Consulting the Community

A New and Vibrant Future for Benjamin Court Healthcare Unit -A Resource for Everyone in North Norfolk and rural Broadland Public Consultation and Engagement

Consultation and Public Engagement ExerciseJune 19th to September 11th 2017

FEEDBACK REPORT

Prepared for the

NHS North Norfolk Clinical Commissioning Group (NNCCG)

Dr Steven Wilkinson Steven.wilkinson@talktalk.net Consulting the Community September 2017

Contents

Background......................................................................................................3Responses........................................................................................................3Method and Methodology..................................................................................3Feedback Overview.........................................................................................4Summary of Themes.........................................................................................5Services (18%)..................................................................................................5Hospital Beds - 15%.........................................................................................6Community Based Care - 13%.........................................................................8Staffing - 11%...................................................................................................9Funding - 9%....................................................................................................9Planning - 9%.................................................................................................10Care Quality - 7%...........................................................................................11Location - 6%..................................................................................................12Consultation - 6%...........................................................................................12Logistics - 6%.................................................................................................12Questions........................................................................................................13Conclusion......................................................................................................14

Consultation & Public Engagement Feedback Summary Report

Background

NHS North Norfolk Clinical Commissioning Group (NN CCG) in conjunction with the Benjamin Court Steering Group proposed a vision for the future use of Benjamin Court in Cromer and the development of a new Supported Care Service. Full details of this proposal can be found at

http://www.northnorfolkccg.nhs.uk/ (accessed September 2017)

A Consultation & Engagement Exercise included public meetings and an invitation to make submissions on line and/or in writing. NNCCG were interested to learn;

How these proposed changes impact people? What else the CCG should consider in making this decision?

Responses

All Reponses to this exercise were provided to Dr Steven Wilkinson – an independent consultant, who analysed the feedback and produced this report.

In total 84 Reponses were collected. These included submissions from;

North Norfolk District Council (Letter)Cromer Town Council (Letter and email)Kelling Hospital Friends (email)Cromer Group Practice (Letter and email)Norfolk County Council (email & minutes)Opening Doors - a charity for people with learning disabilities (email)

A public meeting held on the 29th August in Cromer also invited written responses either on a form, or as ‘post–it’ note responses. Further correspondence was received in the form of letters and emails.

All responses from individuals were redacted and/or anonymised and returned to the CCG after this report had been constructed..

Method and Methodology

1st Stage Analysis Responses received are entered into the central database. The free text is then coded. Questions raised are included at the end of the analysis to help facilitate the CCG response to the consultation.

2nd Stage analysis The Second Stage analysis combined the coded free text into themes.

Report This report has been written using (as far as possible) the words and phrases used in the free text. No corrections of fact, grammar or syntax have been made.

This report summarises the themes. The themes with the most responses are discussed first followed by the next in descending order. This provides a relative indication of the weighting of each theme.

None of the views expressed in this report are those of the author or any organisation for whom the author may work.

Feedback Overview

The following ‘Word Cloud’ (https://wordart.com/create) has been developed from the free text.

The following table shows the themes developed from the feedback showing % weighting and summarizing the key points raised.

Theme % Response ContextServices 18% Satisfied with existing services. Satisfied

with proposals. Services are needed in this region – particularly palliative care.

Hospital Beds 15% Beds are needed. No reduction. Flexibility in bed usage required. Retain beds until Supported Care model is in place and proven.

Community Based Care

13% Care in the community and joined up care are needed. The Hub will provide benefit.

Staffing 11% The Staff are appreciated. Staff need to be informed of changes. Staff training is needed. Staffing numbers are important.

Funding 9% This is a cost saving exercise. Patients should be the priority.

Planning 9% Consider the demographics of the area and patients. Local services are needed. Confirmations have been requested (sequence, bed numbers, resources, timescales)

Care Quality 7% Concerns about Supported Care, safety, staffing and funding.

Location 6% Difficulties with accessing services. Care closer to home is needed.

Consultation 6% Concerns regarding the consultation document and Communication process. Conclusions drawn by the CCG are disputed and more information is requested. The consultation is also praised.

Logistics 6% Parking concerns. And public petition to retain BC has been raised.

Summary of Themes

Services (18%)

The unit is a good central Cromer unit and was a successful unit which when it had one ward to stabilise and one to prepare for discharge, sent patients home ready to be home - this prevented re admission. A small close knit (fantastic) team at Benjamin Court - a high (invaluable) level of professionalism and compassion has been provided by the staff to both patients and their families.

NNDC recognises that Benjamin Court currently provides a range of excellent inpatient and outpatient intermediate care services. It is highly valued by residents across North Norfolk and in particular by people living in Cromer and the surrounding area.

It is considered that the proposed changes to the use of the intermediate care beds or the other beds for palliative care and I.V therapy at Benjamin Court will have little impact on Council services. The rationale, need and benefit of each element of the preferred option is clearly identified and accepted. Overall, it is considered that the impact of the proposed changes at Benjamin Court on the resident population of North Norfolk should be benefit.

The suggested option would result in the loss of 2 intermediate care beds from 18 to 16 beds. Given that the beds are not always fully occupied and the anticipated reduction in demand following the introduction of Supported Care this is considered acceptable.

Cromer Town Council sees the merits of all of the different options put forward by North Norfolk Clinical Commissioning Group for the future of Benjamin Court and is not opposed to the principle of the ideas. The Town Council broadly supports the recommendations of the Benjamin Court Steering Group of a mixed use of the unit. Norfolk County Council made supportive comments about the Benjamin Court Steering Group’s preferred options for the future use of Benjamin Court.

As people age, they become more susceptible to disease, disability and experience multi, chronic or long terms health issues and are more likely to need physical, mental and social care services. This combined with the rural topography of North Norfolk and the issues residents in North Norfolk face in terms of travel, time and cost to access any of the 3 acute general hospitals in Norfolk makes it essential that as many specialist and generic inpatient and outpatient clinics are provided in North Norfolk as possible.

Wrap around care is fine if illness is diagnosed prior to hospital admittance, however sudden illness/fall cannot often be predicted. It is this eventuality that is not being addressed by these changes.

We recognize the need for intravenous therapy; voluntary services and outpatient services to be locally accommodated. Great idea to have Big C there. Carer support and respite services are needed. We welcome that the existing Outpatient Treatments provided at Benjamin Court, such as Speech Therapy and Podiatry, will be retained following this consultation.

Palliative care (end of life facilities) is already provided, at Benjamin Court, and this should continue (is ultra important, pleased to see more). Residents praised the Palliative Care provided. Support the argument for increasing, or formally commissioning such services there.

Hospital Beds - 15%

Please consider very carefully, changing the use of the building and the beds that are available now at Benjamin Court. Using all parts of the ward and Poppy Wing will enhance the building. My experience was that Benjamin Court had a shortage of beds in 2012 – and not underused beds.

I feel that it is misleading to say that North Norfolk currently have four sites of inpatient beds: North Walsham, Benjamin Court, Kelling Hospital and Cranmer

House.  Cranmer House is closing its health beds from beginning of August so this site should not be factored into the consultation as it misleads people to think there are more beds in North Norfolk than there will actually be. 

Benjamin Court should not lose the current intermediate beds. While the options put forward appear innovative, the reality is that it will do little to relieve the problem of 'bed-blocking' in the acute hospital situation. An issue that has been compounded by the closure of so many of these so called intermediate beds. Clarity is sought on the total number of specialist care beds to be provided.

The inflexibility of providing a set number of beds (diverse services, beds are ear marked for specific issues) means this could lead to beds being unused. I strongly feel that Benjamin Court should retain the intermediate beds, at the same number, but utilise them with flexibility. The consultation identifies the provision of up to 8 palliative care beds, 6 Discharge to Assess beds and 2 IV chairs / beds. This implies there would be a maximum of 16 inpatient beds assuming there are 8 palliative care beds and the IV beds are able to be used for inpatients if required. Confirmation is specifically sought on the number of palliative care beds that will be provided and assurance is required that if the 8 beds are not needed for palliative care they will be used for other specialist or intermediate care services and will not be decommissioned.

As the Supported Care service only started recently and its success in reducing demand for intermediate care beds in North Norfolk is not likely to be evidenced for at least a year, the Council would not currently support any proposals to further reduce or decommission intermediate or specialist care beds at Benjamin Court or at any of the other three intermediate care facilities in North Norfolk. Rehab beds have been full all the time.

There is a major difference between this group of patients in theory being at home with care / OT / physio input and the reality of the major difficulties this often involves for this frail group of patients with multiple co-morbidities. The CCG is being naïve in making such a major decision largely on the basis of this audit. Supported care will involve care for a different group of patients than those currently at Benjamin court. It is thus unlikely to reduce the need for intermediate care beds. The audits of Intermediate Care carried out by NNCCG in partnership with NCH&C showed an 82% occupancy of beds across 4 units in North Norfolk, which indicates a significant demand of Rehabilitative Care across North Norfolk. Following any changes, there would still be patients in need of the ward based Rehabilitative Care Benjamin Court currently provides, despite a net reduction in this service area.

A change in use of the beds to palliative care will reduce the admissions to secondary care for palliative care. However there is also an unmet need for local palliative care beds, and so bed numbers cannot be solely based on current palliative care admissions to NNUH. We wished to register our disappointment that the palliative care beds at Kelling Hospital were not carried on.  

One correct comment mentioned that all the emphasis is on bed clearing and needs to concentrate on wrap around care. Inappropriate admissions from the NNUH have been a long standing issue - unrealistic discharge times due to patients condition and home situation all led to 'Bed Blocking', which though they

were too unwell, or support in the community not available, was seen a failure on the part of Benjamin Court.

Palliative x 8 would be good. Keep some rehab beds. There are not sufficient numbers of Respite Care facilities to complement such changes.

Although it is not mentioned in the consultation, the Council are pleased that NNCCG have publicly stated that none of the facilities in North Norfolk where they commission inpatient beds and services namely Kelling Hospital, Cranmer House, North Walsham Memorial Hospital and Benjamin Court will close.

Community Based Care - 13%

The clinical audit further identified that 46% of the patients assessed as part of the audits either did not need to be admitted to hospital or could have been discharged home directly from the acute trust if access to appropriate Physiotherapy or Occupational Therapy assessment and a care package were available. Discharge to assess should be part of the Supported Care Service – in patient’s homes. The longer people stay in bed the more they loose of their independence. Increase people’s independence, enable them to stay in their homes and in turn reduce the number of people going into residential care. This will build on the success of our home-based reablement and it will of course benefit the whole system. The Town Council broadly supports the principle of care and treatment being administered to patients in their own homes where possible.

A health at home team was initiated some years ago, which was then dismantled - these are costly initiatives, which have led nowhere. We have concerns regarding supporting the community locally if they are unable to be cared for in their own home but do not require a nursing home. Careful physical and mental checks are needed to ensure that patients are reasonably capable of self care plus assistance at home. We would like to see investment in district nursing.

I know Benjamin Court provided an 'Outreach service' - it provided after care on discharge. This service should continue. There is an opportunity to create a fantastic integrated community service in Cromer with Benjamin Court, Cromer Hospital – the new GP surgery with links to Keeling etc…

The Hub which forms part of the county wide, multi-agency early help service is a partnership of voluntary and statutory organisations that work collaboratively to offer help, advice and support services to children, families and adults of all ages. A key aim of early help is to reduce, delay or avoid the need for intense, intrusive, long term and costly interventions from statutory services. The location of additional voluntary / third sector provision at Benjamin Court will offer greater opportunities for partnership working and integration with the North Norfolk Help Hub located at the Council. This is joined up thinking (sounds good) - organizations should be prepared to work closely together (i.e. Age Concern, local centered Cromer Drop In, Cromer Hospital, Dementia UK or Alzheimer’s UK). Must involve everyone who has an interest in looking after loved ones.

Staffing - 11%

Benjamin Court is well sourced by excellent and loyal staff who are capable of adapting to any of the proposals and have continued to give 100% under the climate of uncertainty. Paramount is the respect for staff who in all this give their all to the service, rely on job security and in this age are hard to replace. All the staff there are exceptional – look after them.

The staff provide the best care they can, but everyone knows that palliative care is requiring of a higher staffing ratio, as in Pricilla Bacon Lodge. There is for example unlikely to be a resident daytime palliative care consultant. Any initiatives need to be staffed adequately. The delays to make clear decisions on what services are to be provided causes me difficulties to be able to manage the staff needs. More staff training will be needed.

Using the building as day care would underutilise the staff, result in job losses. The excellent district nursing team has been decimated spread too wide and has had its skill mix cut, due to funds.

Staff are exhausted from worry. Ensure staff are kept up to date with timely decision making - consider staff morale.

Encourage staff to join the home care team and maybe do shifts on wards as well. The Home Care team and Supporting Care at Home should team up.

The service will require around 50 extra health, social care and voluntary sector staff across NNCCG area. Confirmation as to whether these staff have been recruited and the proportion and numbers of health, social care and voluntary sector staff is sought.

The Town Council is concerned about fluctuations in the number of carers who are able to provide care to patients in their own homes. Volunteers are already overstretched.

Funding - 9%

The consultation document identifies the challenges faced by NNCCG and the need to make changes at Benjamin Court for financial reasons and more importantly to meet current and future intermediate healthcare needs in North Norfolk. Good to see the NHS investing as opposed to cutting (re Supported Care).

Benjamin Court has been overused by NNUH in its aim to save their costs. The building which was not rented back to itself initially now must have a cost incurred which it didn't before.

We need to have realistic ideas about seeing these issues as genuine needs, which can't be ignored and though undesirable, have to be funded. Patients who do not progress, or deteriorate can't be just a financial figure. From my experience physio at home subject to a few sessions – then stopped due to funding restrictions.

Even older people who have adequate finance are scared their money will not last out. This is particularly relevant to those who have family in care and see money disappearing fast. Lots of older people wouldn't be able to find £1,500 to spend on taxi fares and yet it would worry them enormously not to be able to visit family. Dementia should be addressed in ‘Dedicated funding’. It used to be that patient care was the priority of the NHS – Now the priority is money.

There is the rising issue of families and patients frustrated with the system being finance driven asserting their rights to support their relatives now overstaying their admission.

If they do what they say they will do it will cost more and we are already overstretched and under funded services. This is just another cost saving exercise. The proposals are borne from cost cutting, this has to be remembered. Sincerely you have my sympathy with the constraint this government is imposing. There is only so much money.

Planning - 9%

The plans are constructive and forward thinking. Support very much in principle. It sounds like BCU could become the community hub we need.

There is a steady but relatively low increase in the overall population in North Norfolk but a significant and disproportionately high increase in the age profile of North Norfolk residents. The latest figures show that 32% of people living in North Norfolk are aged over 65 compared to the England average of 18%.

These services would be better provided at the local GP centre, where most people requiring these services, would already be attending. Bearing in mind the demographic trends of an ageing population.

Lets think more widely as to how these resources can best serve people locally. Work on the patient journey. Plans must be well made and funded for the long term. As chairman of NNDC, the oversight of our area is that things will not get better!

The consultation confirms that the preferred option still presents a number of challenges in relation to finance, specialist staff recruitment and training and the reconfiguration of internal layout of Benjamin Court. Further detail is requested in relation to this and the proposed timescale for the change of use from the current intermediate care beds to specialist beds.

Confirmation is requested; that no further changes to intermediate care beds or services at Benjamin

Court, Kelling Hospital, North Walsham Memorial Hospital or Cranmer house will be considered until the Supported Care service is fully implemented and evaluated.

of the minimum number of specialist care beds to be provided at Benjamin Court

that the identified additional finance, staff, training and building reconfiguration to enable the changes to take place has been secured.

of the timescale for the proposed implementation of the changes

The steering group was not allowed to consider if this proposed change was the right decision for Benjamin Court. Thus any conclusions from the steering group are fundamentally flawed. They need to sharpen up on their managerial and communication skills if they are to be running the NNCCG's care programme.Not practical. Good idea in theory but wont work in practice.

Care Quality - 7%

The Council acknowledges and shares some of the challenges facing NNCCG, such as the increasing need and demand to deliver accessible high quality services across a rural area, with a dispersed and disproportionately high elderly population at a time of financial restraint.

The location of 6 Discharge to Assess (D2A) beds at Benjamin Court should enable better long term outcomes for patients and may result in their level of mobility and independence being maintained or improved. For some patients, this could reduce or delay the need for adaptations to properties via the Council’s Disabled Facilities grant process. Part of our strategy is to deliver better outcomes for people.

There are currently concerns regarding delays in assessment and commissioning of care packages. Whilst the philosophy of Supported Care is recognised, there is a concern that the multi disciplinary social care needed to ensure the service is effective – as it has current resource issues. The Town Council is concerned that the benefits of the Supported Care Model could be outweighed by increased isolation amongst patients, and a difficulty in the ability to monitor the level of care being provided.

The inflexibility of the options put forward do little to address the situation and can only lead to more people having to spend time in an acute busy hospital ward, where their more slower rehabilitation is not addressed adequately. Safety issues with palliative beds at Kelling came from having one trained nurse for 8 patients and using the existing HCA's - thus did not constitute a palliative care unit. Check the responsibility of relatives (or no relatives) for visits and welfare. Loneliness can be a killer.

Care for older people will be more limited in the future. This is inevitable. Many are frightened. If they will need care they are terrified of old age, and know the old have no place in today’s society. Anyone in health care will deny this – but this is the impression you give.

Health and social care workers do not listen to what is said. They have set questions, boxes to be ticked, and a ‘one size fits all’ mentality.

It will end up costing the NHS more as patients will be going home too soon – that puts them at risk and increases the likelihood of re-admissions.

We had no problems with the care in Norwich.

Location - 6%

Some people may have difficulty in accessing the services - the problem of distance. Travel to NNUH takes forever – 3 changes of bus – time – cost & wears family out. When an older person becomes ill and is taken to hospital miles away from their rural village home to Norwich, it is difficult enough to cope with especially if their other half can't cope with the travel. If people had to go elsewhere, such as Kelling, they may not be able to visit family - e.g. an elderly relative who can't drive and can't get a bus to the hospital.

Maintain a number of beds in Keeling and North Walsham (local) to alleviate difficulty in travelling.

The proposed changes should however be a positive benefit to residents of North Norfolk as there will be increased specialist inpatient and outpatient services available in Cromer. These will be of specific benefit to people with a variety of chronic, long term and palliative care conditions.

I’m concerned about local NHS resources as I rely on local services.

Merchant Place has poor footfall to attract drop-ins.

Consultation - 6%

There is a lot of writing [in the consultation document]. The writing is small. It is not easy read. There are a lot of abbreviations not everyone will know what they mean. Please can you send us this in Easy To Read. When producing flyers All relevant contact options need to be given not just website contact details.

Did try to speak to someone at NCH&C but my voice message was cut off. Tried phoning the NCH&C switchboard phone rang for 2 minutes no answer. Gave up after that. Improve communication with CCG & Public. There has been poor communication. The process is not open and transparent. Public opinion matters. Ensure the community is engaged and kept up to date.

We dispute the conclusions / outcome of the audit done at the community hospitals.

We are unsure we have enough information to comment specifically in relation to the potential for additional Outpatient services and how any changes might complement those existing at Cromer Hospital.

The Town Council would also like to thank North Norfolk Clinical Commissioning Group for closely engaging with the Town Council and the Cromer Community.

Good luck.

Logistics - 6%

My immediate thoughts are of parking capacity, there is proposed extra clinics, intravenous bed chairs, Big C drop in centre, Voluntary and care support groups. This will obviously considerably increase the number of staff and visitor traffic

movements.  This site is not large, as stated on page 15 of your consultation document.  There are already problems with parking and at certain times we have problems accessing our homes which lie beyond Benjamin Court in Fletcher Way. There is already 30 units of sheltered housing care for the elderly, managed by Broadland Housing on this site.

At the present time, before any increased traffic movements, parking can be a real problem. This is not always due to lack of spaces, but more to staff and visitors alike, feeling free to park anywhere, just as long as it is near the entrance.

Further down the site 9 spaces often remain vacant. It is quite probable that visitors are unaware of these spaces as there is no signage. Cars park on the pavement, obstructing the dropped curb and forcing mobility scooters to use the road.

There are four properties to the left of Benjamin Court, with very limited turning facility at the top of the close, and 27 flats to the right of Benjamin Court. (The old Fletcher Hospital site). Any large vehicle requiring access to 1 - 4 Fletcher Way (e.g. refuse collection vehicle) has to reverse up Fletcher Way. Inconsiderate parking limits the access to all of these properties and could be a real hazard if an emergency vehicle (e.g. fire engine) required access. Any increased use of Benjamin Court which would result in more traffic movements would exacerbate this problem.

The Town Council believes that the lack of parking and transport infrastructure could prohibit ideas such as the Community Hub or any service which significantly increases footfall at Benjamin Court.

It seems that this is a significant change to the use of this building and I urge you to check that you will meet the planning requirements necessary for this increased number of cars and make adequate provision.

Cromer Town Council has previously supported the distribution of a petition started by a ward patient of Benjamin Court and has encouraged public comments on the existing use and the possibilities of change in the future. The petition is "to keep Benjamin Court open, and for the facilities to remain the same". The petition has 1,205 signatures.

Questions

Q: (Cromer Town Council) Is the £1.5 million additional resource being invested by the CCG from capital funding. If not then from what source? Will that be from the savings made on the loss of the 2 intermediate beds?

Qu - What is not mentioned is will any of these ideas be funded adequately, or will they fail due to having existing staff spread thinner?

Qu – Have the new proposals been fully scoped?

Qu – Beds are fully used at Benjamin Court now so why change?

Qu – Have NNUH spoken to staff at Cromer Hospital about these proposals or spoken to Unison/RCN?

Qu – Palliative care is very expensive to maintain – will you link with Priscilla Bacon Lodge?

Qu - What happens to patients discharged from N&N who are still not fit to be discharged to their own home – especially if they are on their own – who is going to look after them?

Qu – Care at home is fine, but I have visited many who for different reasons cannot be cared for in a home situation. What then?

Qu - What happens to beds set aside when not filled?

Qu – Will these treatments augment or take the place of Cromer Hospital? Are you thinking of closing Cromer Hospital?

Qu - We would also respectfully ask for a plan of what is happening to Kelling Hospital going forward and in what timescale?

Qu - I work on the bank, what happens to those staff - will they still be useful?

Qu – What provision is being made for the spiritual needs of people?

Qu - Could you work with Dementia UK or Alzheimer’s UK to create a Dementia Café?

Qu – Are you aiming for a centre of excellence?

Conclusion

This report has been developed independently using the feedback provide. All queries concerning this report can be forwarded to the author. All further correspondence should be forwarded to the CCG.

Final Report developed byDr Steven Wilkinson – Consulting the Community*Steve.Wilkinson@talktalk.net

* Consulting the community is a research centre of academics from the social sciences. This method for analyzing feedback has been developed by colleagues from this centre. Enquiries concerning this report and/or analysis of public consultations can be made by contacting the author.