Torrington Health Centre

Report: High Bickington Engagement Questionnaire

February 2024

Contents

Executive Summary……………………………………………………………………………………………………….. 2

Introduction…………………………………………………………………………………………………………………. 3

Background to the Engagement………………………………………………………………………………………… 3

Engagement Methodology………………………………………………………………………………………………. 3

Results………………………………………………………………………………………………………………………… 4

Effects of previous closure and service reduction of High Bickington branch surgery……………… 5

Anticipated effects of permanent closure of High Bickington branch surgery………………………… 5

Other thoughts for consideration………………………………………………………………………………… 5

Correspondence…………………………………………………………………………………………………………………………………5

Rationale for seeking permanent closure……………………………………………………………………………. 6

Next Steps…………………………………………………………………………………………………………………… 6

Appendix 1 Covering Letter to Patients………………………………………………………………………………. 7

Appendix 2 Engagement Survey……………………………………………………………………………………….. 16

Appendix   3 Raw Results………………………………………………………………………………………………….. 17

Comments…………………………………………………………………………………………………………………. 18

Monitoring Questions…………………………………………………………………………………………………… 21

Executive Summary

This report details the results and recommendations following our engagement work which sought the views of patients with regards to the past reduction of services at High Bickington branch surgery and the impact of a potential permanent closure.

We conducted a patient and stakeholder engagement during February 2024 to identify any adverse effects that were due to the reduction in services and that may arise in the event of a permanent closure.

Following completion of the patient and stakeholder engagement and a review of the feedback received, Torrington Health Centre is applying for the permanent closure of the High Bickington branch surgery.

The results of the survey indicated a lot understandably strong feeling relating to the ongoing presence of a branch surgery within High Bickington. The main theme from the feedback provided was of convenience for the residents of High Bickington. Given the constraints on the primary care workforce, the limitations of the premises and the introduction of more modern methods of primary care delivery it is becoming increasingly difficult to continue to deliver healthcare services from the High Bickington Branch.

If the application to permanently close High Bickington branch surgery was accepted, we would be seeking to formalise this with all relevant parties and for this to be communicated to patients and stakeholders as soon as possible. Since Torrington Health Centre is not applying to alter the current practice boundary, all patients will continue to be registered with Torrington Health Centre, with their usual GP, unless they chose to register elsewhere.

Torrington Health Centre can provide comprehensive primary care services to all patients from the main practice site at Great Torrington. Alternatively, patients will have the choice to register with other GP practices, such as Litchdon Surgery, which is situated in Barnstaple and is accessible by public transport.

In the interim, because of long standing difficulties to provide High Bickington branch surgery with medical staff, reduced medical services will continue at that site.

Introduction

Torrington Health Centre is a GP practice covering Great Torrington and surrounding villages. There are approximately 5200 people registered with us and we operate from two sites:

• The main site is located in Great Torrington
• A branch site is located in High Bickington

Torrington Health Centre is open for five days per week, has eight clinical rooms and is a purpose-built facility with access to a broad range of primary care services including doctors, nurses, and an extended specialist team e.g., pharmacists and physiotherapists. We are a training practice, and we teach and supervise medical students. We are members of Torridge Health Primary Care Network, along with Castle Gardens Surgery, Bideford Medical Centre, Northam Surgery, Wooda Surgery and Hartland Surgery.

High Bickington is a branch surgery site; it is operated as a single-handed GP practice providing pre-booked appointments for three mornings per week. People who require a face-to-face GP appointment at other times, same day services or who require services from the practice nurse or those of the wider primary care team, currently have to make an appointment and travel to Torrington Health Centre (8 miles away). The building is owned by the partners of Torrington Health Centre.

Prior to the pandemic, there were five GP clinics and four nurse clinics per week at the High Bickington branch surgery, totaling 15hrs. From March 2020 until August 2021, as a result of the COVID-19 pandemic, services at the branch surgery were suspended with all care provided from Torrington Health Centre. This was to ensure safe levels of service were maintained for our patients and to provide a safe, COVID-secure environment for staff and patients, which we were unable to offer at High Bickington. Since August 2021 reduced services were restarted at the branch surgery. Currently, the surgery is open for three GP clinics per week, that is every Tuesday, Wednesday, and Thursday, totaling 4.5hrs. Within the six months leading up to February 2023, 281 patients had face to face appointment at the branch site.

Over the past year, continuing to provide primary care services from the High Bickington Branch has become more difficult. There are three main reasons for this difficulty:

1. Staffing – Prior to March 2020, four nurse clinics per week were provided at the branch surgery. Torrington Health Centre employed a practice nurse who lived in the locality of the branch surgery and worked some of her hours at the branch. After the lifting of pandemic restrictions, when the branch surgery reopened, that member of staff had left. Despite multiple attempts to employs a nurse or health care assistant who would be able to work at the High Bickington branch, we have not been able to find a suitable candidate. Existing practice staff based at Torrington Health Centre have previously provided ad hoc sessions at the branch surgery providing phlebotomy services but do not wish to do this on a more regular basis.
2. Premises – High Bickington Branch surgery is a single story converted stables. The floor area is metres comprising two consulting rooms, a waiting room and WC. The property is accessed off the High Street in High Bickington. The building has no provision for poorly mobile or disabled users. The single corridor which provides access to the consulting rooms and to the single toilet from the waiting area is too narrow for wheelchairs. There is no dedicated patient parking and no public parking nearby, meaning that use of the surgery is almost exclusively for the patients living within walking distance of the branch rather than patients from the surrounding villages or elsewhere.
3. Modern General Practice Model – Since the introduction of the Network Contract Direct Enhance Service in 2019, the work carried out in primary care and the workforce required to deliver primary care has changed. Currently, the NHS England ‘Delivery plan for recovering access to primary care’ (NHS England 2023) is moving practices towards the Modern General Practice Model which directs practices to focus on the following areas:
   1. see all patient need, by providing inclusive, straightforward online and telephone access
   2. understand all need through structured information gathering
   3. prioritise and allocate need safely and equitably (including continuity of care)
   4. make best use of other primary care services and the multi-professional team
   5. improve the efficiency of their processes and reduce duplication.

NHS England 2023

Historically, primary care was provided by a GP in a face-to-face consultation. Torrington Health Centre now offers a mixture of online, telephone and video consultations along with the more traditional face-to-face consultations. Home visits are carried out by the Torridge Health Primary Care Network Visiting Team, and we are trying to divert doctors away from spending time travelling within our boundary area towards offering additional appointments and prioritising the management of more complex patients who are in greater need of continuity of care.

Maintaining the branch site at High Bickington requires extra administrative resources and planning, and focuses clinical provision towards a limited geographical area rather than allocating services to those who live in other areas within our boundary who may have more pressing healthcare needs.

Patients who access services at Torrington Health Centre have a wider and more comprehensive range of primary care services including practice nurses, pharmacists, nurse practitioners, health and wellbeing coaches, mental health practitioners and physiotherapists. These services are not available at the High Bickington branch surgery and due to the limitations of staffing and the building, as discussed previously this is unlikely to change.

 Background to the Engagement

We undertook a patient and stakeholder engagement, the purpose of which was to evaluate how patients had already been affected by the reduction in services and understand the potential impacts a  permanent closure would have on patients using the High Bickington branch surgery.

 Engagement Methodology

We actively sought feedback from those patients registered with Torrington Health Centre who had used High Bickington branch surgery in the last 6 months and from those patients who lived in the locality of the branch surgery. The number of patients who had used the surgery during that time was 278. We invited those patients to take part in the survey either by using text and email if we had consent to do so, or otherwise by letter.

We also made the survey available online on our website and on Facebook. Printed copies were available at the High Bickington branch surgery and at our main site in Great Torrington. We advertised and provided links to the online survey on social media, on our web site and via Healthwatch Devon.

We also directly approached several stakeholders. These included our patient participation group, the High Bickington Parish Council, the High Bickington Parish Nurse, the Local Medical Committee, and our local MP. Devon ICB Communications Team sent an information pack to statutory bodies.

The survey questions were created with the support of the Devon ICB Communications Team and validated against other similar surveys used within the Devon area. Online surveys were created using Survey Monkey and printed versions were produced within the practice. Online survey results were collated automatically by Survey Monkey and completed paper surveys have been stored within the practice with the data uploaded to Survey Monkey for interpretation.

Summary of Results and Commentary

A total of 283 surveys were returned, 190 online and 93 received in printed format. A copy of the raw survey results in graph form is at Appendix 3. A copy of all the written comments is available electronically if required. What follows is a summary of the results and commentary.

Question 1

Which of the following best describes you?

Out of 279 responses (4 responses did not answer this question)

 Question 2

What effect, if any, has the temporary closure and the reduction in services at the High Bickington branch surgery had on you?

Out of 274 responses (9 responses did not answer this question)

Commentary – We sought to ascertain the effect of the service reductions on patients and whether this was positive, negative or neither positive nor negative. The response of negative effect or neither positive nor negative effect equated to 87.6% of the total who responded. Respondents to this question were asked to state why they had responded and themes emerging were that the branch surgery is very convenient, can be accessed on foot and negates an otherwise long journey to Torrington Health Centre. Most people reported travel to Torrington as a significant problem, with a lack of public transport, difficulties in access for patients without vehicles, challenges for regular users (such as collecting prescriptions) and costs associated with patient travel in financially challenging times.

Commentary – We appreciate that travel to Great Torrington, even by car is a long journey (16 miles return trip). It is also clear that public transport provision between High Bickington and Great Torrington is unsuitable for patients needing to attend appointments. We would comment that this journey is already being undertaken by our patients regularly to attend nurse appointments and same-day appointment when required. It is also relevant that the branch surgery was closed for 16 months during the pandemic and even though patients experienced difficulties in accessing the surgery, they were still able to receive effective healthcare in the same manner as patients living in other villages within our boundary who have never had the benefit of a branch surgery. In mitigation, patients can avoid travel by choosing to consult remotely where clinically appropriate. For dispensing patients, the practice is willing to support group medication collections from the dispensary enabling multiple prescriptions to be picked up by a named person, thereby reducing travel requirements. Dispensing patients might also choose to switch to an online prescription delivery service. This can be daunting, particularly for older patients who are not familiar with computer systems. The practice can support these patients with our social prescribers, who have already helped set up and instruct patients how to use online services.

Question 3

If High Bickington branch surgery closed permanently, would you be adversely affected by this, and if so, how? Out of 276 responses (7 responses did not answer this question)

We sought to obtain feedback on whether patients felt there would be any adverse effects if High Bickington were to close permanently. A total of 82% said they would be adversely affected. Respondents to this question were asked to state why they had responded and themes were similar to the responses to Q2. Specific comments related to the convenience of being able to walk to the branch surgery and to the potential adverse effects on the environment due to increased car journeys needed to attend appointments in Torrington.

Commentary – We acknowledge that getting to Torrington is much less convenient compared to walking the High Bickington branch for those patients who live within walking distance. It is not economically, or environmentally sustainable to maintain a branch surgery for exclusive use for patients within walking distance of a rural surgery. The 278 patients that were seen at the High Bickington branch in the 6 months prior to February 2024 represents just over 10 patient journeys per week (or 160 patient miles per week for a round trip). We are not happy contributing to any need for increased vehicle use but this represents a relatively small increase and is offset by not needing to heat, light and maintain the branch surgery building which is used for 4.5hrs each week.

Question 4

Is there anything else you think we should consider about the future of High Bickington branch surgery?

Out of 249 responses (34 responses did not answer this question)

81%     yes

11%     no

8%       undecided

The final question sought feedback from patients with regards to whether they felt there were any other factors we ought to consider during our review of this engagement. 81% offered further thoughts.

1. Why not develop the existing premises?

Commentary – There is no scope to develop the existing site at High Bickington. The footprint is too small to meet the needs of primary care as a fully functioning surgery. The investment required to provide adequate improvements would be disproportionate given the age of the building, the size of the site and the lack of any parking available. It would require a significant cost to develop this building which we are unable to undertake with no prospect of further staff and to provide service to a small local population

2. What about the needs of the elderly, young families and people who do not drive?

Commentary – We recognize the possibility that certain groups who do not have access to a vehicle will be more disadvantaged. We cannot promise to solve an issue that is intrinsic to rural communities everywhere in the UK. There is now more choice for access to primary care services due to telephone and video consultations, econsultations and availability of extended opening times such as evenings and weekends. The opening hours at High Bickington are currently 0830 to 1000hrs three mornings per week and due to lack of staff, there are no plans to change this in the future. We face an extremely challenging situation to maintain existing services at High Bickington as well as providing services at Torrington Health Centre. It has not been possible to attract and recruit medical staff who are willing to work away from a multi-disciplinary, multi-purpose, fully equipped facility.

Like patients from other villages in our practice area, those asking for or invited to attend face-to-face appointments would drive, use public transport, rely on family and friends, or use one of the community transport schemes. During the pandemic, neighbourhood support networks were set up to provide a wide range of help and services. It is envisaged that these networks will continue to support those who need transport.

3. What about people who have moved to High Bickington because it had a doctors’ surgery? What about future development of the area with 50 new houses proposed?

Commentary – We understand the obvious disappointment that a service is being removed from the village. This is not an isolated situation within High Bickington. Within the local area, whole practices have shut (in the case of Shebbear Surgery) and are struggling to stay open (in the case of Lynton Health Centre). We are aware of the potential development within High Bickington, which is a designated Local Centre. However, general practice is also developing, with a move towards provision of primary care remotely and from larger hubs by larger teams of healthcare professionals. This is not a local choice but a reflection of the direction for general practice provided by NHS England.

Monitoring Questions

The monitoring questions were included to assess if certain groups had been or had the potential to be more significantly affected by changes in healthcare provision at the branch surgery.

Age – 73% of respondents were aged 55 and over, which indicated a good response from those patients who are often more frequent users of general practice. When adjusting the results for age, there was no correlation between the age of respondent and their responses relating to the changes in the branch surgery provision.

Ethnicity – respondents described themselves as 93% White British, with 1.1% Mixed heritage with 5.4% preferring not to say. When adjusting for race, there was no evidence that ethnic minority patients perceived worse effects relating to the changes in the branch surgery provision.

Gender – 35% were male and 60% were female with 5% preferring not to say. When adjusting for gender, there was no evidence that any group of patients perceived worse effects relating to the changes in the branch surgery provision.

Sexual orientation – 88% were heterosexual, 0.4% described as a gay man, 0.4% described as a gay woman and 0.4% described as bisexual. 11% preferred not to say. When adjusting for sexual orientation, there was no evidence that any group of patients perceived worse effects relating to the changes in the branch surgery provision.

Disability – 79% described themselves as having no disability, 10% had a physical disability, 3% had a hearing impairment, 1% had a visual impairment, 0.75% had a cognitive disability, 1.9% had a mental illness and 4.5% preferred not to say. When adjusting for disability, there was no evidence that any group of patients perceived worse effects relating to the changes in the branch surgery provision.

Religion – 62% were Christina, 0.4% were Jewish and 37.6% stated no religion or preferred not to say. When adjusting for religion, there was no evidence that any group of patients perceived worse effects relating to the changes in the branch surgery provision.

Correspondence

We also received correspondence from the following stakeholders:

• Devon County Council representative, Andrew Saywell had a telephone discussion with our Practice Manager. Councillor Saywell wished to understand the background to the challenges facing the branch surgery and talk through all the options available.

• Parish Council representative, Alan Matthewman, raised a series of concerns. These have been addressed below:

Response

1. Circulation of surveys. Online and paper copies were provided according to the methodology described previously. We feel that the total number of returned surveys was a good reflection of the relevant population. Some have commented that they did not receive the survey in a timely manner, which is the reason why we had a 1 month survey period to enable completion and submission.  We tried to encourage completion of the online survey for ease and environmental reasons, but the return rate of  93 paper surveys suggests that some people wished to use these instead.
2. Decline in use. The information leaflet did not aim to describe a decline in use. It provided the previous and current hours provided at the branch surgery as an illustration of our increasingly limited ability to provide staff. We apologise if this was misconstrued.
3. Difficulty of travel to Torrington. This has been addressed above in the commentary to the survey.
4. Disabled access. Neither the building nor the toilets are accessible within modern standards. We have previously investigated the cost and time involved in making adjustments to the existing building. We appreciate the offer of support from the village to facilitate these. However, this does not increase the availability of staff or the lack of parking and the changes in general practice, which are also relevant to our decision.
5. New housing. We are aware of a yet unapproved application for 50 new houses. This is reflective of wider development throughout our practice area. In reviewing the North Devon and Torridge Local Plan 2011 for High Bickington , policy HBK01 (c) indicates a provision for 0.6ha for a doctor’s surgery at the land south of Little Bickington Lane, intended within the first phase of development. This recognized the unsuitability of the current branch surgery. This area has since been developed with housing and allotments. At the present time, even if new land became available, Torrington health Centre is not able to develop and build a new surgery.
6. Parking . We understand that the majority of patients walk to the surgery. A map survey of our patient population indicates that 427 or our patients live within ½ a mile (walking distance) to the branch surgery. We are not able to continue providing this service to such a small patient group, which is using disproportionate time and resources which are being deprived from medically high need patients within other areas of our practice boundary.

Rationale for seeking permanent closure

Since the pandemic, primary care is under increasing pressure. Practices are expected to be open longer and offer a wider range of services from a multi- disciplinary, professional clinical team within a large, modern health centre environment. The requirement to book and attend a face-to-face appointment with a doctor is no longer the only choice for patients.

The modern workforce expects to be housed in a multi-disciplinary environment with a safe, effective, and high-quality range of equipment and facilities; supported with clinical supervision and education. The premises at High Bickington does not meet any of these standards, nor could it in the future. Furthermore, the provision of face-to-face consultations at the High Bickington Branch Surgery reduces the overall provision of services by Torrington Health Centre due to the lack of parking at the branch site and the travel time required between sites.

We appreciate that the potential closure of a GP branch surgery that has provided care to generations of families over many years will cause concern and anxieties. However, if the proposal was to be accepted then we would seek to provide assurances to patients as soon as possible to support a smooth transition so that they can continue to receive high quality patient care at Torrington Health Centre.

Following the results of our engagement process with patients and stakeholders, we cannot find any substantive reasons why we should not proceed to close the High Bickington branch site.

Next Steps

We will submit our findings to Devon ICB with an application to close the branch surgery at High Bickington. Existing patients can choose to remain with Torrington Health Centre or register at other surgeries within the area of their choosing.

We would like to thank everyone who took part in this engagement.

Appendix 1 Covering Letter to Patients

15 January 2024 Dear Dear Patient,

We are seeking your feedback on High Bickington Surgery, High St, High Bickington, Umberleigh EX37 9AX, branch site of Torrington Health Centre, New Rd, Great Torrington, Torrington EX38 8EL.

We are keen to hear your feedback and experiences following the reduction in services of the High Bickington branch surgery since March 2020.

Prior to the pandemic, there were five GP clinics and four nurse clinics per week, at the High Bickington branch surgery, totaling 15hrs. As a result of pressures arising from the COVID-19 pandemic and medical staff shortages, services at the branch surgery have been reduced. Currently, High Bickington branch surgery offers three GP clinics per week, totaling 4.5hrs. Full general practice services are available to you at our main site, Torrington Health Centre, in Great Torrington.

The limited service at High Bickington has been under review since the pandemic, and we want to understand the impact that this has had on people in High Bickington and the surrounding areas.

We also realise that the building isn’t in line with modern healthcare facilities.

Therefore, we want to hear from people in High Bickington and the surrounding areas who have previously used the branch surgery. We also want to hear from any High Bickington residents, who are registered with the surgery, about the effect on a possible option to permanently close the branch surgery.

With this in mind, we have attached an engagement document detailing the current position, as well as a questionnaire to provide you with an opportunity to share any thoughts or feedback you might have as a recent or potential user of the branch surgery.

Please do not hesitate to contact us if you have any questions relating to the documents enclosed. The best way to do so is to email the practice at:

d-icb.thc@nhs.net

Yours sincerely

Nikki Down

Practice Manager

Appendix 2 Engagement Survey

Torrington Health Centre

Questionnaire

Monitoring Questions

To help us understand the needs of different people, we do ask for some additional information about you. You do not need to answer these questions, but if you do, it helps us to provide a more accurate picture of the needs of those people responding to this survey.

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