An Open Letter from Simon Hoare MP to Tim Goodson, CEO Dorset Clinical Commissioning Group
Re – Improving Dorset’s Healthcare Consultation
I have completed the consultation questionnaire, but also wished to provide a fuller note (it is also appended to my consultation response) for your reference. You may recall that when we spoke last summer I said that I would support proposals that delivered a better service for my North Dorset constituents. I also advised that in order to generate confidence, the CCG would need to be very clear in terms of the costs, future proposals and in providing a route map for delivery. I am afraid to say that these proposals fail on all counts.
While I could provide a line by line critique of the proposals, I make the following general observations. In so doing the contents of the letter, while from me as the Member of Parliament, is endorsed by Shaftesbury Town Council, Gillingham Town Council, Save Our Beds Campaign and the surrounding catchment Parish Councils of Melbury Abbas and Cann, Compton Abbas, Sutton Waldron, The Stours, Fifehead Magdalen, Iwerne Courtney and Stepleton, Iwerne Minster, Marnhull, Motcombe, Silton and Mere.
Priorities – the CCG appears to be in two minds as to the role and value of community hospitals. In some instances they must be bedded while in, for example in Shaftesbury they can be remodelled to deliver a polyclinic, which is unspecified in terms of service. The Prime Minister and Health Secretary have both recently confirmed the key role that community hospitals do and can play within the broader NHS landscape. The CCG proposals sell the north of the County short. If we accept the premise that there is an overprovision of beds but that bedded community hospitals will continue to play a part in Dorset’s healthcare, then one of those bedded community hospitals must be in Shaftesbury given its location and the scarcity of other provision in the North.
Commissioning beds in the care sector – I have a number of points to make on this proposal. Page 26 of the consultation document states ‘we could also use short-term beds in care homes as an alternative to community hospitals …..Care home beds with the right support from the community, would be more cost effective and more suitable for rehabilitation and end of life care’. This is the first and only time that the vision of support from the community is referenced. Is this support of the principle, or community engagement via volunteers? The lack of clarity is worrisome. The CCG has produced no meaningful financial modelling to support this care home commissioning proposal. However, even if it had I would question the medical efficacy of this proposal. I understand that when a patient leaves an acute bed to go to a community hospital bed they are transferred within the NHS, but when a patient is moved to a care home they are discharged. This dilutes the duty of care as the patient has ceased to be a patient and is therefore, arguably the responsibility of the social care provider, rather than the NHS/CCG.
Having surveyed care home providers in my constituency, there was little knowledge about the CCG proposals (only one had knowledge of it), few have capacity or space to expand, and all charge in excess of those envisaged by the CCG (between £950-1050.) I dispute that it is wise to align rehabilitation and end of life care as set out in the document. Having discussed the proposal with both the Royal College of Physicians and the Kings Fund, my initial anxiety as to the appropriateness and desirability of providing rehabilitative healthcare in a care home environment is inappropriate and unlikely to be successful. I question the impact on a patient’s mental health and ‘spirit’ to find oneself in a care home environment, rather than receiving intermediary care on a ‘return to home-care’ path. The confusion expressed by various representatives of the CCG has heightened rather than lessened anxiety around these plans. We have heard that the beds (6) would be commissioned in one care home (unspecified) and also that they would be commissioned in care homes across the catchment. The latter would be served by a peripatetic ‘flying squad’ of health care professionals. Again, given the geography and journey times, I doubt that this model could provide reliable healthcare. Once again, I question the medical efficacy of this proposal.
Underserviced North - the service provision map (page 23) underscores the key point of a heavily biased provision in the South and East of the County and with only a skeleton coverage for the North / North West. All County residents are taxpayers and this continued negligence of the North is neither supportable nor equitable.
Usage – I remain to be convinced that the CCG’s assertion that the County is over bedded in terms of community hospital beds is accurate. I have seen figures of 94% occupancy for Shaftesbury. This does not suggest an oversupply.
Mental health – there appears to be no strategy for delivering non acute localised mental healthcare.
Geography & Travel – the geography and topography of North Dorset suggests to me that a bedded community hospital is critical to serve the needs of local residents. I fundamentally dispute the assertions made in the document about travel times. They have been underestimated. I have examined the bus timetables and it is impossible to get to either an early morning or late afternoon appointment from many parts of the catchment. Rural public transport is scarce in any event, and the proposals as currently set out do not reflect this.
Demographics - there continues to be confusion as to which population figures the CCG has based its proposals on. Gillingham is the growth area for the entire County with circa 1,800 homes to be delivered over the life of the Local Plan. Shaftesbury itself is growing. North and North West Dorset has a very high aging population. With aging comes an increase in demand and complexity of care needs. The proposals as set out seem to take neither of these points into account.
Relieving pressure on the acute sector – we are all conscious that we need better meshing between health and social care. This is an organic process and we need to be realistic about timetables for full integration. It is clear that health care beds in a community hospital play a part in relieving pressure on the acute sector.
Future of Westminster Memorial - the lack of consistency in the CCG’s narrative surrounding both future provision in general, and the future of the hospital buildings in particular, are confusing and only add to the sense that the CCG is simply not being straight with the public. At the same meeting we have heard the CCG describe the Westminster as being ‘old, physically constrained and very costly to run’, followed by ‘we will be commissioning a larger range of services from the Westminster’, to ‘we could provide a brand new building’.
Let us examine these in turn. Either the building is old, constrained and too costly, or it is not. Removing beds and providing a larger range of services does not alter these assertions; arguably it increases pressure e.g. for car parking. For reference, I do not accept the first description of the Westminster. If the building is capable of hosting a deeper range of services, what point is there for the CCG to highlight the age and constraints of the building? As I said last summer, communities are suspicious of change and have little faith in the veracity of ‘the powers that be’. The mutually contradictory narrative that has accompanied the assessment of, and vision for, the Westminster has only compounded this suspicion. The suspicion is multiplied following the CCG’s confirmation that the Westminster has no restrictive covenant on it. Given the reduction in beds over the years and the proposal to de-bed the hospital altogether the CCG will, I hope, forgive me for having serious doubts about the medium term intentions for the Westminster.
We fear the surreptitious salami slicing of the Westminster until services have been so reduced and degraded as to be wholly financially unviable to keep the Westminster open for any healthcare, resulting in its commercial redevelopment. The prospectus of a new building is wholly fallacious. The CCG would not enjoy the capital receipt secured from redevelopment nor is it in a position to deliver or commission a new build. Another body, possibly NHS England Property, would secure the capital receipt, but even if it was Dorset Healthcare, neither has made any commitment to ring-fence released capital to the North Dorset catchment to provide a new build. There is no capital budget and no site identified or secured. The CCG commissions services not buildings, and to suggest otherwise is deeply misleading. Notwithstanding this point, given the budget pressures on the local health economy it really is beyond belief that there is the funding for a new building.
Proposals for acute hospitals – in my judgement the major emergency hospital must be in Poole due to its central location and transport links. The justification for Bournemouth, as stated on Page 30 that it is ‘better situated in the East of the County because that is where most people live’ is the wrong premise upon which to base the decision. Given the rurality and population sparsity of so much of the County, accessibility should be the primary criteria. Siting the major emergency hospital at the farthest part of the County is deeply prejudicial to rural areas.
I have raised the role of Community Hospitals recently in Parliament. On 18th January I asked, at Prime Minister’s Questions:
“In supporting my RHF’s endeavours in facing the difficult challenges in social care and the NHS, may I invite her to endorse the concept and continuance of community hospitals in our market towns across the country? Those hospitals, including the WMH in Shaftesbury in my constituency, provide a vital piece of the jigsaw in our NHS”.
In reply the Prime Minister said:
“I am sure that the WMH in Shaftesbury is providing good services for local people. The structure of local services is of course a matter for discussion at local level, and it is crucial that local clinicians and others agree that we have a safe and secure service for people and that they are provided with the NHS services that they need at the most appropriate level. I fully accept my Hon friend’s point that we often think only about the major district general hospitals and acute hospitals when actually the NHS is made up of many different parts. We need to ensure that patients are being treated at the most appropriate level for their needs.
On 7th February I asked the Health Secretary, in a supplementary question:
“I am grateful to my right hon. Friend and the Prime Minister for their commitment to this important area of health [mental health] and the parity that the Government are giving it. Does the Secretary of State agree that, as well as providing mental health support in both schools and colleges, community hospitals, due to their locality, status and scale, can often provide a useful forum for providing these vital services?”
In reply Jeremy Hunt said:
“I am pleased that my hon. Friend raises that point, because when we discuss mental health we often talk about services provided by mental health trusts but do not give enough credit to the work done in primary care, both in community hospitals and by general practitioners, who have a very important role as a first point of contact. He is absolutely right to make that point.”
I certainly do not believe that the NHS is so perfect that it is inured from change or that it should be preserved in aspic. However, change should be predicated on logic, publicly supported priorities, and clear diagnosis and prescription. As far as proposals for the Westminster are concerned, the CCG’s proposals fall foul of all four. There has simply been too much contradiction from the CCG and lack of robust, reliable analysis to make this a meaningful or reasonable consultation. The opaqueness or absence of detailed critical analysis provided by the CCG has only compounded the, perhaps, cynical view, that there are undisclosed but well advanced plans for the Westminster. The advice I gave the CCG last year has been totally ignored. From my many conversations with constituents, my prediction of the community’s response will be borne out in the consultation responses. The CCG has not helped itself.
At the start of the process I was assured that the CCG, if the proposals for the Westminster did not command public support, would reassess them. If this is to be the case, I would urge the following:
- the key role that bedded community hospitals play in the NHS landscape is embraced and that community hospitals are better prioritised within the CCG’s strategy;
- the needs of both a growing and aging North / North West population of the County are better taken into account;
- the model of care home commissioning is abandoned on both deliverability and clinical outcome grounds;
- the drive to integrate more closely health and social care is accelerated;
- the unused space within the Westminster is commissioned to provide non-elderly additional beds. This would relieve pressure on other sectors of the local NHS while diluting staffing costs on a staff: patient ratio while creating a polyclinic-type service, but without losing intermediate medical care beds.