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

David S Halpin MB BS 1964 FRCS

Annexe to submission of 14 February 2013 - 24 February 2013

Some points regarding fault in process and other concerns have been raised in the prior submission.

There remains a need to examine the alleged factual bases for the proposed closure of these beds by the 'Care Trust' from a medical service perspective. It has seemed, at the public meetings, that assertion dominated fact and record.

Dr Derek Greatorex BSc, MB ChB, DRCOG, DGM, FPCert, MRCGPG addressed several meetings. At Ashburton he said 'hospitals are dangerous places'. Any doctor would agree with that possibility, just as they might say the same for the GP surgery. Are not hundreds of patients admitted each day throughout the UK with haemorrhage or perforation due to anti-inflammatory prescriptions, especially diclofenac? He emphasised care in the home as the way forward and implied this would reduce the need for acute in-patient beds, and thus by implication, intermediate care beds such as those at the BT and A&B Community Hospitals (CH). No costs were given and no clue as to the spread of the level of care that would be required. Of course these are difficult projections to make and thus cause for great caution in putting forward such plans.

Dr Greatorex was not envisaging homogeneity of need and difficulty. But how in an age of induced austerity and with an increasing proportion of elderly citizens, is it planned to increase care in the home/community greatly. Factors that were not mentioned – poor housing stock, increasing private and public transport costs, decreasing public transport availability and fuel poverty. Excess winter deaths, some from insidious hypothermia, are said to be greater than 2000 pa in the SW The integrated care team visit the elderly lady – sound of mind but frail in body, or vice versa. Any coal in the shed for a fire to warm the icy home? Who feeds the cat? Who gets her groceries? Who washes and irons her clothes? Pays the corporations for the water and gas from a reduced state pension? Poverty is the central problem and ill health often comes out of that as Dr Edwards and Dr Field have said, and that we know. Where do the efforts and good intentions of the integrated care team start and finish? The fact is that poverty is increasing in all ages, and will continue to increase. The government is patently not concerned. Indeed it is the opposite. But we can agree that if health is maintained in the home, residential care home or nursing home, acute illness and the need for admission to a DGH is less likely.

On increasing need is grafted a growing population. The population of Ashburton, BFL and rural area will have increased from 2006 to the year 2021 by 9479. 24%, a quarter, will be aged 65 or over. That is 2,300 people will be 65 or over.

Dr Greatorex's integrated care team will be fighting brush fires in the community but they will be finding pathology which will require hospitalisation in the DGH. I have made the obvious point that a third of us die of a cancer. Almost all such cases will require investigation and treatment, and the latter might be both costly and lengthy. Then there is all the cardiovascular pathology with stroke, coronary thrombosis, dysrrhythmia, valve disease and heart failure. The DGH is fire fighting now to cope with all this. After care within the DGH, intermediate care will be required more and more in kindly and competent places like Ashburton hospital. This is as certain as night following day.

Dr Vivienne Thorn MB ChB BSc MRCGP Letters that Dr Thorn has written to Dr Peter Edwards help clarify the position of the 'Care Trust' and its intentions. There is unanimity of support for her statement - '‘What is important is that the right sort of care is delivered in the right place at the right time….’.

It is also very important that we utilise tax payers’ money, who fund the NHS, as efficiently as possible. At present we cannot afford to open all the beds in Newton Abbot Hospital and keep Ashburton & Buckfastleigh and Bovey Tracey Hospitals open for in-patient care. I am sure you will appreciate that it is more expensive to run small hospitals because we require proportionally  more nurses and allied health staff  than in a larger unit. It also seems illogical to have empty beds in a modern hospital with state of the art facilities.”

The financial motive for closure is clear. The claim that it is more expensive to run small hospitals is not substantiated with figures. And set against the Torbay and RD&E hospitals, NA hospital is small. It is very unlikely, any way, that the cost per bed day at A&B CH is greater than it would be if every one of the 60 beds at NA CH were in use, especially in the face of the annual PFI charge. However, without solid figures, all is speculation.

We know from our work in Torbay that many services which traditionally have been delivered in Community Hospitals are now delivered in patients own homes and that is a vision that we would like to spread out across our trust’s entire footprint.”

This claim is also unsubstantiated. No evidence or account is presented. I have found several wordy 'papers' on the internet, and in particular -

Older people and emergency bed use: Exploring variation Candace Imison, James Thompson, Emmi Poteliakhoff August 2012

Integrating health and social care in Torbay: Improving care for Mrs Smith, Peter Thistlethwaite March 2011

I studied the 28 pages of the latter carefully. There are some broad costs of the three organisations but few definitions.

The value of integrated care is extolled. There is no doubt about the good sense of integrated care. The systems were sometimes changed but social workers came on my rounds on the fracture wards in Torbay hospital.

One conclusion - 'The daily average number of occupied beds fell from 750 in 1998/99 to 502 in 2009/10.

A sustained 30% reduction of occupied beds would surely have been followed by closure of at least 3 wards at Torbay. What are the facts? The two relevant papers came out of the King's Fund. The studies are tainted given that corporations, including private medical firms, provide funding. The vice-chair of the trustees is Dr Penny Dash. She has been one of the most energetic people, inside and outside the DoH, in support of 'marketisation' of our NHS.

The vision of TSDHCT is to continue to develop services closer to peoples’ homes, so that managing long term conditions, dementia and end of life care can be done while people are still at home.”

Having friends whose wives have severe dementia from Alzheimer's disease brings to mind the fact that is widows instead who greatly predominate in the elderly cohorts. No person with dementia, nor one who is dying or who has other needs for round the clock care, can manage without a partner. The wife of one of these friends first showed signs 15 years ago. She has just been taken into a nursing home and partly because his hip condition was very severe.*

We do not have enough money to continue to fund in-patient beds in Ashburton & Buckfastleigh hospital when this would mean a huge capital investment to bring the hospital up to standard.”

What is huge?

We know the morbidity of patients being transferred to community hospitals over the last few years has increased dramatically. Paignton and Newton Abbot hospitals, which take the largest number of transfers from the DGH, both have doctors who are present on the ward 9-5 Mon-Friday, such is the demand for their services. Gone are the days when it was acceptable to pop into the Community Hospital for ten minutes between surgeries- patients are too sick for that to be sufficient to adequately care for them.”

It probably is preferable to have one doctor dedicated to the care of these people although in the case of Ashburton a doctor who is familiar to the patient is but a stone's throw away. Where is the duty doctor after 5pm and for those 16 hours which follow? Is he one of some dozens of doctors from Devon Doc who will not be known by the patient?

So, you must ask yourself, is having approximately 150 patients cared for in Ashburton and Buckfastleigh hospital a year worth sacrificing the district nursing and intermediate care teams  which care for many thousands of patients in their own homes in Ashburton, Buckfastleigh and the surrounding area, because that’s the tough decision we may be  faced with?

Many thousands?

Responsibility for the PFI project at NA
I have facetiously characterised the way the board distances itself from this 'saddling' as 'not me guv'. But we need to be direct. I recalled that Dr Nick D'Arcy was quoted in the MDA for details of this proposed 'build' back in 2007. I recalled it because I knew the dangers and absent principle in PFIs and took the trouble to arrange a public meeting at my cost in Totnes about PFIs in 2007. All the local councillors etc were invited but none came. A health economist, Dr John Lister PhD, came from Oxford and spoke to just 32 of us. Dr D'Arcy was the Professional Executive Committee Chairman of Teignbridge PCT and took the same role at NHS Devon between 2000 and 2011 (CCG website). He is now Clinical Lead for Patient Safety and Quality (Designate). The CCG is clearly intent on seeing the beds removed from the two community hospitals in an attempt to square the circle at the NA PFI or for some other yet unknown reason. There is surely some irony here given Dr D'Arcy's new post and his central position in the PFI project. He is quoted on the web site as saying “I think that involving patients in their care and putting them at the head of what we do is so important, and my colleagues feel the same.” Were they 'put at the head of what we do' when the go-ahead for the PFI was given, or when the shadow CCG joined the 'Care Trust' in proposing removal of the 20 CH beds?

The provider: efficiency brings 'commissioning' ie Buying
I am very puzzled why the ability for Torbay DGH (I leave out the trust title) to discharge patients as promptly as possible is being hamstrung by having any intermediate care beds extinguished. The professor friend* from school days had a hip replacement in the Princess Elizabeth Orthopaedic Centre of the RD&E on the Monday, 6 days ago. On the second day he was transferred to Ottery St Mary CH. I can be sure my successors at Torbay are doing the same but it depends on having some leeway in the intermediate care beds. That means not closing any. And they have what the board officer, Mr Paul Cooper called a backlog at the last meeting. I have learned that the RD&E had two modular wards added about a year ago This was in response to winter bed crises and 'bed blocking.

I understand one of these wards is for older people who are fit for intermediate care in CHs but where no bed is available. I have asked for details from the communications department. I assume that the board at the RD&E consider this extra cost is fully justified and that they will be competitive in the mad market which has been thrust on our hospital services. How might the SDHCT compete for elective surgical care if patients cannot be promptly transferred when appropriate.

Availability of beds at A&B and BT CTs
We quoted 2 anecdotes in our submission where two local ladies were sent to Dartmouth, and a third where a NA lady ended up in a NH, allegedly with poor care. I have since read a letter, addressed primarily to Mr Stride, from Ms Zoe Newton. The allegations are very disturbing.

The questions are –

a. How many patients from the two catchment areas of A&B and BT CHs, who are ready for transfer to intermediate care, end up in a CH elsewhere?

b. How many patients whom the GPs wish to admit to these hospitals are admitted by default to the DGH?

c. How many discharges from the DGH are delayed, and for how long, by the absence of a bed in the CHs and at A&B and BT CHs in particular.

I have asked the trust for the figures and will forward them when they arrive.

The submission and this annexe is necessarily critical but a good deal of time and thought has been spent because I/we wished it to be constructive. Above this need, we strongly believe this is an inappropriate time to put forward these proposals when our NHS is undergoing an earthquake.

This extract from Hansard has symmetry with this current exercise. The debate was about Lewisham and its sister hospitals. The former had been sucked dry of funds by a PFI project elsewhere in the group. Thank you.

Col 169 House of Commons 8 January 2013South London Healthcare NHS Trust

Mr Hunt The Secretary of State for Health (Mr Jeremy Hunt)

…..............However, I have made it clear that any solution would need to satisfy the four tests outlined by the Prime Minister and my predecessor, my right hon. Friend the Member for South Cambridgeshire (Mr Lansley), with respect to any major reconfigurations: the changes must have support from GP commissioners; the public, patients and local authorities must have been genuinely engaged in the process; the recommendations must be underpinned by a clear clinical evidence base; and the changes must give patients a choice of good-quality providers. ….........