FREQUENTLY ASKED QUESTIONS

The NHS is wholly committed to working with social care professionals to develop fully integrated health and care services, indeed we are already working together to this end.  But this consultation is not about integrated working, it is about a number of specific, potential changes to NHS services which is why it is being led by the NHS.

Responses submitted during the pre-consultation engagement period were taken into account in developing the recently published consultation options.  What the NHS heard from patients, public and staff during the engagement period will be considered again when the NHS makes decisions about any service changes in the spring of 2017.  It is important to remember, however, that during the engagement period the NHS was seeking views on its emerging thinking.  It had not developed the options which are now the subject of consultation.  We would therefore urge everybody who wishes to express a view on the consultation options to complete the consultation questionnaire, whether or not they submitted a written response during the pre-consultation engagement period.

Yes, you can.  Please indicate in one of your answers that this is an additional consultation response.  We want to hear the thinking behind any views you may express and, if your thinking has changed, why it has changed. 

Across the country, there is an estimated 9% vacancy rate for nurses and 7% for doctors, compared to an average UK economy vacancy rate of 2.7% (source: BBC FOI). These figures highlight the national difficulties with medical and clinical recruitment and retention, which compound the local challenges.

There are national workforce issues, especially in relation to the availability of paediatrics, psychiatry, neurology, obstetrics and gynaecology and emergency department specialties.

Whilst some specialities are predicted to have adequate national training numbers coming through over the next five years (obstetrics and gynaecology, for example) to meet anticipated staffing needs, it still does not guarantee recruitment to Cumbria at all, or in a timely manner; nor is it reflected in all specialties.

The General Practice Forward View acknowledges that many practices face recruitment issues and are increasingly reliant on temporary staff, and a higher proportion of older GPs signalling that they are considering leaving the workforce early. The GP Forward View sets out ambitions for 5000 net more GPs by 2020/21, as well as minimum of 5000 other staff working in general practice in the same timeframe.

This is the market within which Cumbria is trying to recruit, exacerbated by the geography of the region and the perception of potential staff of the organisations in WNE Cumbria; for example, issues relating to clinical quality and financial challenge along with uncertainty about future organisational form and service configuration.

Locally, this has manifested itself in workforce instability and reputational damage including repetitive negative media coverage. There is difficulty attracting junior doctors to the acute Trust as the lack of substantively filled consultant posts inhibits a first class teaching/learning experience, especially in the west of the region. Geographical location is a hindrance, especially in the west. All of this has resulted in high demand rotas and professional isolation – which has made recruitment, and retention, more difficult. This has impacted on the continuity of clinical services, acknowledged increased risks around quality and safety of care, and high levels of additional costs incurred for locum and agency staff to cover vacancies.

Of last year’s 13 available places on the local GP training scheme, only one was filled. In Copeland the GP vacancy rate is 21%, while 47% of current GP partners across west, north and east Cumbria are planning to retire over the next 10 years (as at March 2016).

There is a shortage of practice nurses with many working part-time in multiple practices and specialising in particular illnesses such as chronic obstructive pulmonary disease (COPD), heart failure and diabetes. Recruitment of pharmacists is also difficult in west, north and east Cumbria.

The challenges around recruitment at North Cumbria University Hospitals NHS Trust (NCUHT) have been well documented. The complexities of the health economy in west, north and east Cumbria along with geographical challenges mean the Trust finds it difficult to recruit and retain staff at two district general hospitals that are both trying to provide very similar services. This has led to vacancies in specialist areas (20.6% vacancy rate of consultant posts, as at end of July 2016, including job offers pending) and a heavy reliance on locum and agency staff which also impacts on the Trust’s financial position. The most challenging areas to recruit medical staff to are currently services such as general medicine, gastroenterology, stroke services, elderly care and paediatrics.

Cumbria Partnership Foundation NHS Trust (CPFT) has faced challenges in recruiting medical staff in a number of specialties and, although the position has improved, it remains fragile; the current consultant vacancy rate is 2.7% (as at end of July 2016, including job offers pending). There are around 5% of vacancies in the nursing workforce in general but with severe problems in Community Hospitals who have around 40% of posts vacant.

The primary care workforce, and in particular GPs, is a cause for concern for the areas. Focused efforts have made a difference in some areas; for example, there are now 12 GP trainees in North Cumbria, four in the west.  A number of innovative joint posts have been identified across CPFT, NCUHT, Cumbria Health On-Call (CHOC) and NHS Cumbria Clinical Commissioning Group (CCCG)/GP practices.

The two NHS trusts have been working to improve the recruitment and retention of the consultant workforce, with a number of successes. Using a flexible reward offer, NCUHT has been able to attract nine senior medical staff that they might not otherwise have been able to recruit. A further five posts have been appointed to in CPFT, also using flexible rewards.

With some successes already, the trusts will be working together on international recruitment in quarters three and four of 2016/17, for both medics and nursing staff, also seeking to encompass GPs. It is noted that NWAS will be looking at overseas recruitment too, so together the NHS trust will try to maximise joint approaches.

Recognising the ongoing challenges facing consultant recruitment, a composite workforce strategy has been developed for West Cumberland Hospital in the first instance. This looks at new and extended roles for other healthcare professionals, including physician associates and an increased number of advanced nurse practitioners. The model could be applied elsewhere but does require investment in education and development of staff.

Nurse recruitment remains challenging across the partners. In order to improve the position in NCUHT, 34 newly qualified nurses have been recruited to start in September 2016.

Early in September it was announced by Health Education England that, as part of a national initiative to attract lapsed registrants back into nursing, the Nursing and Midwifery Council will be contacting 803 people across Cumbria. We will be working on a system wide approach to maximising this opportunity.

NWAS is over-recruiting support staff but recognise that this is not a long term solution.  It is in discussion with University of Cumbria over a Cumbria-based direct entry programme beginning in 2017 which should aid both recruitment and retention. It is working with the University of Central Lancashire (UCLAN) to try to attract existing students to North Cumbria and are considering recruitment and retention payments for staff.   Cumbria County Council is exploring a number of options for recruiting the necessary workforce and new ways of working.

We have enhanced our approach to “grow your own” and, as a result, a collaborative approach to working with schools and colleges across west, north and east Cumbria, including a work experience programme for potential doctors, has been developed across the two hospital trusts. They are developing a joint apprenticeship strategy too.

The establishment of the UCLAN School of Medicine at Whitehaven has been significant and it has links with a number of Success Regime members; there are also joint academic and clinical posts in place.

Yes, we have. NCUHT has appointed a total of 15.05 working time equivalent posts in surgery and medicine, while a further 35 nurses and eight advanced clinical practitioners have been recruited. The trust has also made two joint appointments with UCLan who will spend 50% of their role as lecturers and 50% as physician associates

CPFT has also had success in filling a number of posts that have previously been difficult to recruit to, including clinical director and associate medical director posts for community north, a general manager for community south and an associate medical director for children and families, among others. It has also recruited thirty-one nurses over the past three months.

In October 2016, NWAS welcomed 11 new Polish paramedics who are based in the west of Cumbria in Egremont, Distington and Flimby Stations, while a further 16 conditional offers have been made for a second cohort to begin work in January 2017.

Despite these successes, the scale of the staffing problem locally is still enormous. Changes also need to be made for other reasons, not just staffing, such as quality concerns which have been raised by the Care Quality Commission.

Whilst there is rightly a concentration on recruitment, there are also significant efforts to improve the retention of our existing staff through development, engagement and culture change initiatives. As the proposals for Cumbria become reality, staff will be supported to develop and adapt to any required new ways of working.

There are two areas where changes have been made to services at West Cumberland Hospital that were not explicitly covered by previous public consultation and where some formal consideration is therefore necessary:

• Trauma – where a decision was made on safety grounds, in 2014, to stop minor trauma operations, emergency admissions and on call services.

• General surgery – where there has been a gradual shift in lower-risk emergency surgery to Carlisle.

The underlying aim in relation to changes made to both of these services are identical… the overriding primary objective is to safeguard patients.

Well evidenced and nationally acknowledged improvements to patient outcomes have been achieved as a result of the changes with a sustained reduction in deaths and improvements in quality indicators.

In addition the changes allowed us to reduce our use of locum doctors which has saved the NHS nearly half a million pounds a year.

These changes have also allowed staff in West Cumberland Hospital to concentrate on developing specific skills in managing patients with complex and multiple problems and in maximising their rehabilitation.

Subject to consultation we now propose to make these changes permanent but we also propose to ensure that wherever it is safe to do so some lower risk procedures take place at West Cumberland Hospital and that services are maintained for people in West Cumbria.

We have already re-introduced some general surgery procedures such as drainage of abscesses and exploratory keyhole surgery for abdominal pain at West Cumberland Hospital.  This will soon be followed by some minor trauma operations.

No.  We have spent a lot of time and money planning, building and opening a brand new hospital in Whitehaven.  We now have some state-of-the-art health facilities in Whitehaven.  We are delighted with the new hospital and we know that those who work in it, stay in and visit it are similarly impressed.

Far from running down services at West Cumberland Hospital we are seeking to expand them.  We see a really bright future for the hospital as a centre for outpatients, day case and lower-risk operations.  We have already increased planned inpatient and day-case operations by more than 600 a year.

There are many people living in West Cumbria who for many years have been travelling to Carlisle for their outpatient appointments.  While this will remain necessary for some patients due to the specialist nature of the clinics they attend, we expect more patients to be provided for in future much closer to home.  This could be in GP surgeries or it could involve a greater use of telephone, email and other technologies to help prevent the need for outpatient appointments, particularly follow-up appointments.  We are looking to provide more face-to-face appointments in local community hospitals and clinics wherever possible.

It is also worth remembering that those patients who do need to go to Carlisle for an operation can often be returned to West Cumberland Hospital in Whitehaven a few days later.  As soon as they are fit to travel - and no longer require the specialist input only available at the Cumberland Infirmary - patients will be transferred back to Whitehaven for the remainder of their hospital stay.  We know this will make it easier for family and friends to visit and how important this is in terms of the recovery process.

So in summary, while a small number of emergency patients will need to go to Carlisle for their care, we expect more West Cumbrian patients in future to be receiving care either in Whitehaven or at home.

When the trauma and general surgery changes were made on safety grounds, it was agreed by the local hospital Trust, NHS Cumbria Clinical Commissioning Group and the Local Authority Health Scrutiny Committee that it would be better to consider these changes alongside other plans for change.

They are certainly common operations but this does not mean they are without risk.  Hip fractures generally occur in elderly patients who are often frail and have other health problems.  Nationally just over 8% of patients with a hip fracture die within 30 days of admission to hospital.  There is good evidence that by improving the care of those with hip fractures, deaths can be prevented and patients will be more likely to be able to return to independent living.

Although surgery to remove an appendix is a relatively straight forward operation – indeed a less complex operation than much of the surgery carried out at West Cumberland Hospital – a proportion of patients with acute appendicitis will have associated severe sepsis (wider infection).  Such patients require a higher level of care and support and these patients will continue to be admitted to the Cumberland Infirmary.

A number of incidents at West Cumberland Hospital arising from emergency general surgery have highlighted these and other risks and have suggested it is more suitable to treat higher risk patients in Carlisle.  There is evidence that this shift of emergency surgery to Carlisle has improved outcomes for patients.

Nevertheless, patients in whom the diagnosis of appendicitis is less certain, and in whom there is no evidence of sepsis, can be managed and undergo surgery at West Cumberland Hospital, often without needing to stay in hospital.

In addition, we intend to offer many patients with troublesome gallstones or hernias presenting as emergencies urgent appointments for surgery at West Cumberland Hospital, avoiding waiting for clinic appointments and being placed on a waiting list. All these operations will be carried out under the direct care of our very experienced consultant surgeons, based at West Cumberland.

In developing plans to improve services we used guidance on trauma services issued by the British Orthopaedic Association and the Royal College of Surgeons in England.  We also liaised with other high performing trusts and with the Northern Trauma network which inspects our services annually and provides us with feedback and guidance.  The clear advice was and remains that we should undertake these acute services on one site.

We have been carefully monitoring the impact of the changes made and have found a sustained reduction in deaths in patients with hip fractures and overall deaths relating to general surgery.

The bar chart (which can be found on the Trauma and Emergency General Surgery Briefing Note) illustrates a downward trend in deaths relating to emergency trauma and orthopaedics (ET&O) that have been achieved over the last few years for those living in west Cumbria postcodes (i.e. west of the blue line).

We have noted from previous public engagement sessions specific areas of concern relating to community hospitals, maternity and paediatric and emergency department services. The relevant Success Regime workstreams have been working closely alongside these services and with NWAS to understand the impact of potential options on transport for staff, patients, carers and families using a specific demand profiling tool.

NWAS works to an overarching model that one 12-hour vehicle is required for every three additional site to site transfers. As well as site-to-site transfers some of the proposals suggest that a number of patients should be transported directly from home/place of incident to hospital in Carlisle without going via West Cumberland Hospital. This has all been modelled for each option and has allowed us to understand the impact each may have on local ambulance provision, and the number of additional emergency ambulance needed. This information is included within the Pre-Consultation Business Case with the range of additional ambulances required between one and eight vehicles depending on the agreed options.

We know that getting more ambulances in place will take time, so as well as building in the costs of the extra ambulances required, we will also build this ‘lead-in’ time into our final plans once we are clear which options are to be implemented.

On top of this, a DAV for pregnant women/new mums forms part of the proposals under some options. There are different possibilities for exactly how the possible DAV vehicle might work. In developing more detailed proposals, we are learning from experiences in Wales where this approach has been successfully used. Once it is clear post consultation which clinical models will be implemented, these possibilities can be fully worked through to ensure the best staffing models, including nursing and medical escort arrangements, are in place as needed and that we have covered arrangements for all eventualities (what we call our ‘what if?’ scenarios).

The DAV is commissioned by the Health Board from the Welsh Ambulance Service Trust (WAST) to transport urgent maternal, neonatal and paediatric transfers from Withybush to Glangwili – a journey of just over 33 miles. We have used the experience in Wales to conclude that this would be a good additional service to support West Cumberland Hospital’s (WCH) services.

There are many similarities between Cumbria and Wales including geography, levels of deprivation and poor road infrastructure. Both areas have lower than average car ownership and public transport is limited.

Public concerns about the time taken to travel from the west coast in Wales are very similar to those expressed by residents in west Cumbria; in particular they are anxious that delays in reaching urgent and emergency care may result in deterioration of condition or outcome.

The DAV is staffed by a 10-strong team of paramedics and emergency technicians who provide 24/7 cover. Following a review of activity data, the RCPCH review concluded that there had been “no measurable deterioration in clinical outcomes” as a result of this service development.

As the team is underutilised in terms of transfers, the staff provide additional support to Withybush Hospital providing emergency training to staff, support for activity in the emergency department and on the wards, as well as occasional assistance in the midwife-led unit.

The vehicle is a ring-fenced resource provided to transfer women, babies and children from WCH to Cumberland Infirmary Carlisle (CIC) – and other specialist centres if the need should arise – and is in addition to the existing ambulance establishment.

As a result of recent international recruitment, 10 additional trained paramedics have been recruited to work in north Cumbria which is excellent news for us locally, and further international recruitment is planned. NWAS is also working closely with higher education partners to introduce paramedic courses to the new West Lakes campus, Whitehaven, to help build a workforce for the future. This activity forms part of NWAS’s ongoing recruitment and retention programme. Additional recruitment would potentially be required to implement any changes as a result of the consultation process.

Any child who needs to be transferred will be transferred in an ambulance with a trained escort (usually a nurse or paramedic).

There will be appropriate levels of clinical support dependant on individual need available for transfers. For all site-to-site maternity transfers a midwife will travel with the patient and ambulance crew. In the event the call is received for a patient in the community and a midwife is not at scene when an ambulance crew arrives, then in emergency situations the patient may be transferred without this provision, as is current practice.

We support the principle of providing high quality care as close to home where feasible, thereby reducing as much as possible the need for patients and families to travel unnecessary distances. This means providing outpatient appointments locally and avoiding them altogether by supporting our Integrated Care Communities to manage patients at home or in their GP practice without needing to send them to hospital. However, when travel is necessary, we are working to make this as easy as we can.

In keeping with all parts for the NHS, we use national criteria to determine who is eligible to use the Patient Transport Service (PTS). Although we are constrained to some degree by this, we are continually working to improve this service including ensuring staff are able to apply the criteria consistently as this has been an issue of concern fed back to us. The contract with NWAS has recently been changed and now allows for the service to be provided into early evening, as well as a ‘text ahead’ service to inform patients when transport will arrive and other quality improvements. We are also working with North Cumbria University Hospitals NHS Trust and NWAS to see if we can better streamline current arrangements to reduce any waste in the system. We will continue to ‘top up’ patient transport services as required using private ambulance services.

We know that many people who are not eligible for PTS can find it difficult to get to hospitals and GP surgeries, so we are looking to help improve other transport options too. This means maximising use of voluntary and charitable schemes including community transport services, and working with public transport providers. An important part of this will be to make sure we can help patients, their friends and families to easily understand what transport options there are available. Staff can have difficulties knowing what is available too, which can affect discharges and booking of appointments. The Transport Enabling Advisory Group will consider possibilities for what a ‘single point of access to transport information’ could look like.

We are also working hard at improving car parking arrangements on site; there have been a number of recent improvements at Cumberland Infirmary already with more expected in the next few months, while more work is also planned for improvements at West Cumberland Hospital.

There will be no facility to accept postnatal transfers back into WCH. National guidance (NICE) says most women should be well enough to go home six hours after birth and it is good practice to support women to return home as soon as possible. If you require medical care after birth in Carlisle you will stay there until you are ready to be discharged home.

NWAS can accommodate family members to travel with their children in most cases, but space may be limited. In general there is a maximum of two spare seats but this also depends on the size of the transfer team if one is utilised, and discussion with the family also takes place at the time of the transfer with a view to supporting the child being transferred. NWAS are unable to facilitate a return journey for those travelling with a patient and will discuss before they leave site that if possible it may be appropriate for a family member to follow so they have transport on arrival.

We are being supported by a Scottish emergency transfer and retrieval medical expert to make improvements to our transfer arrangements. Dr Stephen Hearns has been helping us look in detail at the medical needs of patients, and at our pathways and protocols to improve speedy transfers, and enhance communication and escort arrangements in line with international best practice. This work is also picking up on the outcomes and recommendations of other transfer reviews including the North East Quality Observatory Service review of a Trust audit of patient transfers recently published by the Clinical Commissioning Group.

We have recently repeated the previous survey of patients’ experience of transfers undertaken in 2014 and we will be publishing this as soon as the results are available.

NWAS has business continuity plans in place that mean alternative routes are planned and available for crews who encounter blockages due to road traffic collisions. In the event of road closures due to weather related issues then again the Trust’s business continuity arrangements provide access to providers who can assist in patient transfer. These include, Mountain Rescue vehicles with all-weather capability, air assets from both the Great North Air Ambulance and North West Air Ambulance and both military and civil providers for search and rescue operations. It should be remembered that both the volume of transfers and frequency of these events are also relatively small with alternative options available.

Some specialist work has been undertaken looking at the possibility of a new helicopter service for west, north and east Cumbria. This concluded that there is no case for a dedicated helicopter service for west, north and east Cumbria as the aim is to continue with full acute medicine services locally and so we would not expect large numbers of patients to be moved out of the area. For patients staying within the area, it is quicker to transfer by road than air due to the complexities of helicopter transfers.

The work did however make some recommendations for how we could improve on air and road transfers for the small number of patients who do need to travel further afield through closer working with current air transfer providers and hospital partners in the north east. The report also made helpful suggestions as to how we could improve on our emergency transfers between Cumbria sites and this work is being actively pursued right now.

It is true that we would like to see staff working as larger, stronger teams across the patch rather than small isolated units, and that in the future we may therefore see more staff moving between sites. The Transport Enabling Advisory Group is investigating the possibility of a Wi-Fi enabled hopper bus between sites which could be used by staff instead of them driving themselves. These sorts of services are used very successfully by other hospitals, and are popular with staff. We think we could expand this service to help patients, and family visitors and we are looking at different funding models to support this. The buses should also help relieve some of the parking pressures on hospital sites. Any such proposals would be subject to proper consultation with staff side and affected staff.

ICCs will form an extended primary health and care team, where GPs, social workers, nurses, therapists, support workers and the voluntary sector work together in teams to wrap themselves around individuals, families and communities. They will provide both person centred co-ordinated care and an organised approach to improving the population health. This will mean less fragmented care and, as a result, your GP will be able to provide more effective care as part of a multi-disciplinary team. In the longer term this should reduce pressure on GP practices. If we don’t do anything to support GP practices to change, many of them will struggle to maintain services.

Your practice will still have a patient list and you will able to able to contact your practice as usual. In time, as ICCs develop, your practice will be able to navigate you to the best person to address your needs – which may not be the GP – so you are booked in to see the right person, first time.

Currently patients can access out-of-hours services by calling NHS 111. The GP service is provided by Cumbria Health on Call (CHOC) which provides urgent primary care when GP surgeries are typically closed, from 6:30pm to 8am on weekdays and all day at weekends and on bank holidays. Between now and April 2020 as part of the government commitment to increase access to general practice we are working with local GP practices and in collaboration with CHOC on new approaches to same-day demand and extended access, which aligns with the development of ICCs.

Whilst there is a strong tradition of general practice being high quality, innovative and central to the local health system, many practices are now regarded as vulnerable because of financial, workforce and workload pressures.

In addition, west, north and east Cumbria has higher prevalence rates for almost all disease groups compared to the national and peer group average, as outlined in the graph below (the graph can be found on the Primary Care Briefing Note). This, coupled with a projected 3.4% decrease in the number of people aged under 60 and an expected 8% increase in those 60 or over – a so-called “super ageing” population – will put increasing demands on a number of services, including general practice. We need to act now to ensure people still have access to the best primary care in the future.

SSPAU is a way in which children with acute illnesses, injuries or other urgent referrals can be assessed, investigated, observed and treated without being admitted to an inpatient bed. Conditions particularly suitable for management in an SSPAU include breathing difficulties, fever, diarrhoea and vomiting, abdominal pain, seizures and rash, as well as some head injuries and non-intentional poisonings.

The consultant will make a judgement based on the condition of the child at that time and how they are likely to respond to treatment, and the time it is expected to take for the child to improve. The consultant will also consider any other underlying conditions the child may have. This will always be a consultant paediatrician assessment.

Yes. Staff in A&E are skilled to deal with emergencies.

The Trust’s teams are working closely to make departments including A&E more child-friendly and addressing any training needs in respect to paediatric care.

They will be re-assessed and transferred to Carlisle as quickly as possible using the DAV. A consultant will always be available for telephone advice during the night if required. Additionally the Trust nurses are skilled paediatric nurses. The Trust is currently training a number of nurses to complete advanced paediatric nurse practitioner courses. This will enable them to assess and treat children in the absence of a doctor.

The development of SSPAU will also see an increase in community-based services to ensure the right care in the right place and that families are supported, post-discharge, where needed. There will be an increase in community-based paediatric nurses.

We would operate a similar model to the one adopted in Wales. There, a Dedicated Ambulance Vehicle (DAV) is commissioned by the Health Board from the Welsh Ambulance Service Trust (WAST) to transport urgent maternal, neonatal and paediatric transfers from Withybush to Glangwili – a journey of just over 33 miles. We have used the experience in Wales to conclude that this would be a good additional service to support West Cumberland Hospital’s (WCH) services.

There are many similarities between Cumbria and Wales including geography, levels of deprivation and poor road infrastructure. Both areas have lower than average car ownership and public transport is limited.

Public concerns about the time taken to travel from the west coast in Wales are very similar to those expressed by residents in west Cumbria; in particular they are anxious that delays in reaching urgent and emergency care may result in deterioration of condition or outcome.

The DAV is staffed by a 10-strong team of paramedics and emergency technicians who provide 24/7 cover. Following a review of activity data, the RCPCH review concluded that there had been “no measurable deterioration in clinical outcomes” as a result of this service development.

As the team is underutilised in terms of transfers, the staff provide additional support to Withybush Hospital providing emergency training to staff, support for activity in the emergency department and on the wards, as well as occasional assistance in the midwife-led unit.

The vehicle is a ring-fenced resource provided to transfer women, babies and children from WCH to Cumberland Infirmary Carlisle (CIC) – and other specialist centres if the need should arise – and is in addition to the existing ambulance establishment.

Any child who needs to be transferred will be transferred in an ambulance with a trained escort (usually a nurse or paramedic).

Due to problems with availability of paediatric doctors. Newly qualified doctors find it particularly attractive to work in large specialist units or in a specific area of children’s medicine. In west, north and east Cumbria we cannot offer either of these benefits and, therefore, we do not have enough paediatric consultants in permanent employment. This means we rely heavily on locums which can cause issues of continuity of care and is expensive and means the children’s service at both Whitehaven and Carlisle is sometimes at risk of temporary closure or reduction in service due to the lack of staff.

Under current rota arrangements we need 5.2 whole time equivalent (wte) consultants to staff the unit at West Cumberland Hospital. North Cumbria University Hospitals NHS Trust (NCUHT) currently has one wte substantive consultant.

NCUHT has attempted to recruit to all vacant consultant posts four times within the previous 12 months. This has resulted in one appointment to date whose preference is to work at Carlisle rather than Whitehaven. The new rotas will include a larger number of consultant posts which will satisfy Royal College of Paediatrics and Child Health standards and make the rota more attractive for applicants.

NCUHT is advertising for junior grade Trust doctors on a continuous basis and has recruited to two posts to date. One of these new recruits will work at CIC and one at WCH.

The table below gives some indication of the recruitment difficulties the Trust has faced.

This has involved rewriting the job description, offering a recruitment premium, international recruitment, liaison with the Great North Children’s Hospital and promoting the job ad to paediatric focused Twitter community.

No, they do need to change. Fewer children now have long stays in hospital but more children face short episodes of ill health. In response to this change the NHS has developed short stay paediatric assessment units (SSPAU). We currently have two such units in Carlisle and Whitehaven.

These units assess, monitor and treat or discharge children and young people more quickly. The success of these units depends upon close working between hospital and community services, good community nursing services, rapid access to paediatrician-led clinics and the support of GPs. It also depends on effective services to support children and young people with long term conditions.

Nationally, evidence suggests that up to 97% of children who come to hospital as an emergency can be safely cared for in a SSPAU without needing to be admitted as an inpatient. Currently, the majority of children who come to Carlisle and Whitehaven including A&E attendances (86%) do not need to be admitted as an inpatient. Of the children who are admitted, 37% stay less than 12 hours and 83% stay for no more than a day. Developing and enhancing the SSPAUs at Carlisle and Whitehaven would mean more children get the care they need without having to be admitted as an inpatient.

These models of care are already being used in Cumbria and we must ensure we continue to develop contemporary services in line with the rest of the UK.

The staffing issues are very different in Carlisle and it is easier to recruit. At WCH we have not been able to recruit enough permanent doctors to safely provide a full service, despite many attempts and offering many incentives. The Cumberland Infirmary in Carlisle is closer to The Great North Children’s Hospital in Newcastle which is the regional centre for poorly children.

We don’t have enough consultants and they simply cannot be in two places at one time. The Cumberland Infirmary sees more patients on a daily basis than West Cumberland Hospital. It is also closer to specialist services in Newcastle.

There are incentives to make working in Cumbria more attractive, job descriptions and work conditions are being redeveloped to be more attractive and we are developing our workforce to meet changing needs such as advanced nurse practitioners/advanced neonatal nurse practitioners. There will be more robust community support and Integrated Care Communities will support primary care services and reduce reliance on hospital admissions.

There will undoubtedly be some impact on staff and the organisations will work very closely to support staff at this time. NCUHT will fully involve all staff who may be affected by change and their views and personal preferences will be taken into consideration. The Trust will work with HR and staff side representatives to ensure that staff members are treated fairly, but the priority will be to sustain good quality, safe paediatric services.

This is where there are both doctors (obstetricians) and midwives available. Obstetricians are doctors who specialise in pregnancies and births where there are complications. Obstetric units offer epidural pain relief, and have an operating theatre nearby in case a baby needs to be delivered by caesarean section. They also have special care baby units. Midwifery-led care is also offered within a CLU but has the support/availability on site of medical staff if complications arise.

MLUs provide a welcoming, relaxed, comfortable and support environment for women and their families. We are committed to normal birth and view childbirth as a physiological process and a positive life experience, which enhances the long term physical and emotional wellbeing of women and their families.

Midwives work with women and their birth companions, involving them in all aspects of care to enable them to feel safe, confident and empowered. The midwives and support staff deliver high quality, evidence-based care, thereby supporting normal birth with competence and confidence and achieving positive outcomes for women and their families. Midwives provide antenatal, labour and postnatal care to women who fit the criteria for midwife-led care.

These are units where birth is viewed as a natural event. These are either ‘alongside’ a labour ward or delivery suite in a consultant unit, or ‘freestanding’ in a community setting. Both types of midwifery units are run by experienced midwives, who try to make the birthing environment homely and tranquil.

Such units do not offer epidurals but they offer other types of pain relief such as Entonox. The type of pain relief available will vary depending on the unit.

It is important to note that midwives are skilled and competent with managing labour and birth without medical assistance. Community midwives develop resilience to dealing with all types of scenarios and emergencies. The main point is developing strong contingency and support plans to deal with unforeseen events as they occur.

If you are having your baby in a midwifery-led unit or birth centre and the labour doesn’t progress as it should or if you or your baby need extra support, you would be transferred to the consultant unit. This would mean that a doctor and medical equipment would be on hand if needed.

Women with no ongoing health problems who have been assessed as low risk can give birth at an alongside or freestanding MLU or plan a homebirth.

In Wales a Dedicated Ambulance Vehicle (DAV) is commissioned by the Health Board from the Welsh Ambulance Service Trust (WAST) to transport urgent maternal, neonatal and paediatric transfers from Withybush to Glangwili – a journey of just over 33 miles. We have used the experience in Wales to conclude that this would be a good additional service to support West Cumberland Hospital’s (WCH) services.

There are many similarities between Cumbria and Wales including geography, levels of deprivation and poor road infrastructure. Both areas have lower than average car ownership and public transport is limited.

Public concerns about the time taken to travel from the west coast in Wales are very similar to those expressed by residents in west Cumbria; in particular they are anxious that delays in reaching urgent and emergency care may result in deterioration of condition or outcome.

The DAV is staffed by a 10-strong team of paramedics and emergency technicians who provide 24/7 cover. Following a review of activity data, the RCPCH review concluded that there had been “no measurable deterioration in clinical outcomes” as a result of this service development.

As the team is underutilised in terms of transfers, the staff provide additional support to Withybush Hospital providing emergency training to staff, support for activity in the emergency department and on the wards, as well as occasional assistance in the MLU.

The vehicle is a ring-fenced resource provided to transfer women, babies and children from WCH to Cumberland Infirmary Carlisle (CIC) – and other specialist centres if the need should arise – and is in addition to the existing ambulance establishment.

The main issue facing small units like ours is the ability to recruit sufficient numbers of appropriately qualitied staff across a range of specialties in the short, medium and long term. Consultant-led maternity units are fully dependent on having access to other specialist support 24/7 including paediatrics, anaesthetics and emergency surgery. We currently face difficulties with the availability of paediatric doctors at different levels. Newly qualified doctors find it particularly attractive to work in large specialist units or in a specific area of children’s medicine.

In west, north and east Cumbria we cannot offer either of these benefits and, therefore, we do not have enough paediatric doctors in permanent employment. This means we rely heavily on locums which can give problems with continuity of care and is expensive and means the special care baby unit at Whitehaven is in danger of not being staffed properly. There may also be future problems with the availability of appropriately qualified neonatal nurses.

We currently are able to recruit enough obstetricians to staff a new model of care – one team across two sites – but there are concerns that we will struggle to recruit in the near future especially if consultants are expected to do resident-on-call work at Whitehaven. The recruitment challenge at the moment is in interdependent specialities – namely paediatrics and also anaesthetics.

The Royal College of Obstetricians and Gynaecologists (RCOG) review advised us to look at transferring some higher risk births to bigger units e.g. multiple births due to the issues arising from keeping adequate skills in place with small numbers of births and also the level of backup available when required. So things do need to change to make births in west, east and north Cumbria as safe as possible.

Antenatal care is the care you receive from health professionals during your pregnancy. You will be offered a series of appointments with a midwife or sometimes with a doctor who specialises in pregnancy and birth (obstetrician). They will check that you and your baby are well, give you useful information to help you have a healthy pregnancy and answer questions. This is when the discussions will take place with you about the type and place of delivery available.

In all options antenatal care will be provided at both WCH and CIC or community centres, children’s centres, home visits or Penrith Birth Centre as current service delivery.

All antenatal services provided today at WCH will continue and in the future more services could be introduced such as more specialised clinics to be held at WCH.

ICCs have been described as:

“A defined community where community services, general practice, social care and groups come together to provide both person centred co-ordinated care and organised approaches to improving the population’s health.”

But what does this really mean in practice?  It means:

• Health and Social Care organisations breaking down barriers to enable staff to work together to effectively deliver locally based care

• Within an ICC creating one multi professional ‘ICC community team’ with a shared approach to referral, assessment, care planning and case management and care co-ordination

• Aligning these teams with clusters of GP practices and their registered populations

• Staff from different professions or organisations working together to meet the needs of the individual who needs care rather than referring between one another

• Providing a ‘rapid response’ function so that when there is a crisis individuals are supported to remain in their own home and that when they are admitted they can return home as soon as possible.

• Pooling data and knowledge of all those working in the ICC to identify those most in need of care or at risk of needing care and working together to meet these needs: a more proactive approach to care.

• Thinking about the public health needs of the ICC population and working with partner agencies such as third sector groups or district councils, to meet these specific needs.

• Enabling individuals to manage their own health

• Aligning budgets, thinking about how we get better value for money as a whole system and stopping the ‘whose budget is it?’ debate getting in the way of delivering what is right for the individual who needs care

• Aligning these teams with clusters of GP practices and their registered populations.

Benefits for service users, carers and communities:

• Care and support is delivered in the most appropriate setting
• It will reduce the amount of times you need to keep explaining your story to different people – we know this causes frustration and anxiety
• We are working to ensure you are not passed around from one team to another
• People are given information and support to self-manage their long term conditions
• More care and support is accessed  locally from third sector and communities
• Simplified pathways improve patient outcomes and experience and reduce variation in the quality of services received
• More empowered and involved individuals:

“I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me.” – National Voices

Benefits for staff:

• Improved morale/job satisfaction
• Fewer hand offs and less duplication, freeing up valuable time
• Opportunity to share skills and experience
• Better working environment can lead to improved recruitment and retention of staff
• Reduced bureaucracy

Benefits for the system:

• Getting more from our existing resources
• Reduced waste through avoidance of duplication
• Reduction of hospital admissions and reduced length of stay
• Improved self-management of long term conditions
• Fewer residential/nursing home placements
• Greater independence post discharge

The chief executives of the local organisations sit on a Delivery Board which will oversee an ICC Steering Group responsible for the implementation of ICCs in west, north and east Cumbria.

There will be eight ICCs covering populations of between 30,000 and 60,000.

Three ‘Early Adopter’ sites in Cockermouth & Maryport, Eden and Workington have been identified and in July 2016 three ICC managers were seconded from existing roles within CPFT and CCCG to support the development of ICCs over the next 12 months.  Managers will be recruited for Keswick & Solway ICC and Carlisle Healthcare ICC in Autumn 2016 with other ICCs coming on line in April 2017.

The managers will work locally with a small multi-agency leadership group advised by a wider ICC reference group comprising local stakeholders, including third sector groups and public representatives, which will determine the ways in which ICC team staff work.

Yes and no.  Each ICC will have a defined set of functions and they will be expected to deliver the same ultimate outcomes and meet the same standards for delivering high quality and safe care. But each ICC will be a different size, have different historic provision and different public health needs so there will be variability in how they go about the delivery of some services.   A key aim of the ICC ‘one team’ model is to allow frontline staff to collaborate and innovate to provide the best care possible based on their understanding of the needs of their local population.

The needs of the people of west, north and east Cumbria people are changing with a growing elderly population and increasing numbers of people living with long term conditions.  Health and social care services need to adapt to meet the changing needs of our population and to improve people’s experience of services.

Health services provided by the NHS and social care services provided by the Council do not always join up in the way that our residents need and expect them to.  Individually, health and social care services are doing a good job, but people’s experience of the system as a whole is that it is often confusing and care is disjointed.

Existing services tend to focus of treating ill health rather than supporting people to stay well.  Too many people are in hospital or in residential care when they could be cared for at home if the right support was available.  Our residents often feel disempowered by a system that deals with problems after they arise and would rather be supported to make their own choices about how services can help them to remain well and independent.

For many years, health and social care professionals have been working more closely together but this has often occurred on a fragmented basis and dependent on historic investments or only in particular geographies.  The way our health and social care system has been set up has often hindered rather than helped professionals to provide joined up person-centred care.

Other communities do need support to develop closer links and the support and commitment of all of the partners involved to work together with one budget is a key step in working together more effectively for the community.

In each of the Integrated Care Communities, we will align the existing resources more effectively across health and social care services.  In addition we are proposing to re-invest significantly through the clinical strategy in primary and community based services to support the ICCs to develop and provide the level of care needed for the future.

Services that need to operate on a larger footprint than an ICC will sit at a ‘network’ level (east or west Cumbria).  It is anticipated that Network Co-ordination Hubs will link with the ICC hubs to help speed up the discharge process, prevent inappropriate acute admissions and allow for smooth referral to and from specialist services.

It is acknowledged that there will need to be a phased approach to teams working within an ICC framework, i.e. community nursing/community therapy teams but other roles will be incorporated over time as it will take time to adapt current methods of working to an alternative model of integration.

Alston, Wigton and Mayport have been identified to have no beds following a comprehensive assessment process by clinicians and partners against a number of criteria developed by NHS Cumbria Clinical Commissioning Group.

The preferred option retains at least one bed base in each geographical area (west, north and east Cumbria) and minimises the number of units closed to make them sustainable and safe in the future.

The criteria included the deliverability of providing units with a minimum of 16 beds.  To assess the current condition of the buildings, national benchmarking (PLACE standards) was considered along with the financial implication of changing or updating the building.  The PLACE standards are Patient Led Assessments of the Care Environment and rate units based on a number of environmental criteria.

Alston
Although there are not major current estate issues in Alston, the cost of expanding the building to meet the minimum of 16 beds was high in comparison to other units.  In addition to this the local population size does not warrant a larger unit and, because this is our most isolated unit, it is very difficult to use the beds efficiently across the east network.

Maryport
The building at Maryport requires significant improvement and scores poorly against national PLACE standards required to deliver 24 hour inpatient care.  The current layout of the unit does not adequately support additional beds to meet minimum 16 beds criteria due to a lack of space and facilities.  The cost of extending and refurbishing the building to meet the privacy and dignity and facilities requirements for 16 beds means that Maryport did not meet the set criteria.

Wigton
Wigton Hospital building scores poorly when assessed against national standards (PLACE) and scores the lowest of all our buildings with five out of eight standards of PLACE and building assessment rated as red.  This includes suitability for observation of patients, privacy and dignity, facilities, maintenance and a dementia friendly environment required for providing inpatient care.

We acknowledge that Wigton could easily meet the minimum of 16 beds criteria set.  However, the age, condition and suitability of the building mean that it will require significant investment or replacement in the near future.  The remedial work required to improve this building would cost more than re-providing the building.  The high cost of replacing the building to provide a modern appropriate unit meant that Wigton did not meant the criteria in comparison with other units.

In order to provide safe staffing to care for patients safely particularly in small units Cumbria Partnership NHS Foundation Trust (CPFT) has adopted National Institute for Health and Care Excellence (NICE) guidelines in relation to staffing levels which state that there should be one registered general nurse per eight  patients.

The NICE guidelines are designed for acute trust use, however CPFT has adopted them following recommendations of an independent assessment of our units by staffing expert Keith Hurst.  The findings of the assessment were that the patient group (except for delayed discharges) had a similar dependency to an elderly care ward in an acute trust.  In addition to this finding, the Trust also recognised the isolation of the units with no ability to call for back up, and having sole responsibility for the building and staff on duty out-of-hours.  It was therefore agreed from a quality and safety perspective these staffing levels would be adopted.  The ratio drops to 1-12 during the night.

Our community hospitals operate on a standard of one registered nurse for every eight patients.  We do not believe it is feasible to operate an isolated unit with just eight beds.  This is because they are more vulnerable to closure in the event of staff sickness and it is difficult to release staff for essential training and supervision which puts pressure on our staff working there.

Where beds are consolidated and managed as larger units it creates a better working environment for our staff and the units become more resilient in terms of clinical expertise, offering staff greater opportunity to develop and maintain skills, and offering patients a better service.

Patients from those communities who require a community hospital bed will be able to access one from one of our other community hospitals.

The historic placement of community hospitals has never provided inpatient beds for each community and so the bed base is utilised for the whole population of west, north and east Cumbria, not just the communities in which they are situated, and this approach would need to continue.  Whilst each hospital does take admissions from their local area, they also take a significant amount of admissions from the wider west, north and east cumbria to ensure that the system uses capacity wisely and efficiently.  In 2014/2015 less than half of admissions to community hospitals were from within the postcode town of the hospital.

At the same time, our plans to develop more care within communities will mean less people needing to be in hospital at all.

In reality, the community hospitals have been running with fewer beds for some time due to staff shortages (as indicated below) and we are already managing with fewer beds across all of the sites.  The table below shows beds that have been open over the last 18 months and the bed numbers proposed by the preferred option.

The table below shows bed numbers in each community hospital that are commissioned, currently operate and proposed in the preferred option.

In addition, the direction of travel nationally and locally is to deliver far more care in the patient’s home.  Monitoring supported by internal and external reports shows that at least one third of our patients could be supported in the community, and that there are flow problems preventing patients from moving to the next stage of their pathway or care, particularly where this requires intermediate or community care.

The development of Integrated Care Communities (ICCs) is designed to address this problem, with health and social services working together to ensure patients are cared for in the correct environment, and that community bed admissions are based on clinical need, not filled as an alternative to the correct care package or environment being in place. As a result, fewer beds will be required in the system as a whole.

Half of the money saved through changes to inpatient beds will be invested into the development of ICCs.

The recruitment of staff is a very genuine problem for us; there is a national as well as a local problem in recruiting staff, particularly trained nurses.  The table below shows the number of registered general nurse (RGN) vacancies we had in August 2016.

We have been monitoring bed closures due to staffing issues since 2013 when recruitment difficulties first started to become a problem.  At this time three beds temporarily closed at Wigton Hospital because we were unable to recruit RGNs.  We opened an additional bed at Alston to mitigate against the problem.  The chart below highlights the difficulties we have had during that period of time. In August 2016 we had 24 beds closed due to staffing difficulties.

We have undertaken numerous initiatives to recruit staff to the wards over the past few years.  These include:

• Advertising via NHS jobs including leaving posts open for extended periods of time until applications are received
• Advertising in local media
• Nurse cadet scheme
• Taking nursing students with a view to encouraging them to work for us in the future
• Transferring staff between units when vacancies arise to ensure retention
• Offering nursing students posts prior to completing training so they have guaranteed work
• Recruiting to bank to entice staff into permanent roles
• Working with Erasmus scheme to support nursing student placements from Germany and Italy
• Providing placements for return to nursing candidates
• Attending recruitment fairs
• Working with wider colleagues to develop recruitment strategies

We have been successful in recruiting some staff, however we have also experienced retirements and we remain understaffed overall.

A travel analysis has been completed against all of the options and, although it is not possible to make changes with no impact on travel, option 1 has the least impact overall.  It is acknowledged for Wigton particularly that this will increase travel time for patients and carers using their own transport.  However we must remember that the future aim is to have as few people as possible in hospital and for a short period of time – unlike the current system where patients can spend more time in community hospitals than they need to.

National evidence shows that 10 days in hospital for someone over the age of 80 leads to the equivalent of 10 years of muscle ageing, reducing people’s mobility and independence and so it is not good for patients to be in a hospital environment when they do not need to be.  The elderly, who are often in a hospital bed longer than needed, are then no longer able to return home but instead get discharged to long term care when it was not previously needed.

Claire Molloy, the chief executive at Cumbria Partnership NHS Foundation Trust is currently meeting with representatives from each of the community hospitals and the League of Friends to look at proposals that have been made by the group for the future of the hospitals.  This piece of work is exploring possible solutions that the League of Friends, local GPs and staff have proposed.

Although this is a separate piece of work to the Success Regime consultation process, we will feed the outcome of this work into the consultation process.

The new community hospital model will require less staff.  However, we are already starting at a point where we have a large number of vacancies across our units and we know that in areas where beds are lost there will be reinvestment back into the community which will lead to more jobs in the community.  We will make every effort to retain all of the staff affected by the proposals, working with them individually to provide appropriate redeployment opportunities to suit their needs.

This will follow the approach we took when we closed the 14-bed unit at Reiver House in Carlisle and moved the staff into the Hospital at Home service.  This included supporting two members of staff to drive so that they could work in the community.

The proposals relate to community hospital inpatient beds only.  The consultation does not propose to change the wide range of other services provided from the community hospitals.

The preferred option will save £2m over five years with half of that (£1m) being reinvested into ICCs.  After the reinvestment there is therefore a relatively very small saving of around £1m annually from 2021/22 onwards.  Whilst this will help with the local health economy deficit, it must be remembered that the main reasons for the changes to the community hospitals are the long term stability of the service and safety of patients and staff.

There is a vibrant future for all of our community hospitals regardless of whether they have inpatient beds on site.  As we work with our communities to develop ICCs Communities, it is our ambition to utilise this space to provide services needed by the local community, with the community hospitals acting as hubs from which to co-ordinate the health and wellbeing needs of the population.

Re-ablement is a term describing short-term intensive services which seeks to restore maximum independence to those in a period of recovery from illness or injury

We have sought advice from the National Stroke Tsar (Professor Tony Rudd) and from both the Northern and North West Clinical Senates (senior clinicians providing independent opinion to regional Trusts). There is unanimous opinion from these experts that a single HASU as part of a wider stroke pathway including rehabilitation is the best model for Cumbria.

We have also considered a range of research including some of the early research evidence in relation to HASUs in London as well as longer-standing evidence in relation to the benefit of stroke units. The table below shows the level of benefit that could be expected compared to outcomes where there is an absence of dedicated stroke service provision. It should be noted that, as we already have a number of elements of excellent stroke services, we will only stand to gain a proportion of these benefits; it is impossible to say exactly how much, although a HASU operating seven days per week against the current five-day consultant provision would be a marked improvement.

We currently run extremely fragile services from two sites. Our current arrangements are reliant on approximately 1.25 full-time-equivalent consultants despite our very best efforts to recruit more. This reliance on two over-stretched individuals is clearly inappropriate, and could result in either or both services ‘falling over’ at any minute.

The recommendations to run a stroke unit – or indeed any discrete specialist service – are that it requires at least six consultants to make it viable. Viability issues relate in part to on-call requirements and weekend cover for A&E, stroke unit/wards and specialist clinics such as TIA (transient ischaemic attack) clinics. The low volumes of patients across two sites also make it difficult to maintain skills. To run a proper unit we need specialist nurse and therapy staff who see sufficient numbers of patients each year to ensure they have well-maintained skills; this is demonstrated to result in better outcomes for patients.

We believe it is entirely unrealistic to think that we could provide HASUs from two sites, seven days a week, and that trying to do so would jeopardise all of our stroke services. After lengthy consideration, our clinicians are of the view that it would our patients would receive better outcomes if we were to concentrate what little resource we have on one site.

This answer is chiefly because of the availability of additional services on the CIC site which can provide extra support where required for the sickest patients. For example, greater levels of weekday and weekend specialist and diagnostic support, substantive cover from acute care physicians, and a larger intensive care and critical care outreach service.

It also makes sense to choose the site closest to the tertiary centre – in our case in Newcastle – as sometimes patients develop difficulties which need more specialist input, for example neurosurgery.

Recruitment of specialist staff, and in particular consultants, will be a major challenge, but we do however believe that we have a far better chance of recruitment by having a clear and agreed model in line with best practice. We are also looking at how we can link up with other providers to provide services through a networked and shared post approach. For example, neurologists from other trusts could deliver a number of aspects of stroke care, and some stroke consultants employed elsewhere may provide weekend support. If agreed following consultation, we would not intend to move to the new model until we have a critical mass of staff secured.

We also need to be sure that we have the right ‘protected’ bed capacity at CIC, which is not always the case at present, but this is an easier challenge to solve than recruitment, and work is already underway to help us achieve this.

We have previously asked colleagues from Lancaster University to undertake simulation modelling to understand the impact of the changes on patients living in the south Copeland area. Based on a population of slightly less than 30,000, we would expect 30 patients to suffer strokes each year, of whom 10 would be assessed for thrombolysis. Of these, three would be assessed as potentially benefitting from thrombolysis. One of these patients would get some level of improvement and every other year one of the two would gain complete independence post-recovery as a result of thrombolysis.

We estimate that more than 20 people per year in south Copeland will receive net benefit from the new arrangements, although it is difficult to quantify precisely how much given that we already have a number of elements of good stroke services.

For patients in south Eden, as there will be no anticipated difference in journey times as a result of the proposals, some of these patients may continue to miss out on thrombolysis because of the narrow window of opportunity for thrombolysis coupled with long distances from hospital (either Carlisle or Lancaster). These patients will, however, benefit from swifter pathways, HASU arrangements and early discharge improvements.

This is an issue which our clinicians have looked at long and hard. The model for local thrombolysis prior to transfer is not currently used in the UK but is used in other parts of the world. However, such a model would not meet current national requirements of stroke best practice and patient safety.

We have listened to patient concerns and propose that, should the proposals be implemented, we take early action – pre-establishment of the HASU - to work with academic partners in exploring the potential for setting up an approved national pilot. This pilot would carefully test the viability of a WCH thrombolysis and transfer model, and potentially other alternatives such as initial assessment – or even potentially thrombolysis - undertaken by paramedics in the ambulance with telemedicine support, in order to offset the impact of travel time delays.

It is, however, important that any pilot does not deplete the workforce necessary for HASU functioning and thus jeopardise its successful establishment.

In the proposals, early rehabilitation and re-ablement are core elements of the stroke pathway. Rehabilitation would continue on both sites where hospital-based care is still needed, but significant strengthening of the early supported discharge service would ensure patients can benefit from the advantages of this as an important part of our plans. This represents a particular improvement in care in the west of the county.

It is also critically important to look at prevention and early detection. Some recent research papers suggest that 90% of strokes are preventable through lifestyle changes such as control of diet and exercise and monitoring weight and blood pressure. Integrated Care Communities and developing health and well-being programmes are designed to enable this type of prevention.

Individuals and communities should also be aware of the warning signs of a possible stroke and know what action to take in calling for an ambulance to enable earliest possible treatment at an appropriate stroke unit/HASU.

It is important that individuals can take responsibility for many of these aspects of their care as these factors can have a far greater impact on reducing deaths and disability from stroke than treatments once at hospital.

West Cumberland Hospital is a comparatively small hospital so it can be difficult for the small team of doctors and senior nurses to support the training of medical staff. In addition, the breadth and volume of cases that are ideally available to support medical training is not always available at a small hospital.

Many training centres are reducing the number of sites that trainees are placed, in order to concentrate training resources. In WCH’s case, this was triggered by the rising number of consultant vacancies which, in turn, reduced the levels of training and supervision available to medical trainees.

Most junior and middle grade doctor posts form part of regional training schemes, with doctors receiving specialist medical training as part of their role. This allows them to progress towards the career goals of becoming a GP, hospital consultant, or some other specialist. Junior and middle grade medical roles where specialist training is not part of the role are less attractive and there are fewer doctors looking for these types of roles. Without the ability to fill training posts, the Trust is reliant on non-trainees and locum doctors, or to look at non-medical alternatives.

In some specialities, UK-wide, there are shortages of doctors at consultant level, particularly so in acute medicine specialities. Furthermore, it’s more difficult to recruit to consultant posts when the junior doctor team is almost entirely composed of locums, which puts the Trust at a competitive disadvantage to others of the UK when it comes to consultant recruitment in acute medicine. This is why the Trust wants to develop a more stable junior and middle grade workforce in acute medicine.

They are clinicians performing a role to high level of clinical skill and expertise. They must be professionally registered, have acquired an expert knowledge base, complex decision-making skills and clinical competences for specific areas of expanded scope of practice. Education must be at a Masters level to meets the education, training and continuing professional development requirements for advanced clinical practice as identified within the national framework. ACPs can be drawn from many professional backgrounds, such as nurses, physiotherapists, paramedics and pharmacists. On completion of training they will be able to work at an equivalent to SHO level and, after more experience and further training, can work at the medical equivalent of registrar level.

All of our clinical staff (doctors and all other staff) are only employed in roles for which they are qualified and assessed as competent. ACPs working at SHO level will have completed a Master’s degree in advanced practice and will have also been assessed as competent to work at that level. ACPs working at registrar level will, in addition, have completed a higher advanced practice course and will again have been assessed as clinically competent by consultants based at WCH.

The physician associate is a new role to the UK. They are health care professionals who have been trained in a similar way to doctors (‘the medical model’) but start training as post-graduate students. They will typically already hold a 2.1 in a medically-related science degree. Their training equips them with the attitudes, competencies and knowledge base to deliver holistic care under defined levels of supervision.

Physician associates are already widely recognised as part of the clinical workforce in the USA, Canada, Australia, New Zealand and the Netherlands, where research has shown that as part of the wider team they “provide comprehensive, co-ordinated care which enhances the patient’s journey”.

In response to the shortage of doctors in a number of specialities such as emergency and acute medicine, elderly care/rehabilitation and general practice, the appetite for introducing physician associate roles is growing steadily across all health care sectors in the UK. On qualification, physician associates will perform a role similar to that of a first year house officer doctor.

All staff must be suitably qualified, experienced and assessed as competent and, in common with other clinical staff, will receive professional supervision and mentorship, and regular appraisal. Staff are encouraged to raise any concerns that may have through these mechanisms.

NCUHT also has the following systems in place, which are able to monitor patient safety, service quality, untoward incidents, and patient opinion of standards of care:

• Like all NHS trusts, NCUHT has extensive incident reporting systems and processes to allow staff to report any incidents, or near misses of concern, so that swift action can be taken. Action taken and learning is fed back to teams, and trends are also monitored.

• Patients and relatives’ complaints are closely monitored for safety issues and specific trends.

• The Trust conducts staff surveys.

• The Trust conducts ‘Friends and Family’ surveys to ensure that the quality of patient experience is understood and kept at a high standard.

• Mortality and morbidity information is subject to regular review.

Far from running down services at West Cumberland Hospital (WCH), we are seeking to expand elective services. The change in service delivery has already allowed staff in WCH to concentrate on developing specific skills in managing patients with multiple complex problems and in maximising their rehabilitation. The cost savings come from using resources more efficiently, avoiding the need for patients to seek what may be unnecessary – or at least less cost effective – treatment elsewhere.

There is wide variation across the country with some areas successfully managing patients to a much greater extent through the use of much better joined up pathways without the need to refer to hospital. These are the sorts of models we intend to replicate locally through our new elective pathways and delivered by our Integrated Care Communities.

Reducing the need for some traditional outpatient appointments through better community-based management, as well as altering how we deliver those that are still required, frees up time and allows clinical staff to concentrate on delivering more surgical procedures, enabling waiting lists and waiting times for operations to be reduced.

Re-locating clinics from Cumberland Infirmary in Carlisle to other sites will make appointments more accessible for patients and allow the space to be used for more efficient urgent or particularly complex care which should be the prime focus at the Cumberland Infirmary.

As part of concentrating high risk elective and emergency surgical care to the Cumberland Infirmary site, there has been an inevitable concentration and focus of 24/7 specialist resource on that site as well. This is necessary to realise the improvement in outcomes centralisation is expected to achieve. This has required a re-configuration of resource at WCH.

Currently at WCH there are trained surgical nurse practitioners, middle grade anaesthetists and physicians on site 24 hours a day, supported by consultant anaesthetists and clinicians no more than 30 minutes away. In addition, there are daytime on-site consultant surgeons and anaesthetists seven days a week. This level of cover, along with robust escalation and transfer policies, makes WCH a safe place to undertake all but the highest risk procedures.

In developing plans to improve services we used guidance issued by specialist organisations such as the British Orthopaedic Association and the Royal College of Surgeons of England. We liaised with other high performing trusts and have consulted with clinical experts and with national organisations such as NHS England.