WCHW response to Poltair consultation

January 2014

Since the loss of inpatient beds at Poltair Hospital over twelve months ago, there has been much concern in the community about the future not only of the hospital building but also, and more particularly, of the services offered within it.  This concern heightened as Peninsula Community Health has given successive reasons since then for the closure of the beds – firstly it was staff shortages; then problems with the state of the building; then awaiting the results of the review into Penwith’s community provision.  More recently a leaflet was discovered, outlining Peninsula Community Health’s community hospital provision across the county, but omitting not only Poltair, but Edward Hain St Ives and Fowey Hospitals as well.  Despite reassurances that this was ‘an oversight’, it was easy to imagine how easily Penwith could lose all its community beds. 

As a long-standing independent health watchdog for West Cornwall, representing and speaking out for local people since 1997, West Cornwall HealthWatch has been listening and reflecting on a suitable response to the current situation and to the proposals so far put forward for the future; this response follows, under the headings of
1.    Strategy
2.    Geography
3.    Acute or Community
4.    Whole system capacity
5.    The Consultation process
6.    Funding
7.    Politics
8.    Care in this community
9.    Our preferred solution
We have concluded that
* none of the five options on the table are acceptable
*more community hospital beds are needed in the western tip of Cornwall
*beds and services need not be on the site at Poltair, but must be accessible to the residents of west Penwith in particular i.e. close to Penzance
*core NHS services should not depend upon either private providers or volunteer organisations for their delivery
*there is an opportunity to create ground-breaking integrated services in the Penzance area, if the health and social care community can share such a vision

 1. Strategy
There seems to be no overall strategy for community hospitals in this county.  As a result, we are being asked in this consultation to consider just one hospital; this is unhelpful.  There needs to be a clear definition of what we want our community hospitals to do.  There should be a vision for the future.  If we are considering West Cornwall, for example, Edward Hain at the very least should be included in the consultation.

There needs to be an acknowledgement of the importance and value of community hospitals across the county, including the need for inpatient beds.  This makes total sense to local residents, patients and carers; now it needs to be understood by decision-makers, commissioners and providers.  We believe that our community hospitals should be ‘jewels in the crown’ of the NHS, not ‘thorns in the flesh’ ready for the plucking.

Over the last nine years the NHS has reduced 140 (30% of the total) beds from our Cornish community hospitals, none of which have been taken out through proper process of public scrutiny – it has just happened.  Beds have been lost to allow single sex accommodation, better bathrooms etc., but there has been no plan to replace the beds lost.

We are therefore forced to the conclusion that the often invoked ‘direction of travel’ towards more treatment nearer home is being implemented through a strategy of reducing community beds and moving people into private nursing and residential beds; or trying to nurse them in their own homes.  This strategy also encompasses the use of the third sector, as evidenced in Newquay
Pathfinder, a project run by Age UK using volunteers, and about to be rolled out in Penwith.  The assumptions are all there in the consultation document, but there has been no formal approval of this policy. 

When movement in this direction seizes upon one piecemeal change, without a clear view of what facilities will be available to provide what community hospitals now provide, concern is bound to arise – especially if financial pressures are being emphasized as largely shaping that replacement. 

Our fears are that the private sector will want to cherry-pick those parts of the service that make a profit, and that public money will be diverted into the private and voluntary sector.  It is very important that we recognise potential gaps in services and avoid the cliff edge scenario when patients leave the acute sector. This is where community ‘step-down’ beds are so vital
for people who are not quite ready to return home.

2. Geography
We ignore the distinctive geography of West Cornwall at our peril.  West Penwith has a distinctive remoteness due to the fact that it is surrounded on three sides by the sea, and has no other adjacent neighbours except for those ‘up the line’.  And it is a long way to go to get there.

Those in the far west will be the most disadvantaged by the loss of the facilities previously offered by Poltair; it is clear that neither Edward Hain nor Helston hospitals are sensibly accessible for the residents of West Penwith.  Recent changes in public transport provision will make matters palpably worse.

 3. Acute or Community
We have to acknowledge the differences between acute and community hospitals. Some of the options for Poltair pre-suppose the use of West Cornwall Hospital - but this latter is an acute facility, run by RCHT, an acute Trust.  RCHT needs to increase acute work on its Penzance site, not shoulder the community responsibility more properly the remit of Peninsula Community Health. 

We have become particularly frustrated over the past months with media reports of cancelled operations and lack of beds in the acute Trust.  When we know, as we do, that the number of community hospital beds across the county has been significantly reduced in recent years, and those remaining are operating at overly high occupancy rates (frequently 95%), it is abundantly clear that patients will end up unnecessarily in acute beds, causing the problems in the system which no-one has wanted to experience.  In short, ‘bed-blocking’, cancelled operations, and over-occupancy are all symptoms of a lack of capacity in the system.           

Domiciliary care provision in West Cornwall is poor, and there is growing evidence to support our assertion that there is a lack of adequate provision in the far west.  Private providers are unwilling to deploy care workers in more remote areas because of the distances, journey times and lack of profit.  The impact is perhaps greatest west of Penzance, where a projected increase in population of approaching one thousand over 50s will only compound existing problems.

4. Whole System Capacity
We understand that Andrew Abbott (NHS Kernow) has commissioned work on capacity, including community hospital beds - where we need them and how many there should be.  But this work is not yet complete – yet it should inform the consultation process, and no decision should be made without it.  This relates back to section 1 above – there needs to be an evidence-based strategy to support decision-making and change.

5. The Consultation Process
We have serious misgivings about the process adopted so far to determine priorities and options:
a) Stakeholders in September expressed concerns about the process used to determine priorities, and whether it was a statistically valid exercise.
b) The September Stakeholder meeting has been used to justify the criteria of Affordability and Safety, which wasn’t as stakeholders recalled it.  Indeed, although safety was, later in the day, assumed as a ‘given’, stakeholders were expressly told not to consider costs in their earlier discussions.
c) There is a suspicion that the pre-requisite ‘Safety’ can be and is being used to justify losing a service.
d) Some stakeholders felt that they should have been consulted about the Consultation document before its publication; the follow-up meeting in November gave little feedback on progress since September, and didn’t prepare stakeholders for the launch of the consultation options.
e) There is serious concern about the 5 beds proposal, which is simply not a valid option, and seems to have been included simply to prove that community beds can no longer be provided.
f) The reinstatement of the previous 10 beds has been ruled out as an option with insufficient justification.  It should have been one of the options.  Our understanding from the Independent Reconfiguration Panel is that if this is referred to the Secretary of State, ruling out an existing service would be frowned upon.
g) Such an extended ‘temporary closure’ has been disappointing, and will lead to challenges if a decision is taken to reinstate the previous service.
h) The consultation document is misleading in that many people will think that Poltair beds will move to Edward Hain and Helston, i.e. reprovision; however, upon detailed reading it is clear that there will be no additional beds provided in either place.
i) It follows on from this that the number of available ‘step-down’ beds from acute hospital care is being reduced.  It seems to be taken for granted that any shortfall can be made up by using beds in private residential or nursing homes.  It is not clear how such provision can be guaranteed in terms of its scale, its quality, or its stable, long-term existence.
j) Some of the assumptions in the consultation document have not been adequately tested, leading respondents down a road they may not wish to take: for example, being asked to rank five options in order of importance, and being asked to choose a favourite, when none are preferred.
k) Other options have been discarded, and inadequate opportunity has been given to explore new and creative options.  This has led many to view the process as ‘less a consultation, more a sell’. 

6. Funding
a) The redevelopment of Poltair, either on the existing site, or as a new build, or as an add-on build at West Cornwall Hospital, does need to be explored, on the grounds of necessity. It is not acceptable to dismiss this on the grounds of affordability (see below).
b) We believe that there is insufficient bed capacity in the community hospital sector within the Penwith area, which has contributed to the problems experienced by the acute sector. We also believe that not all patients can safely and adequately be cared for in their own homes, where home care is simply not in place – and will not be without truly massive investment.  We have noted that options involving a new build or reopening 10 beds have been discounted on grounds of ‘affordability’. Frankly, we can’t afford not to consider these. To deliver adequate care to the growing numbers of frail elderly people who need it is going to cost a lot of money – we have no other option.
c) There is agreement that the money from any sale should be kept in the community but, whilst it may be said that it would be an aspiration to retain the profits from sale, there has so far been no major effort to achieve that.  This needs to be undertaken.
d) We have the opportunity to plan for and provide cutting edge services, where the money could come back for a capital project in west Cornwall.  We have a moral right to the money, and should plan for it.
e) We understand that the St Clare site will shortly come on the market.  This should be investigated as a site for such a cutting edge scheme, incorporating therapies, treatments and ‘step up/step down’ and assessment beds for frail patients.
f) We are told there is a cap of £760,000 pa for running costs.  We need to note that no money will be ‘saved’ until the property has been disposed of – which could take years.  In the meantime, the money won’t be available for other things.  So the envisaged ‘savings’ from disposing of Poltair will be neither as great nor as swift as might be imagined.
g) St Just Town Council has submitted the view that none of the options are acceptable, that money from any sale should remain in the west of the county, and that provision needs to be accessible for those in the far west.  We support this view.

7. Politics
 We are mindful that what is proposed is being driven by government policy, which we are not convinced is always in the best interests of patients.  Our role is to support proposals which will benefit our community, regardless of which government is in power.

8. Care in the Community
We in West Cornwall HealthWatch are passionate about NHS delivery of high quality, seamless and compassionate care to everyone in our community.  In considering the services offered by Poltair, we are considering the most elderly and vulnerable members of this community.  We have real concerns - and have voiced them on many occasions - about these vulnerable people being let down by a system which cannot cope with their needs.  “Care in the community” is being promoted when frankly often it is not of high quality, not seamless and not compassionate. 

It is stated that a full range of services cannot be provided at Poltair.  However, if they are all needed, and more besides, then it is not acceptable to say it can’t be done.  The alternative to acceptable provision is a reduction in the quality of service.  Is that what the community wants to see?

Community beds play an essential part in nursing care, assessment and rehabilitation.  They need to be embedded in local communities, for equity of access, and their beds cannot simply be sacrificed to leave people at home, where we know that adequate community nursing or social care is by no means in place.

Neither are we convinced by the oft-quoted statement that ‘patients would rather be at home’. Whilst this is true in most cases, and we would of course support this, it is also the case that far too frequently patients are sent home from hospital to a bleak, isolated and unsafe environment, with visits from carers being insufficient and nursing care a long way short of 24/7.  These patients too often end up as hospital readmissions, or – even worse – found dead at home alone.  We have received too many reports of cases where families are under pressure to take sick relatives home; or patients encouraged to go home because ‘you will get better quicker and won’t pick up hospital infections’ – in both cases the pressure is often because the hospital needs the bed for another patient, rather than because the patient is ready for discharge. 

We cannot accept such a reduction in hospital beds, given a growth in our population, a growth in the numbers of elderly people, and a growing complexity in their health needs.  Alongside an essential expansion in community nursing and social care provision, to look after patients who really can be supported in their own homes, there will always be a need for community hospital beds. How this can be funded in a time of funding cuts is a serious challenge, but it must be addressed.    

9. Our preferred solution
1.  As a temporary measure until replacement provision elsewhere has been stabilised, to reinstate five of the beds at Poltair.  Our case is that patient safety at home is more of a cause for concern than the temporary re-opening of a ward at Poltair.

2.   To work up a Business Case and Plan for a brand new, fit for purpose, 'Integrated Care Centre', offering the opportunity to house all those health, social care and third sector personnel involved in supporting people at home in West Cornwall to avoid hospital admission.  Such a Centre would deliver the out-patient, outreach and rehabilitation services currently provided at both Poltair and Edward Hain Hospitals, along with day care facilities and a minimum of 24 'community' inpatient beds to provide step up/step down nursing care, rehabilitation and frailty assessment, as well as end of life care for those patients expressing the wish to die in hospital close to family and friends. 
From the outset, it should be possible to plan the co-provision of all these alongside West Cornwall Hospital. 

Such a Centre would also exercise a training function, dedicated to raising the levels of provision in residential homes and in domiciliary care in ways that anticipate, rather than react to increased reliance on these sectors. 

The imminent availability of the St Clare site in Penzance offers a golden opportunity to develop this alongside the much valued and respected West Cornwall Hospital and this option should be explored as a matter of urgency, before the site is sold by Cornwall Council for alternative use.

The time to close Poltair and Edward Hain will be when the new facility is ready to open. Meanwhile there need to be robust negotiations with NHS Prop Co about applying the profits of eventual sale to fund the new facility.

It is our belief that this community would enthusiastically embrace such a scheme and would once again demonstrate its full support for the NHS in Cornwall going forward in this way. We strongly urge NHS Kernow's Governing Body to look favourably at this and use its Pioneer status to deliver a cutting edge solution, addressing the problems of current and future service delivery, and becoming a model of best practice for the rest of the UK.

Submitted to NHS Kernow on 20th January 2014