Redesigning Inpatient Services in East Sussex Report for: East Sussex Health Overview and Scrutiny Committee

Date:

28/05/21

Version:

v.1

Name of originator/ author:

Paula Kirkland

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.0      Background

 

Improving Mental Health Outcomes is a key priority area for the Sussex Health and Care Partnership (SHCP). While supporting people in the community remains a priority, the SHCP Strategic Delivery Plan also identifies the need for capital investment in mental health impatient facilities to enable single sex accommodation, remove dormitories, and increase therapeutic activity with the aim of reducing length of stay.

 

On 4th March 2021, East Sussex Clinical Commissioning Group (ESCCG) and Sussex Partnership NHS Foundation (SPFT) Trust presented early draft proposals for a change in the way that acute adult mental health inpatients services are provided in East Sussex to the Heath Overview and Scrutiny Committee.  At that meeting East Sussex HOSC confirmed that any proposals that include a relocation of current inpatient services will likely constitute a substantial variation in services and will require a formal consultation.

 

A pre-consultation business case has now been prepared that builds on the early draft proposals and this has been supported by NHS England and NHS Improvement as part of an assurance process. It has also been considered and approved by the SPFT Board of Directors at its meeting on Wednesday 19 May.

 

At its meeting on Wednesday 9 June, members of the East Sussex CCG Governing Body are invited to review and consider the pre-consultation business case (PCBC) for the re-provision of the Department of Psychiatry – Eradicating Dormitories, endorse the proposals and agree that the CCG commences a consultation process with the East Sussex Health Overview and Scrutiny Committee (HOSC), and agree that the proposal should be subject to formal public consultation.

 

The full PCBC and appendices are available on the SHCP Website Homepage | Sussex Health & Care Partnership (sussexhealthandcare.uk)and the PCBC Executive summary is provided as Annex 1 to this report, together with our plans for consultation which are set out at Appendix 2.  

 

2.0   Executive Summary

 

In January 2020, a Case for Change to the way that inpatient mental health services in East Sussex are delivered was developed.  This has informed our engagement to date.

 

The Case for Change provided a baseline assessment of the current state of adult inpatient mental health services in East Sussex, examined current and future demand for services and how this fits in with national, regional and local priorities.  It did not seek to identify any proposals or solutions at that stage but simply to confirm the need for change.

 

This concluded that current adult inpatient provision is no longer fit-for-purpose, does not meet the objectives of Sussex Partnership NHS Foundation Trust’s (SPFT) Clinical and Estates Strategies, is a barrier to staff recruitment and retention and does not enable 'People to feel valued, supported and cared for', a key tenet of the trust’s organisational strategy. 

 

In addition, the Care Quality Commission has reported that, while staff continue to provide high-quality care despite the limitations placed on services, steps should be taken to improve, or remove, outdated dormitory-style wards. The work aligns with wider Sussex developments to eradicate dormitories such as the work taking place in West Sussex following consultation on proposals for that area.

 

National eradicating dormitories programme

 

In response to an invitation to bid, SPFT, supported by the CCG, applied for Department of Health and Social Care (DHSC) capital funding in December 2020 to remove its dormitory style beds and provide sufficient capacity  in modern, high-quality, safe and compliant accommodation.

 

This followed a Government announcement, on World Mental Health Day in October 2020, of additional funding to further support mental health trusts to eradicate out-of-date dormitory accommodation.  This new funding followed the government’s commitment to accelerate investment in health infrastructure, and to level up access to mental health services, so that every inpatient can receive treatment in an appropriate setting. Capital funding has been allocated that allows for a like-for-like replacement of dormitory accommodation in order to:

 

·         enhance the safety, privacy and dignity of patients

·         improve the individual care that can be given to patients

·         enable a reduced length of patient stay in a facility

·         improve patient safety, including better infection control

·         reduce the risk of incidents involving patients or staff, and

·         provide a better environment for patients and staff to support improved outcomes.

 

This re-provision must be complete by March 2024 to meet national timescales for the eradication of dormitories. 

 

SPFT has also been advised that a capital funding application to eradicate dormitories by refurbishing Raphael Ward in the Woodlands Centre at Conquest Hospital, St Leonards on Sea, has been successful. This does not require a change in location and, therefore, does not form part of this proposal.

 

This proposal has been prepared to improve adult inpatient mental health services currently provided at the Department of Psychiatry, Eastbourne, and locate these on to a different site.

 

Our review of local services

 

The CCG and SPFT have reviewed and modelled demand for mental health inpatient services over the period to 2040 and this shows fairly stable to falling demand for working age adults but larger increases in demand for services for older people and people with dementia.  

 

This must be seen in the context of our continued investment in community-based services to support people close to home as well as ensuring these proposals can align to future need so that as funding becomes available, further capital proposals can support a potential increase in capacity for inpatient beds over time.

 

While the capital funding currently available is only sufficient to support a re-provision of existing beds (and this is an important step in improving facilities and eradicating dormitory provision), the proposal ensures that a site development would be able to expand in future years dependent on anticipated demand, changes in population and disease prevalence and the impact of improved community based services.

 

This is a significant opportunity available to East Sussex to support improvements to inpatient services for our local populations and sits within the strategic context of our vision across the Sussex Health and Care Partnership.

3.0   The proposal

Our proposal is to move mental health inpatient services, which are currently based at the Department of Psychiatry in Eastbourne District General Hospital, to new facilities to be built on a different site.

The services could be relocated to

·         a greenfield site next to Mount View Street, North East Bexhill, Bexhill-on-Sea, or

·         a site around Amberstone Hospital, Nr. Hailsham.

The Bexhill site is our preferred option.

If approved, this would be the first phase towards a potential long-term vision to create a leading centre for mental health services on a single ‘campus’, which could, over time, address all our inpatient needs and enable us to keep and attract the best staff.

This staged approach provides an opportunity to benefit from national funding being made available now to remove all out-dated dormitory accommodation - which the Department of Psychiatry has - and replace it with individual rooms with ensuite bathrooms. If the proposals are approved, we would aim to complete the new facilities by the end of March 2024.

 

4.0   How we developed the Proposal

 

We have worked with patients, their families and careers, wider public and stakeholders, alongside our clinical teams and local GPs throughout the development of this programme, specifically engaging in how we have:

 

·         set out the case for change for the relocation and modernisation of the current inpatient adult mental health services currently delivered at the Department of Psychiatry (DoP) at Eastbourne District General Hospital in the context of a wider programme of transformation and improvement

·         described the agreed clinical model for inpatient services in the context of the Trust’s wider service provision and Clinical Strategy and wider national and local drivers

·         worked with stakeholders to inform, develop and evaluate viable options for the redesign of inpatient services in East Sussex.

 

All information gathered in the pre-consultation phase has shaped the development and selection of the shortlisted options and feedback has provided a rich source of information which has been used to further shape and refresh the Equality and Health Inequality Impact Assessment (EHIA).

 

This PCBC describes our case for change, needs assessment, engagement process, development of options, and sets out the scope of the shortlisted options for reconfiguration and modernisation and the associated costs, risks and benefits.

 

5.0   The process of assurance

 

When developing our proposal and the Pre-Consultation Business Case (PCBC):

·         We considered the outputs from engagement with local people and clinicians and used these to inform the PCBC.

 

·         We developed the PCBC with due regard to the CCG’s duties to reduce inequalities and promote integration of health services where this will improve the quality of those services, in addition to ensuring compliance with all relevant equality duties.

 

·         We assessed the impact of our proposal by undertaking a Quality Impact Assessment and an Equality and Health Inequality Impact Assessment to identify any potential negative impacts, and we identified appropriate mitigating actions.

 

·         We assessed our proposal against the NHS Four Tests for service reconfigurations.

 

·         We developed our proposal and associated consultation plans in line with the Gunning Principles to ensure that:

·         local people and stakeholders have information to engage in the consultation to inform our decision

 

·         there is adequate time for people to participate in the consultation and as such the consultation is proposed to run for 12 weeks between 14th June and 6th September 2021, and

 

·         we demonstrate how we have taken account of the responses to the consultation in coming to our decision, by publication of a consultation feedback report describing this.

 

·         We have engaged extensively with NHS England and Improvement (NHSE/I) and completed a rigorous NHSE assurance process in relation to the proposal and our consultation and engagement plans.  This has been underpinned by engagement across our wider Integrated Care System and a shared approach to assurance as we move towards the new ICS infrastructure.

 

A Quality Impact Assessment has been completed and scored highly in terms of a positive impact on safety, experience and effectiveness. The QIA will continue to be developed as the proposals progress to ensure that quality and safety considerations are built into the outcome.  It will particularly support improvement to the therapeutic environment and improve privacy and dignity.

 

The Programme has also completed an Equalities and Health Inequalities Impact Assessment. The EHIA concludes that the proposed changes will have a positive impact on all protected characteristics. The EHIA also indicated that through the design and location, there may be an opportunity to reduce health inequalities through these proposals. The EHIA is a live document and will continue to be developed with the proposals.

 

 

7.0   Conclusion

 

This proposal represents an opportunity to significantly improvement mental health inpatient services in East Sussex.   The CCG and SPFT welcome the opportunity for wider engagement through public consultation look forward to engagement with and feedback from the HOSC.

 

 

 

Annex 1

Pre-Consultation Business Case

 

Reprovision of the Department of Psychiatry, Eastbourne

Eradication of Dormitories

 

 

 

 

 

 

26 May 2021

Version 015

 

 

Executive summary

 

1.1 Introduction

 

This Pre-Consultation Business Case (PCBC) was produced by the NHS East Sussex Clinical Commissioning Group (ESCCG) in partnership with the Sussex Partnership NHS Foundation Trust (SPFT).

 

It proposes to relocate and reprovide 36 Working Age Adult and 18 Older Adult inpatient mental health beds from the Department of Psychiatry (Department of Psychiatry) at Eastbourne District General Hospital (EDGH) to one of two new site options in either Bexhill-on-Sea or Hailsham.

 

In doing so it supports the Government’s Eradicating Dormitories Programme, replacing multi-bed bay accommodation with single ensuite bedrooms and ensures a high-quality modern environment for people using these services. This represents a significant opportunity for East Sussex to improve the inpatient environment and maximise the quality of service provision for local people.

 

1.2 Background

 

The Sussex Health and Care Partnership (SHCP) Strategic Delivery Plan for the Integrated Care System identifies and notes the need for: “capital investment of around £70m for mental health inpatient services in East Sussex to ensure that they are fit for purpose and able to flex to future service developments. This will enable us to eliminate mixed sex accommodation, remove dormitories, and increase therapeutic activity with the aim of reducing length of stay."

 

In relation to this, the Care Quality Commission (CQC) noted in its 2019 inspection report on the Trust’s services that, while staff continue to provide high-quality care despite the limitations placed on services, steps should be taken to improve, or remove, out-dated dormitory-style wards.

 

As SPFT was cited[1] as being one of the five NHS trusts nationally with the highest number of dormitory beds provision still operating, there is a clear and compelling strategic rationale and imperative for reproviding inpatient services currently at the Department of Psychiatry.

 

In response, SPFT and ESCCG established a programme – Redesigning Inpatient Services in East Sussex (RIS:ES) - with the objective of redesigning and improving adult inpatient mental health services and supporting these service improvements with investment in the estate.

 

There are two specific short-term issues that have driven the development of these project proposals now as the first phase of a wider programme of improvement and change for adult inpatient mental health services in East Sussex.

 

The first is that the overall quality of all adult inpatient accommodation delivered across East Sussex by SPFT does not enable 'People to feel valued, supported and cared for', a key tenet of SPFT’s Organisational Strategy, is no longer fit-for-purpose, does not meet the objectives of SPFT’s Clinical and Estates Strategies and is a barrier to staff recruitment and retention.

 

The second is the need to find a new site which is sufficient to enable SPFT to meet longer term capacity needs to support our local population.  This will also enable the longer-term redevelopment plans of East Sussex Healthcare NHS Trust (ESHT) to be delivered, maximising the outcomes for all our patients.

 

Following an invitation to bid, and in accordance with RIS:ES programme objectives, SPFT, supported by the CCG, applied for Department of Health and Social Care (DHSC) capital funding in December 2020 to eradicate its dormitory style beds and provide sufficient capacity in modern, high-quality, safe and compliant accommodation. SPFT was successful in its application for capital funding and the Department of Health and Social Care confirmed a funding allocation of £46.6m for the replacement of the Department of Psychiatry which must be spent by March 2024. 

 

The replacement of dormitory accommodation, which comprises 40 beds in multi-bed rooms in the Department of Psychiatry (as part of an overall complement of 54 beds), with 54 single ensuite bedrooms (18 beds for Working Age Males, 18 beds for Working Age Females and 18 beds for Older Adults) is expected to:

 

 

Improved inpatient accommodation with ensuite single bed rooms configured optimally to enable unobtrusive patient supervision and with provision of improved indoor and outdoor therapeutic spaces will play its part in supporting delivery of the Trust’s Clinical Model. It will maximise the positive impact of inpatient stays as part of a holistic service with a single pathway to community and inpatient services.

 

 

1.3 Need

 

The CCG and SPFT have reviewed and modelled demand for mental health inpatient services over the period to 2040.  Data from the Projecting Adult Needs and Service Information (PANSI)[2] and Projecting Older People Population Information (POPPI)[3] databases have been used to project local growth and prevalence in healthcare need. 

 

This shows fairly stable / to falling demand for working age adults but larger increases in demand for services for older people and people with dementia over time.  This must be seen in the context of continued and increasing investment in community based services to support people close to home, reducing the need for inpatient stays where appropriate, and reducing the length of time people need to stay in hospital.  In addition, these proposals make sure future need is taken into account so that as funding becomes available, further capital proposals can support a potential increase in capacity for inpatient beds over time.

 

This is supported by findings in the 2019 Strategy Unit publication for the Royal College of Psychiatrists Exploring Mental Health Inpatient Capacity across Sustainability and Transformation Partnerships in England[4], which recommends that Trusts with bed persistent occupancy rates above 95% should also consider investing in additional local psychiatric beds as a part of their transformation plans to deliver the NHS Long Term Plan.

 

The capital funding currently available is only sufficient to support a reprovision of existing beds and this is an important step in improving facilities and eradicating dormitory provision.  These proposals therefore concern the replacement and relocation of the Department of Psychiatry and do not entail any change in the number of beds or change in the use of beds. The capacity modelling provides confidence that the 36 Working Age Adult and 18 Older Adult beds to be reprovided under these proposals will definitely be needed in future, and the proposals ensure that a site development would be able to expand in future years dependent on anticipated demand, changes in population and prevalence of mental health conditions and the impact of improved community based services.

 

 

1.4 Engagement

 

SPFT and the CCG recognise the importance of engaging with all relevant stakeholders and listening to feedback that has informed the development of these proposals.

 

Extensive engagement has taken place to date with

 

 

This is further supported by an Assurance Group made up of five Experts by Experience (EBE) to act as a 'critical friend' and provide scrutiny, challenge and endorsement of all communications and patient and public involvement activity.

 

As well as this Group, an Advisory Group of Service User and Staff Governors from Sussex Partnership Foundation Trust is established, again to provide scrutiny and assurance of all involvement activity being undertaken.

 

Early-stage engagement took place between October 2020 and early 2021. During this period, service users, their families and carers, key clinicians and other service leads, and other stakeholders were invited to provide feedback through a range of methods, including:

 

 

Feedback showed that there was broad recognition of the challenges facing inpatient mental health services, and agreement with the vision and priorities identified by East Sussex CCG and Sussex Partnership.  There was also strong agreement about the need to make significant changes and improvements to address these issues. For example, the online questionnaire showed that:

 

 

Initial views on approaches to improvements were balanced between refurbishing and extending existing buildings, and building on a new site (or sites). However, many people felt the Department of Psychiatry at Eastbourne District General Hospital is unfit-for-purpose and should be replaced.

 

There was broad agreement among respondents that improvements to acute inpatient mental health services, currently delivered at the Department of Psychiatry in Eastbourne and Woodlands Centre in Hastings should be prioritised – but there should also be a broader programme aimed at improving all services.

 

Some people felt that, while “bricks and mortar” are important, real improvements to inpatient mental health services will be achieved through better staffing, greater investment, greater coordination with community-based services, improved communications with carers and family, and easier discharge processes.

 

Overall views between refurbishing existing sites or creating a new campus site were mixed, with most people acknowledging the pros and cons of both.

 

Some people expressed very clear support for a new campus site and strong opposition to refurbishing existing sites on the basis that:

 

Others preferred an approach which maintained existing services on current sites, citing:

 

 

Overall, there was a view that any immediate improvements to inpatient services need to be just one part of a long-term and far-reaching programme of changes to mental health services. 

 

Engagement will continue through and beyond the public consultation to ensure that feedback continues to inform this work. 

 

 

1.5 Options

 

Following this involvement activity, an online (videoconference) options development workshop was arranged for a group of ’Experts by Experience‘(EBEs) who had, or continue to have, direct experience of using mental health services in East Sussex and surrounding areas, and members of relevant voluntary and community sector organisations. Three NHS mental health professionals working with service users in East Sussex also attended to answer questions and contribute to discussions.

 

This was followed up by an Options Appraisal workshop, again involving Experts by Experience and other stakeholders, which met to consider a longlist of options and to help reach the preferred option set out in this PCBC document.

 

In addition, a comprehensive site search across East Sussex was commissioned from a local independent chartered property surveyor with the intention of identifying sites that met the following broad criteria to identify all potential available sites:

 

 

Shortlisting considerations comprised:

 

 

Ultimately following a multi-stakeholder option assessment and further detailed due diligence on the shortlisted sites, two viable options remain from an initial list of 17.

 

This shortlisting and assessment discounted:

 

Following this work the shortlisted options were:

 

These sites were all analysed in more depth and:

 

The Bexhill and Hailsham sites were selected as the best options, meeting the criteria established and offering improvement in the short term and flexibility on the longer term.

 

These options would each enable the reprovision of the 54 beds from the Department of Psychiatry and provide an improved therapeutic and physical environment, including better outdoor and therapy spaces. It would also potentially provide the option to be able to accommodate later, incremental developments to consolidate other inpatient mental health services from across East Sussex onto a single site.

 

The conclusion of the options appraisal is that a new build on a new site is the preferred way forward and that this new building can be accommodated in either Bexhill-on-Sea or Hailsham.

 

Bexhill-on-Sea was the preferred site in the options appraisal on the basis that it has a larger, clear site that enables greater flexibility in design and accommodating future phases, it lies between large population centres of Eastbourne and Hastings and is closer to acute hospitals to enable fast transfers for physical care.

 

While the Bexhill-on-Sea site is preferred, both Bexhill-on –Sea and Hailsham are considered deliverable options and are proposed for public consultation.

 

In spring/early summer 2021, SPFT is undertaking a due diligence exercise on both sites to ascertain in more detail the town planning risks and understand better the prevailing conditions of each site that will need to be accounted for when developing costed construction proposals. This information will be used to help inform the selection of the preferred option, alongside feedback from the public consultation and other relevant evidence and feedback including implementation timescales.

 

1.6 Impact Assessments

 

Transport, Quality, Equality and Health Inequalities, and Privacy Impact Assessments have been carried out and are provided with this PCBC.  These have been used to inform the options appraisal.

 

The Equality and Health Inequalities Impact Assessment will be iterated further as part of public consultation in order to ensure all relevant information learned is reflected in our assessments It highlights strong patient and population and workforce data, identifies key service user groups and describes clearly the impact of the changes across the protected characteristics, together with any action required.

 

Overall, the changes are expected to reduce health inequalities by enabling more effective integrated mental health care. It also shows benefits in addressing health inequalities, in particular with regard to access for our populations in the lower socio-economic deciles.

 

 

1.7 Affordability

 

This PCBC demonstrates that the proposals are affordable and supported by appropriate capital and revenue modelling. This detailed financial planning work assessed the financial impact of both site options.  The analysis concludes that redevelopment on both sites, i.e. Bexhill and Hailsham, is affordable to the local health and care system.

 

This is important as it demonstrates the options being taken forward for consultation are sustainable financially.  The plans are supported by the wider Integrated Care System.

 

1.8 The five service reconfiguration tests

 

The proposed service changes meet the four reconfiguration tests and the fifth ‘bed test’ is not applicable:

 

1.       Strong public and patient engagement

 

A Communications and Involvement Oversight Group meets regularly and is supported by an Assurance Group (service users) and Governors’ Advisory Group (including staff representative) which have both established to act as ‘critical friends’.

 

Opinion Research Services (ORS) - an independent social research practice that works across the UK  - has been commissioned to advise on, and independently manage, our patient and public engagement programme.

 

A period of early involvement activity was carried out and completed between October 2020 and January 2021, involving wide range of stakeholders including service users, carers, clinicians and other representative organisations.

 

Engagement in the options appraisal process has been critical to the programme.

 

An interim report setting out findings was completed and made available to all relevant parties, informing next steps.

 

A Communications and Involvement Strategy and Plan is in place to provide the foundations for the formal public consultation which is provisionally scheduled for Monday 14 June for 12 weeks.

 

2.       Consistency with current and prospective need for patient choice

 

For most people using services at the Department of Psychiatry, the clinical model will remain the same, although the ability to deliver this in an improved environment will maximise benefits for local people. However, it is anticipated that there will be improvements in the co-ordination between community, crisis and inpatient services on a single pathway.

 

With most mental health services being delivered in the community, the range of service user choice is unaffected. Also, the proposed changes will have minimal impact on the choices available as there is no change in the number of providers or beds serving the local area.

 

Patients, carers and staff will benefit from higher quality services offering improved privacy, dignity, safety and more and better therapeutic interventions. Patient choice would be improved as the proposed redevelopment offers service users a purpose-built, higher quality, and safer facility from which to receive care than is available currently.

 

3.       A clear clinical evidence base

 

The proposals set out in this PCBC have been generated with significant clinical input which forms the foundation for a clear clinical evidence base. The clinical model of care will benefit from delivery in an improved environment.  The proposals for the new clinical environment have been informed by using a wide range of clinical evidence, including national standards, clinical guidelines and the expert knowledge of stakeholders.

 

Development of the proposals has been overseen by a Clinical Working Group (CWG), made up of clinicians, operational leads, quality leads, business intelligence and commissioners. 

 

Implementation plans will continue to be supported by the CWG to ensure they have a robust clinical evidence base. As a result, the clinical environment will help address current challenges in the delivery of care, meet high service standards and provide the best outcomes for patients.

 

4.       Support for proposals from clinical commissioners

 

The RIS:ES Programme Board is chaired jointly by the CCG/Trust Senior Responsible Officers and includes CCG representatives such as clinical leads.

 

A Clinical Working Group has been established which includes CCG Commissioners and GP Clinical Leads. The GP Clinical Lead represents the Executive Clinical Leadership function for the CCG, and has supported a continued robust primary care engagement strategy.

 

There is a clear plan in place to further engage with primary care representatives in East Sussex and make sure that this voice is incorporated as part of wider engagement and feedback. East Sussex GPs are part of the Primary Care Networks (PCNs) and a PCN Clinical Director has recently joined the East Sussex Mental Health Oversight Board which will offer place-based oversight of this programme of work. 

 

The Communications and Involvement Oversight Group includes leads from both the CCG and the Trust as well as representatives from Healthwatch and East Sussex County Council.

 

The early draft proposals were reviewed by Sussex Partnership Board of Directors and East Sussex CCG

Governing Body and support was given to progress the Programme on that basis.

 

5.       Bed closures

This test is only applied where the proposal includes plans to significantly reduce bed numbers. The proposals re-provide the 54 inpatient beds currently at the Department of Psychiatry in Eastbourne. Therefore, this test is not applicable.

 

 

1.9 Governance and Implementation

 

Programme and project governance is established and as well as the pre-engagement plans already delivered, a plan has been established for both the public consultation phase and the project implementation phase that would follow.  This reports to SPFT and CCG governance and to the wider Sussex Health and Care Partnership.

 

A full communications and engagement plan is in place. The public consultation would run for 12 weeks, supported by a consultation document (including questionnaire), available in all formats, website presence and other awareness-raising materials. This will be sent to a definitive list of relevant stakeholders.

 

A series of forums, either online or face-to-face, with relevant groups, organisations and individuals will be held. There will be significant communications activity such as media announcements, advertising, online activity, including websites, social media and other interactive tools.

 


[1]https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/policy/next-steps-for-funding-mental-healthcare---infrastructure-royal-college-of-psychiatrists-august-2020.pdf

[2] www.pansi.org.uk

[3] www.poppi.org.uk

[4]https://www.strategyunitwm.nhs.uk/sites/default/files/2019-11/Exploring%20Mental%20Health%20Inpatient%20Capacity%20accross%20Sustainability%20and%20Transformation%20Partnerships%20in%20England%20-%20191030_1.pdf