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Consultation by TSDHCNHST: Proposal to 'transfer' all 10 beds from each of the two community hospitals – Ashburton & Buckfastleigh, and Bovey Tracey.

David S Halpin MB BS 1964 FRCS and Susan J Halpin – Orthopaedic Nursing Certificate SRN 1960

14th February 2013

Relevant experience

Closely involved in the communities of South Devon since DSH was appointed consultant in orthopaedic and trauma surgery in 1975 at Torbay and the Princess Elizabeth Orthopaedic Hospital, Exeter. Chairman PC Combe-in-Teignhead at one time. Lead other village activities – formation of recreation field, pavilion etc.

Fostered 12 distressed children from South Devon and two newborn babies – separately! Cared for elderly tenant with chronic airway disease. She died in Wolborough hospital. Nursed mother of SJH with cancer of the pancreas at home. Professional help from GP, DN, Macmillan nurses, and Marie Curie nurses at night. She died peacefully in our home, pain and discomfort being relieved by IV morphine. Mother of DSH, with severe rheumatoid arthritis and a possible tumour, died in a Surrey NH. Grandmother of SJH died in peace in Swanage Cottage Hospital, which is also threatened with closure. An aunt, a nurse, also died there. She had received much good in-patient and out-patient treatment at this hospital over the years including the excision of malignant skin tumours under LA.

It was one of DSH's many tasks to see patients in any one of the community hospitals at the request of the GP (example – a person of working age with severe sciatica) or in the follow up of patients discharged from Torbay or the PEOH. Early discharge, when the patient was fit for that, was an essential part of the efficient running of the acute or elective (PEOH) hospitals. DSH systematised that at the PEOH. Sisters came up from the South Devon community hospitals to learn what was necessary for the care of post-op orthopaedic patients – mostly hip and knee replacements. Arrangements were made before admission between the admissions officer (no computer), the PEOH ward sisters and the community hospital sisters for discharge on the fifth day. That meant the patient for the next operating list (3 on the Thursday) could be admitted to the vacated bed on the same day. Thus the Thursday list was always full and no theatre time was wasted. The opposite happened at Torbay following the closure of the elderly 'pre-convalescent' King's Ash hospital in Paignton. Myself and my two orthopaedic colleagues opposed this closure vigorously. I learned later, after retirement and from colleagues in anaesthesia, that some operating lists were vacant at Torbay because patients could not be discharged appropriately.

Our daughter Fiona is a carer.

I sat on a committee with other consultants and GPs to consider whether the community hospitals had a future. This was in about 1989 and it was chaired by an administrator, Mrs Cunliffe. There were at least 6 meetings. It was recommended that they should all be retained; they were of great value.

This consultation

Both DSH and SJH have reservations, some strong, about the propriety/lawfulness of this consultation process. DSH has been to 5 of the public meetings and SJH to 2. They have also listened to the experiences of many people about the 2 community hospitals.

1. We understand the consultation process to have been flawed by the following

a. There is a primary monetary motive for proposing that these 10 beds be closed in each hospital. This was confirmed by an officer of the trust at several public meetings. That re-configuration is required for economy is confirmed in a letter from Dr Vivienne Thorn to Dr Peter Edwards 13-02-13. This motive should have been declared at the start, and clearly.

b. There should have been a pre-consultation phase involving the DCC scrutiny committee etc

c. The leaflet/questionnaire is not even handed in its layout or wording, and especially in its 'tick box' section. Councillor Andrew Prince has recorded these defects accurately and we concur.

d. It would seem that no record has been kept by the trust at each meeting. Certainly there has been no reference made by each chairman or trust members to previous meetings in any detail. Have records been made of pertinent points put, and questions asked, at each meeting? If they have, sight of the minutes by members of the public would be welcome even at this late stage. If they have not, how does the trust measure the response of members of the public to these proposals?

2. The proposals for BT and A&B should not have been joined. The demography of BT is distinctly different. We have been told by the chairman of BT LoF that 38% of the BT catchment area is nearer to NA hospital than BT. The average wealth of the homes in BT is probably greater than in A&B.

3. Part of the polemical presentation of the alleged defects at A&B and BT involves the services/surfaces etc. We have been told of the problem with foul drains at BT. A friend and neighbour of the BT hospital tells us there was a blockage with overflow onto the road. A firm quickly cleared it, the health authority sent a note to near neighbours and that was the end of it. The need for a lift at Ashburton was noted when the only space served was a changing room for nurses, a facility which is lacking, sadly, in many DGHs. No comments should have been made about the 'engineering' other than from a professional surveyor. We understand a contract has been awarded recently for the survey of the whole of the 'cluster' estate. It would seem highly unlikely that will be available before 24 February. Thus no note should be taken of any allegations in this area. Furthermore, it is understood that considerable refurbishment and fitting took place in both hospitals within the last few years. They were presumably 'fit for purpose' then, to use that trite phrase. Substantial contributions were made by the Ls of Fs; the large amounts of time and energy spent in raising funds is being brushed aside.

4. Much has been made of the age of both hospitals. We trained in old hospitals. The care of the patients depended on our skills and devotion, on the esprit de corps of each hospital, the morale of every member of staff and not on the bricks and mortar.

DSH was trained in orthopaedic surgery at the PEOH - built in 1926 as a TB sanatorium, at the Royal Cornwall Hospital, Infirmary Branch - building starting in the 1790's and the Massachusetts General Hospital - founded 1812.

The environment in the PEOH was stark. The wards were of Nightingale type, the corridors painted concrete and the atmosphere 'airy'. But the patients knew they were getting the best care of anywhere; the esprit de corps was of the highest.

"When the Stafford hospital site opened in 1983 ......It was widely described as a "showpiece" hospital on its opening. However in early 1985 it was the site of the serious 2nd major outbreak of Legionnaires' disease.[3]"

The board of the TSDHCNHST will be very careful in making any recommendations which might possibly affect the excellence of care patients currently receive at A&B and BT given the conclusions of the Francis report into the poor care of some people at Stafford. The 'showpiece' quotation above underlines nicely that structures have very little to do with the care received.

5. Dr Greatorex, in particular, has emphasised the intention of increasing the quality and supply of 'homecare'. It is intended (and this is partly a national drive) that in this way many more people can be 'helped' to stay at home. There is nothing new in this of course. Florence Nightingale saw that poor families had little or no care and could not afford hospitals. The Nightingale Pledge - '....zealously seek to nurse those who are ill wherever they may be and whenever they are in need." In a 1935 revision to the pledge, Gretter widened the role of the nurse by including an oath to become a "missioner of health" dedicated to the advancement of "human welfare"—an expansion of nurses' bedside focus to an approach that encompassed public health." She (FN) set an example of compassion, commitment to patient care and diligent and thoughtful hospital administration.

The GP, with the DN, and the carer have looked after very many people in their homes over the years without any formal title being given to that care. There is every reason for widening this but it is likely to prove too expensive in this time of 'austerity' when applied to the old person who presently requires admission to a community hospital. Rule of thumb costing - £6,000 per month for 18 hours (untrained) cover per patient. This assumes presence for a constant 18 hours per day (but see below). Given the variety of needs, location, home conditions - the UK has very poor housing stock etc costing is 'how long is a piece of string?'

6. Dr Thorn says this in her letter to my erstwhile GP colleague, Dr Peter Edwards. “... the primary reason for the proposed move is to maintain excellent patient care.” The CQC report quoted by Messrs Honeywill and McDonagh says this exists at A&BCH. The board members have stated often that the care given by the nurses and other staff at the two hospitals is excellent. There is no reason based on the quality of care for closure of these beds.

Ashburton and Buckfastleigh Community Hospital.

The hospital is in the hearts of the townspeople and those living on the slopes up to the moor. It is within walking distance for many in the town or within a 'lift' by car. It is regarded as homely and patients and staff often know each other. The cooking is done there and patients asked what they would like I understand. I love to hear that. The feeding of patients on 'my' ladies fracture ward, Ainslie, was often less than good. I tried with letters and meetings to get it better but to no avail, especially the help being given to eat. The ladies often came in with clear evidence of negative calorie and protein balance, and too often they went out worse. A gentleman at the Widecombe meeting said how lovely it was for his wife to see their dog's face appear at the window. And so it must have been.

Bovey Tracey Community Hospital.

There is equal affection for this hospital. A gentle little lady spoke at the BT meeting – Jean Elliot. She related how she and many volunteers had, for instance, given tea to visitors and patients for 40 years. The value of this cannot be underestimated. The 'talking through' with friendly faces, the news from home and the melting of cold anxieties. Community, something which the Revd Neal who was first to launch at the BT meeting, did not mention. I do not know whether cooking is on the spot. Again the value of seeing one's pet is great. If I was ensconced there I would love to see our Jack Russell, Stanley. A fillip. There is little doubt that older patients will feel more secure in a little hospital that is familiar to them. It is easy for those within our NHS to underestimate the strangeness and the anxiety that comes with admission to hospital. How does the ill person feel as he is brought to the dark Satanic mill of Derriford hospital with its vast chimney pointing to heaven?

Newton Abbot Hospital.

As it happens we had occasion to visit this last Tuesday evening. A neighbour from our former village of Combe-in-Teignhead had a severe stroke 10 days ago. A very heavy smoker. She was treated at Torbay and transferred a few days ago to the stroke unit at NA. She is doing well and her severe expressive dysphasia is likely to go given her excellent hand function. It is luxurious in its spaces and decor, and very 'clinical'. The cubic metres per patient must be double that of the Nuffield in Exeter and treble that of the Mount Stewart. We were very pleased to meet Dr Clarvis from the Kingsteignton practice who cares for all the patients until 5 pm each day. He and I worked together at Torbay on the fracture wards. He spoke well of the hospital (the stroke unit was in the charge of a Consultant Physiotherapist) and relished the fact that he was doing doctoring with no paper apart from patients notes! There were about 7 empty beds out of the 15 'stroke' ones but obviously they want to maintain the specialist focus and the daily rate of stroke in the community will vary.

We felt that an old person, and especially a 'traditional' one without great wealth, would not feel at home in a Hilton.

NA hospital is obviously a very costly hospital to run. I imagine the NHS part of the team that planned it might regret that it is lavish, but not the owners. This PFI scheme has been characterised as a 'white elephant', or 'we have been saddled' by another. The board have been quick to say this was put in place by a previous team – 'not me guv.'

If one considers the PFI cost per bed with 35 beds in use - 2.5 million per year £71,428 per bed per year £1373 per bed per week. If one considers the PFI cost per bed with 60 beds in use - 2.5 million per year £41,666 per bed per year £801 per bed per week.

How much of the annual charge includes elements of service is not known to us, but medical and nursing salaries, and more, will be added to the cost per bed.

It is, of course, a great pity that 25 beds have remained empty since the hospital was opened in 2009. And the cost has been great. 25/60 X £2,500,000 = 1.04 million. £4.16 million of our money has been wasted. Enough for 520 THRs at say £8000 each.

The cooking is off site? Chill/cook?

The occupancy of the 35 beds in use is 93.5%. That is higher than safe - the optimum being 85% as I know very well. This occupancy may be reflected in the anecdotes below.


a. From the eldest daughter of our neighbour with the R sided stroke, who was helping her eat. A very experienced carer with a lot of common sense.

Mrs B aged 91. Short term memory bad and hallucinations associated with reducing sight. Charles Bonnet syndrome. At home in Teignmouth. Fractured clavicle >Torbay >Shoulder clinic. No bed at Teignmouth or near so sent to Dartmouth, her muddled state increasing. Now home - social services 4 x per day but in a rush - 10 minutes. Not enough for dressing and washing, or for helping her mental ease.

b. Mr T. BT resident. Letter in paper from his wife. Several bad falls > Torbay > assessment ward. Fit for discharge to CH. NO bed at BT > Dartmouth

c. NA resident – frail. THR or similar in Torbay. Pre-convalescence needed. No bed in NA > NH on Wolborough Hill. Her friend/neighbour, a senior cleric from our orthopaedic clinic, visited after some days. As she opened the door the smell hit her. She had not been helped to wash since transfer.

We have heard other similar stories. It is obvious there is not the leeway to provide intermediate care at present. There would be a real improvement in availability with the opening of the 25 beds at NA and with the maintenance of beds from A&B and BT.

Out-patient services.

There is sufficient space in the A&B and BT hospitals for all that is required for out patient consultations and treatments at present with in-patient care continuing.

We have provided good reasons for the retention of beds at these two much loved hospitals.

I concluded thus at the Widecombe public meeting -

“The board is abrogating its responsibilities in the provision of medical services if it proceeds with closure. And just as the NHS will never be revived if the Health and Social Care Bill kills it, which is likely, if the beds at Ashburton and at Bovey are closed, there will never be in-patient facilities there again. Never.” The lesson from Stafford and Lincoln etc is that the care of the patient comes first. Top down pressure for 'economy' or whatever must be resisted by the responsible officers. The central fault is that political dogma always dictates policy and action. OUR NHS must no longer to be a political football. In microcosm, the £25 million PFI at NA was an expression of such dogma.

For truth, reason and justice

David and Susan Halpin

The letter is open to factual corrections.