BRISTOL HEALTH WELLBEING AND ADULT SOCIAL CARE SCRUTINY COMMISSION 15 OCTOBER 2013 BRISTOL ACUTE SERVICES REVIEW

BRISTOL HEALTH WELLBEING AND ADULT SOCIAL CARE SCRUTINY COMMISSION 15 OCTOBER 2013 BRISTOL ACUTE SERVICES REVIEW 1. INTRODUCTION The purpose of this paper to is to provide the Bristol Health Wellbeing and Adult Social Care Scrutiny Commission with information about the outcome of the Bristol Acute Services Review and next steps. The Review identified a financial challenge facing the two acute Trusts in Bristol in excess of 230 million over the next five years. The challenge expressed at a whole health economy level (not just the acute sector) is in the order of 290 million. This is on top of significant reductions in local authority funding which in turn has the potential to adversely affect the care of vulnerable people. A significant proportion of these savings are for local health organisations to deliver by focusing on internal cash releasing schemes. The evidence from the Review, however, suggests that the overall scale of change required can only be delivered through ambitious, health economy-wide solutions, especially those aimed at the integration of health and social care. 2. CONTEXT Since April 2013, University Hospitals Bristol NHS Foundation Trust (UH Bristol) and North Bristol NHS Trust (NBT) have led a joint project to review the issues facing acute services in Bristol. The Trust Boards agreed the following scope for the Bristol Acute Services Review: 1. Hospital specialty review: a review of eleven specialties (grouped as seven service areas), conducted through benchmarking analysis, best practice review and consideration of alternative service models submitted to stakeholder workshops. The specialities examined were: Trauma & Orthopaedics and Rheumatology General Surgery Maternity & Neonates Cardiology Plastic Surgery & Dermatology. Gynaecology Clinical Haematology and Medical Oncology. 2. Whole system urgent care pathway review: a review at patient pathway level of the urgent and emergency care system in Bristol, North Somerset and

South Gloucestershire, building on the existing programmes of work being undertaken by the Clinical Commissioning Groups and the Healthy Futures Programme and including consideration of the hospital-based specialties of general medicine, geriatric medicine, emergency medicine and stroke care. 3. Addressing the financial challenges ahead: development of a range of options aimed at addressing the financial challenges facing the two Trusts whilst ensuring the sustainable long-term delivery of safe, high quality care. 3. CONDUCT OF THE REVIEW The Bristol Acute Services Review was overseen by a programme board chaired by Professor Steve West, Vice-Chancellor of the University of the West of England and including representatives of NHS England, the Trust Development Authority and Clinical Commissioning Groups, as well as Non-Executive Directors and officers of the two Trusts. The scope of the specialty review work-stream was determined jointly by the Medical Directors and Chief Nurses of both Trusts, while the decision to review the urgent and emergency care system in Bristol, North Somerset and South Gloucestershire was taken jointly with health and social care partners at the Healthy Futures Programme Board. Options for addressing the financial challenges facing the two Trusts were developed and prioritised jointly by the executive teams of both Trusts. External advice was commissioned from PWC, using funds made available by the former NHS South of England Strategic Health Authority. The service review was clinically led and achieved strong clinical engagement across the two organisations at all stages. A range of clinical workshops were held at speciality and pathway level with close working by a number of clinical leads across the two Trusts. Feedback from the process and workshops demonstrated an appetite to continue these valuable conversations. Personal, clinical relationships have developed, laying the foundation for improved clinical services. The system-wide review involved many stakeholders, including commissioners and partners in primary, community and social care and public health. Patient and public involvement was secured where possible through existing Trust mechanisms, with additional support from HealthWatch and the Bristol Equalities Health Partnership. A formal workshop took place on the 16th of July with very positive feedback. The Review concluded at the end of July with submission of final reports to the Chief Executives of both Trusts. The findings have been considered separately by the Trust Boards and presented to both the Clinical Commissioning Group Partnership Board for Bristol, North Somerset and South Gloucestershire and the Healthy Futures Programme Board. Brief on the Acute Services Review Dated 04 Oct 13 2

4. FINDINGS 4.1 FINANCIAL CONTEXT The review identified a financial challenge facing the two acute Trusts in Bristol in excess of 230 million over the next five years. The challenge expressed at a whole health economy level (not just the acute sector) is in the order of 290 million. This is on top of significant reductions in local authority funding which in turn has the potential to adversely affect the care of vulnerable people. A significant proportion of these savings are for local health organisations to deliver by focusing on internal cash releasing schemes. The evidence from the Review, however, suggests that the overall scale of change required can only be delivered through ambitious, health economy-wide solutions, especially those aimed at the integration of health and social care. 4.2 SERVICE REVIEW The eleven specialties for detailed analysis were short-listed through formal prioritisation by the Medical Directors and Chief Nurses of both Trusts, taking account of appropriate benchmarking information and other intelligence. The Review identified a number of opportunities within the eleven specialties that may merit further exploration. It should be noted that the estimated total savings derived from these opportunities does not exceed 2 million. Nevertheless, these options may deliver patient benefit, outcome gain, reduction in the need for increased investment to secure compliance with national standards or general improvements which increase the professional standing and national profile of the Bristol health system. It is important to note, however, that the review has not produced a definitive set of recommendations for the Trusts and health community to take forward. Rather, it has identified multiple opportunities for further examination by relevant players in the health and social care system. 4.3 URGENT AND EMERGENCY CARE SYSTEM It is clear that significant efforts are being made by all organisations involved in the commissioning and provision of urgent and emergency care and these efforts should be recognised in the approach to further work. The health system has a wide range of schemes, in various stages of development and implementation aimed at improving the quality and efficiency of urgent care. The Review suggests that successful delivery of these schemes is hampered by a lack of coordinated approach across the system and multiple forums for planning and delivery and unclear accountabilities. Current urgent and emergency care pathways are too complicated, involve multiple entry points, are difficult for patients to navigate and reliant on multiple agencies with unclear responsibilities for management. Brief on the Acute Services Review Dated 04 Oct 13 3

Key areas for focus, largely derived from the views of system players inside Bristol, North Somerset and South Gloucestershire, include: Discharge planning and implementation Increasing management of patients in or closer to their homes Co-location of community urgent care services The emergency care ambulatory care pathway Geriatrician input early in the pathway and outside of the hospital setting Seven day working across the health and social care system Early identification of complex patients with input from social care partners System wide bed management Undertaking the continuing healthcare process outside the acute hospital setting. 4.4 FURTHER OPTIONS FOR ADDRESSING THE FINANCIAL GAP The Review identified a number of options for internal consideration by the two Trust Boards, including the rationalisation or outsourcing of corporate functions. On a wider scale, it demonstrated the potential contribution of integrated care, notably in relation to the frail elderly pathway, in reducing system costs and realising patient benefit. International evidence (such as from the Valencia region in Spain) of a fully integrated and embedded model with outcome based commissioning indicated that an overall health economy saving of 30% was possible. Applying this percentage to the Bristol health economy spend on the frail and elderly of 200m suggests a potential saving of 60m. Integrating across other care pathways could achieve further financial benefits. The Review acknowledged the medium term nature of likely developments to integrate existing care provision and highlighted potential interim benefits in securing out of hospital care for those patients for whom the skills and resources of an acute hospital are no longer needed - not only in delivering more cost effective care but in ensuring patients are cared for in environments more suited to their needs as early on in their recovery as possible. In preparation for the coming winter, both acute trusts are currently in discussion with health and social care commissioners about the development of additional out of hospital capacity through the deployment of reablement funds, such as those accrued through readmission penalties and emergency marginal tariffs. 5. NEXT STEPS Among all participants, there is a growing appetite for positive changes which will support more integrated care. Discussions since July about next steps have produced a broad categorisation of the different options presented in the reports into the following: Brief on the Acute Services Review Dated 04 Oct 13 4

1. Options that require joint working by health and social partners across the health economy The Clinical Commissioning Groups in Bristol, North Somerset and South Gloucestershire have confirmed the intention to take forward planning for improvements to the urgent and emergency care system on a locality basis under the auspices of the newly-created Urgent Care Fora. The Healthy Futures Programme Board has agreed to take a system-wide overview of the programme, recognising the importance of ensuring effective communication and coordination between these fora. 2. Options that can be taken forward by each Trust independently These are for each Trust to appraise, using established internal planning and prioritisation processes. 3. Options that involve cooperation between the two Trusts There is a limited number of options in this category, involving potential adjustments to existing service models or care pathways. Priorities for further work will be set jointly by the Trusts Partnership Programme Board, according to key criteria likely to include avoidance of investment necessary to address a lack of service resilience and impact on the quality of care, meeting commissioner compliance standards, especially for specialised services designation, and addressing structural inefficiencies in existing pathways, where these exist. Already in progress between the Trusts are a number of collaborative ventures, including the centralisation of specialised paediatric services at the Bristol Royal Hospital for Children, and a review of vascular services. These follow the recent centralisation of breast, urology and head and neck, ear, nose and throat and oral maxillofacial services between the two organisations. The Trusts have instigated a review of lessons learned and a benefits evaluation from these recent service transfers to inform future service developments. While the two Trusts remain committed to working in partnership to make improvements to patient care, changes in executive leadership at North Bristol Trust, the requirement to progress existing collaborative schemes and the significant short and mid-term operational pressures facing both organisations mean that the Trusts have yet to agree priorities for further joint working and the programme approach to be adopted, including mechanisms for further patient and public involvement. Brief on the Acute Services Review Dated 04 Oct 13 5

6. CONCLUSION The Bristol Acute Services Review concluded in July having identified a very challenging financial outlook for the acute sector in Bristol and the wider health and social care system. The Review fell short of identifying a means of closing this financial gap across the two acute Trusts. However, it clearly demonstrated that the greatest gains, in potential to improve patient care and reduce overall system costs, will come through integration of services between the health and social care sectors, alongside the simplification of the existing urgent and emergency care pathways in Bristol, North Somerset and South Gloucestershire. Pursuit of this agenda will require consensus across the Bristol health and social care economy, especially clinical ownership and leadership across the whole health system, commitment to major service change by individual organisations and appropriate co-ordination and programme governance by a strategic partnership of health and social care commissioners, public health and providers. Andrea Young Chief Executive North Bristol NHS Trust Robert Woolley Chief Executive University Hospitals Bristol NHS Foundation Trust 4 October 2013 Brief on the Acute Services Review Dated 04 Oct 13 6

1 Purpose The purpose of this covering note is; to introduce reports relating to proposals for health and social care services at Frenchay presented by South Gloucestershire Clinical Commissioning Group, and to highlight additional information relating to the impact on service users in Bristol. 2 Background Bristol CCG s plans for rehabilitation and reablement have been previously considered separately by this Commission and by the Health and Wellbeing Board. Both of the reports relating to Frenchay were received by the Public Health and Health Scrutiny Committee for South Gloucestershire on 19th September 2013 and were also described in outline to this Commission in a verbal update on the 17th September. The first report deals with changes to the 2010 proposals for health and social care services at Frenchay previously considered by Bristol Health Scrutiny Commission. This report is presented for consideration by the Commission of the potential impact of the proposed changes for service users in Bristol. The second report relates to interim arrangements for inpatient rehabilitation beds. Implementation of these interim arrangements has already commenced in order to ensure continuity of service for patients in May 2014. The report on the interim arrangements is therefore presented for information and comment by the Commission. 3 Additional information relating to the impact on service users in Bristol 3.1 Outpatient and diagnostic services In relation to the proposal to focus outpatient and diagnostic services at Cossham and Yate, and therefore to not replicate these services at Frenchay; an assessment of travel times by public and private transport has been undertaken for the whole Bristol population and also for the Bristol population identified in the notional catchment for Frenchay in the 2010 proposals (see attached tables and map). It can be seen that for the total Bristol population, access to one of the outpatient and diagnostic facilities is possible within 30 minutes for 100% by car and for 92% by public transport. Furthermore, access is possible within 30 minutes both by car and by public transport for 100% of the Bristol population in

the notional catchment areas for Frenchay. In either case, access is unaffected by the addition of Frenchay as a location for these services. 3.2 Interim arrangements for inpatient rehabilitation beds 4 Conclusions In relation to the interim arrangements for inpatient beds, in the 2010 proposals it was assumed that around 20% of the capacity could be utilised by patients from Bristol. Based on this figure the Bristol activity to be accommodated in the interim beds would be limited to approximately 5 patients a week. The proposals to focus outpatient and diagnostic services at Cossham instead of Frenchay will provide good local access and choice to patients in Bristol. Any replication of these services at Frenchay will exacerbate the underutilisation of capacity without improving access for Bristol patients. The interim arrangements for inpatient beds will impact on a relatively small number of people from the proportion of the Bristol population in the notional catchment area for Frenchay. Ben Bennett, Programme Director October 2013

Yate Yate West West Gate Gate Centre Centre Emersons Emersons Green Green NHS NHS Treatment Treatment Centre Centre Southmead Southmead Hospital Hospital Frenchay Frenchay Hospital Hospital Bristol CCG CCG Bristol Cossham Cossham Hospital Hospital North North Somerset Somerset CCG CCG Bristol Bristol Royal Royal Infirmary Infirmary South South Gloucestershire Gloucestershire CCG CCG South South Bristol Bristol Community Community Hospital Hospital BANES CCG CCG BANES Bristol Strategy for Local Services South West Commissioning Support Boundaries used to calculate populations Brendan Stone - 04 October 2013 Crown copyright and database rights 2013 Ordnance Survey 100050537. Contains Royal Mail data Royal Mail copyright and database right 2013. X:\CCG\Bristol\Strategy for Local Services\ Bristol_Pop_Boundary_v2.wor

Information Details: Title Bristol population with access to health sites Broken Down By Health site and Drive Times/Public Transport Times Data Period 2011 Definition Calculation of number and percentage of Bristol population with access to health sites within 0 to 90 minutes drive time and public transport travel time. Interpretation The population information uses Office for National Statistics (ONS) mid-year population estimates for 2011. The populations are provided within Census Lower Super Output Areas (LSOA), which are geographic areas of approximately equal population size around 1,600. The calculations are based on the geographical centre of each LSOA which fall within the travel time zones. There are 263 LSOAs in Bristol Data Source/s Ordnance Survey ITN road network (Mar 2013) Public Transport timetables - July 2013 Office for National Statistics - 2011 mid-year popualtion estimates (2011 LSOA polygons) Technical details RouteFinder Settings - Route Options: Fastest; Mode 1; Oneway=Y; Exact with offroad (10mph) Contact Details: Name Brendan Stone Position Senior GIS Analyst Telephone 0117 984 1521 Email brendan.stone@swcsu.nsh.uk Address South West Commissioning Support, South Plaza, Marloborough Street, Bristol, BS1 3NX File Details: Date Created 9/19/13 File Path\ File Name X:\CCG\South Glos\Strategy for Local Services\

Total Bristol CCG Population: 428,074 (ONS 2011 mid-year population estimates) Travel Time Hospital BRI Southmead Cossham SBCH Private Vehicle Yate West Emersons Frenchay Nearest of all 7 Sites Nearest of all sites, excluding Frenchay Number % Number % Number % Number % Number % Number % Number % Number % Number % 0-5 mins 34,113 8.0% 36,782 8.6% 36,122 8.4% 16,703 3.9% 0 0.0% 0 0.0% 1,369 0.3% 125,089 29.2% 123,720 28.9% 5-10 mins 113,265 26.5% 85,027 19.9% 48,149 11.2% 60,911 14.2% 0 0.0% 0 0.0% 32,642 7.6% 218,204 51.0% 216,389 50.5% 10-15 mins 161,393 37.7% 99,195 23.2% 74,704 17.5% 53,754 12.6% 0 0.0% 25,071 5.9% 117,056 27.3% 75,343 17.6% 78,527 18.3% 15-20 mins 98,618 23.0% 71,855 16.8% 140,705 32.9% 26,391 6.2% 0 0.0% 50,708 11.8% 106,290 24.8% 6,223 1.5% 6,223 1.5% 20-25 mins 20,685 4.8% 70,007 16.4% 89,455 20.9% 126,083 29.5% 14,305 3.3% 96,979 22.7% 79,739 18.6% 3,215 0.8% 3,215 0.8% 25-30 mins 0 0.0% 40,212 9.4% 34,117 8.0% 93,316 21.8% 37,744 8.8% 118,590 27.7% 65,346 15.3% 0 0.0% 0 0.0% 30-45 mins 0 0.0% 24,996 5.8% 4,822 1.1% 50,916 11.9% 298,933 69.8% 136,726 31.9% 25,632 6.0% 0 0.0% 0 0.0% 45-60 mins 0 0.0% 0 0.0% 0 0.0% 0 0.0% 77,092 18.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 60-90 mins 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% >90 mins 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Total <30min 100.0% 94.2% 98.9% 88.1% 12.2% 68.1% 94.0% 100.0% Total <30min Travel Time Hospital BRI Southmead Cossham SBCH Public Transport Yate West Emersons Frenchay Nearest of all 7 Sites Nearest of all sites, excluding Frenchay Number % Number % Number % Number % Number % Number % Number % Number % Number % 0-5 mins 1,888 0.4% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 1,888 0.4% 1,888 0.4% 5-10 mins 6,106 1.4% 4,483 1.0% 5,621 1.3% 3,986 0.9% 0 0.0% 0 0.0% 1,369 0.3% 21,565 5.0% 20,196 4.7% 10-15 mins 26,363 6.2% 16,897 3.9% 9,568 2.2% 15,417 3.6% 0 0.0% 0 0.0% 5,233 1.2% 73,478 17.2% 68,245 15.9% 15-20 mins 61,329 14.3% 37,694 8.8% 13,342 3.1% 25,651 6.0% 0 0.0% 0 0.0% 10,397 2.4% 136,922 32.0% 135,981 31.8% 20-25 mins 84,405 19.7% 47,718 11.1% 25,245 5.9% 23,545 5.5% 0 0.0% 0 0.0% 16,485 3.9% 101,408 23.7% 102,954 24.1% 25-30 mins 86,347 20.2% 70,259 16.4% 28,108 6.6% 26,655 6.2% 0 0.0% 11,725 2.7% 38,210 8.9% 61,332 14.3% 67,329 15.7% 30-45 mins 139,576 32.6% 111,939 26.1% 122,960 28.7% 82,353 19.2% 30,746 7.2% 75,453 17.6% 160,391 37.5% 26,795 6.3% 26,795 6.3% 45-60 mins 17,374 4.1% 103,363 24.1% 152,605 35.6% 142,956 33.4% 146,663 34.3% 148,449 34.7% 143,684 33.6% 1,632 0.4% 1,632 0.4% 60-90 mins 3,215 0.8% 34,250 8.0% 65,939 15.4% 102,825 24.0% 228,196 53.3% 187,761 43.9% 47,619 11.1% 1,583 0.4% 1,583 0.4% >90 mins 1,471 0.3% 1,471 0.3% 4,686 1.1% 4,686 1.1% 22,469 5.2% 4,686 1.1% 4,686 1.1% 1,471 0.3% 1,471 0.3% Total <30min 62.2% 41.4% 19.1% 22.3% 0.0% 2.7% 16.7% 92.6% 92.6%

Frenchay locality population within Bristol: 17,139 (ONS 2011 mid-year population estimates) Travel Time Hospital BRI Southmead Cossham SBCH Private Vehicle Yate West Emersons Frenchay Nearest of all 7 Sites Nearest of all sites, excluding Frenchay Number % Number % Number % Number % Number % Number % Number % Number % Number % 0-5 mins 0 0.0% 0 0.0% 4,560 26.6% 0 0.0% 0 0.0% 0 0.0% 1,369 8.0% 5,929 34.6% 4,560 26.6% 5-10 mins 695 4.1% 791 4.6% 9,856 57.5% 0 0.0% 0 0.0% 0 0.0% 13,905 81.1% 10,551 61.6% 9,952 58.1% 10-15 mins 4,801 28.0% 6,074 35.4% 2,723 15.9% 0 0.0% 0 0.0% 9,402 54.9% 1,865 10.9% 659 3.8% 2,627 15.3% 15-20 mins 11,643 67.9% 10,274 59.9% 0 0.0% 0 0.0% 0 0.0% 6,540 38.2% 0 0.0% 0 0.0% 0 0.0% 20-25 mins 0 0.0% 0 0.0% 0 0.0% 2,078 12.1% 7,758 45.3% 1,197 7.0% 0 0.0% 0 0.0% 0 0.0% 25-30 mins 0 0.0% 0 0.0% 0 0.0% 13,692 79.9% 7,489 43.7% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 30-45 mins 0 0.0% 0 0.0% 0 0.0% 1,369 8.0% 1,892 11.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 45-60 mins 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 60-90 mins 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% >90 mins 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Total <30mins 100.0% 100.0% 100.0% 92.0% 89.0% 100.0% 100.0% 100.0% 100.0% Travel Time Hospital BRI Southmead Cossham SBCH Public Transport Yate West Emersons Frenchay Nearest of all 7 Sites Nearest of all sites, excluding Frenchay Number % Number % Number % Number % Number % Number % Number % Number % Number % 0-5 mins 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0.0% 0 0.0% 0 0.0% 0 0.0% 5-10 mins 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0.0% 1,369 8.0% 1,369 8.0% 0 0.0% 10-15 mins 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0.0% 3,829 22.3% 3,829 22.3% 0 0.0% 15-20 mins 968 5.6% 0 0.0% 3,231 18.9% 0 0.0% 0 0.0% 0.0% 6,591 38.5% 7,155 41.7% 4,199 24.5% 20-25 mins 12,516 73.0% 1,663 9.7% 6,480 37.8% 0 0.0% 0 0.0% 0.0% 5,350 31.2% 4,786 27.9% 6,207 36.2% 25-30 mins 3,655 21.3% 1,561 9.1% 6,195 36.1% 0 0.0% 0 0.0% 6,277 36.6% 0 0.0% 0 0.0% 6,733 39.3% 30-45 mins 0 0.0% 13,915 81.2% 1,233 7.2% 0 0.0% 7,921 46.2% 10,324 60.2% 0 0.0% 0 0.0% 0 0.0% 45-60 mins 0 0.0% 0 0.0% 0 0.0% 8,777 51.2% 9,218 53.8% 538 3.1% 0 0.0% 0 0.0% 0 0.0% 60-90 mins 0 0.0% 0 0.0% 0 0.0% 8,362 48.8% 0 0.0% 0.0% 0 0.0% 0 0.0% 0 0.0% >90 mins 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% Total<30 mins 100.0% 18.8% 92.8% 0.0% 0.0% 36.6% 100.0% 100.0% 100.0%

PROPOSED INTERIM ARRANGEMENTS FOR INPATIENT REHABILITATION BEDS Prepared by: Ben Bennett on behalf of South Gloucestershire Clinical Commissioning Group Date: September 2013 1 Decision requested The Committee is requested to: 1.1 Note the report describing the assessment of options for the interim provision of inpatient rehabilitation beds for the South Gloucestershire population 1.2 Note that decision of the Governing Body in August 2013 to confirm Elgar House at Southmead Hospital as the preferred solution and the requirement to mobilise these arrangements without further delay in order to ensure continuity of services following the planned closure of Frenchay Hospital in May 2014 2 Summary The previous emerging themes proposals for health and social care services to be provided at Frenchay were published by South Gloucestershire PCT in 2010 and included a new community health services facility on the Frenchay site providing up to 68 inpatient beds for people needing rehabilitation from May 2014. Following a review of rehabilitation services informed by patient and public involvement and consideration of future health needs, the Governing Body of the CCG s formally agreed proposals for the development of health and social care services at Frenchay including the development of up to 68 inpatient rehabilitation beds to be provided on a flexible basis. The CCG also agreed a commitment to work in partnership with South Gloucestershire Council to achieve an integrated approach to commissioning and delivery of health and social care services and facilitate the development of extra care housing capacity at Frenchay. The proposals for rehabilitation services are considered in further detail in the separate paper about proposed changes to the 2010 proposals. Subject to the development of further details and a project plan, it is anticipated that the earliest date for the availability of the new services at Frenchay wil be April 2016 whereas the existing acute hospital at Frenchay is scheduled to close in May 2014. The CCG has therefore commissioned North Bristol NHS Trust to operate a temporary solution providing up to 68 inpatient beds while the further work on new services to be provided at Frenchay is completed. South Gloucestershire CCG Leading you to Better Health Clinical Chair: Dr Jon Hayes Chief Officer: Jane Gibbs

Having considered the available options for interim beds based on temporarily retaining existing ward blocks at either Frenchay or Southmead respectively as presented by North Bristol NHS Trust the CCG has accepted the recommendation of Elgar House at Southmead Hospital site as the preferred option. 3 Background to selection of preferred option The options appraisal undertaken by North Bristol NHS Trust is included at Annex 1 together with the detailed financial analysis undertaken by the Trust. It can be seen that whilst both options have been assessed as being broadly similar in terms of operational delivery, the recurring costs associated with the Frenchay option are significantly higher than for the alternative option at Southmead, a difference estimated at 2,400,000 per annum in total. This difference arises because the building at Frenchay is significantly larger than the Southmead option and therefore attracts a larger capital charge and higher overheads associated with unused space. Given the significant difference in running costs it is therefore not surprising that North Bristol NHS Trust has concluded that Southmead is the preferred option. Whilst it would clearly be preferable both from a service user and from a commissioner perspective for the interim beds to be located at Frenchay, it would be very difficult to justify the significant additional costs to the health system arising from this option. It should be noted that local people and members of the South Gloucestershire PHHSC have already expressed concerns about transport and travel for people accessing the rehabilitation services while temporarily located at Southmead. The CCG will give therefore further consideration to the specific impact and possible mitigation, particularly in relation to carers. There is also an underlying concern from some stakeholders that the beds might remain at Southmead permanently if plans for locating health and social care services at Frenchay fail to be realised. Subject to establishing a project plan the CCG expects to be in a position to demonstrate progress in securing the revised plans for health and social care services at Frenchay before services are relocated from Frenchay in May 2014. 4 What is proposed for the interim arrangements for inpatient rehabilitation beds? As detailed in the separate paper about the changes to the 2010 proposals, the proposals for future rehabilitation services including up to 68 inpatient beds for rehabilitation to be located on the Frenchay site, are based on the findings from the recent rehabilitation review and a detailed snapshot audit of patients. Subject to the development of a detailed specification for a future community rehabilitation service for South Gloucestershire, it is envisaged that a procurement exercise would be undertaken to secure one or more providers for this service and that this would include the delivery of associated building infrastructure for the inpatient rehabilitation beds. The earliest that new inpatient services are expected to be available at Frenchay is 2016, therefore in order to ensure continuity of service following the closure Frenchay South Gloucestershire Public Health and Health Scrutiny Committee 3 July 2013 Page 2 of 7

Hospital in May 2014 it is proposed to retain an existing ward block at Southmead Hospital in order to operate 68 beds for inpatient rehabilitation. The proposed interim arrangement at Southmead will provide up to 68 beds for inpatient rehabilitation of adults of all ages identified as requiring inpatient rehabilitation following acute medical or surgical admission to hospital and therefore broadly matches the plans originally described in the 2010 proposals. In addition to providing service continuity from May 2014 the interim arrangements will also be used to refine the model of care and contract arrangements for rehabilitation services in order to facilitate the transition to the long term arrangements at Frenchay. 5 Why are these changes being proposed? The interim arrangements are necessary to ensure continuity of services from May 2014 when acute services are transferred from Frenchay Hospital. As set out in section 3 and Annex 1, the selection of Southmead rather than Frenchay as the preferred site for the interim arrangement reflects the fact that whilst both options have been assessed as being broadly similar in terms of delivering patient care, the recurring running costs associated with the Frenchay option are significantly higher than for the alternative option at Southmead, a difference estimated at 2,400,000 per annum in total. 6 Feedback from public patient and stakeholder involvement The decision of the CCG to confirm Elgar House at Southmead as the location for the interim provision of inpatient rehabilitation beds for South Gloucestershire the CCG has been informed by engagement with local people, patients and stakeholders Active engagement by the CCG with public, patient and stakeholders about the review of proposals for health and social care services at Frenchay has been on-going since October 2012. During this period formal reports have presented to the South Gloucestershire PHHSC in January, April and July and these have included updates on the involvement activities. In particular through the report to the PHHSC in April 2013 the Committee were advised of the requirement for interim arrangements and accepted a recommendation to present these along with long term proposals for services a stakeholder summit event in June 2013 Further to this the stakeholder summit was held on the 25 th June and was jointly hosted by the CCG together with commissioner colleagues from South Gloucestershire Council and provider colleagues from North Bristol NHS Trust. A wide range of stakeholders attended the summit including local people, representatives of patient groups and local councillors. The summit provided local people, patients and other stakeholders with an opportunity to hear in more detail, and to ask questions and provide feedback about the options for providing inpatient services in the interim and also about the proposals for rehabilitation services including the proposed inpatient beds at Frenchay in the future and the proposal to focus outpatient and diagnostic services at Cossham and Yate. South Gloucestershire Public Health and Health Scrutiny Committee 3 July 2013 Page 3 of 7

A report from the summit was sent to all those who attended and presented to the PHHSC in July 2013 and is included at Annex 2 to this paper for reference. Following this, a further period of communication and involvement was undertaken on the plans for Frenchay and the interim arrangements. The purpose of this was to communicate the proposals as widely as possible and to provide further opportunities for people to ask questions and comment. A summary of the proposals with reference to the options for interim arrangements were set out in a Have your say leaflet a copy of which is attached at Annex 3. The leaflet was distributed to GP surgeries across South Gloucestershire. Copies were also sent to a wide range of stakeholders including Health Watch, local community groups, council and parish councillors and local MPs together with an offer to provide further information and to meet in person to discuss any questions or issues that arise. A copy of the distribution list is included at Annex 3. During this period in response to a request from stakeholders a follow up meeting was held on the 20 August at which further detail was provided about the interim options for providing inpatient rehabilitation beds. The notes from this event are included at Annex 4. Representations relating to the interim arrangements for inpatient rehabilitation beds were also made directly to the August 2013 meeting of the CCG Governing Body at which recommendations relating to the preferred option where considered. As outlined above the requirement for interim arrangements for inpatient beds was confirmed publicly in April 2013. Further to this feedback has been received from a wide range of stakeholders through the 25 th June stakeholder event, the follow up meeting on the 20 th August and through feedback received to the further communication and involvement. In addition to this specific representations were made regarding the interim arrangements through public submissions to the August meeting of the Governing Body. The main themes of the feedback received are summarised in the table below along with the CCG response in each case. The stakeholder feedback about the interim arrangements was presented to the August meeting of the CCG Governing Body to inform the selection of Elgar House at Southmead Hosptial as the location for the interim beds for inpatient rehabilitation. Main themes emerging from public, patient and stakeholder involvement Involvement theme Concern, particularly from older people, about the accessibility of Southmead as an interim solution for rehabilitation Concern that the rehabilitation beds remain at Southmead permanently and CCG response The CCG will work with North Bristol Trust to further consider any specific mitigation for travel and access issues arising from the interim arrangements. North Bristol Trust are working with the both local Councils to agree how extra investment in public transport and in road improvements will be implemented in order to improve access to Southmead Hospital for South Gloucestershire residents. The CCG has made a public commitment to develop long term plans for community rehabilitation services in South Gloucestershire including inpatient beds at South Gloucestershire Public Health and Health Scrutiny Committee 3 July 2013 Page 4 of 7

the proposals for Frenchay will not materialise a Frenchay. 7 Opportunities for further stakeholder involvement The CCG has made a public commitment to on-going stakeholder involvement and further to this the approach to future involvement will be discussed with public, patient and stakeholders and with the health scrutiny committee, and this will inform the development of a project plan to progress the proposals for future services. As part of this, subject to the outcome of discussions with the health scrutiny committees, the CCG will write to everyone who has been engaged with to date and other stakeholders that have expressed an interest explaining the outcome of the engagement to date and the next steps for the project, including future opportunities to get involved. There will be opportunities for public and patient involvement in the planning and implementation of the interim arrangements for inpatient rehabilitation beds at Southmead and in the development of the long term proposals for services to be provided at Frenchay in the future. As part of this the CCG will work with stakeholders to ensure that we fully understand the impact of the interim arrangements on service users and particularly on carers. Further to this regular updates will be provided to the PHHSC. 8 Equality Impact Assessment An Equality Impact Assessment has been undertaken and is documented at Annex 5. In summary it can be seen that when considering each of the each of the characteristics protected against discrimination by the Equality Act 2010, the standard or care which can be provided in either the Frenchay or the Southmead option has been assessed as broadly equivalent. Notwithstanding this access to Southmead may entail travel for carers and relatives which may impact disproportionately on older people, people with disabilities and people from different ethnic groups. Further assessment is required to understand the specific implications for travel and access to Southmead during the interim period and the potential for mitigation. 9 Timescales for the Proposed Change The proposed interim arrangements for inpatient beds wil involve retention and reoccupation of Elgar House, an existing ward block at Southmead which will be vacated when acute services transfer to the new Brunel building at Southmead on May 2014. A programme of capital works will be undertaken by North Bristol NHS Trust much of which is focused on infrastructure changes (e.g. electricity, water and sewage) to enable Elgar House to function independently from the rest of the vacated buildings on South Gloucestershire Public Health and Health Scrutiny Committee 3 July 2013 Page 5 of 7

the Southmead site. Some internal improvements and adaptations will also be undertaken. Subject to the main elements of these capital works being completed, the interim impatient beds are expected to be available from May 2014 as required to ensure service continuity. 10 Conclusions The revised proposals for rehabilitation services described in the separate paper on changes to the 2010 proposals, maintain a commitment to commission inpatient beds for rehabilitation at Frenchay site as part of health and social care services to be developed on the site including extra care housing. Furthermore, the model of care for rehabilitation has been informed by senior clinicians, local people, patients and carers. The revised proposals are entirely consistent with the original objectives of providing locally accessible services to people in South Gloucestershire from a network of community facilities, including inpatient beds for rehabilitation. In time the plans for rehabilitation will improve the quality and effectiveness of these services, with more care available outside of hospital in line with best practice and patient preference. Notwithstanding the issues raised by the location of the interim rehabilitation beds, the implementation of the proposed arrangements at Elgar House will mean that for the first time inpatient rehabilitation beds for South Gloucestershire will be available as an identifiable and separately commissioned service. The move to the interim arrangements therefore represents an important opportunity to begin the transition to a dynamic community facing model for rehabilitation that will facilitate progressive investment in community services and reduce reliance on hospital beds. 11 Next Steps The proposed interim arrangement for providing inpatient rehabilitation described in this report were formally agreed by the Governing Body for South Gloucestershire CCG on 21 August. Copies of the minutes from this meeting are included at Annex 8. As has been highlighted, it is essential that these plans are now implemented without further delay in order to ensure continuity of service from May 2014. Notwithstanding this the CCG will involve local people, patients and other stakeholders in the planning and implementation of the interim arrangements for inpatient rehabilitation beds at Southmead and in the development of the long term proposals for services to be provided at Frenchay in the future. As part of this the CCG will work with stakeholders to ensure that we fully understand the impact of the interim arrangements on service users and particularly on carers. South Gloucestershire Public Health and Health Scrutiny Committee 3 July 2013 Page 6 of 7

12 Annexes 1 North Bristol NHS Trust option appraisal 2 Report from 25 th June Frenchay stakeholder summit 3 Have your say leaflet and distribution list 4 Notes from 20 August stakeholder meeting to discuss interim options 5 Equalities impact assessment South Gloucestershire Public Health and Health Scrutiny Committee 3 July 2013 Page 7 of 7

Frenchay HSCC NBT Service Continuity Options Situation The procurement process for identifying the optimal commercial partner to build and partly operate the Community Hospital on the Frenchay Health Campus (Health and Social Care Centre) has been on pause since March 2012. Through the Healthy Futures Programme BNSSG Commissioners are conducting a review of Rehabilitation/Reablement Services and also the existing infrastructure within the BNSSG area (henceforth referred to as the Review ). Commissioners informed the South Gloucestershire Health Scrutiny Committee in April 2013 that: The CCG is committed to development of community beds on the Frenchay site as part of a Health and Social Care Centre which includes independent sector nursing home capacity and opportunities for development of extra care housing together with a number of related services that will be retained on the Frenchay site following the transfer of acute services. The delivery model for the community beds must be affordable without the need for significant additional investment and capable of being scalable to support progressive investment in community services, reducing reliance on beds over time. This is in line with best practice and patient preferences for care at home and is also broadly consistent with the draft Joint Health and Wellbeing Strategy for South Gloucestershire. The delivery models considered to date required significant additional investment and a fixed long term commitment. The CCG will now lead the further development of the delivery model and associated procurement for these community beds as part of a Health and Social Care Centre. South Gloucestershire Commissioners have written to NBT confirming their expectation that NBT provides a service continuity solution for those patients and services that were expected to be delivered from within the proposed Frenchay Community Hospital. Given the likely procurement timescales and associated build programme, it is reasonable to assume that the service continuity solution would be for a period of around 2-3 years, allowing time for the delivery of a fully operational facility providing inpatient capacity at Frenchay within a HSCC. This paper summarises for Commissioners the work that NBT have completed in response to this request, and makes a clear recommendation. Timely approval is necessary in order that the preferred solution can be delivered, enabling NBT to continue to provide the best care for these patients from May 2014 onwards. Background The Bristol Health Services Plan (BHSP) articulates the requirement for a Community Hospital on the Frenchay hospital site. Although the clinical specifications/criteria are not agreed at this point, the Community Hospital was anticipated to provide inpatient care for patients requiring rehabilitation/reablement (c.68 beds), along with 10 consult/exam rooms and 2 procedure rooms from which to deliver a range of outpatient services including Pain Management (with supporting diagnostics and a variety of therapies services). This document could be made public under the Freedom of Information Act 2000. Any person identifiable, corporate sensitive information will be exempt and must be discussed under a 'closed section' of any meeting. 1

The full list of services confirmed within the original Frenchay Community Hospital Schedule of Accommodation includes: Inpatients Outpatients Diagnostics Reablement Other Rehabilitation Services 68 beds with a focus on rehabilitation o o Pain Management Service (c.5 rooms) Other Specialties (c.5 rooms) o o X-Ray Ultrasound o o o o o Physiotherapy Speech/Language Therapy Dietetics/Nutrition Occupational Therapy Communications Aid Centre o o o Head Injury Treatment Unit (HITU) Headway SLT Research The New Hospital Operating Plan was developed by the Building Our Future Transformation Programme in 2012/13, and this has re-designed the way that Outpatient services will be delivered from 2014 onwards. Continuing work by NBT via the Outpatient Theme on operationalising these plans has shown that by implementing these new ways of working (i.e. longer opening hours, reduced DNA rates etc.) alongside greater utilisation of Yate/Cossham the 10 outpatient rooms originally planned for Frenchay may no longer be required. Commissioners have supported the concept of focussing outpatient services for the population of South Gloucestershire in both Yate and Cossham, as well as in the new hospital at Southmead. Assessment This assessment considers two options, namely: Option 1 Service Continuity delivered at the Southmead site Option 2 Service Continuity delivered at the Frenchay site A series of Option Appraisals took place which considered all of the available information required for those present to make an informed judgement on both options. The key stakeholders were all senior members of the NBT teams who would be responsible for delivering and managing this interim solution. This information is listed below for both options. In conducting this assessment it is important to note the following interdependencies, assumptions and constraints: 1. Due to the requirement to provide absolute service continuity it is understood that there is no window in which to do any non-essential property works for either option. It is assumed that stand-alone works are completed prior to May 2014 2. Whilst NBT strives to provide the very best environments for its patients, carers and staff, capital availability is significantly limited in financial years 2013/14 and 2014/15 3. HITU and Headway services would remain at Frenchay 4. It is assumed that all equipment in the existing buildings is retained, maintained and used for the service continuity solution This document could be made public under the Freedom of Information Act 2000. Any person identifiable, corporate sensitive information will be exempt and must be discussed under a 'closed section' of any meeting. 2

Option 1 Service Continuity delivered at the Southmead site This option would see the existing wards within Elgar House retained for use as an inpatient rehabilitation facility. As three of the existing four wards within this building currently accommodate patients requiring sub-acute rehabilitation (Care of the Elderly and Stroke) this provides ideal service continuity. It should be noted that only a proportion of the Elgar House building would be needed for an interim solution. Clinical quality/safety and patient experience o Provides an opportunity for the pathway changes to be tested and 'bed-in' whilst managing the risk on the site. o Inpatients would have to transfer into the main hospital if there was ever a need for unplanned diagnostics Logistics and continuity of essential services o Hard FM Services: Elgar House is currently connected to the existing main hospital, and there would be considerable mechanical and engineering work required to make this a stand-alone building (e.g. supply of medical gases, water, ventilation, electrics, drainage, fire escapes etc.) o Soft FM Services : Due to the Trust moving to a cook-chill approach to inpatient meals on the Southmead site, Elgar House would also need to be fitted-out with food regeneration facilities. o IT Services: Network switches and wireless capability may need to be put into the buildings. The exact need for these would need further refinement at detailed design stage. o Internal Modifications: A do minimum brief ensures minimal alterations are made, however there would be modifications required to create a fully operational Rehab Unit i.e. re-provision of the gym area. o Parking/Access: This option would reduce the parking at the Southmead site by c.100 on the total available in 2014 Increasing concentration of activity to site likely to increase journey-times to Southmead Potential to benefit from increased/improved public transport to/from the site Continued construction works for SMD Phase 2 Financial implications o Estimated one-off capital costs required to make these buildings stand-alone, and to make essential internal modifications to ensure that all core services are provided are 1.3m. This breaks down as: This document could be made public under the Freedom of Information Act 2000. Any person identifiable, corporate sensitive information will be exempt and must be discussed under a 'closed section' of any meeting. 3