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                              AIREDALE PRIMARY CARE TRUST MEETING IN PUBLIC: TUESDAY 17 FEBRUARY 2004




                                                                                  AGENDA ITEM:   17
                              AIREDALE PRIMARY CARE TRUST

      PHYSICAL REHABILITATION UNIT, SKIPTON GENERAL HOSPTAL

1.   Introduction

     Public Consultation, led by Craven, Harrogate and Rural District Primary Care Trust, on the
     Relocation of Services provided at the Physical Rehabilitation Unit at Skipton General Hospital.

2.   Background

     On the 05/08/03, Craven, Harrogate and Rural District (CHRD) PCT Board agreed to lead a public
     consultation on the future services provided at the Physical Rehabilitation Unite at Skipton General
     Hospital. The public consultation commenced on the 15/09/03 and concluded on 15/12/03. Under
     new guidance laid out in the Health and Social Care Act 2000 CHRD PCT worked closely with the
     North Yorkshire County Council Overview and Scrutiny Committee for health. A summary of
     responses is included in „Making yourself heard‟ in appendix A.

     CHARD PCT and APCT identified a „service gap‟, namely for people with physical rehabilitation
     needs. This was highlighted by clinicians, local people and the Overview and Scrutiny Committee for
     Health. A commissioning strategy has been developed in collaboration with ANHST. See appendix B

3.   Recommendation

     It is proposed that: -

     Stroke

     Rehabilitation for people suffering from Stroke be provided at the Stroke and Rehabilitation Unit,
     Ward 5 at Airedale General Hospital under the leadership of Dr Sam Mawer.

     Severe Head Injuries

     The Services for this small group of people be carried out in specialist centres. When clinically
     suitable, patients will be provided for locally. CHRD PCT and Airedale PCT await the outcome of
     the strategic review of these services commissioned by West Yorkshire Strategic Health Authority
     before any changes are proposed.
       Physical Rehabilitation:

       The future shape of physical rehabilitation services will be based upon a community model
       supporting people in their own homes, where possible.

       This service will promote independence. If community beds are required, Airedale Primary Care
       Trust would look to buy purchase those from the independent sector after an individuals needs.
       Dependent on clinical need, these can be used for physical rehabilitation. This will be subject to
       ongoing monitoring and review.

       Eight beds will be provided for acute rehabilitation at Airedale General Hospital.

       A transitional phase for patients currently using the services at the Physical Rehabilitation Unit at
       Skipton General Hospital will be agreed, after clinical assessment and review.

       A consultant in rehabilitation medicine will be appointed, based at Airedale NHS Trust, with links to
       Leeds. The post will continue to provide consultant level input and build on the work of Dr Duncan
       Cotter.

       The board are asked to:

          adopt and approve the upstated recommendations.




Lyn Wilkinson
Deputy Chief Executive/Director of Community & Nursing Service                              4 February 2004
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                                  AIREDALE PRIMARY CARE TRUST

                                             Board Meeting

                                           17 February 2004


1.    PURPOSE

1.1   To inform the board on the process, content, responses and scrutiny of the public consultation on
      “proposed changes to the location of services currently provided at the Physical Rehabilitation Unit
      at Skipton General Hospital”.

1.2   To explain changes to the proposals outlined in the document and demonstrate how the local NHS
      organizations have listened to local people and partner organizations.

1.3   To provide a clear way forward on the clinically driven proposed service changes for the following
      groups of patients who use such a service, namely:

            Stroke
            Severe head injuries
            Physical rehabilitation

1.4   To explain our plans and proposed solutions for responses received during the public consultation
      period. To highlight how Airedale Primary Care Trust and partner organizations plan to respond to
      specific issues raised and identified in the response to the consultation document entitled “Making
      Yourself Heard”.

1.5   To listen to professional clinical advice, guidance and good practice to influence the new proposed
      shape of services currently provided at the Physical Rehabilitation Unit.

2     Background

2.1   On the 5 August 2003, the CHRD PCT Board agreed that a public consultation should take place on
      the future location of services provided at the Physical Rehabilitation Unit (PRU) at Skipton General
      Hospital.

2.2   The original proposal for change was received by CHRD PCT from Airedale NHS Trust in July 2003.
      The proposal stated that “a modern specialist Stroke Rehabilitation Unit located at Airedale General
      Hospital will provide better care for stroke patients, people with head injuries, neurological disease
      and degenerative conditions, than care currently provided at the PRU at Skipton”. The PCT
      believed this proposal for a significant service change required a period of public consultation. This
      action was supported by national guidance and regional advice. Recognising that although the
      majority of the service users were from the Airedale patch and beyond (over two thirds of patients),
      Skipton General Hospital is located in the Craven area, then CHRD PCT would take the lead on the
      consultation.

2.3   This public consultation commenced on the 15 September and concluded on the 15 December
      2003. The consultation was taken forward according to guidance in the Health and Social Care Act
      2000, paragraph 11.

2.4   This report explains the process used in the consultation period, together with headline responses
      and our joint action planned and agreed. A more detailed report of these responses can be found in

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        a separate public document attached. This summary write-up, entitled “Making Yourself Heard” is
        listed as Appendix A.

2.5     During the period of consultation, local people and partner organisations identified broader elements
        of service provision needed to comprehensively re-provide care currently provided at the PRU.

2.5.1   This perceived service gap expressed by listening to local views, clinicians and public, led to another
        piece of work to complement the public consultation proposals, namely for physical rehabilitation. A
        report goes on to explain this in more detail, attached in Appendix B.

2.6     During the public consultation period, the PRU was closed before Christmas 2003 due to staffing
        pressures and re-opened again on the 5 January 2004. Service is currently provided there.

3.      Progress to Date

3.1     The Process, content and responses.

3.1.2   Four public meetings were held during October and November 2003 The case for change was
        presented by Airedale NHS Trust with CHRD PCT providing an opportunity for the debate and
        ensuring local views were publicly heard. The process was supported by Airedale PCT and all of
        the four public meetings chaired by Councillor Carl Lis, Leader of Craven District Council. These
        meetings were publicised in the local press, on notice boards, the CHRD PCT web site and on local
        radio. Newspapers publicising the meetings and reporting on the debate included:
        The Craven Herald
        Westmorland Gazette
        Keighley News
        Lancaster Guardian
        Bradford Telegraph and Argus

3.1.2   Two additional public meetings, were led by the North Yorkshire Community Council Overview &
        Scrutiny of Health Committee on the 17 November 2003 and the 3 December 2003. The Committee
        considered the proposals and presented a number of observations which have been taken into
        account in preparing this report. The Committee‟s findings are contained in full in the document
        “Making Yourself Heard”, appended to this report.

        On 16 December 2003, Bradford Metropolitan Overview and Scrutiny Committee resolved that: -

        Airedale NHS Hospital Trust be asked to report to this Committee on:

        1)     Services provided to Bradford residents at Skipton Hospital.
        2)     Services provided to Bradford residents at other NHS resources in North Yorkshire.
        3)     Foundation Hospital Trust status within the context of the Trust’s financial position.

        See appendix C

3.1.3   1,500 copies of the documents were distributed to health centres, community pharmacists, social
        services outlets, libraries and other public buildings. The document was also available on the CHRD
        PCT web site and via Airedale PCT. The document encouraged approaches from community
        groups and the voluntary sector to request more informal meetings to complement and add value to
        the process.

3.1.4   The process itself engaged a number of concerned ex service users. An idea of a reference group
        to monitor progress of any new service put in place was suggested and agreed. Airedale NHS Trust
        is committed to take this forward to ensure high level of public involvement is central to the new
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        service established. Commitment from local people and partner organisations was also put forward
        to help guide the current public consultation, “The Way Forward for Craven, consultation on the
        future shape of primary, intermediate and community health and social care services in the Craven
        area”, launched on 22 December 2003. A stakeholder health panel has been identified to further
        support and guide this process. The establishment and work of this group will link to CHRD PCT,
        Airedale NHS Trust and Airedale PCT.

3.1.5   The final resolution of the Overview and Scrutiny Committee (OSC) confirmed that, at this time,
        there would be no use of the power of referral to the Secretary of State. This is contingent on the
        PRU remaining open at least until the outcome of the Working with Local Communities Initiative
        (WWLCI) consultation is known, or if proposals improve patient care for all parties on any new
        service proposed. Other concerns raised by the OSC have been addressed elsewhere in this
        report.

3.2     Service elements to be re-provided for

        Severe Head Injuries

3.2.1   The number of head injuries is small across Airedale PCT: one person with a head injury was
        admitted to the PRU during the period of April 2002 and March 2003. To enable people to get the
        most up to date expert care, clinicians must treat a certain number of this group of patients every
        year to keep their skills and knowledge up to date. Nationally it has been recognised that such
        services should be improved across a broader geography (on a supra regional basis) in a highly
        specialist unit with day to day experience of treating such conditions. These cover large populations
        to maintain professional skills and also make cost effective use of public money.

3.2.2   To enable the best possible care for Craven residents, as well as those from a broader geographic
        area West Yorkshire Strategic Health Authority has commissioned a specific piece of work. This
        piece of work will inform the future commissioning of services for patients with severe head injuries
        in Craven and Airedale. This work includes key doctors, nurses and other rehabilitation specialists
        who will provide guidance on the most appropriate way to provide clinically safe services for
        patients.

3.2.3   In the interim, a specialist service for people with severe head injuries is being carried out in
        Bradford NHS Trust, the Leeds Teaching Hospital and the Mid Yorkshire Trust Pinderfields Hospital.
        At these hospitals such specific clinical skills are available and patients come over a long distance to
        receive such specialist care.

3.2.4   We are currently awaiting a publication from a specialist looking at the health needs for people with
        differing levels of head injuries. This will inform the work across the West Yorkshire Strategic Health
        Authority. Airedale PCT has made these strategic links and believes this local work will further
        support the development of national and local plans.

3.3     Stroke Rehabilitation

3.3.1   Local people, partner organisations, clinicians and the Overview & Scrutiny of Health Committee
        praised Airedale NHS Trust for establishing a new Stroke Unit, provided at Ward 5 at the new unit at
        Airedale General Hospital, led by Dr Sam Mawer. This new 28 bed Stroke and Rehabilitation Unit
        was opened in November 2003, with 20 beds for Stroke and eight for Rehabilitation. The Unit has
        been visited by PRU service users, CHRD PCT, Airedale PCT and the members of the Overview &
        Scrutiny of Health Committee.



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3.4     Physical Rehabilitation

3.4.1   During the public consultation process local people and the Overview and Scrutiny of Health
        Committee, CHRD PCT and Airedale PCT became concerned about the specific element of the
        service re-provision, namely people with physical rehabilitation needs, such as Parkinson‟s disease
        and multiple sclerosis, and those recovering from severe head injuries. The concerns of CHRD PCT
        were strengthened by the views of local people, clinicians and the work of the North Yorkshire
        Overview & Scrutiny of Health Committee.

3.4.2   CHRD PCT and Airedale PCT responded to this by developing a commissioning plan for “physical
        rehabilitation”. This plan, driven by clinical experts, was built on the proposals outlined in the
        consultation document and CHRD PCT worked closely with Airedale NHS Trust on its development.

3.4.3   Directors from the three organisations met on 23 December 2003, led by Airedale NHS Trust, to
        help take the plan further forward and give positive support for this work. This clinically driven plan
        for “physical rehabilitation” can be seen as Appendix B. Dr Vera Neumann, consultant in
        rehabilitation medicine at Leeds Teaching Hospital has had the opportunity to comment on the plan.
        Dr Neumann was also an independent expert advising the Overview & Scrutiny of Health
        Committee. The plan reflects the emergent national guidance and best practice for the developing
        National Service Framework on “Long-Term Conditions” to be published in the near future.

3.5     Links to the Working with Local Communities Initiative (Craven)

3.5.1   A partnership initiative, led by CHRD PCT, including North Yorkshire County Council (NYCC),
        Craven District Council, the voluntary sector, Airedale PCT, Airedale NHS Trust was established in
        summer of 2003 with a view to developing a proposal for how primary, intermediate and community
        based health and social care could be provided across Craven.

3.5.2   Under the guidance of this local partnership, CHRD PCT published a public consultation document
        entitled “The Way Forward for Craven”. This consultation on the future shape of primary,
        intermediate and community health and social care services in the Craven area was launched on the
        22nd December 2003. The consultation exercise is to conclude and will be considered by the CHRD
        PCT Board in April 2004. This document, copies available from CHRD PCT and on the web site,
        www.chrd-pct.nhs.uk, amongst other options, highlights potential changes to the Skipton hospital
        site.

3.6     Strategic fit of this work to “The Way Forward for Craven” Consultation

3.6.1   Changes to services currently provided at the PRU will only be brought forward if they are seen to
        improve care for:
            Stroke rehabilitation care
            Physical rehabilitation care
            Severe head injuries care

        It is proposed that any change in services currently provided at the PRU is fully tested against the
        following indicators:
              The new plan for services represents an improvement on what is currently provided.
              It has received clinical support and clinicians have been fully involved in the proposed
                 service redesign.
              It reflects the comments made during the PRU consultation both by the public, by clinicians
                 and local organisations.


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              Appropriate arrangements are in place to ensure an orderly transition to any redesigned
               service.

4.      Next Steps

4.1     Consultation process and content

4.1.2   A document explaining the process, content and feedback of the consultation, “Making Yourself
        Heard”, notes the views received from local people and organisations in response to the
        consultation. It also addresses potential solutions and highlights our current position. In addition,
        the document “Making Yourself Heard” also highlights broader concerns expressed about transport,
        Skipton hospital and other issues.

4.1.3   The document entitled “Making Yourself Heard” will be collectively shared across Craven and
        Airedale and used for monitoring purposes.

4.1.4   Airedale PCT will continue to work positively with CHARD PCT, the Bradford Metropolitan District
        Overview & Scrutiny of Health Committee and, when established, the Patients Forums, to ensure
        that local voices are included and have influence on what we do and how we do it.

4.2     Service elements to be re-provided for

4.2.1   Severe Head Injuries
        It is nationally recognised that services for this group of people needs improvement. Care and
        treatment of this small group of people is catered for with the highest specialist and technical skills in
        Leeds, Bradford and Wakefield. Nationally and locally, the NHS wants to improve this type of care
        for local people. CHRD PCT is in a key position to influence the development of this regional
        service. It is proposed to receive an update on the longer term work across West Yorkshire
        Strategic Health Authority.

4.2.2   Stroke Rehabilitation
        According to local people, partner organisations and clinicians from the Craven and Airedale patch
        and beyond, a case was made for the provision of Stroke Rehabilitation. This service (the original
        Airedale NHS Trust proposal) is currently provided at the Airedale NHS Trust site on Ward 5 by Dr
        Sam Mawer. It is proposed to continue to support this service.

4.2.3   Physical Rehabilitation

        The proposed physical rehabilitation service is to support people with long-term physical
        rehabilitation, monitoring and maintenance needs. For patients this can mean:
         Reducing the disability or impairment
         Acquiring new strategies and skills through which the impact of the impairment, disability or
           handicap could be minimised
         Altering the environment so the impairment or disability no longer result in handicap
         Timely information on all available opportunities for improvement or maintenance
         Information on financial assistance
         Access to counselling

        The model has been developed based on national guidance such as the National Institute for
        Clinical Excellence guidance on Multiple Sclerosis and other nationally published documentation,
        which it is anticipated will underpin the National Service Framework for Long Term Conditions due to
        be published in the near future. A full list of references can be found in the proposed service model
        in Appendix B.

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        In addition the feedback from local people has influenced the development of a physical
        rehabilitation service, particularly the comments which identify an acute Hospital as not being the
        ideal place for ongoing rehabilitation.

        The proposed way that services will be organised is based on a community model. These
        arrangements will be based around the existing localities of Craven and Airedale. The community
        team will continue to support patients at local clinics and in there own homes to prevent avoidable
        complications, support independent living and enable them to be cared for at home wherever
        possible. They will provide a monitoring and support service for people with long term disability,
        maintaining where possible there functional ability.

        Community rehabilitation beds may be used if there are no acute needs for assessment. These beds
        may be provided by social services or the independent sector and will be arranged as part of an
        individual services users care package.

        In addition to this and in line with national recommendations, eight beds will be provided for acute
        rehabilitation in Airedale hospital. These beds will mainly support people who have suddenly
        become disabled, who have an acute problem, which requires treatment in an acute hospital, or
        have a rapidly progressing disability. These beds will provide access to specialist services such as
        neurology, rheumatology, psychiatry, orthopaedics and nutritional support. This will include patients
        who are transferred to Airedale from specialist services at places like Leeds and Wakefield.

        A joint implementation plan will need to be agreed at the board meeting to give more detail on the
        proposal and how the transition from existing services to the PRU would be achieved.

        It is, however, proposed that, dependent on clinical need and after a multi-disciplinary assessment,
        people currently using the physical rehabilitation service at Skipton will be re-provided for in an
        appropriate setting as outlined in this report and guided by the joint physical rehabilitation strategy
        shown in Appendix B.

        A consultant in rehabilitation medicine will be appointed to be based at Airedale NHS Trust. The
        new consultant will also provide guidance and advice to the community rehabilitation teams and
        support patient needs. It is proposed this consultant will also carry out work at Leeds NHS Trust to
        ensure robust clinical links are made to a specialist centre. This post will continue to develop the
        work started by Dr Duncan Cotter who also worked between the two organisations and will link to
        the work of Dr Sam Mawer.

4.3     Consultation – Scrutiny and Public Monitoring

4.3.1   APCT, CHARD PCT and local organisations will work with local partners to ensure that comments
        and concerns expressed by local people, organisations, the Overview & Scrutiny of Health
        Committee, regional advisers and clinical experts will continue to feed into our planning and
        monitoring of any service changes.

4.3.2   Established links from this consultation will remain and connect with the Working with Local
        Communities Initiative in terms of resolution on service change, engagement, involvement, inclusion
        and influence of local organisations and local people.

5.      Recommendations

5.1     That services for people with stroke rehabilitation be provided for at the new Stroke and
        Rehabilitation Unit at Ward 5, Airedale General Hospital, under the leadership of Dr S Mawer.

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5.2   That West Yorkshire Strategic Health Authority continue to commission and develop the regional
      work on how services need to be organised and developed for people with severe head injuries.
      This progress will be reported back to both PCT Boards later this year.

5.3   That services for “physical rehabilitation” are outlined in Appendix B [NB: This is a working
      document] and the recommendations for service change agreed. To support this, a clear clinically
      led programme of transition will be agreed. This will be supported by all three organisations,
      Airedale NHS Trust, Airedale PCT and CHRD PCT.

5.4   APCT continue to support CHARD PCT to continue to work with the Overview and Scrutiny of
      Health, North Yorkshire County Council Committee and Bradford Metropolitan Overview and
      Scrutiny Committee, local people, partner organisations and the emergent patient and public
      involvement forums, to scrutinise and monitor the implementation of the recommendations agreed at
      the PCT Board Meeting.




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