This report follows on from here, which covers the first five questions asked by members of the public at the 14th April 2016 hospital cuts consultation meeting in Halifax.
The theme of answers with more holes than a string vest continues.
The few remaining Q&As will follow shortly in a final report on this public meeting.
This was about:
- outlying areas
- concerns that urgent care centres won’t take the pressure off A&E
- why there aren’t going to be urgent care centres in Todmorden and Holmfirth.
Matt Walsh said it’s not right that the CCGs aren’t planning to enhance services in Tormorden, and that a separate process is going on around Vanguard, including enhancing out of hours GP services, so they decided not to make Tod Health Centre part of the Consultation.
He said, in term of taking pressure off the Emergency Department, it’s not simply expecting to change how the system is working, it’s linked to Care Closer to Home, moving services out of hospital to improve the management of long term conditions in order to reduce them becoming emergency conditions. A combination of proposals.
Dr Ollerton said the CCGs are looking to totally redesign the urgent care system, eg using NHS 111 to book into urgent care centres or GP surgeries. People will access urgent care differently. It won’t be taking the 50%-ish people who currently go to A&E with urgent care conditions and sticking them into an urgent care centre, it will be through a range of options.
Jo Middleton, CHFT Associate Director of Nursing, surgical and anaesthetic services, said that at Ashworth Hall care home in Todmorden, community matrons go in twice a week to manage conditions so patients don;t need to go to A&E and care homes staff are skilled up.
Kieth Birkinhead said that 50% of people who currently attend A&E will go to an urgent care centre.
True, false or bullshit alert?
Vanguard is bunch of schemes across the country that are being given extra funding from NHS England to speed up the implementation of NHS England’s Five Year Forward View. This aims to introduce new care models, less skilled cheaper clinical jobs and sell off and marketise the NHS Estate. Vanguard schemes are fast-tracking the alignment of their local NHS organisations with American private health insurance company care models, working practices and contracting methods. This involves a merger of the NHS with Local Authorities’ means- tested, privatised social care and leisure services, and co-locations and collaborative working with job centres – for instance GPs coaching patients to get them back to work – and other government agencies.
There are massive problems with the idea that the Care Closer to Home scheme is going to reduce emergency hospital visits and admissions. First off, the idea that identifying patients at high risk of needing emergency care and giving them care plans will reduce emergency admission has recently been shown to be unfounded. Official data from a £162m NHS England scheme to pay GPs extra to do this found that it results in increased emergency admissions.
There are equally big problems with the idea that urgent care can be designed using 111. A member of the public who works in a relevant bit of the NHS said after the meeting that NHS 111 is a joke. Many patients are directed into A&E not away from it, as the out of hours provision is one doctor and has gaps, patients wait ages for call backs so attend A&E. And patients can wait 3 weeks for a GP so attend A&E .
Where does the figure come from that 50% of people who attend A&E are there because of urgent conditions, so can be diverted to urgent care centres and other treatments? The College of Emergency Medicine says that 20% of patients who attend A&E would be as well or better served by clinicians other than A&E doctors. (This was in a 14.4.2016 press release.) What if the College of Emergency Medicine is right and our Clinical Commissioning Groups are wrong? The Emergency Centre would have to admit 30% more emergency patients than planned. How can that be safe? The College of Emergency Medicine press release says,
Our Members and Fellows report relentless pressure, so much so that this College is becoming increasingly concerned about the risk of burn-out for the medical and nursing teams working so hard to deliver the service. We know that lengthy waits in emergency departments are consistently associated with excess and avoidable deaths.
It is now routine for many staff to arrive at work faced with congested and overcrowded departments in which it is impossible to deliver best care. Similarly many leave work, hours after their agreed finish time, exhausted by the scale of the task.
The College is in regular dialogue with the Department of Health, NHS England and NHS Improvement. Urgent action to increase capacity within A&E departments is the focus of these discussions.
111 currently struggle massively, there have been issues. It would be very interesting to find out what work the CCGs have done with 111/999 re capacity and referral/signposting into urgent care/emergency care. The CCGs suggest a reliance on 111 to signpost patients about where to go for treatment. But the 111service is already pushed and there have been ‘issues’. Patients directed to A&E from 111 are not always in the right place. If these urgent care centres are just for set minor ailments and injuries, then 111 should have had some training around decision making in terms of whether patients need urgent care/out of hours GP or the emergency care centre, and how they safety net – ie how over the phone are they going to assess these patients and get them to the right place? Patients’ conditions change, so there is a big question around safety netting while waiting for call backs too. This should be looked at in the same way the impact of paramedic/ ambulance service should be.
The PCBC (p54) says that there will be refreshed protocols in place for NHS111 and YAS to make sure that any children needing emergency care are directed to the specialist Paediatric Emergency Centre. Do NHS 111 and YAS have the resources to follow these protocols? And what about refreshed protocols and resources for adult emergency patients?
These questions are particularly urgent for the CCGs to investigate, since at the Paddock consultation drop in, on Saturday 16th April, they were unable to answer them. They were unable to answer why , given that there has been much work undertaken at the interface between primary care and secondary care in terms of hospital admission avoidance teams, walk in centres and minor injuries units which had since been dispensed with, that these plans would be different in outcome. Nor how the urgent care centres would work . They had no answers on how 111 would triage, how they would signpost or how there would be improvements to issues patients currently experienced with 111 response time and where 111 directed to. There appears to be no work with 111 around capacity or training . There appears to be no blueprint for urgent care – how staffed, how it will function. The CCG person did mention triage at urgent care with planned appointments but flexibility to assess more urgent needs -but no plan as to how this would work .
A member of the public said that having worked in one of the few remaining walk in centres, they had a high throughput, demand is there. Patients vary massively and all sorts come through the doors from one extreme to the other in terms of severity. But after the walk in centre staff were TUPE’d into a social enterprise, the service deteriorated and the remit was less and less tight as the CCG agreed to broaden remits. Quite often staffing meant the capacity did not meet demand so at 4pm all appointments till 8pm could be full. This meant patient waits, pre booked inflexible appointments and transfers.
A recent study in the Journal of Emergency Medicine (Emerg Med J 2016;33:200-207 doi:10.1136/emermed-2014-204603) on Referral outcomes of attendances at general practitioner led urgent care centres in London, England: retrospective analysis of hospital administrative data by Thomas E Cowling and others looked at the effectiveness of some urgent care centres (UCC) in deflecting people from A&E. It found that 74.1% of patients were treated within the UCC but a large absolute number of patients were referred onwards each year. Of these, 17% were transferred to the Emergency Department on the same day. The CCGs bang on that around 50% of people who currently attend A&E for urgent care will go to the urgent care centres. But if 17% f these are then transferred to A&E, 17% of 50%- ish is 8.5%. So the single Emergency Centre is likely to have at least 8.5% more patients than the CCGs are planning for.
As stated above, if the College of Emergency Medicine is right that 20% of patients attending A&E could just as well be seen by urgent care centres or other clinicians like community pharmacies and crisis mental health teams – not the 50% claimed by the CCGs – that means 80% of patients who currently go to A&E would attend the single Emergency Centre. Add to that, 17% of the 20% of urgent care centre patients who transfer to A&E, and you get 83.4% of patients who currently attend A&E, going to the single Emergency Centre. This would mean that the Emergency Centre would be dangerously overcrowded.
Overcrowding at A&Es when a nearby A&E is closed – and later referral of emergency patients who put off attending a more distant A&E – may be some of the reasons why inpatient hospital mortality increases by around 5% in hospitals that retain their A&E when a nearby A&E closes. This finding was reported in a big 2014 Californian study published in the Health Affairs Journal doi: 10.1377/hithaff.2013.12.03 Health Aff August 2013 vol 33 no 8, 1323-1329
And when you factor in the inadequacy of 111 and ooh provision, and the fact that people won’t be able to self-refer to the Emergency Centre but will only have triaged access, this is not looking good for patient safety or NHS staff.
Adnan Mohammed, consultant paediatrician, said he disagreed with colleagues because they are totally wrong. The proposals are seriously compromising the people of Huddersfield and Calderdale and will have serious repercussions on the health of people. Dr Brook’s reasons are all self made or are based on totally wrong previous measures. The proposals are driven by financial issues and spin. He said the urgent and emergency care proposals won’t work because parents will put their sick children in the car and bring them to the nearest hospital. Children will die. He said,
“You are massaging things, you are massaging the argument.”
Owen Williams said the heart of these proposals is because they know they’re not providing the care they should. The quality of care doesn’t meet national standards.
Adnan Mohammed said
“But we have imposed this.”
Owen Williams said,
“I don’t quite recognise that we have manoeuvred ourselves into this position. On the question of whether it’s spin or rhetoric or truth, that’s what this consultation’s for.”
He went on to say these proposals have come from clinicians and added,
“Write down these comments and let us have them.”
Dr Brook said,
“Come to drop ins and ask questions and get a detailed one to one opportunity to get answers.”
True, false or bullshit alert?
Assessments of the quality of care at CHFT – such as the National Clinical Advisory Team Report – point out that the reasons the quality of care doesn’t meet national standards is because of shortage of resources – mainly A&E and paediatric consultants – and that this is a national problem. A national problem requires a national solution. A national solution is not forthcoming. Instead the government is using a crisis of its own making to impose unpopular policies on the NHS. This is the Shock Doctrine described by Naomi Klein.
The roots of the NHS crisis lie in the 2008 financial crash. Having poured £trillions into the corrupt and feckless financial sector to stop a global financial meltdown, the Brown government called in McKinsey, the privatisers’ management consultant of choice, to tell them how to cut NHS spending. McKinsey duly obliged by coming up with QIPP (Quality Innovation Productivity Prevention) – aka efficiency savings.
Also known as the Nicholson Challenge, this proposed shaving off varying amounts of the NHS budget. In March 2010 the Department of Health described QIPP as being “£15-£20bn [savings by] 2013/14”, which is a 3 year efficiency drive if you assume that QIPP would start in April 2010. The 2010 Coalition government morphed QIPP into £20bn “efficiency savings” over the period 2011/12 to 2014/15. Once that was carried out, then they decided to make it another £30bn by 2020/21. And this is why we have the 5 Year Forward View, The Sustainability and Transformation Plan, and this Right Care Right Time Right Place hospital cuts proposal. And massive hospital deficits right across the country.
These Right Care Right Time Right Place proposals have not come from clinicians, they are a top down national template being imposed across the country and as the Clinical Senate said, there is no evidence that local clinicians have been asked if the local resources exist to deliver the national standards that the hospitals clinical model aspires to.
Evidence from the public who have attended drop ins is that it’s next to impossible to get a straight and accurate answer from anyone at the drop ins. The CCG staff are patronising and do people’s heads in. One member of the public came out of a drop in and said she had experienced gaslighting at the hands of one CCG staff member. This is a form of abuse in which information is twisted, spun or selectively omitted, or false information is presented with the intent of making victims doubt their own memory, perception, and sanity.
How much of the £22bn efficiency savings by 2020/21 required by the government is being provided by this reorganisation?
“We’re not talking about efficiency savings. We’re talking about a national gap in funding arrangements and the cost of how services are currently run. One of the purposes of reconfigurations is to reframe services within the available funding gap. Our share of that gap is £300m.”
Andy from Tod, who asked the question, said:
“ The Treasury uses the term ‘efficiency savings’ a lot so I would have thought the term would have filtered up to the NHS. Is the NHS maybe using a different language?”
Matt Walsh said that Andy could be right about that.
True, false or bullshit alert?
Matt Walsh says they are talking about a funding gap, not efficiency savings. This doesn’t mean that efficiency savings are not the issue, it simply means they’re defining the issue as something else. Which is the very definition of spin. There is no doubt that “efficiency savings” – the need for which translate into cuts – is what the issue is. See information about QIPP/efficiency savings in Question 6 above.
The Pre Consultation Business Case (p 97) says that a key assumption is
“Delivery of Cost Improvement Plan targets that offset the annual efficiency requirement, equivalent to £54.4m between 2016/17 and 2021/22.”
On p 110 the PCBC says that the CCGs’ funding gap “challenge” is £59.7m by 2020/21 and they have QIPP (efficiency saving) plans of between £30m and £59.7m (base case and best case respectively). So the CCGs have to make the best case QIPP if they are not to go into debt.
The Pre Consultation Business Case (p 102) says that “significant changes to workforce” are planned (the loss of 964 wholetime equivalent hospital staff) and that “a significant driver” for this is planned QIPP.
Greater Huddersfield CCG’s transformational plan (QIPP) is outlined on p107 of the Pre Consultation Document.
I’m not going to go on, but this is enough to show that the PCBC is clear about the fact that QIPP/efficiency savings are driving the hospital cuts plans.
The Pre Consultation Business Case is also explicit that the ability to make the “efficiency savings” in Calderdale depends on Care Closer to Home achieving tough QIPP goals. P 109 says Calderdale CCG’s QIPP transformational plan is based on delivering this CC2H scheme.
The Vanguard scheme is key here. This is fast tracking the rollout of Care Closer to Home by introducing “new care models” and a “modern workforce” – both based on systems copied from United Health, the global health insurance company that the head of NHS England, Simon Stevens, previously worked for.
Will the proposed changes reduce the mortality rate?
Keith Birkinhead said he hoped so but doesn’t know why the rates are higher than the national average. They are looking at patients’ cases to try and see why they died. He thinks transferring patients between sites and delay in getting care may have something to do with it. He said they have centralised one service that deals with things like perforated intestines that has halved mortality rates from 12% to 6%.
True, false or bullshit alert?
This sounds like a reasonable answer. But there is more to finding the reasons for higher than average patient mortality rates than looking at the care patients received. So I think a bullshit alert is called for.
The Health & Social Care Information Centreʼs interpretation guidance on Summary Hospital Mortality Indicator (SHMI) figures says:
• The SHMI is not a direct measure of quality of care – without a detailed case note review, itʼs impossible to know whether or not a death could have been prevented.
• A higher than expected SHMI should be further investigated, starting with the most likely explanations (data handling and patient case mix) and drawing on additional information such as staff and patient feedback.
In addition, the SHMI doesnʼt make any adjustment for deprivation – although it is known that there are higher mortality rates for populations with higher levels of deprivation. The Summary Hospital level Mortality Indicator figures for the year July 2014 – June 2015 shows that our hospitals Trust had a higher than average level of deprivation over all finished provider spells AND over all deaths reported in the SHMI.
Further, recent Trust finance directorsʼ reports show that the quality of care is declining as funding shortages increase. The year when our hospitalsʼ SHMI figure was an above-average “outlier” was the year when frontline staff warned that if any more “efficiency” cuts were made, patientsʼ safety and wellbeing would suffer. But £ms more cuts were made – although not enough to stop the Trust going into the red, because the necessary cuts could not be made without damaging patient safety. But maybe patient safety was damaged by the considerable cuts that WERE made.
The Pre Consultation Business Case (p21) seems to fly in the face of HSCIC guidance on the interpretation of SHMI data. It says that if the hospital services were to stay the same as now, reducing the SHMI figure would require work on patient pathways and improved coding of patient care. But this is exactly what the HSCIC guidance calls for. It needs doing whether or not the hospital reorganisation happens. Misleadingly, the PCBC suggests that hospital reorganisation is an alternative to this necessary work.
Nowhere does the HSCIC say that wholescale hospital reoganisation is an appropriate response to a higher than average SHMI.
Nora from Barnsley Save our NHS said that Barnsley CCG is concerned that these changes will put Barnsley Hospital at risk. Changes to CHFT Maternity services have already led to overcrowding at Barnsley Hospital. Now the A&E is overcrowded and Barnsley Hospital is at risk of being closed.
Carol McKenna, the Greater Huddersfield CCG Chief Officer, said that outside organisations can respond to the consultation.
She has met Barnsley CCG and Barnsley hospital trust at an early stage and again when the proposal to close Huddersfield A&E was made.
She said money follows patients so Barnsley will get paid for any Kirklees patients who go there.
“It’s about safety of services and meeting targets that A&E have to meet. The hospital is old.”
True, false or bullshit alert?
Carol McKenna totally missed the point. She showed that she thinks in terms of money, as if paying to overcrowd an old and overcrowded hospital made everything ok.
If Barnsley hospital hasn’t got space for patients, paying for them to go there won’t help that problem. Plus, if through overcrowding Barnsley misses A&E targets, it then loses money as a penalty.
Overcrowded A&Es have been shown to reduce patient safety – not to mention patient comfort.
This was about the required efficiency savings of £300m from Calderdale and Huddersfield – they can’t be made without stressing the system. it needs more money from the Government.
Dr Ollerton clapped his hands above his head as we the public applauded this statement of the obvious – the elephant in the room. He then said,
“I welcome that comment… We are continually lobbying up that we need more money.”
Carol McKenna said:
It’s about money we get not keeping up with increasing costs, about making sure we don’t get into debt.
True, false or bullshit alert?
A member of the public who works in the NHS in frontline patient care said that as someone who works and has been carried along on this tide of innovation and change, they left the meeting with a heavy heart. They said,
The clapping from the CCG regards underfunding was a joke. Front line staff see but are compromised and unprotected to talk and trusts are paid to walk the line and produce the expected redesign. We should be obstructing target cultures and focusing on patients , many are shouting across social media but our leaders and those that hold the purse strings are very much toeing the line.
Another member of the public said:
“This is more than Huddersfield A&E this is about underfunding and the CCG should admit this and on residents’ behalf turn around to government and NHS England and say no. What’s the worst that could happen?”
Where are their ethics? Some people stand by theirs.
This is about underfunding as the deliberate first step in dismantling the NHS and handing it over to private health companies to profit from. Owen Williams may shed crocodile tears, as when he claimed in response to a later question that he has common ground with the public who oppose the cuts but the Trust and the CCGs have to make these cuts in order to stop the government/NHS England making worse cuts to our Calderdale and Huddersfield services – which he said are better provided for than many other places. But neither his nor Dr Ollerton’s attempt to make common cause with us is going to do the slightest bit of good and no one should be deceived by them.
Assuming all these changes go through, where are finances coming from for the new hospital in Huddersfield?
Owen Williams said the business case will include a transition from now to the future care model. That will include where the funding is coming from.
“If there are better ideas out there we will listen to them.”
There are 3 potential funding sources:
- The Dept of Health is having a conversation with the Treasury about a capital pot between the DoH and Treasury. Repayments would be required.
- The DoH could give the Trust a borrowing limit to get a loan on the commercial market and DoH would pay the interest
- PFI 2 is an option.
Owen Williams described2PFI 1 as a “new and advanced way of PFI.” He said the Trust could be required to go down that route, That decision will be determined centrally.
He said that PFI at the moment is a relationship between a set of financial organisations – bankers & financial institutions. The CRH buildings’ PFI loan costs £10m/year in repayments.
Dr Brook said that the sale of the HRI land will only generate a modest income after the demolition of the hospital and removal of asbestos. It wouldn’t contribute funding to the new hospital.
True, false or bullshit alert?
The Ernst and Young 5 Year Strategic Plan for CHFT says (p144):
“The financing of capital expenditure has been assumed to be through loans raised through the Independent Trust Financing Facility.”
So I don’t know how that sits with Owen Williams’ answer. Is this maybe “the capital pot that sits between the DoH and the Treasury”?
In 2014-15, the total cost of Calderdale Royal Hospital Private Finance Initiative (PFI) was £23.570m.
This “unitary charge” was made up of:
- Interest on the debt……… £10.929m
- Repayment of the debt…..£ 1.497m
- Service charge…………….£11.144m
The value of the hospital building is £80.451m. The total cost (capital and interest) of the PFI debt over its 30 year life is £289,908,000. This leaves out the high service charges, which cover services like portering, domestics, security, catering, maintenance etc
The PFI charges are set at a level that allows the private investors to get the annual rate of return that they want. The rate of return on PFI investments is way higher than on other types of investments that carry similar risks.
The public were outraged at the prospect of another PFI. PFI 2 being new and advanced is still PFI.
Members of the public were very puzzled by Dr Brook’s answer. If the Huddersfield Royal Infirmary land sale isn’t going to contribute funding to the new hospital, why is it included as a positive tick in the decision making box about which option to go for in the hospital cuts?
They were also puzzled about the CHFT paying rent for the outpatients’ department on the Acre Mill site.
Answers from the CHFT Estates person, Lesley Hill, at the Hebden Bridge drop in, may shed a bit more light.
She said CHFT owns the HRI site. Like Dr Brook, she also said that the demolition would be costly because of the need to remove asbestos. She said that they don’t know what they’d do with the site, it will depend on what government policy is in 6-7 years when they will be considering what to do with the site. (Simon Stevens’ 5 year forward view aims to sell off and marketise NHS Estate – although she didn’t say that. His so-called Sustainability and Transformation Plans scheme has just introduced the mad idea of making the NHS pay a market rate rent to use its own premises.)
She said they may keep some for car parking.
She said CHFT owns the Acre MIll site that would be used for building the new planned care clinic/hospital, but,
“there are no means of delivery of the new planned care hospital.”
I said what that means. She said they don’t know what the means of delivery are. A joint venture with Henry Boot might or might not be the right vehicle. I said,
Does ‘means of delivery’ mean, who you work with to build it and how you pay for it?
She said yes, and there will be some kind of OJEU process. This is when the construction contract has to be put out to competitive tender across the EU. She said they have done some costing work but no design work until the consultation outcome is decided. She said they are talking to the Dept of Health about how to take it forward but they don’t know what the options are. (This is not what Owen Williams said, he outlined 3 options, including PFI2).
Re the CHFT paying rent for the outpatients’ department on the Acre Mill site, Lesley Hedges said that CHFT has a joint venture Public Private Partnership with Henry Boot, the company that built the outpatient dept; and the outpatients bit of the Acre Mill land sits in the joint venture. So I guess that is why CHFT pays rent on the outpatients dept. But it doesn’t explain why CHFT didn’t make that arrangement clear to the public at the time when they decided to move the services across the road.