A consultation is expected to be begin soon on how to provide specialist hospital care for Wiltshire’s severe dementia patients who suffer serious crises as their condition develops.
The number of patients needing this level of care each year in Wiltshire is about 120. But a hospital stay to stabilise their condition averages 84 days.
The provider of Wiltshire’s mental health care is the Avon and Wiltshire Partnership (AWP.) Last February they had to close the 24 dementia beds at Charter House in Trowbridge. As a temporary replacement similar beds were established at Amblescroft South in Salisbury.
The consultation (from December 1 to February 28) will put forward three options for a permanent solution:
1. To renovate and improve Charter House – and close Amblescroft South.
2. To move all specialist dementia care to an upgraded Avebury Ward at Green Lane Hospital, Devizes.
3. Make Amblescroft South into Wiltshire’s sole facility for this level of dementia care. (There will still be the opportunity to send some patients from the north and west of the county to AWP beds in either Bath or Swindon.)
The first two options have ‘significant financial implications’ – in capital costs and in consequent annual interest charges for the private finance needed. Only the Salisbury option is capital and annual cost free – indeed it would give the Wiltshire Clinical Commissioning Group (CCG) a £440,000 a year saving. And you get the chance to advise the CCG how they should spend that saved £440,000.
The Charter House/Trowbridge option involves extensive works, but it is not stated how these will overcome “the stand alone nature of the site” which was one of the main reasons for its ‘temporary’ closure.
For many people in Wiltshire deciding on their favoured solution will probably be about geography more than money. And if Salisbury is chosen, there will be a renewed feeling north of the Plain that ‘everything goes to the south of the county’.
However, much of the significance of this consultation is basically about politics.
The first public acknowledgement of this plan and its consultation comes in papers – now published – for Wiltshire Council’s Cabinet meeting on Tuesday (November 11.) The draft of the consultation document had been agreed at a private meeting of the CCG in September.
And the CCG’s senior accountable officers can only sign the consultation papers off once the Cabinet has agreed them – it is the CCG that will bear all the costs and most of the risks.
There appears to be something of a turf war developing between Wiltshire Council and the CCG over the county’s health provision. Several sections of the paper for Cabinet discussion explain (some might say ‘justify’) the Council’s involvement.
The basic argument is spelled out in this lengthy paragraph: “Whilst the commissioning and provision of specialist dementia hospital care is health-led, it is acknowledged locally that these services make up only a small element of the whole dementia pathway that people living with dementia may pass through. In addition, it is recognised that any changes to a service within the pathway will impact upon other care and support services, including those commissioned and delivered by Wiltshire Council.”
The paragraph continues: “For this reason and in its role as a community leader, Wiltshire Council is supporting Wiltshire CCG in developing and delivering specialist dementia hospital care, including them proceeding to consultation on these options, pending approval from the Cabinet.”
You do not have to read between many of those lines to see the gist of the Council’s real position.
Council and CCG have worked together on the county’s “Dementia Strategy 2014-2021” and on the Better Care Plan (BCP.) However, the latter was negotiated through the Health and Wellbeing Board. There is no mention of the Board in this Council document.
The BCP involves passing millions of pounds from the CCG’s budget to Wiltshire Council. The savings for the CCG that the BCP aims to make from reduced hospital admissions costs will be very small compared to the sums the Council get.
[It has just been revealed by the Health Service Journal that of the £5.3bn pooled by councils and CCGs, £2.07bn will be spent on councils’ social care services, and £1.66bn on community healthcare provided by the NHS via the CCGs.]
Consultations, tender processes for contracts and lawyers fees are all lines of the CCG’s budget that are ballooning. This consultation exercise involved paying for cost estimates for the building work.
The government has frequently told us that sort of ‘bureaucracy’ was being cut – instead it is increasing. It is not yet clear how much this consultation will cost – but it is a cost that will be borne by the CCG and not by Wiltshire Council.
This consultation on critical dementia care is not a simple box-ticking exercise. It requires complex balancing of financial and many other factors and shows again the complexity of the CCG’s role.
The Lansley reorganisation of the NHS in England – now described by Nos. 10 and 11 Downing Street to The Times as the coalition government’s ‘greatest mistake’ – was supposed to put patients in charge of choosing their treatment and clinicians in charge of commissioning how those treatments are provided.
In fact only 25 per cent of CCG’s accountable roles are held by GPs. Now we have more and more involvement at the edges of commissioning by unelected council staff and politicians. And the government is now talking about encouraging more ‘joint commissioning’ between local authorities and CCGs.
Is this what was meant to happen or are we drifting into the choppy waters of unintended consequences? Or is this the way the government is planning to try and make good its ‘greatest mistake’?
Wiltshire's new Air Ambulance - picture by Chris Watkins MediaWiltshire’s new Air Ambulance – with distinctive green and yellow markings and a big W on its belly – has been unveiled.
A fly-in and landing happened at Trafalgar Park, near Salisbury on Friday, and Sarah Troughton, the Lord-Lieutenant of Wiltshire, officially welcomed the new helicopter, a 180mph Bell 429.
The helicopter will come in to service in January, when Wiltshire Air Ambulance’s 24-year partnership with Wiltshire Police comes to an end.
Operating its own helicopter means the charity will need to raise £2.5 million a year – or £6,850 per day – to stay in the air.
The new helicopter will be leased from Heli Charter, Bell’s UK agent, based in Manston, Kent. Under the ten-year contract there is the option for a replacement helicopter to be provided after five years.
Wiltshire Air Ambulance’s chairman, Mandy Clarke, thanked supporters, volunteers and staff and said: “We are delighted to receive our new helicopter and begin a 10 year partnership with Heli Charter, who are providing the aircraft and the pilots.
“Our patients will benefit as the Bell 429 is fast so we can get patients to hospitals very quickly.
“We hope that the new colours and the distinctive ‘W’ will enable people to recognise us more easily when we fly and they can be proud to know that we are flying to save lives.”
The crew on the air ambulance will be a pilot and two paramedics. A doctor will fly with a paramedic on occasions.
Paramedics will continue to be provided by South Western Ambulance Service NHS Foundation Trust (SWASFT). All of the paramedics have Critical Care Skills and have all worked on Wiltshire Air Ambulance previously.
Ken Wenman, chief executive of SWASFT, said: “I am delighted that SWASFT is able to continue its longstanding association with the Wiltshire Air Ambulance.
“Our crews on board the helicopter work tirelessly to provide seriously injured and ill patients across the county of Wiltshire and surrounding areas with the best possible care.
“This new helicopter will undoubtedly provide a benefit to patient care as well as providing the crews with a vehicle that is top of its class.”
Training for the pilots and paramedics will begin next month (November) and the air ambulance is due to start operating on January 1.
The air ambulance will fly up to 19 hours a day. Initially it will operate in the daytime with night flying commencing in Spring 2015. This is to allow the pilots to accumulate experience with the aircraft and operating area while at the same time training for night flying.
The air ambulance will operate from a hangar at Wiltshire Police Headquarters, Devizes, until the charity has found a suitable site to build a permanent home and visitor centre.
A shortlist of potential sites are being actively considered and it is hoped that a new base could be operational in two to three years.
Having just successfully sorted out the change from Primary Care Trust to Clinical Commissioning Group – or for that matter from Lansley to Hunt – there’s a new health service name claiming its place in the headlines: Better Care Fund.
It has not yet been reduced to a generally accepted acronym (which it surely must if it is to be fully accepted in the NHS) because they cannot make their minds up whether it should be known generically as a Fund or a Plan. Some term the whole scheme ‘the Better Care Fund plan’. That’s a bit confusing.
We will stick with Better Care Fund and for now ‘BCF’. But then, in Wiltshire the BCF has already given birth to a fully-fledged plan – a joint venture by the Clinical Commissioning Group (CCG) and Wiltshire Council. What’s more it has become one of the first five in England to be officially signed off by the government.
The idea of the BCF is to concentrate more treatment in the community so as to keep people out of acute hospitals – the average bed in an acute hospital costs £1,785 per week before you count in treatment costs. And hospital is certainly not always the best place to be, especially for the elderly.
Most of the money for the BCF is not new but comes from funds re-assigned to a pooled budget for use in integrated care by the CCG and Council working together.
Wiltshire’s Health and Wellbeing Board (HWB - set up under the Lansley reorganisation) is the body responsible for the BCF. Jane Scott, leader of Wiltshire Council and chair of the HWB, wanted the fund to cover patients from cradle to grave. But the government decreed that in its first full year (2015-2016) it must be restricted to the ‘frail elderly’.
Jane Scott was at the Marlborough Area Board on Tuesday (September 30) to explain the BCF. Also there were Maggie Rae (Wiltshire’s public health chief), Simon Truelove (the CCG’s head of finance), Dr Jonathan Rayner (Ramsbury GP and a leader of our area’s locality group of the CCG), Dr Abi Griffiths (from the Marlborough Medical Practice) and two frontline representatives from GWH’s community health service.
Wiltshire’s scheme is being piloted this year in three areas – Calne, Salisbury and Bradford on Avon – with brand new integrated teams of social care and health professionals.
It will only get its full budget of £27million next year to develop integrated community based service teams across the county which should reduce the need for hospital care and protect the existing level of social care services. The aim is to provide teams for each community of 20,000 centred on GP practices. (Our area’s size will be larger - over 30,000.)
Of the BCF’s £27 million, £15.5 million will be top-sliced off the CCG’s budget – that’s three per cent of the CCG’s total funding for 2015-2016.
Official government guidance states that the ‘expected minimum target’ for BCF plans (there we go again) is a 3.5 per cent reduction in emergency admissions to hospital. But four of the first five plans have set reductions below that figure.
Wiltshire’s plan is aiming for a 3.75 per cent reduction, but only after the expected annual rise of 2 per cent in non-elective hospital admissions is taken into account. This equates to a reduction of just under two per cent or, over the next two years, 37,000 bed days.
In financial terms this should save Wiltshire CCG in the Fund’s first full year £3.6 million of its ‘purchase’ of beds in the main three acute hospitals that serve the county.
If it worries readers that the CCG is foregoing £15.5 million of its budget in order to save £3.6 million – the Better Care Fund is not just about money. It is aiming, as it says on the tin, to provide ‘better care’ – better care before hospital admission becomes essential.
Wiltshire’s Better Care Plan originally envisaged a reduction in hospital admissions of 4.75 per cent, but the government became anxious about the effects on the finances of hospitals and ordered a reduction in the ‘admission avoidance ambition’ to a more realistic level.
The continuing year-on-year rise in hospital admissions has been worrying many acute hospitals. The Great Western Hospital believes the BCF will allow it to keep operating safely with its existing number of beds.
Indeed they had expected a shortfall of 55 beds by the end of 2016 if there had not been a change in the care system such as the BCF should provide.
The basic tenet behind the BCF was spelled out by Jane Scott: “We want care in our home…the last place we want to be, unless we have to, is in an acute hospital or care home for the rest of our lives.” Not everyone, it should be said, agrees with that – among them people who have had experience of services to the frail elderly in their own homes.
There is recognition in Whitehall that the BCF may cause problems – notably that reduced income – for acute hospitals. So it has been made mandatory to have a “Risk Share agreement with Acute hospitals in the event that acute activity does not reduce in line with plans.”
But Simon Truelove told the meeting that the BCF was not at all about destabilising the acute hospitals – like the GWH, Salisbury Hospital and RUH Bath: “We absolutely need our three acute hospitals with their specialist care.”
Apart from the risk that there are bound to be cases where people are not admitted to hospital soon enough, there are other risks as responsibilities blur between CCG and Council.
When the BCF plan went before Wiltshire Council’s cabinet, Cllr Ron Hubbard questioned why it stated there were no direct safeguarding implications – his question was brushed away on the grounds that “Officers would of course continue to work closely with the Safeguarding team.”
As Jane Scott told the Area Board: “Funding is going to be a huge challenge – on top of the funding challenges that the Council has, which are huge.” One risk for the BCF is the looming cost of the new Care Act, which may, from April 2016, set the Council back an extra £15 million.
And there is always the risk of friction between the Council and the CCG. Already there was talk about this at the Health Fair in the Town Hall before the Area Board met.
The Council feel they are helping through their efforts on the social care side of the partnership to make savings on treatment costs, which accrue solely to the CCG. This they feel is not fair.
This quite overlooks the fact that even before the BCF hove into view, the CCG was helping with social care costs. They were, for example, funding quicker exits of patients from hospital – reducing the dreaded ‘delayed transfers of care’ or ‘bed blocking’.
As we have seen, most of the BCF for Wiltshire comes directly from the CCG’s budget. And from the pooled BCF budget there is £9.18 million set aside both this year and next to support such Council social care responsibilities as care home admissions, the Council’s Help to Live at Home Service and hospital social work services.
What was that about robbing Peter to pay Paul?