I left the drop in after 2 hours feeling slightly dazed and stunned, after close encounters of the argumentative kind with Calderdale Clinical Commissioning Group’s Governing Body Ancient Mariner, Dr Brook.
I wanted to ask about health inequalities and whether/how the proposed hospital cuts and care closer to home scheme would address them, particularly in terms of Ovenden and Mixenden.
Health inequalities in Calderdale and what the hospital cuts and care closer to home scheme would do to them
I started out talking with Dr Hazel Carsley, a GP member of Calderdale Clinical Commissioning Group Governing Body and David Birkenhead, Medical Director at the hospitals Trust. Here are the questions and answers:
Q: The infant mortality rate in Calderdale is significantly higher than the England average (7.7 per 1000live births, compared with 4.6 per thousand live births). What is the infant mortality rate for Ovenden and Mixenden, is it different from the Calderdale average?
A: The Calderdale infant mortality rate has improved a bit. It’s higher in Ovenden and Mixenden than in Calderdale. It’s worst in Town ward. The figures may be in the Joint Strategic Needs Assessment and if not, Paul Butcher the Public health Director at Calderdale Council will have them.
Q: What is life expectancy in Ovenden and Mixenden compared with the Calderdale average?
A: It’s in the Joint Strategic Needs Assessment, there’s something like a 7 years difference for a boy born in Ovenden compared with a boy born in Northowram.
Q: The Care Closer to Home scheme wants to tackle common illnesses such as diabetes, asthma, alcohol and drug abuse, child and adult obesity. Is the incidence of these health problems the same in Ovenden and Mixenden as the rest of Calderdale?
A: The trend tends to be that if people have poorer access to services and health opportunities, like access to healthy food, this impacts on these conditions.
Q: I asked how people might have poorer access to services, because I thought they were fairly evenly shared out across Calderdale.
A: Shift patterns related to low income jobs can mean people have poorer access to services. It’s a job to rebalance services according to what people’s needs are, eg putting breast feeding services into communities.
At this point Dr Brook, the Calderdale Clinical Commissioning Group Governing Body Chair, hove into view, pulled up a chair and demanded to know why I was asking these questions.
I said I thought the drop in was an opportunity for people to come and ask questions. He again questioned my questions. I said that as Ovenden is a relatively economically deprived ward, I wondered how the hospital cuts proposals & Care Closer to Home proposals were going to affect people who live there, who already have more ailments and lower life expectancy than in other parts of Calderdale.
Dr Brook said,
“We have done what we can to make sure communities aren’t negatively impacted by these proposals.”
“What have you done?”
Dr Carsley said tentatively to Dr Brook,
“There’s Dawn’s work with community champions, and work about travel time.”
“It’s not for us to address all these fine details. Calderdale Council are aware of the travel problems…”
Hearing the words “Calderdale Council” “innovative” “transport”, I tuned out Dr Brook’s spin that the Council would sort it all out – which was not the impression created at the most recent Joint Health Scrutiny Committee meeting, where the bus guy identified many significant transport problems that the Council and the CCGs had not even talked to the bus people about.
No health inequalities impact assessment
When Dr Brook had finished his “all is for the best in the best of all possible reconfigurations” spiel, I asked why there isn’t a Health Inequalities Impact Assessment in the Equality Impact Assessment.
Dr Brook questioned my question, as if he thought it was daft. When he failed to convince me I was daft, he summoned Jen Mulcahy, the Right Care Right Time Right Place Programme Officer, to answer my question.
Jen Mulcahy said there was an Equality Impact Assessment in Appendix E in the Pre Consultation Business Case. I said yes, but it doesn’t have a Health Inequalities Impact Assessment and I understood from someone who works on public consultations that this is a requirement for major service changes. Jen Mulcahy said she didn’t know who that person was or where they got their information but she generally thought the CCGs had done what they are required to do.
Children’s Care Closer to Home pilot in Ovenden
Q: What care closer to Home proposals are there for Ovenden and Mixenden?
A: Dr Carsley said the Clinical Commissioning Group had run a 12 week pilot for children’s Care Closer To Home at the Innovation Centre in Ovenden that had had good feedback and will go into the Vanguard scheme. This was in family-friendly hours from 4pm-8pm, for paediatric general services, on GP referral, instead of going to hospital. It was piloted in a few GP practices.
I asked how it had been evaluated.
Dr Carsley said they were hoping to look at it again, it had been evaluated from the point of view of patient satisfaction and a Masters student had done research on it. The evaluation hadn’t been published, it was in house.
I asked why it hadn’t been published and Dr Carsley said she didn’t know why they wouldn’t publish it. She said CHFT people – Gill Harries and Dr Ashraf – had presented it in a public meeting at the Royal College of Paediatricians.
Resources for GPs and primary care
Q: How many GPs are there in the Ovenden ward?
A: Dr Carsley said there were 4.
I asked if there were any Ovenden GP practices without any permanent GPs that rely solely on locums.
Dr Carsley said,
Between them, she and Dr Brook went off on a confusing explanation that there were GP Practices with Alternative Provider of Medical Services contracts and salaried GPs. And many GP Practices employed locums. The Meadowdale GP practice that is run by Virgin employs salaried GPs on APMS contracts. Dr Carsley said her GP practice employs locums. But there are no GP practices in Ovenden that employ only locums, without any permanent GPs.
I asked about the problems a while back with Keighley Road GP practice, that had said it couldn’t take on any new patients and couldn’t cope.
Dr Brook said that the Clinical Commissioning Group had managed to save GP practices before they imploded. The Keighley Road GP surgery have backed off from their previous position and got themselves back on their feet. He said he is anxious that any practice that’s struggling will get support from the CCGs.
Q: What support can the CCGs give?
A: Managerial advice, recruiting locums.
Q: What are the average waiting times for Ovenden GPs?
Dr Brook snorted that it was ridiculous to expect them to have ward level data.
Dr Carsley said that the CCGs have experimented with assessing waiting times for GP practices but can’t do it because of lack of standardised processes for GP sessions with patients across Calderdale. She said this diversity of GP processes is a strength but it means you can’t compare like with like. They desperately want to do it, but the CCGs don’t have parallel measures for primary care like they have from hospitals.
Q: If you’re trying to develop a primary care strategy and you have problems with data to tell you what’s going on, how are you going to do it?
A: (Dr Carsley) There’s a lot of data we do know but not the availability of GP appointments and how long people have to wait – there are lots of confounding variables in this.
Dr Brook: It’s not always true that patients attend A&E because they can’t get a GP appointment. Appropriate access to a GP is key.
He said that GPs have an obligation to see urgent patients the same day. Dr Carsley said that doesn’t necessarily stop patients going to A&E – she had offered a patient a 4pm appointment and he’d gone to A&E to avoid waiting till 4pm.
Dr Carsley said that additional winter capacity for GPs has helped.
Dr Brook said that they need to be sure that they are “purchasing additionality” so they need to have decent data about GPs accessibility and providing adequate access.
Q: What’s the difference between CCGs taking on delegated responsibility for primary care and NHSE commissioning primary care?
A: Dr Brook: It’s early days, it’s work in progress, we haven’t cracked it yet.
Public health cuts and health inequalities
Q: Given the cuts to Calderdale Council’s public health budget, how is that going to affect public health programmes aimed at reducing health inequalities in Ovenden and Mixenden?
A: Dr Brook said they were targetting resources to where there are the greatest needs, as identified in the Joint Strategic Needs Assessment.
Dr Carsley said the 20s plenty scheme had reduced road traffic accidents.
I said it was all very well to say you’re targetting resources to where there are the greatest needs but what about the other needs?
Dr Brook said he’s not aware of any important service that’s jeopardised.
Urgent care centres
Q: The Royal College of Emergency Medicine says that only around 20% of A&E patients can be appropriately treated by urgent care centres and other sources of treatment like GP out of hours services, NHS 111 etc. But the hospital cuts proposal plans to treat 54% of patients who’d have previously gone to A&E, at urgent care centres. If RCEM is right, that means CRH would need to treat 113,600 patients/year not the planned 65,320. Are the Trust/CCGs revising their plans in the light of this RCEM figure?
A: Dr Brook said the RCEM were not talking about the wonderful new urgent care centres, they were talking about GPs etc and that was why the figure was so low.
I said I wasn’t sure about that, I’d go back and check. I have since contacted the RCEM to find out and they confirmed that their research shows that 22% of patients who go to A&E could appropriately be treated in an urgent care centre co-located at the same site as an A&E.
I also checked the RCEM source documents, which say,
“RCEM PRESS STATEMENT 14 April 2016 Publication of A&E performance statistics for February 2016
Our studies have shown that over 20% of patients attending A&E departments would be as well or better served by clinicians other than emergency medicine doctors. The RCEM has argued for some time that we must create A&E hubs with co- located services including urgent out of hours primary care, crisis mental health teams and community pharmacies. Additionally the need for services to better assess and care for the frail elderly must be available in all A&E departments.
Providing such hubs will decongest our overcrowded departments benefitting all patient groups.”
“RCEM Emergency Department closure position statement
The amount of traditional A&E work that can be undertaken by the replacement unit (such as a GP- or nurse-led urgent care centre) is likely to be grossly over-estimated.”
Dr Brook said said that CHFT have looked at the figure of 54% of patients who could go to urgent care centres, and that is dependent on the level of care and facilities in urgent care centres.
Facilities will include x ray facilities, and x rays can then be looked at in the acute hospital “down the wire” and the urgent care centre can put on a temporary cast until the patient can go and get a permanent one done.
David Birkenhead said the 54% figure is based on local data that’s been analysed eg though going through the codes for what treatments have been given at A&E. He said it’s an ambitious target for the Urgent Care Centres.
Dr Brook said the 54% figure “is an illustration not a fixed number” and that it is corroborated by data seen by GPs after patients have visited A&E.
Q: What staff will there be at urgent care centres?
A: GP-trained doctors – but won’t be “stealing” from existing workforce – they could be new GPs who are putting together a “portfolio career” who would work there 1-2 days/week. There would be emergency nurse practitioners 24/7.
I asked if the doctors would be there 24/7 or just in the daytime.
Dr Brook said they will be there as much as it turns out to be worthwhile. Possibly by video.
“Who will staff it, will be who it emerges will be appropriate to have there.”
I asked if it had been done somewhere else so they could see how it works there.
Dr Brook said it had been done at Cramlington Hospital in Northumbria, which was an Emergency Centre hospital with three satellite urgent care centres in hospitals in surrounding areas, including N Tyneside.
(However, a member of Defend Tynedale NHS – set up to campaign against downgrading of the A&E department,and against any further downgrading or privatisation of the hospital – has commented on the Right Care Right Time Right Place proposals:
“We already have this in Cramlington ,Northumberland and it is happening across UK, fight with all your might we managed to save some services, NHS England call it centralisation, when they really mean downgrading services.”)
Dr Brook said
“We can’t afford for the staff not to be there.”
I asked how the Northumbrian urgent care centres were staffed.
Dr Carsley said that technology and remote care facilities are evolving, and they may need to spend money on video links and technology instead of staff.
David Birkenhead said that the UCCs will be doctor-led. They will be doctors with GP skills, given training in advanced life support.
Reducing unplanned hospital admissions
Q: GPs’ use of risk stratification to identify patients most at risk of unplanned hospital admissions and to put care plans in place for them has just been found to increase acute and emergency hospital admissions of these patients – not reduce them. Since this is a key part of Care Closer to Home & the Vanguard scheme, how are the CCGs factoring this finding into their plans?
A: Dr Carsley said the Direct Enhanced Payment Scheme (DES) for reducing unplanned admissions was a blunt tool.
Dr Brook said that care planning for vulnerable patients requires Care Closer To Home. He said that there are care plans for about 2% of the population and they are reviewed monthly for the DES reducing unplanned admissions scheme.
He said the common theme for unplanned hospital admissions is “carer breakdown”.
I asked what that meant and he said it is when the people who are looking after the patients are not aware of plans in place and ring for an ambulance. He said when the ambulance “hear see treat” scheme starts, they will be able to do more than taken the patients to hospital – ie get in touch with Care Closer to Home.
Dr Carsley mentioned End of Life care.
I said I’d seen it mentioned in the Pre Consultation Business Case that the plan was to move end of life care out of hospital into the community. I asked how that would work.
A: Palliative Care Consultants would visit patients in their homes, the Consultants would be based both in the hospital and the community. The patient would have more access to out of hours care but if necessary the patient would still be admitted to hospital.
Q: I asked about plans to involve charities in End of Life Care, like Age Concern.
A: The CHFT community palliative care team will care for dying people at home. Charities will be involved. As well as Overgate hospice, there are Marie Curie nurses at night. Charities are interested in setting up complementary schemes and incorporating them with joined up out of hospital services. At the moment there are Macmillan nurses linked up with GP practices and linked back to consultants.
Government-driven NHS cuts and sell offs
Q: Dr Brook asked me what I felt about the proposals.
A: I said I thought that they were driven by the government’s dual agenda of totally unnecessary “austerity” cuts to public spending and stealth privatisation, that it imposed through the undemocratic Health & Social Care Act 2012, which was not in any party’s election manifesto for the 2010 general election.
Dr Brook said if they didn’t make the cuts and changes, NHS Improvement will come in and close the hospital or take away services.
I said that was what the hospitals Trust Chief Exec Owen WIlliams said at the Halifax public meeting.
Dr Brook said they are doing the best they can in circumstances.
I said if I were in their position I would challenge those circumstances, that are entirely of the government’s making.
The Clinical Commissioning Groups could tell the government to stop making unnecessary so-called austerity cuts and promoting the sell off the NHS through their totally undemocratic 2012 Health and Social Care Act, that was not in any party’s 2010 election manifesto, and its consequences.
Dr Brook said the government wouldn’t take any notice of them.
I said the gov’t have a very small majority in the House of Commons and if all the CCGs around the country who are having to cut services and close A&Es went to the government and told them where to put their NHS-destroying policies, they could have a real effect. They would also have to tell the Shadow Health Secretary, who seems to share most of the government’s NHS policies and who would need to ditch these if there is to be any effective Parliamentary opposition to the NHS cuts and sell offs.
Dr Brook changed tack and said the funding shortage isn’t a problem because there’s waste in the system, which both Dr Carsley and David Birkenhead agreed with. They think cutting waste means they can manage on less money
Since a rep of one of the charities that are commissioned by the CCG to provide health services had said the same thing when Katherine and I were talking with her outside the drop in, and I’d never heard the CCGs make this argument before, the “cutting waste” line could be the spin of the day.
I asked where there was waste in the NHS. Dr Carsley said there was duplication of effort eg physiotherapists not talking to schools. And people could be seen at home. David Birkenhead said it’s waste keeping 2 A&Es open at night.
Dr Brook said privatisation is ok. I challenged that and both he and Dr Carsley chorussed triumphantly:
“GPs are private providers.”
I disputed that, saying that GPs on traditional GMS contracts may be independent contractors but they are so regulated by the NHS, and not allowed to hand on or sell the GP practice they own/run when they retire, that they are not private providers in any meaningful sense of the term.
We chewed the fat about that a bit and one of them mentioned dentists being private providers and I said
“Look where that’s taken dentistry.”
They agreed GPs should not go down that route with a two tier system for NHS and private patients, and that dentistry should be properly brought back into the NHS.
Dr Brook said it would be ok as long as the NHS stays free at point of delivery and provide national standards of care.
I said I there was a lot more to the NHS than being free at the point of delivery and reducing it to that was not a good idea.
Dr Brook started reciting his script about Keogh etc. I said I’d heard it all before.
We then discussed the 30 yr roots of the NHS privatisation problem, and the nearly 20 year roots of the Care Closer to Home idea, planted in the Kaiser Permanente ideas imported into the Dept of Health by McKinsey and other advisers to the New Labour government after they basically privatised the Dept of Health by replacing civil servants with management consultancy people.
Dr Carsley was prepared to listen and try to understand where I’m coming from, she engaged in constructive listening, saying back to me what I’d said, accurately, and said she could see from my point of view that the Clinical Commissioning Groups are not looking at the context that they’re working in. I appreciated that. It could have been the start of an interesting discussion
But David Birkenhead and Dr Brook seemed programmed to direct the conversation back onto their scripts – without any deviation that could come from entertaining anyone else’s point of view.
Ancient Mariner Awards are due.
Updated 17 May 2016 with comment from Tyndale Defend Our NHS