Introduction

We live in times of great change and few areas are changing faster than the NHS. Better drugs and therapies, new technology and improved surgery are helping to improve quality of life and life expectancy. Such changes are also reducing the time people spend in hospital for routine treatments. The number of patients treated as day-cases is growing as techniques improve. And the use of new technology, like digital x-rays, mobile scanners and electronic records, is transforming how doctors and nurses work.

In addition, we are seeing change in the way the NHS is managed and organised. Initiatives to give GPs control over the services they commission, and choice for patients over where they are treated, are revolutionising delivery of health services.

Alongside these changes in technology, drugs and patient management are the changing needs of local people.

All these changes provide us with a chance to offer a better service. At Cotswold and Vale Primary Care Trust, we want to develop a new way to deliver health services that local people are involved with, want and need. We want to ensure that care is as local as possible. We want to provide a model of care that is modern, integrated and right for this century. And, of course, we need to provide value-for-money and ensure we live within our means.

Since February, we have been involving people around the future of local health services. We are now moving to consultation on change. This document is about Fairford Hospital and has three sections:

1. Reasons for change
2. The case for change
3. Options for change

At the end, we explain what is to happen in the next few months and how you can take part. (The Consultation period is now over)

Elizabeth Law
Chair
Cotswold and Vale Primary Care Trust

September 2005

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1. Reasons for Change

1.1 Why we need to think about change

We launched our involvement process earlier this year with a document that set out the reasons why change within the NHS was necessary. This document focused on older people as the main users of the NHS. The reasons for change included:

• people living longer but healthier lives;
• a change in the pattern of acute illness with more treatment at home than in past;
• more long-term illness that needs support at home rather than in hospital;
• changing social services with emphasis on keeping people independent.

1.2 What we heard from people

We listened carefully to what people told us and a report on our involvement with patients and the public is available on this website.

Most people want a full range of health services on their doorstep. They recognised this as an ideal that is hard to achieve. Most were prepared to travel for specialist NHS care.

People said that, as they get older, they want to stay in their own homes. Most thought older people in Gloucestershire receive excellent care.

Asked to choose three from 12 priorities for local health services, people gave top votes to GPs and nurses (62% of voters) and home support for older people (52%). Next were hospital beds (38%) and local outpatient clinics (35%).

Most people were prepared to see change. A majority had needed a health service that was not available locally. Most thought Fairford Hospital could do more to meet people's needs.

What was also clear was the affection for Fairford Hospital and its work. People place great value on the Hospital and want it to stay. There are, however, reasons for change that directly involve the Hospital.

1.3 Fairford Hospital

Clinical safety

Fairford Hospital, like all other hospitals, must ensure high standards of care and provide a safe service. As medicine advances, so does specialisation. It is increasingly clear that doctors and nurses who specialise provide better and safer services. Everyone wants their local hospital to be a safe place. These days, that means more specialisation, which limits what can be undertaken in a small hospital.

Since our public involvement work began, we have felt the effect of a new GP contract in which GPs no longer have 24-hour responsibility for patients. Primary care trusts have set up countywide night and weekend medical cover to respond to patients at home, with fewer GPs taking part. The out-of-hours doctor is not likely to know the patient in a community hospital as in the past.


Best value

Fairford is a busy hospital with beds for care of local people who are unable to be treated at home and for those on the way home after a spell in a general hospital. Cotswold and Vale PCT inherited community hospitals with this role. Other PCTs have had to develop such services, sometimes bought in more cost-effectively from a nursing home. Such beds – which generally include individual bedrooms with en suite shower and toilet facilities – then form part of a larger facility, which makes them economical to run and maintain. We all now expect private facilities, but it would be difficult, if not impossible, to provide such facilities at Fairford Hospital.

1.4 Work since February 2005

Across the NHS

The government's policy is that the NHS should be a patient-led organisation with more services and support for people in their own homes. This summer, our local Strategic Health Authority put forward a range of possible roles for community hospitals:

• new alternatives to surgery (pain relief, physiotherapy, etc);
• screening, including more x-ray, ultrasound and pathology;
• pre-operative assessments and sites for mobile day surgery units;
• minor injury units linked to primary health care;
• beds for observation, nursing and therapy (but not medical assessment);
• local ante-natal and post-natal care.

Cotswold and Vale Primary Care Trust

Since February, further work has been done across the Primary Care Trust. This work has suggested answers to two questions that are explored in the next section:

• Can local health services include specialist outpatient and similar care?
• What pattern of inpatient care do we need to develop?

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2. The Case for Change

2.1 Fairford Hospital today

Fairford Hospital serves some 10,300 people, patients of the local general practices. GPs manage the care of patients in the hospital's 15 beds. Last year, the average age of an in-patient was 81 years. 164 in-patients were treated. Of these, 44 were admitted more than once, making 279 separate spells of in-patient care. On average, each in-patient spell lasted 15 days.

There is also a 24-hour Minor Injury Unit at Fairford Hospital. 727 people used it last year and there were 216 follow-up appointments. The Hospital also has regular chiropody clinics, physiotherapy, minor surgery, a falls prevention service and outpatient clinics each month in urology and psychiatry.

2.2 Services for a wider range of people

The Primary Care Trust wants to develop local health services for a wider range of people. At present, much local health care is just for older people. We need to widen the scope of our services to cover all ages. We could develop outpatient clinics, x-ray, blood testing, pathology tests, day care and therapy. We could also develop our social and home care teams, offer healthy living advice and care that anticipates ill health before it becomes a problem.

Outpatient treatment

Patients from the Lechlade and Fairford general practices attend 8,100 hospital outpatient appointments each year . For most of these people, an outpatient appointment means travelling to Cheltenham, Swindon or elsewhere.

The PCT wants 75% of outpatient appointments to be at local clinics, though highly specialist clinics will, of course, still have to be held at acute hospitals, like Cheltenham General.

For many patients, the stress and inconvenience of travel to distant hospitals could be avoided. Consider eye clinics, for example. Local people attended some 650 eye appointments last year. These people tend to be older with some visual impairment. For them, local clinics would greatly lighten the burden of travel and treatment.

Given the numbers, the Primary Care Trust calculates that Fairford and Lechlade could support local outpatient clinics in the following main specialties:

To support these clinics, x-ray and other diagnostic services will need to be developed locally. New technology makes all of this possible and it will add to the richness of services. These are good foundations on which to build the services foreseen in a patient-led NHS.

2.3 Inpatient care

This summer, the Primary Care Trust examined inpatient care at Fairford Hospital and elsewhere.

Rehabilitation

The PCT looked at patients who transfer from Cheltenham General and Gloucestershire Royal Hospitals. Patients usually transfer to community hospitals because they no longer need the sophisticated services of a general hospital but they are not yet independent enough to care for themselves at home.

In the Cotswolds, in contrast to other parts of the county, there are large movements of patients to community hospitals. 86 patients transferred to Fairford Hospital last year.

Analysis shows that such a dispersed pattern of rehabilitation does not fit with best modern practice, which requires intensive work from a wide range of professions not least to help patients become mobile again. Speed is essential to recreate independence.

The PCT, with two new physicians specialising in rehabilitation, is working towards directing transferred patients to two centres: Stroud and Cirencester. Improved practice will reduce the rehabilitation period for each patient. In this way, the service will continue to accept the same numbers of transferred patients.

On average, Fairford Hospital receives fewer than two transferred patients a week. An intensive rehabilitation service is not feasible.
However, the change does affect Fairford Hospital because one-third of the Hospital's beds are now used for transferred patients.

Continuing care

The most frequent reason for admission to Fairford Hospital is programme care. Last year, 13 patients had this, a form of respite care.

Social services and the NHS provide alternatives to programme care for people assessed as eligible for continuing care. This is available to all Gloucestershire residents. Primary Care Trusts can only provide for people who meet the criteria for continuing care. The Cotswold and Vale PCT is not in a position, therefore, to continue to support programme care at Fairford Hospital. Last year, programme care represented 12% of the Hospital's work.

Financial considerations

GPs have pointed out that the NHS financial regime works against hospitals like Fairford.

For example, in certain circumstances general hospitals can charge social services for each patient whose transfer of care is delayed. They can recoup costs. Fairford Hospital cannot.

Acute care hospitals, like Cheltenham General, also now charge for each patient treated. There are tariffs for each condition, set to cover the whole treatment. The PCT pays the tariff for each patient. The cost of their community hospital care is extra, however. There is no tariff reduction if a patient is transferred.

The GPs are right that such examples work against community hospitals. For the PCT, though, the problem remains; it has no powers to change the NHS financial regime.

The effect is that the PCT has to find money for both the tariff and the cost of care in community hospitals for transferred patients. It has to ask whether this is best value for a PCT that the NHS regards as over-funded and living beyond its means. It has to ask what else it could sacrifice to keep funding this service.

There is a further problem in the future, when services at Fairford Hospital will have to earn income from NHS tariffs. Were this financial policy to have been in place last year, the Hospital's income would have been £684,000 . Its direct expenditure, however, amounted to £760,000. Expenditure exceeds income by £76,000 making it difficult to sustain in the future.

2.4 The challenges we face

The Primary Care Trust wants to provide a sound future for Fairford Hospital.

The Hospital dates from 1887. It was well built, but its design is not suited to modern health care needs. It has a warm atmosphere and provides good care but the improvements to the interior of the building have gone as far as they can.

The Primary Care Trust has to accept that there is no likelihood that the NHS will fund a new hospital. It must assume, therefore, that change is made within the current buildings and hospital site.

There are two challenges the PCT needs to consider.

Services for a wider range of people

Last year, the Hospital cared for 164 inpatients and offered a limited outpatient service. The PCT's work suggests that between 1,500 and 2,000 patients might receive outpatient treatment in Fairford (many of them attending several appointments over the course of the year). This is a major increase in local health services, taking outpatient attendances from less than 100 to around 5,000 a year. It would benefit older people but would also bring services for children, mothers and people of working age.

This would give Fairford a sound future and represents a mix of services that could be provided within the existing building. However, it could not be achieved without affecting what goes on at the hospital now.


Inpatient care

Local people have made clear that they value Fairford Hospital. However, for reasons given in section 2.3, the numbers treated will reduce. Together, transfer and programme care patients account for over 40% of the bed usage, which equates to seven of the 15 beds.
GPs made good use of the other beds for patients admitted from home. They regard this care as very valuable . The question is how to retain this service? The options that result from these challenges are the subject of the next section.

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3. Options for Change

This section outlines options that might address the challenges described above. At Fairford Hospital we want to achieve:

• more local outpatient services for a broader range of people;
• continued access for GPs to manage inpatient care.
  
  

3.1 The options

For reasons set out above, the Primary Care Trust believes that things must change. No change is not an option. It does not meet the Primary Care Trust’s aims, nor does it meet the challenges described above. That leaves three possible options:

1. Outpatient services only at Fairford Hospital with inpatient beds at Cirencester Hospital
   
   This option develops Fairford Hospital for outpatient and diagnostic services and offers inpatient beds at Cirencester Hospital. This creates a broader range of local health services for a wider range of people. It retains inpatient beds located at Cirencester, where there would be 24-hour medical cover. However, the beds would be less local than now.
   
   The PCT believes there is merit in this option. It is a possible solution to the challenges we face.
   
   
   
2. Outpatient services at Fairford Hospital and some local inpatient beds at Fairford Hospital
   
   This option develops Fairford Hospital for outpatient and diagnostic services and retains some beds at Fairford Hospital. However, the Hospital's matron is not sure that she can scale down running costs to match future income and, without local 24-hour medical cover, there may be a safety risk to inpatients.
   
   If these problems can be overcome, this option could be a solution to the challenges we face.
   
   
3. Outpatient services at Fairford Hospital and some local inpatient beds elsewhere locally
   
   This option develops Fairford Hospital for outpatient and diagnostic services and retains some beds locally, perhaps at a nearby nursing home. This could offer a cost-effective solution to the provision of inpatient beds. However, it might limit the scope of inpatient treatment for want of 24-hour medical cover.
   
   If these problems can be overcome, this option could be a solution to the challenges we face.
   
   
   

3.2 An additional option if a new site were possible

The three options in section 3.1 make the assumption that only the current hospital site is available for development.

Were another site possible, there may be the opportunity to develop a new health facility for the area alongside, for example, a nursing home.

For the PCT, this would require local land and an arrangement to re-provide the hospital facilities at affordable prices. The Primary Care Trust believes local people, not least the Friends of Fairford Hospital, might find this an attractive option. It is likely to be an option only in the longer term, but could be combined with one of the other options in the short term.

The PCT believes this option is feasible and intends to explore it further.

During the consultation, the PCT will begin assessing the options, including ideas for any other options.

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4. What Next? Consultation Questions

What is the timetable for consultation?

This consultation lasts from 15 September to 14 December 2005.

What are the issues and questions in this consultation?

The consultation period is now over.

If you want to expand your views, you can send an email to questions@glos.nhs.uk or you can write to:

How can I get involved?

We have arranged public meetings in Fairford and Lechlade. All are welcome to attend.

Farmor's School, The Park, Fairford

• Saturday 1 October: 11:00am

• Thursday 13 October: 18:30pm

• Tuesday 1 November: 14:00pm
  
• Thursday 24 November: 10:30am
  
  

Memorial Hall, Oak Street, Lechlade

• Saturday 8 October: 11:00am

• Wednesday 12 October: 18:30pm

• Thursday 3 November: 10:30am

• Monday 21 November: 14:00pm

If your group would like us to come and meet with you or for more information, contact Joanna Wynn on 01285 884694 or at joanna.wynn@glos.nhs.uk.

What evaluation will be done? When will decisions be made?

We shall keep notes of each meeting, responses to the issues and other matters raised. We will use this information at the end of the consultation to prepare a report. This will help with any decisions to be taken. We expect the Primary Care Trust Board to consider decisions at its meeting in January 2006.

How does this fit in with other PCT changes?

Other areas across Cotswold and Vale and in rural areas across the UK face issues similar to those in Fairford and Lechlade. From October 2005, the Primary Care Trust will be engaging with the wider community to consider services elsewhere.

How will feedback be given?

We shall post all information about this consultation on our website. Everyone with whom we have had contact will receive this consultation document and any report on its outcome. We will keep the local media informed of progress.

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