Poorly attended Todmorden consultation drop in raises more questions than it answers

The Todmorden Drop in was signposted with a sign on the side of the building. Very few people attended – one member of the public said about 6 in the hour she was there, which was from 4.30pm; another, who was there from 2.30 to around 4.15pm, said about 10 people attended in that time.

Questions for future consultation drop ins

The drop in raised more questions that it answered. Questions that the Clinical Commisioning Groups now need to answer include:

1. What will happen if the public rejects the current proposals? The officials at the Tod drop in said there is no plan B, if this happens
2. At what point in the “medium term” will the £9m/year hospitals Trust deficit (predicted to accumulate to a £47.5m deficit by 2020/26) move into surplus?
3. Since the Healthy Futures Sustainability and Transformation Plan for the West Yorkshire “footprint” cannot allow the region’s NHS spending to go into deficit, will the Sustainability and Transformation Plan accommodate CHFT’s proposed clinical model, that will keep CHFT in deficit even 10 years from now?
4. If the Health Futures STP  will accommodate this proposal, what other NHS services in West Yorkshire will be cut to make it possible for CHFT to carry its deficit?
5. If it won’t accommodate this proposal, what kind of hospitals clinical model will replace the proposed clinical model? Bearing in mind that Calderdale and Greater Huddersfield CCGs and the hospitals Trust have no plan B?
6. What do GPs and Calderdale Council think about the fact that within the West Yorkshire STP footprint, called Healthy Futures, decision making powers will be limited to the CCGs’ Chief Officers, and the GPs’ representatives on CCGs will not have any voting powers?
7. In Calderdale, the Sustainability and Transformation Plan will be overseen through the Health & Well Being Board. Why haven’t Councillors bothered to inform the public about this, or seek their consent for this radical step in dismantling the National Health Service?
8. The hospital bed capacity of 734 proposed in the Right Care Right Time Right Place Pre-Consultation Business Case, breaks down to 1.61 beds per 1000 population.  Only Indonesia, India and Columbia have fewer hospital beds per 1000 population than this. Is it right that we are to have a third world hospital service?
9. Ernst & Young’s Strategic 5 Year Plan for CHFT, identifies a “new commercial venture such as private patient wing” as a “significant longer term investment”. Is a private patient wing  part of the 734 beds planned for the “Right Care” hospitals clinical model?
10. Will the Clinical Commissioning Groups respond in full and in public to our list of misinformation and lack of information in the consultation document?
11. Is the reason for dropping the proposal for an Urgent Care Centre in Todmorden Health Centre the result of Ernst and Young’s 5 Year Strategic Plan for CHFT? On p144 it says that all the options for capital expenditure for the proposed hospital clinical model exclude the expected £1.2m of costs to run an UCC at Todmorden. So is the Tod UCC a victim of Monitor’s/Ernst & Young’s plan to cut the Trust’s deficit?
12. With the Trust refusing to buy into the costly Tod Health Centre white elephant  is this going to upset the Vanguard plans to make Tod Health Centre the base for Care Closer to Home in the Upper Calder Valley?
13. In the absence of adequate information about how and whether Yorkshire Ambulance Service  will be able to provide the extra 10K hours/year ambulance journey time that will be required as a result of downgrading Huddersfield and Dewsbury A&Es to Urgent Care Centres, how can you expect the public to say whether or not we are in favour of the hospital cuts proposals, or how the proposals will affect us?
14. What are the Clinical Commissioning Groups doing about Royal College of Emergency Medicine information that 20% of patients who currently go to A&E could be seen in Urgent Care Centres – not the 54% that the Clinical Commissioning Groups propose? Doesn’t this mean that the proposed Emergency Centre in Calderdale Royal Hospital will be dangerously overcrowded?
15. When are Calderdale and Huddersfield hospitals trust (CHFT) and the Clinical Commissioning Groups going to clarify how CHFT staffing plans will deal with the extra 40K patients/year who will go to CRH Eemergenct Centre and 16K/year to Huddersfield Royal Infirmary Urgent Care Centre? And when will they make this info available to the public?
16. When are Calderdale and Huddersfield hospitals trust (CHFT) and the Clinical Commissioning Groups going to admit that the vast majority of CHFT staff do not agree with the proposed hospital cuts/clinical model, and that the Trust has not adequately informed or sought the views of most CHFT Staff?
17. What did Matt Walsh mean when he told the 19 April Joint Health Scrutiny Committee meeting “there is consensus around 45m accessibility to ED time after stabilisation”?
18. When are the Clinical Commissioning Groups going to quantify the risks of increased emergency patient mortality associated with increased distances to A&E?
19. When are the Clinical Commissioning Groups going to accurately quantify the anticipated reduction in patient mortality from centralising acute services into a single acute and emergency hospital?
20. What is the source of the figure quoted by Dr Mark Davies, the CHFT A&E head honcho, when he told the 19th April Joint Health Scrutiny Committee meeting that there would be a 30% reduction in patient mortality as a result of centralising acute surgery in one site?
21. Matt Walsh, the Calderdale Clinical Commissioning Group Chief Officer, said that there is a tipping point at which increased patient mortality from increased distance to A&E is outweighed by the reduction in patient mortality from centralisation of A&E services. Where is this tipping point?
22. When will the CCGs show the gains from reduced mortality rates from eg stroke services reconfiguration in London and heart services centralisation in Leeds? (To save the CCGs the trouble in relation to the centralisation of stroke services in London, a British Medical Journal report identifies a 1% reduction in patient mortality.)
23. Where is the evidence that the proposed Care Closure to Home schemes can justify the anticipated 6%/year reduction in non-elective medical admissions to hospital?
24. What additional additional stress on local primary care systems will result from the proposal to downgrade Huddersfield A&E to an urgent care centre and centralise acute and emergency services at a larger site?
25. Where will the resources come from to meet this additional stress?

 

Questions people asked at the Tod Drop In

1. What is this proposal all about?
2. Where is the Ernst and Young report, that changed the previous preferred option for having the acute and emergency hospital in Huddersfield, to siting it in Halifax?
3. How can the proposed reconfigured hospitals – ie half a hospital in each town and only one A&E for both towns – serve all the people in Kirklees and Calderdale?
4. Is there another plan if the public reject this one?
5. What are the plans for Tod Health Centre?
6. Where is the report that includes the information about an increase in ambulance journeys of 10,000 hours/year, as a result of closing Huddersfield Royal Infirmary A&E? And what about the lack of details about ambulance transport?
7. Why is there so much misinformation in the Consultation Document?
8. Do the GPs on the Clinical Commissioning Group understand the wider context of the hospital cuts proposals? (ie 5 Year Forward View, Vanguard, Sustainability and Transformation Plans)

Answers CCGs/hospital Trust managers gave

1) What is this proposal all about?

A member of the public reports:

“I was very much fed the line that the main issue was money, and the lack of it. But the blame was squarely put at central govt who won’t give money to do anything other than a reorganisation like they’re proposing, because Halifax was a relatively new hospital. The govt won’t fund a new hospital in Huddersfield because of Halifax.

Very much given the line that it’s this reorganisation or nothing. No plan b, & they don’t want one.”

Another member of the public said none of the officials or GPs had any more information about funding, except that the £9m deficit after 5 years is a point on a curve that moves into surplus in the medium term. Also that they believed that the government would allow them to borrow the necessary money.

But the £9m deficit after 5 years ie by 2020/21 is predicted to be cumulative over the following 5 years, generating a cumulative deficit of £47.5m by 2025/26.

Where is the information that shows the deficit turning into surplus and when is that predicted to happen?

The officials’ belief that the government would allow the hospitals Trust to borrow the necessary money doesn’t seem to be shared by Monitor.

2) Where is the Ernst and Young report?

A member of the public asked where to find the Ernst and Young report that that changed the hospital Trust’s previous preferred option for having the acute and emergency hospital in Huddersfield, to having it in Halifax. Jen Mulcahy, the Right Care Right Time Right Place Programme Officer, directed him to this link:

“ Ernst and Young Report on the CHFT website – can be found here http://www.cht.nhs.uk/about-us/publications/five-year-strategic-plan/ “

It turns out that this is the CHFT Strategic Five Year Plan, drawn up at Monitor’s direction, to identify how to cut the Trust’s deficit. Joint Health Scrutiny Committee meetings have referred to it and CK 999 are still going through it, it is over 200 pages. Full of wonk.

3) Capacity of hospital after the cuts

A member of the public asked how the proposed reconfigured hospitals – ie half a hospital in each town with only one A&E for both towns – could serve all the people in Kirklees and Calderdale. The officials dismissed the question by saying that the proposals relate to Huddersfield & Halifax, not including Kirklees, “so the number was lower than ‘the opposition’ were saying”.

The Consultation Document states that a population of 452,000 is affected by these hospital cuts proposals. This is made up of:

• 243,000 in Greater Huddersfield (which includes a swathe of Kirklees covering the towns and surrounds of Denby Dale, Holmfirth, Kirkburton and Skelmanthorpe, Honley, Meltham, Marsden and Slaithwaite) and
• 209,000 in Calderdale.

For this 452,000 population, the hospital bed capacity of 734 proposed in the Right Care Right Time Right Place Pre-Consultation Business Case, breaks down to 1.61 beds per 1000 population.  Only Indonesia, India and Columbia have fewer hospital beds per 1000 population than this.

Two other members of the public told the officials that that they didn’t believe we should have only one A&E. They were not convinced by the arguments over staffing and felt that none of their questions were answered.

The 2 GPs said that the plan frees up money for primary care and allows for a joined up plan rather than having surgeries doing what they wanted. Dr Alan Brook, the Calderdale Clinical Commissioning Group Governing Body Chair, also emphasised this point at the Sowerby Bridge drop in, when he said that they hadn’t been able to put in place the work with care homes to reduce hospital admissions until Care Closer To Home, for instance.

This claim is a bit odd. The Clinical Commissioning Groups approved Phase 1 and Phase 2 of Care Closer to Home in August 2014, but Calderdale Clinical Commissioning Group set up the Quest for Quality in Care Homes scheme in 2012/13.

They awarded the telehealth and telecare services contract to Tunstall Healthcare UK Ltd and launched the Telehealth/Telecare service in July 2013. The other part of the Quest for Quality in Care Homes scheme was the Multi Disciplinary Team contract, which Calderdale CCG awarded to Calderdale and Huddersfield Foundation Trust (CHFT).

At the Tod Drop in, none of the officials could quote data to support reductions in hospital admissions, beyond that Quest for Quality in Care Homes scheme, to justify the anticipated 6% reduction in non-elective medical admissions/year. (This is identified in the Pre Consultation business case p 83, as one of the “key assumptions” applied to the proposed hospital cuts activity and capacity modelling). But all ‘expected’ it.

Set against the GPs’ claims that the plan frees up money for primary care, is the Royal College of Emergency Medicine’s statement that in any plans to reconfigure or downgrade emergency departments and centralise services at a larger site,

“The additional stress on local primary care systems must also be considered.”

The matron of Huddersfield Royal Infirmary’s A&E said staff were fully behind the plan because conditions at Huddersfield Royal Infirmary are bad and so they have lots of nurse vacancies. These claims were strongly challenged by Unison and Unite reps at the 19 April Joint Health Scrutiny Committee meeting. A current Unison survey of all CHFT staff shows that 93% oppose the proposed hospital clinical model/cuts.

The HRI A&E matron said that running a relatively small A&E means above average anti-social hours shifts, because you always have to have at least one person on duty, so again difficult to recruit.

But a recently retired CHFT consultant poured scorn on the idea that having just one A&E for both towns is going to solve the national problem of recruiting and retaining A&E doctors.

And the Royal College of Emergency Medicine states:

The College recognises that recruitment and retention of staff is often cited as a relevant factor. However, this is commonly a consequence of historical poor planning and resourcing; in itself it is a poor justification for service reconfiguration.

4) Is there another plan if the public reject this one?

The officials said there isn’t.

CK999 is interested in hearing from people what changes if any are needed to improve our NHS and social care in Calderdale and Kirklees – without falling into the government’s “austerity” trap of requiring £22bn “efficiency savings” by 2020/21, and its proposals via 5YFV and STP, of cutting NHS services and providing these reduced services on a model based on the American private health system.

5) What are the plans for Tod Health Centre?

Two members of the public said that they feel getting Tod health centre going is a good idea but the proposals are the same they were told when it was built and it didn’t happen. They felt none of their questions were answered.

The Pre Consultation Business Case said there would be an Urgent Care Centre in Todmorden. By the time the Consultation Document was published, this had been dropped.

Asked about this at the Hebden Bridge drop in, CCG staff said there would be an enhanced walk in centre instead, as part of the Vanguard scheme. They were unable to give any information about what this meant. They said this would be available at the Tod Drop In. It doesn’t seem to have been.

The Ernst and Young 5 Year Strategic Plan for Calderdale & Huddersfield hospitals Trust (p144) says that all the options for capital expenditure for the proposed hospital clinical model exclude the expected £1.2m of costs to run an UCC at Todmorden. So it looks as if the Tod UCC is a victim of Monitor’s/Ernst & Young’s plan to cut the Trust’s deficit.

With the Trust refusing to buy into the costly Tod Health Centre white elephant the public concern that nothing has happened for years and nothing may go on happening for years seems realistic. Even with extra Care Closer to Home and Vanguard funding.

6) Where is the report on the impact of the cuts on Yorkshire Ambulance Service?

After the drop in, Jen Mulcahy emailed this info to a member of the public who had asked this question: Travel Analysis on Right Care Website – can be found here – Heading is NECS report – then the two reports are straight underneath.

Neither those travel analysis reports nor the Consultation Document provide adequate information on travel issues, and the CCGs are giving contradictory and misleading answers to public questions about them.

At the Tod drop in Jen Mulcahy, the Right Care Right Time Right Place Programme Officer, said that they wouldn’t be spending money on a more detailed plan before the end of the consultation. That there was a balance to be struck between how detailed the data was and how much they were spending on a plan not yet approved. And that also applied to negotiation and planning with Yorkshire Ambulance Service; that would be done when they knew what was to happen.

It is all very well saying the Clinical Commissioning Groups don’t want to spend money on providing information on proposals before the consultation is completed, but how can they ask the public to comment on how the proposals will affect them, in the absence of adequate information about their impact on patient and staff safety and clinical outcomes?

The Consultation Document doesn’t say anything about whether Yorkshire Ambulance Service can provide the extra 10K hours/year ambulance journey time that would be required as a result of downgradiing Huddersfield and Dewsbury blue light A&Es to Urgent Care Centres. And it doesn’t say how the extra 10k hours/year figure was arrived at, so there’s no way of knowing if this is an accurate figure.

The Royal College of Emergency Medicine says,

“The increased demands on ambulance services brought about by longer transport times are seldom properly modelled.”

We need the Clinical Commissioning Groups to give the public all the following information now:

• How was the figure of the 10,000 extra hours/year ambulance journeys arrived at?
• Can YAS provide these extra 10k hours/year ambulance journeys? What extra staffing and ambulances would it need?
• Since the Royal College of Emergency Medicine says that 20% of patients who currently go to A&E could be seen in Urgent Care Centres – not the 54% that the CCGs are talking about, we need a review of the amount of traditional A&E work that can be undertaken by the replacement units (the urgent care centres). The Royal College of Emergency Medicine’s recent Statement on Emergency Department Closure or Reconfiguration says this is likely to be grossly over-estimated in A&E reconfiguration/downgrade plans
• Extra ambulance journey hours/year, modelled on the assumption that 80% of current A&E patient numbers would go to the single Emergency Centre. And then there are extra patient numbers to factor in, from a recent study that found a significant percentage of Urgent Care Centre patients have to be transferred to A&E.
• Yorkshire Ambulance Service is already stretched to breaking point, how are they going to do more with less money? Given that the CCGs are planning to force Yorkshire Ambulance Service to make “efficiency savings” of 2%/year under their contracts, amounting to £2.441m over the 7 years to 2021/22.

7) Why is there so much misinformation in the Consultation Document?

Jen Mulcahy, Right Care Right Time Right Place Programme Officer, mentioned that nobody was filling in the Consultation survey. A member of the public told her we are asking people to hold off until we give them advice based on proper information from the Clinical Commissioning Groups, made available to the public on the Right Care website. She seemed dumbfounded that there was a ground swell behind not filling them in. She later emailed:

“Please could you let me know where you think there are mistakes in the consultation document.”

CK999 is sending the Clinical Commisioning Groups as full a list as possible with this information and will copy in Jen Mulcahy. We would have done it sooner, but it has proved a time consuming task.

8) Wider context of the proposals

At the Tod drop in, two GPs on the Clinical Commissioning Group – Dr Caroline Taylor and Dr Nigel Taylor – said they saw the proposals as ways to fix things that are wrong with GP services but had no idea of the wider context of the proposals, ie NHS ENgland’s 5 Year Forward View/ Sustainability and Transformation Plans. They said the Sustainability and Transformation Plan was just the same as they’re already doing.

They didn’t explain that the 5 Year Forward View spells out NHS England’s plans for meeting the £22bn NHS funding gap that is predicted for 2020/21, if the NHS goes on operating as it did in 2015/16. This is the second wave of “efficiency savings” required by the government, the first being £30bn worth from 2011- 2015. There is information about this here, in the section headed Question 7 How much of the £22bn efficiency savings by 2020/21 required by the government is being provided by this reorganisation?

The 5 Year Forward View proposes to make these savings by importing “new care models” and “modern workforce” practices from American private health companies like United Health (the previous employer of NHS England’s boss Simon Stevens) and selling off as much as possible of the NHS Estate.

Dr Caroline Taylor said that she expected the current plan would be the CCG’s submission for the Sustainability and Transformation Plan. She believed they were ‘ahead of the game’ nationally. On the national situation, Dr Caroline Taylor had no criticisms of NHS England or the Five Year Forward Plan.

The Taylors were also very positive about the working relationships built with the Council etc through the Vanguard.

At the start of this year, NHS England required all areas to outline Sustainability and Transformation Plans in order to identify how they will fast track the implementation of the 5 Year Forward View. Sustainability and Transformation Plans require all providers and commissioners of NHS and social care services in every area to come up with plans for how their local services will fit in with a regional Sustainability and Transformation Plan, based on one of 44 footprints.

Each footprint will have to make sure that the sum of individual areas’ plans stick within the allocated budget ie it will no longer be possible to go into deficit. To make this happen, services will have to be provided on a regional rather than local basis; the Sustainability and Transformation Plans therefore aim to devolve the NHS without the formal process and title of devolution. If NHS England doesn’t agree with the footprint STP plans they will take control of them.

Given the fact that the hospital cuts proposals will not return the Hospitals Trust into the black even by 2025/6 (when a cumulative deficit of £47.5m is predicted), this surely has to put a question mark over whether the proposed hospital clinical model will be acceptable under the terms of the STP; and if it is, what other service will have to be cut to carry that £47.5m deficit – let alone the current deficit.

Within the West Yorkshire footprint, called Healthy Futures, decision making powers will be limited to the CCGs’ Chief Officers – the GPs’ representatives on CCGs will not have any voting powers.

In Calderdale, the STP will be probably be overseen through the Health & Wellbeing Board, but Councillors haven’t bothered to inform the public about this or seek their consent for this radical step in dismantling the National Health Service.

The development of Sustainability and Transformation Plans is supposed to take place through an open iterative engagement process. Asked about this, the Calderdale Clinical Commissioning Group Governing Body meeting on 14.4.2016 said that they had had a workshopping session with Calderdale HWB Board that morning and that they also had

“fantastic engagement evidence from the last two years”

Given that the Chair of Calderdale Council Adults Health and Social Care Scrutiny panel said that Calderdale CCG’s engagement review in summer 2014 showed that they had carried out engagement in their own little goldfish bowl, this is hardly a credible statement.

 

Another question to the Calderdale Clinical Commissioning Group Governing Body meeting on 14.4.16 asked:

When will Calderdale Clinical Commissioning Group robustly engage with the biggest stakeholders – the public?

The answer was: the current consultation. Which makes NO mention of the Sustainability and Transformation Plan or the Health Futures Sustainability and Transformation Plan footprint.

Asked about the priority areas for the Calderdale Sustainability and Transformation Plan, the Calderdale Clinical Commissioning Group Governing Body meeting said that they are:

• initial proposals for “demand moderation”, with most of them in the QIPP section of the draft 1 year plan for Calderdale Clinical Commissioning Group. The report about the previous Governing Body meeting gave an overview of this
• wider productivity changes

Each footprint will have to make sure that the sum of individual areas’ plans stick within the allocated budget ie it will no longer be possible to go into deficit. To make this happen, services will have to be provided on a regional rather than local basis; the Sustainability and transformation Plans therefore aim to devolve the NHS without the formal process and title of devolution. If NHS England doesn’t agree with the footprint STP plans they will take control of them.

Given the fact that the hospital cuts proposals will not return the Hospitals Trust into the black even by 2025/6, when a cumulative deficit of £47.5m is predicted, this has to put a question mark over whether the proposed hospital clinical model will be acceptable under the terms of the Healthy Futures Footprint Sustainability & Transformation Plan, and if it is, what other services will have to be cut to carry that £47.5m deficit – let alone the current deficit.