Agenda item

Purpose of the Report -
 

To report to the Bath and North East Somerset (B&NES) Wellbeing Policy Development and Scrutiny Panel:

·  the proposed re-provision of specialised neuro-rehabilitation services ( inpatient and outpatient)  provided at the Royal National Hospital for Rheumatic Diseases (RNHRD’s) from April 1st 2013; 

·  that additional capacity for the provision of level 1/2A neuro-rehabilitation has been identified and agreed in principle with two alternative providers at Level 1 and a wider range of providers at Level 2A to ensure continuous provision from 1st April should scrutiny vote to support this interim re-provision proposal;

·  that a programme of stakeholder (patients, carers, public, RNHRD staff and providers) engagement  on the short- and long-term provision of neuro-rehabilitation in the South West has been carried out, with due regard given to two extensive reviews of local services recently carried out by Somerset and Devon Local Involvement Networks.

(This paper should be read in conjunction with the Bath & North East Somerset Primary Care Trust’s briefing on the re-provision of the non-specialised Outpatient Neuro-rehabilitation service – marked as part 2).

The B&NES Wellbeing Policy Development and Scrutiny Panel is asked to:

·  note that patients from the South West have and will continue to receive the best quality neuro-rehabilitation services that the NHS is able to provide;

·  note there have been no issues regarding quality or safety in the RNHRD’s decision to cease providing neuro-rehabilitation after the 31st March 2013;

·  note the continued high level of quality care and family experience that the recommendations are able to support;

·  note commissioners’ collaboration with key stakeholders, including patients and the public as well as potential providers, in developing the recommended re-provision option;

·  note that proposals should maintain the existing high quality of care without any adverse effect on current in-patients or future access to the service;

·  support the proposal for service re-provision in the proposed centres.

The Panel also requested from the Royal National Hospital for Rheumatic Diseases to provide their view on the part they played in the process for the future of the Neuro Rehabilitation Services (attached as ‘Update from the RNHRD’).

The Chairman invited Sue Davies (Acting Director, South of England Specialised Commissioning Group, South West Team), Tracey Cox (B&NES Clinical Commissioning Group Chief Operating Officer - Designate) and Kirsty Matthews (Chief Executive of the Royal National Hospital for Rheumatic Diseases) to address the Panel.

The Chairman informed the meeting that the Panel will first get presentations from Sue Davies and Tracey Cox and also a summary from Kirsty Matthews.  The Panel will ask the questions afterwards and make their recommendations.

Sue Davies gave a presentation where she highlighted the following points:

• Overview
  • Outline of the proposal for re-provision
  • Outline of the Patient and Public Engagement process undertaken by the Specialised Commissioning Team
  • Feedback from engagement process
• Specialised Neuro-rehab services
• Where do people come from? (chart)
• Proposals for re-provision – Level 1 & out-patients
• Proposals for re-provision – Level 2A & out-patients
• Arrangements for current patients
• Public engagement process
• Average travel times
• Feedback from PPE events
• Summary

A full copy of the presentation from Sue Davies is available on the Minute Book in Democratic Services.

Tracey Cox gave a presentation where she highlighted the following points:

• Out-Patient Neuro-rehabilitation Services
  • Spasticity clinic
  • Physiotherapy (including Functional Electrical Stimulation)
  • Psychology
  • Counselling
  • Splinting
• Current Patient Activity
• How will patients’ needs be met after April?
• What patients told us….
• Communications with patients
• Current team (picture)

A full copy of the presentation from Tracey Cox is available on the Minute Book in Democratic Services.

Kirsty Matthews explained the background for the decision to close the Neuro-rehab services at the RNHRD.  It was very difficult and sad decision for the RNHRD Board to decide to close this exemplary service but the decision was made purely for financial reasons.  The Board took into consideration that over the past three years there was a significant change in referral patterns, as explained in the report.  This change has led to a 50% reduction in income for this service over the last two years which had critical impact on the ability of the service to continue.  The service was making a loss of on average £430k per year.  This means that the service was not covering its direct cost or making a contribution towards the costs of the estate and infrastructure that supports it.  These immediate service losses contributed to the RNHRD’s overall financial challenge where the organisation was currently losing £10k a day.

Kirsty Matthews explained that, in taking its decision to close the service, the Board took account of all financial pressures and the necessity of responding to a financial position that has resulted in the organisation being found by Monitor to be in significant breach of one of its terms of authorisation.

The RNHRD undertook an engagement exercise during November and December 2012 and comments were received from clinician’s professional bodies, MPs and public.  An equalities impact assessment was also completed and taken into account.

Kirsty Matthews concluded that the RNHRD worked very hard that there is minimum disruption to their patients.  The RNHRD were very rigorous in their approach to their out-patients in terms of review of each out-patient on individual basis and take the decision on what their future care will be.  The RNHRD sent letters to all patients. 

The other important challenge was work with the staff affected by the change, in assisting individuals and seeking redeployment for as many people as possible.  To date the RNHRD found alternative employment for 22 out of the 64 employees placed at risk.

The Chairman thanked Sue Davies, Tracey Cox and Kirsty Matthews for their presentations and updates.

The Chairman informed the meeting that he had telephone conversation with James Scott (RUH Chief Executive) regarding the Neuro-rehabilitation service at the RNHRD and James Scott’s attendance at the Wellbeing Policy Development and Scrutiny Panel meeting on 22nd March 2013 and as a result of that conversation James Scott wrote the following to the Chairman:

‘It was helpful to talk to you recently about the Neuro-rehab services at the RNHRD.  The RUH’s Board’s view on this issue is the following:

Once the RUH is authorised as an NHS Foundation Trust and subject to the necessary legislative processes, it is the agreed intention that the RUH’s Board of Directors will formally assess a business case for the acquisition of the RNHRD.  An acquisition is expected to provide the organisational and financial security of a larger organisation and thus a firm foundation for the future of the services that are carried forward at that time.  However, until any such acquisition process is complete, the two Trusts must continue to function independently and as separate entities.  As part of normal business responsibilities, it is important that the RNHRD Board is able to and continues to make its own independent decisions to improve the financial health of the organisation, including the safe closure of services it deems to be non-viable e.g. Neuro-rehab.

I will leave it to your discretion on whether you believe it would be useful for me to attend the next Panel meeting.’

The Chairman informed the meeting that after he read this letter from James Scott he felt that there was no real need for Mr Scott to be at the meeting for this item.

Service Closure

The Chairman said that he finds this to be very uncomfortable position for the Panel considering that we have an exemplary service, there were two Patient and Public Engagement (PPE) days where previous and current patients have articulated particularly well their concerns over the closure of Neuro-rehab services at the RNHRD.  The Chairman also said that he finds it rather ironic that we have national reports about Mid Staffordshire, with criticism of that operation, and here we have exemplary service and we are seeking to close it.  It is an even more uncomfortable situation because this Panel has been denied the opportunity to do anything about the closure of this service.

Councillor Eleanor Jackson said that she was at the PPE day at the RNHRD and that she was deeply shocked with the level of pain, from spiritual and mental view, from the patients and their carers about the situation they found themselves in.  The clinical excellence of the unit is beyond the doubt remarkable though it will get closed.  Councillor Jackson also said that some of the statements made at the PPE day were not included in the report.  This matter should be before the Panel at January meeting as this is clearly material change of services.  It seems that only now patients and carers will get the letters on the future of the Neuro-rehab services. 

Councillor Jackson said that this is a material change of services and that the Secretary of State should be asked to investigate this case.  Councillor Jackson put this as formal motion.

Councillor Caroline Roberts seconded the motion from Councillor Jackson.

The Chairman said that the criticism he has on this matter is on the apparent acceleration of the process.  For two years it was known that the service had 50% reduction in income but suddenly there is a talk to close the service.  The Chairman said he, and other Panel Members, represent the public, and as community representative he cannot understand why such an exemplary service needs to be broken up.  The half of the 60+ staff will be looking for employment elsewhere, which is waste of the expertise.  The Chairman said that despite the best intentions from the Specialised Commissioning Team to find alternatives, you have to suppose there will be a fall of in standard of services that patients will receive as they will not have that line of continuality.  The Chairman said that he understands that it was financially driven decision but there has to be some compensation from elsewhere.

Councillor Douglas Nicol asked Kirsty Matthew why the RNHRD didn’t promote their services.

Kirsty Matthews said that since last February the RNHRD seen significant change in commissioning behaviour that led to a reduction of income by 50%.  What the RNHRD had to do was to look at how they could to respond to that so they spent the last 12 months looking if there are alternative patient referrals to get into their units to get the clinically and financially viable.  There is a need to have a certain number of patients to be able to deliver the service.  The challenge was on how to react to the changes in commissioning behaviour when patients should be treated more closely to their homes and community services.  The number of patients who required much more specialist requirements significantly reduced.  Taking all these into account the Board was not able to find the route to allow the RNHRD to keep the service open for financial reasons.

Councillor Nicol commented that Oxford centre seemed to find the way to run these services and now it will take those services away from the RNHRD.

Kirsty Matthews said that she doesn’t know anything about the positions of the centres in Bristol and Oxford.  All neuro-rehab acute in-patient services have changed.  The increase in their beds is a result of the closure of services in the RNHRD.

The Chairman said there is a national deficit for places in neuro-rehab and, in that case, Bristol and Oxford are winning those places.  It would be welcome that the RNHRD could be a candidate in challenging to those patients, maintain the service and carry on with the comfortable knowledge that patients will have no interruption at all.  The Chairman asked why this was not challenged.

Sue Davies responded that there was reorganisation of trauma centres in the country over the last year.  It will take little longer to understand where the deficits are between the different types of services.  The PCT have been working in the community rehabilitation services and there was some increase in low level capacity services.  Sue Davies also said that she was not aware on increase in neuro-rehab services in South West.  The Specialised Commissioning Team (SCT) felt that it would be better, for the RNHRD, to try to take patients who could be there only until they are discharged by the end of March 2013 rather than transfer patients in the middle of their care. 

Sue Davies also said that the SCT were notified that the service will cease so they had to try to make arrangements on what is the best pattern of care for the patients.

Sue Davies commented that all three centres (Bath, Bristol and Oxford) provide excellent services.  Sue Davies added that she is sorry that Councillor Jackson felt that some statements from the PPE days are not included in the report.  There is a transcript of the meeting that is available on the website.

Kirsty Matthew said that the service is very small specialist foundation trust with the small number of high income patients.  There was a significant change in the level of occupancy as a result of some decisions made by the commissioners and the service had to close due to financial reasons.

Tracey Cox said that the RNHRD has been hit by the changes in commissioning behaviour, changes in national tariff system and it made it really difficult to stay viable.

The Chairman asked why the RNHRD didn’t work with the Local Involvement Network in terms of the consultation on this issue.

Kirsty Matthews responded that her belief is that the Board followed the process to the best of their ability.  The Board meeting was held in public and papers were available on the website.  Kirsty Matthews also said the Board also went into very detailed communication and engagement during December 2012 and background papers were provided on time and in the right way.

Councillor Katie Hall said that she also attend the PPE day and heard quite moving stories from the patients and carers.  In terms of the timing of the consultation on the closure it did seem that the public consultation was done after the decision was made.  Councillor Hall asked why it wasn’t possible to conduct the public consultation before the decision was made.  Councillor Hall commented that the important stage of the democratically open decision making process was lacking here.

Kirsty Matthews responded that the Board were clear all the way through that they worked really hard as organisation to find the way to keep the service running.  The decision was made due to severity of the financial position.  The consultation process was held during December 2012.  Kirsty Matthews agreed with concerns from Councillor Hall on consultation process taking place in December but that was the process that the Board chose.

Councillor Hall asked if the Board though of any other decision apart from closing the unit.

Kirsty Matthews responded that the Board took the decision to close based on the information in front of them.  During that period the RNHRD was incredibly open and transparent.  The Board wanted to make people understand the situation.  The Board took the preference to close the service and worked through December with many external and internal stakeholders.  The Board also wrote to significant number of people and had some really good responses.

The Chairman asked what Governors’ view on the closure of services was.

Kirsty Matthews responded that Governors were incredibly sad on such difficult decision.  They had to work with us to understand the financial complexity of the organisation in order to understand the financial fragility of the organisation.

The Chairman asked how many staff works in Bristol and Oxford centres.

Sue Davies responded that around 150 staff work across both centres though not necessarily only in neuro-rehab services.

The Chairman closed the debate by saying that it is quite uncomfortable position to close services so well respected and regarded by those who use it.  The Chairman said that he understands that the RNHRD Board worked with the commissioners but that they didn’t engage wide enough to take away the shock element to those people, and families, who depend on these services.  This came to the Panel as an ultimatum.  The staff team has been broken up now and it can’t be resurrected and nothing can put a stop on it because it came to this Panel far too late.  There is a fault in that approach – if the Board engaged with the commissioners at an early stage then the Board should also engage also with this Panel in order to gain some lay view.  The Chairman said that when he heard that all staff were given notice, he knew that it would be hopeless for the Panel to stop this.  The Panel were denied the opportunity to engage with the Board and they were omitted from the proper democratic process.  For those reasons the Chairman supported the motion from Councillor Jackson to send a letter to the Secretary of State asking them to conduct the investigation on the way the Board of the Royal National Hospital for Rheumatic Disease led a process to close the neuro-rehabilitation services.

The Chairman also hoped that the SCT will meet the requirements of all patients during the re-provision of services.

It was RESOLVED:

1)  To send a letter to the Secretary of State asking them to conduct the investigation on the way the Board of the Royal National Hospital for Rheumatic Disease led a process to close the neuro-rehabilitation services;

2)  To note the report from the Specialised Commissioning Team on the proposed re-provision of specialised neuro-rehabilitation services (inpatient and outpatient) provided at the Royal National Hospital for Rheumatic Diseases (RNHRD’s) from April 1st 2013;

3)  To support the proposal for service re-provision in the proposed centres;

4)  To note and support the proposal from the B&NES Clinical Commissioning Group on the proposed re-provision arrangements for non-specialised outpatient neuro-rehabilitation services;

5)  To receive an update from the Specialised Commissioning Team, or equivalent services, in 4-6 months’ time.