearly 200 beds occupied by patients who were ready for discharged - a fifth of the total. Research by the BBC has found this is not an isolated problem. BBC News contacted 64 NHS trusts around the UK to ask about these delays. Of the 29 trusts who responded, all but one had problems with 1,584 beds in total taken up by patients who were ready to go home. These delays happen when there is not support in the community from either social care teams or health services to care for those patients who need help.
Western Daily Press
Bed-blocking blamed for the crisis in A&E.
The crisis in hospital accident and emergency departments was blamed squarely on a dramatic rise in the phenomenon of "bed-blocking", where the "madness" of cuts in social care at the "back-end" of the NHS have gridlocked the system.
With the emergency measures in place for a third day at two Gloucestershire hospitals, and routine operations and appointments cancelled again at other hospitals across the West, it emerged that the Government was warned seven months ago of a crisis this winter, because of the problem of "delayed discharge". The director of Age UK, who warned of an impending crisis back in June, said the real cause of the crisis came in the creaking social care system. That caused a double-whammy for the rest of the NHS – firstly because elderly patients who have to stay in hospital because there is no care package or bed in a care home available means gridlock in admitting people out of A& E at the "front end" of the hospital. And secondly, elderly people at home without an adequate social care package are much more likely to end up in A& E. "We know that social care spending has fallen dramatically and that without social care older people are more likely to end up in A& E because of a health crisis," said Caroline Abrahams, Age UK's director. Meanwhile, health chiefs behind the NHS "non-emergency" 111 number defended it from criticism that its operators are sending too many people to A& E needlessly.
Dr Ben Titford – what purposes are served by the beds in the Community Hospitals? These can be added to his three at the head of this piece :-
4. I added respite care before that meeting. Many friends or spouses will look after a disabled or sick person at home for a long time. Dementia will be a common reason. OUR NHS should ensure that the carer is not be broken as can happen. A two week break away might save the health and sanity of the carer and allow her or him to soldier on.
5. The CH has a spiritual and moral function in any community. A focus of care and compassion is just up the road. It is the beating HEART of a community. The citizens of Axminster have just lost their's. There are many subsidiary benefits, and most have been defined in the consultation. How many youngsters are called to nursing because a dear relative has been looked after so well in the local CH?
The number of beds have been halved in these last two decades. There are now 3.6 beds per 1000 in the UK, one of the lowest ratios in the OECD nations. And yet the population has high rates of chronic sickness.
I have said before that even if only say 10% of the CH beds were closed, the DGHs would grind to a halt. There is a multiplier effect via 'delayed discharges' which cannot be computed and which is subject to many variables. (Some evidence in this – one of many articles http://www.theguardian.com/society/2015/jan/10/a-and-e-doctors-warn-patient-misery-planned-
Note the advice of NHS England to those whose operation is cancelled.) This process is well in train (see the RD&E snapshot) in spite of previously generous numbers of CH beds, 2 extra wards! and a staff that work very hard to minimise length of stay. It could be said that Torbay Hospital has no problem because 'delayed discharges' are few. However, that depends on a very good number of CH beds close to the patient's home and a home care set up of good repute.
In summary, Torbay Hospital is doing its best.
The Community Hospitals are fulfilling their functions very well but there is probably room for increasing their out patient functions. This might include acting as a liaison centre for the care of dependent people in their homes. In the case of Ashburton there is happy proximity of the GP surgery. To say efficient DGH function depends on ready CH beds is a truism.
The log jam is care in the home. It is clear it needs radical and urgent attention across the board. The proper training, development and reward of carers are essential.
David Halpin MB BS FRCS Retired orthopaedic and trauma surgeon, and citizen
NB I have done my best to achieve accuracy and balance. Forgive me if I fail here and there.