This document is available in large print and as a summary form (including Easy Read format). If you would like a copy please use the contact details below.

You can tell us what you think about these proposals by:

Completing the online survey which you can find online here
Request a paper copy by emailing: engagement.morecambebayccg@nhs.net
Call Morecambe Bay Clinical Commissioning Group (CCG) on 01524 519369
Request a paper copy by writing to:
Communications and Engagement
Morecambe Bay Clinical Commissioning Group
Moor Lane Mills
Moor Lane
Lancaster
LA1 1QD

Please tell us your views no later than 23:59 on 31^st December 2021.

Foreword

I am Geoff Joliffe, I’ve been a GP in Morecambe Bay for 36 years, based in Barrow-in-Furness, and I am chair of the Morecambe Bay Clinical Commissioning Group.

In Morecambe Bay, the NHS, together with our partners in Social Care and the Third Sector, have made a commitment to improving health in Morecambe Bay in our Better Care Together strategy. In it, we set out our aims to provide care closer to home, develop services that mean patients are only admitted to hospital if it is essential and use technology to ensure our care is fit for the 21^st century.

The way that we deliver healthcare has changed substantially in the past ten years. We know that people mainly prefer to stay at home unless it is absolutely necessary to be in a hospital setting. However, is it not always practical or possible to stay at home unless the right services are available to support you and your family.

This consultation, therefore, considers the future of how the community services such as district nursing and therapies work, as well as the community beds based at the Langdale Unit at Westmorland General Hospital in Kendal.

During the COVID-19 pandemic, we moved staff around to work differently and temporarily closed the community beds because it was difficult to keep them safe.

We now need to decide what to do next and we are keen to receive your views and ideas to help us improve how we deliver community-based care for the people of South Lakeland.

This document describes how things have been for the past 14 years and four options for how we could deliver this care in future.

We look forward to hearing from you.

Dr Geoff Joliffe

Clinical Chair, Morecambe Bay Clinical Commissioning Group

What is this consultation document about?

The NHS cares for people throughout their lives, through family doctors (GPs), local and specialist hospitals and community teams, and a range of services in between.

This consultation is about how we most effectively deliver step-up and step down care for adults who need it. In Morecambe Bay, the NHS runs this type of service out of three sites: Langdale Unit at Westmorland General Hospital in Kendal, Abbey View on the Furness General site in Barrow in Furness and Millom Hospital in Millom. This consultation relates to the community beds at the Langdale Unit on the Westmorland General Hospital site.

The way that these NHS services are offered in the future may influence the way in which the space in Westmorland General Hospital in Kendal is used.

What is step-up and step-down care?

At Morecambe Bay Clinical Commissioning Group (CCG), one of our roles is to work with our partners to provide healthcare for people who need more support than can currently be provided by GPs or district nurses but don’t need to stay on an acute hospital ward.

Step-up care

You may receive step-up care if you are unwell at home, but not so sick that you need to be admitted to hospital. For example, if you have an infection or have fallen, you may need some extra nursing support because you’re unable to look after yourself, especially during the night.

In these circumstances, there are different types of step-up care that the NHS and Adult Social Care can provide to help you get better.

Depending on your condition, you may have regular nursing, therapy and care support so that you can safely remain at home. Or, you might move from home to a nurse-led ward where you can receive the care you need to recover.

Step-up care is only intended to be a short-term solution, and the nursing team would put together a plan to help you return home as soon as it’s safe for you to do so.

Step-down care

When recovering from a stay in hospital, you may no longer need treatment on a hospital ward, but you might still need to rehabilitate and rebuild skills to look after yourself before you are ready to go home.

This is when you may receive step-down care.

You could be stepped-down from an acute hospital bed, like Royal Lancaster Infirmary or Furness General Hospital because:

You fell and fractured your hip and are still recovering, or
You were in hospital for other surgery, or
You’ve had another illness, such as a stroke, that required a hospital stay

In these circumstances you might stay on a community ward, where nurses, physiotherapists and occupational therapists can help you with rehabilitation, and put together a plan so that you can return home safely.

Doctors might visit community wards at regular times, but tend not to be based on the ward because patients’ conditions are usually stable and predictable by this point in their recovery.

This kind of care is also known as Intermediate Care; there is an expectation that the NHS and Adult Social Care work closely to ensure that their area has a service offer to meet the needs of the local people. Often, Intermediate Care services are jointly funded by the NHS and local County Council. In many areas across the country, County Councils take the lead on commissioning accommodation that is an alternative to home.

Caring for local people

There are a number of NHS organisations that work together to provide health and social care for people living in Morecambe Bay, which includes South Lakeland:

Morecambe Bay CCG - which plans and buys services for people living in the South Lakeland area - came into being on 1 April 2017 and encompasses the boundaries of the former Lancashire North CCG and the southern region of Cumbria CCG.
Through its community teams and hospitals, University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT) cares for people living in the Morecambe Bay Area.
Lancashire and South Cumbria NHS Foundation Trust (LSCFT) provides mental health care in the Morecambe Bay area.

Cumbria County Council (CCC) works closely with NHS services to provide care.

There are also some care organisations that are not part of the NHS but have contracts with or work alongside it. These include St Mary’s Hospice in Cumbria, St John’s Hospice in Lancaster, and a range of voluntary and community services. Family doctors (GPs) also have contracts with the NHS and are usually the first point of contact and provide main medical care for most patients.

Services provided in our community

UHMBT provides community nursing and therapy services across South Lakeland. This includes district nurses, community physiotherapists, podiatrists, speech and language therapists and some multi-disciplinary teams who work with people with conditions such as stroke or respiratory diseases.

These services take referrals from GPs and from hospital consultants. We do not have as many staff working in the community in South Lakes as there are in other parts of the country and this can sometimes be a problem.

Services provided at the Langdale Unit

The Langdale Unit at Westmorland General Hospital (WGH) was opened in 2008 to provide step-up and step-down care. It was set up to care for people who needed treatment by a nurse, or an advanced clinical practitioner, such as a senior nurse, physiotherapist or pharmacist.

Originally, there were two wards with a total of 56 beds. Over time, these were reduced to one ward with 28 beds for a number of reasons including difficulty recruiting enough staff.

The medical support to the ward was via doctors working in the Kendal Urgent Treatment Centre which is also on the WGH site, as well as Cumbria Health on Call which provides out-of-hours healthcare to people in Cumbria, which gave clinical oversight overnight.

From April 2019 to March 2020, 416 people were admitted to the Langdale Unit. The average number of days that people remained there was 22 days. This amounts to about £6,300 per person, per stay.

We know, by talking to clinicians, patients and caregivers, that hospital isn’t always the right place for patients to recover and regain their independence.

The Langdale Unit is laid out like a hospital ward and does not have facilities such as a kitchen or day room for patients where people can make their own drinks and snacks.

This means that older people can lose mobility and the ability to care for themselves during a stay in hospital.

Instead, best practice guidance in the care of older people by the British Geriatric Society shows that care should be delivered at or as close to home as possible, enabling older people who are frail or live with other conditions to stay in or return to the comfort and familiarity of their home as quickly as possible.

Impact of COVID-19

The Langdale Unit has been closed temporarily since July 2020 so that Westmorland General Hospital could offer urgent planned surgery during the COVID-19 pandemic.

From the start of the pandemic in March 2020 to the temporary closure in July, less than 25 per cent of the beds were occupied by patients.

This temporary closure has allowed us to try new ways of working. This meant that we were able to expand our community nursing, Rapid Response service and pilot a Frailty Co-ordination Hub - services that enable older people to remain close to their homes and communities and avoid unnecessary hospital admissions.

The future of the Langdale Unit

Each of the four options for delivering community care in South Lakeland would have an impact on the services that are delivered from the Langdale Unit.

Options one and two would see the Langdale Unit be reopened (28 beds for option one, or in part, to eight beds for option two) as a community ward.

In options three and four, care would be delivered in the community (with additional beds in care homes or community accommodation, in the case of option three).

In these two options, the Langdale Unit would no longer be used as a community ward and would instead free up valuable ward space to enable expansion of services that can only take place on a hospital site such as recovery following planned operations.

Where would local people like to be cared for? Results of our 2019 engagement exercise

From September to December 2019, we talked to people in Morecambe Bay about where they would like to be cared for if they needed step-up or step-down care.

During this time, 270 people responded using our questionnaire and we spoke to 105 people during face-to-face meetings held across South Cumbria.

Sixty-three per cent of people who responded said that they would prefer to receive intermediate care at home, rather than be admitted to a community bed.

However, people were keen to let us know that they would need the care and support to enable them to stay at home – like help with cooking, shopping and personal care – and that there needs to be better communication between organisations and teams. The full report of findings is available online here.

Options to redesign step-up and step-down care

Having described how step-up and step-down services were delivered before the temporary closure of the Langdales, the next section describes four potential options for delivering these services.

The overall budget is £3 million pounds. This is the cost of running the Langdale Unit. All four options cost the same amount of money but deliver different things.

All four options are possible but will take some time to become available because of how services have changed during the COVID-19 response.

People who use the services

Any adult registered with a GP in South Lakeland would be able to use the services described in the following options

Option one

Reopen the Langdale Unit and return to the way care was delivered there before it was temporarily closed in July 2020

In this option, we would reopen the 28 beds at the Langdale Unit, the same number of beds that were available before it temporarily closed.

This option will not include any additional or expanded community services as described in option three because the funding for this will be used instead to run the Langdale Unit.

Number of beds in this option: 28

Approximate number of people this option could care for, per year: 464 patients

This chart shows that the full sum of £3 million pounds remains invested in the Langdale Unit.

A pie chart showing that the full sum of £3 million pounds remains invested in the Langdale Unit.

Things to consider

The existing ward-based multi-disciplinary team will be on hand to care for people during the day, with nursing staff available at all times 24-hours a day, 365 days a year.
There is no extra budget available to invest in additional community services to support people at home.
We know from talking to local people that the care at the Langdale Unit has been excellent and that people feel safe there, however some people have said that they didn’t feel comfortable there.
The Langdale Unit is a nurse-led ward. To be able to open safely, medical cover from a doctor would need to be re-arranged and may not be straightforward due to the current pressures across the NHS and conflicting demands on our already stretched medical workforce.
A review by the North West Utilisation Management Unit (NWUM) in 2017 found that the environment was not fit for purpose as a place to rehabilitate patients who wished to go home.
The 2018 Intermediate Care Bed Based review highlighted that there is no consistent model of intermediate care across the Lancashire and South Cumbria system; it is also complex and difficult for patients, carers and staff to navigate.
In recent years, we know that people on the Langdale Unit had to stay there longer than they needed to because they were waiting for NHS and Social Care to be in place for them to go home.

Option two

Reopen eight beds at the Langdale Unit and use the remaining budget to provide some extra services in the community

In this option, we would reopen eight beds on the Langdale Unit. Most of the budget would be taken by delivering a smaller number of beds due to the cost of keeping a hospital ward open.

We would then spend the remaining money in the budget on expanding community services in South Lakeland to support people in their own homes or the places where they live (such as residential or nursing homes).

Staffing ratios for the type of service delivered on the Langdale Unit is most cost-effective when calculated in units of eight beds.

Number of beds in this option: 8

A pie chart showing that a significant amount of funding would be used in keeping the Langdale Unit open with eight beds. The remainder could be spent on delivering services in the community.

Approximate number of people this option could care for, per year: 133 patients in the Langdale Unit, plus 2,200 patients at home

This chart shows that a significant amount of funding would be used in keeping the Langdale Unit open with eight beds. The remainder could be spent on delivering services in the community.

Things to consider

While there would be some additional services in the community, option two would leave significant costs tied up in estates and facilities in the Langdale Unit and not delivering care and treatment for people in the wider community.
This option does not leave enough budget to bring the staffing numbers up to the levels provided in other parts of the country that are better staffed.
With just eight beds, it would be necessary to set clear criteria for their use to ensure that they are best used.
The Langdale Unit is a nurse-led ward. To be able to open safely, medical cover from a doctor would need to be re-arranged and may not be straightforward due to the current pressures across the NHS and conflicting demands on our already stretched medical workforce.
This option doesn’t give us the best value for money as the overhead costs of running a smaller number of beds will be high and the financial resource that can be released for investment in community services will be insufficient to meet the current and future need.

Option three

Re-distribute full resource into community staffing and a range of complementary services. No community beds on the Langdale Unit.

In this option the Langdale Unit would be redesigned so it is no longer used for community beds. We would seek to use the money released from the Langdale Unit to purchase four beds in an extra care housing setting; this would allow people to rehabilitate in a more domestic homely environment that supports independence. Ward spaces do not compare well with many people’s own homes, so these units would be an easier space in which people can achieve small goals with mobility and self-care that translate better to what might be possible at home.

This releases the greatest amount of money for additional nursing and therapy services working to support people in their own homes or in to Care homes.

This would enable us to recruit 36 additional nurses, occupational therapists and physiotherapists to care for people in their own homes.

The following services could be delivered within option three:

Four end of life care beds – supported by NHS, Social Care & St John’s Hospice staff to look after those who need end of life care, if home isn’t the best place for them to stay.
Four extra care beds - for people who need rehabilitation but who can’t stay at home - perhaps because of poor access or because they need more support.
Additional resources to General Practice.
A falls prevention service.
Additional therapists in the community to help people to regain their independence after a fall or surgery.
Funding to start a community intravenous (IV) therapy service so people who need medication directly into a vein can receive it without needing to go and stay in hospital for the length of time that they need this.
Enhanced community teams such as Rapid Response and District Nurses, providing extra capacity for the night team.

In recent years, our local services have supported many people dying in their usual place of residence. Many care homes have developed skills and expertise in this area to enhance these skills further. Our local hospice, who would like to strengthen their presence and support in this area, has provided clinical education to local NHS and care homes and additional support to the population of South Lakeland.

With more people getting healthcare at home, we recognised this can put more strain on family members. Therefore, this option includes some funding for the voluntary sector to provide more support for carers, and funding to ensure that the NHS services work more closely with Cumbria County Council Adult Social Care.

Number of beds in this option: 4 End of Life care beds and 4 extra care Housing beds

Approximate number of people this option could care for, per year: 66 patients in the End of Life care beds, 66 patients in the Extra care Housing beds plus 3,172 patients at home

This chart shows that we would invest most of the budget in recruiting 36 additional staff in the community to help us offer more nurse-led care in people's homes. We would have enough budget to pay for additional beds in the community for end of life care and reablement. We can ring-fence some of the budget for a future community intravenous (IV) therapy service.

A pie chart showing we would invest most of the budget in recruiting 36 additional staff in the community to help us offer more nurse-led care in people's homes.

Things to consider

In this option, the increased team of staff could care for around 3300 patients per year – more than seven times the 464 patients who were cared for on the Langdale Unit in an average pre-pandemic year.
It fits with the NHS Long Term Plan to deliver care closer to home, and best practice in the care of older people, according to a 2021 report by the British Geriatric Society
It allows us to care for the greatest number of people and helps to provide flexible local health services that are more able to care for a growing, ageing population.
It increases funding for the voluntary sector to help them deliver valuable services, such as advice, practical support and befriending.
It enhances partnership working with Cumbria County Council, taking into account the feedback from the 2019 ‘Where would you like to be cared for’ engagement.

Option four

Re-provide all elements of care in people’s own homes.

Option four would distribute the full NHS sum of money into services supporting people in their own homes.

In other areas of the country, County Councils provide ‘Step up: Step down’ accommodation as part of their reablement offer rather than this being delivered by the NHS like it is in South Lakeland.

We have discussed this with colleagues in Adult Social Care in Cumbria County Council and agreed that this option could de-stabilise Adult Social Care in Cumbria because it is not part of their current service offer and may place an additional financial burden on the Council which may not be sustainable.

The following services could be delivered within option four:

Additional resources to General Practice.
A falls prevention service.
Additional therapists in the community to help people to regain their independence after a fall or surgery.
Funding to start a community intravenous (IV) therapy service so people who need medication directly into a vein can receive it without needing to go and stay in hospital for the length of time that they need this.
Enhanced community teams such as Rapid Response and District Nurses, providing extra capacity for the night team.

Number of beds in this option: 0

Approximate number of people this option could care for, per year: 3,172 patients at home

This chart shows that we would invest most of the budget in recruiting at least 40 additional staff in the community to help us offer more nurse-led care in people's homes. We can ring-fence some of the budget for a future community intravenous (IV) therapy service.

Things to consider

When thinking about this option, you may want to consider the following:

There will be no bed-based care in this option; all support will be provided in people’s homes.
This option does not take into account the feedback from the 2019 ‘Where would you like to be cared for’ engagement.
Option four puts the current configuration of Adult Social Care in Cumbria under pressure through increased demand.
Maximises the amount of money we can invest in additional community nursing, therapy and medical support.

Summary of options

A pie chart showing that we would invest most of the budget in recruiting at least 40 additional staff in the community to help us offer more nurse-led care in people's homes.

All four of these options work within the financial envelope of £3 million.

Option one is no change from the provision we have had for the past 12 years.

Option two means that we retain some beds on the Langdale Unit and invest an amount of money in increasing the numbers of staff who work in our community teams.

Option three is a full re-design of the resource to further increase the staff who work in the community and to fund some additional services that we know are gaps in our local area. This includes commissioning 24-hour provision in care homes and Extra Care Housing.

Option four is a full re-design of the resource to further increase the staff who work in the community and to fund some additional services that we know are gaps in our local area. No care home or Extra Care Housing is included.

Options three and four are the best fit and modernise our local service according to NHS guidance as well as aligning to the local Clinical Strategy about how we use our hospitals and community service to best effect. Option four is not a good fit with the current model of Adult Social Care in Cumbria as it puts the current configuration of Adult Social Care in Cumbria under pressure through increased demand.

Objectives of service redesign

The below objectives of the service redesign are mapped against which options would satisfy the requirements.

Value for money - Options 1, 2 and 4 are not value for money and option 3 is value for money.

Follows best practice – ‘care closer to home’? - Option 1 does not follow best practice and options 2, 3 and 4 do follow does practice.

Aligns to system strategy - Options 1, 2 and 4 do not align to the system strategy and option 3 does align to the system strategy.

Aligns to UHMB clinical strategy - Options 1 and 2 do not align to the UHMB clinical strategy and options 3 and 4 do align to the UHMB clinical strategy.

Takes account of ‘Where would you like to be cared for’ engagement in 2019? - Options 1 and 4 do not take account of the 2019 engagement and options 2 and 3 do take account of the 2019 engagement.

Takes account of service reviews and recommendations made by outside bodies? - Options 1 and 4 do not take account of the service reviews and recommendations and options 2 and 3 do take account of service reviews and recommendations.

Case studies

The following case studies give examples of how care can be delivered currently and what might be possible if services are redesigned.

These are based on genuine people that we have cared for recently.

Jenny

Jenny is 82; she has lots of friends in her village who visit her regularly. She also has a dog who she loves very much; Jenny’s daughter comes and walks him every day.

Jenny has Parkinson’s disease and manages at home with a care package of two visits per day, however, following an infection and deterioration in her mobility, Jenny’s care package no longer meets her needs to stay safely at home.

With the existing service:

Jenny is ‘stepped up to the Langdale Unit by her GP for rehabilitation.

On the ward, she is supported by a team including registered nurses, healthcare support workers, physiotherapists, occupational therapists. After assessment by physiotherapists and occupational therapists, Jenny tells staff that she’s anxious about going home to live independently, she is encouraged to be actively involved in her therapy plan and goals that will help build her confidence to go home.

She is reviewed by a GP or advanced clinical practitioner and at the multi-disciplinary team meeting, which involves social care. At this meeting, they agree her rehabilitation plan and any ongoing therapy or care needs that starts on the day of her discharge. This support is delivered by community teams.

While she feels well cared for on the Langdale Unit, Jenny misses her friends, while she is in the ward for four weeks. Buses aren’t great from Jenny’s village so her friends can’t come to visit as often as Jenny would like. She also really misses and worries about her dog that has had to go and stay with Jenny’s daughter.

With the new service design:

Jenny receives ‘step up’ care at home.

Her GP prescribes antibiotics for the infection. The community Rapid Response team is involved and Jenny is nursed at home, with health care assistants visiting during the day and District Nurse visits at night.

An Occupational Therapist does a home assessment and provides a Zimmer frame and a commode to help while Jenny rehabilitates.

Jenny has daily Nurse and Advanced Clinical Practitioners to monitor how the infection is responding to treatment. The team regularly liaise with Jenny’s GP. Her care package is revised to three visits a day.

Jenny works with a Physiotherapist and an Occupational Therapist to set rehab goals, as Jenny has stayed at home she feels more confident about what she can do. A Rehabilitation Assistant supports Jenny to carry out her rehabilitation plan, getting her ready for ‘discharge’ from the service.

Throughout, voluntary sector support is given for shopping.

Having her dog stay with her helps Jenny’s wellbeing and gives her confidence. As she is still at home, all her friends come and visit Jenny at any time.

Peter

Peter is 79 and enjoys gardening.

He was admitted to the Royal Lancaster Infirmary (RLI) after he fell and fractured his hip.

With the existing service:

After his operation, the consultant recommends that he steps down to the Langdale Unit to get support from the Physiotherapists and Occupational Therapists to rehabilitate and build skills and confidence before he goes home. He does this after a ten-day stay in hospital.

After Peter has discussed his goals with the therapists, he works with them to develop a plan and then works every day on these goals with the support of the whole team on the ward.

Before Peter goes home, an Occupational Therapist visits his home to carry out an assessment and identifies that he needs some grab rails in his bathroom which are installed before he goes home.

After two weeks on the ward and Peter’s rehabilitation is completed, he’s discharged home with a package of care.

Peter is away from home for 24 days, but after such a long time away from home, his confidence is knocked slightly and it takes a while to get back into his normal routines.

With the new service design:

After his ten-day stay at the RLI, Peter is discharged directly home with support from Hospital Therapists. Hospital Homecare is arranged before he is discharged.

While Peter is really looking forward to being at home, he is reassured by knowing if he’s not able to manage at home he could ‘step up’ to an Extra Care apartment for a short period to rehabilitate.

On the first day, the therapists assess what support and equipment Peter needs, the equipment is provided on the same day.

Community Therapists visit Peter for the first few days and they develop a rehabilitation plan. As he is comfortable in his own home and in familiar surroundings, he feels more confident in getting back to tasks like cooking and enjoys being able to go out into his garden.

He is also reassured by knowing if he’s not able to manage at home, he could step-up to an Extra Care apartment for a short period.

John

John is 73 who enjoys going to his church coffee morning with the help of his family and friends. He also enjoys baking with his granddaughter’s help.

John is admitted to hospital and diagnosed with an infection in his spine and requires six weeks of antibiotics that need to be administered through a vein twice daily.

This method of administration is called ‘intravenous or ‘IV’ for short and is used when taking antibiotic medication through a drip because a tablet does not have a strong enough effect.

With the existing service:

As it isn’t possible to deliver this in the community, John ‘steps down’ from hospital to the Langdale Unit.

Whilst there, he receives the two infusions of antibiotics per day and has some rehab on the ward.

In all other respects, John is generally well. He gets up and dressed and tries to pass his time doing the crossword. However, he is frustrated about not being at home and misses baking with his granddaughter and being able to go to church and the weekly coffee morning.

John is away from home for a total of 47 days.

With the new service design:

He is referred to the IV Therapy at Home Team after five days in hospital.

John has a tube called a midline inserted before he leaves hospital. This means that the drugs can be administered without the need for a new injection each time.

The IV is administered by Specialist Nurse’s once daily. The level of infection in John’s blood is checked weekly and the nurses update the Consultant Geriatrician in charge of John’s care.

82 doses of antibiotics are administered whilst John remains living at home meaning that he was able to maintain his independence and social life at home, continuing to see his granddaughter and friends regularly.

Where would you like to be cared for in South Lakeland: Consultation Document