At the 18 May hospital cuts consultation drop it at the Orangebox, Halifax, only about 6 people had attended by the time I left, around 5pm. The out-of-the-way venue was signposted, but people weren’t turning up.Maybe it would’ve been better to hold it in the Central Library, which is easy to find.
Afterwards, on the main shopping street I passed the engagement officer Dawn Pearson who was standing on the pavement encouraging passers by to take the Right Care Right Time Right Place consultation document and to attend the drop in. She didn’t seem to be having much luck.
The room was better laid out than at other venues I’d been to and there were different staff who were more relaxed.
I asked about how the new Sustainability and Transformation Plans (STPs) are going to affect the proposed hospitals “reconfiguration” in Calderdale and Kirklees – particularly given the STP aims of eliminating the NHS deficit this financial year and increasing NHS privatisation.
Katherine Riley, Assistant Director of Strategic Planning at Calderdale & Huddersfield NHS Foundation Trust, said they had not been briefed on this.
She asked what I would like to see happen with the NHS and social care in Calderdale & Huddersfield. I said I’d like to see a proper level of funding from the government – instead of a £22bn funding shortfall by 2020/21, and the NHS renationalised by passing the NHS Reinstatement Bill.
She scoffed that this was a national level change and the NHS Reinstatement Bill wasn’t going to get passed any time soon, so what would I do now, locally?
I said I would protest to the government and NHS England that they were imposing intolerable cuts and sell offs on the NHS. I mentioned Jonathan Allsop’s blog about this and Dr Nigel Taylor looked thoughtful.
I pointed out that the current NHS cuts and sell offs are being carried out as a result of the 2012 Health & Social Care Act, which was not in any party’s 201o election manifesto. This means the Clinical Commissioning Groups exist without any democratic mandate, since they were set up by the 2012 Health & Social Care Act.
Here are the questions and answers.
Sustainability and Transformation Plans
Q: The 2015 Spending Review settlement for the NHS committed the government to encouraging long-term partnerships with the private sector in a number of key areas including:
•development of new models of care including Accountable Care Organisations
•the upgrade of diagnostic capabilities
•hospital groups and acute care collaborations.
Is Calderdale CCG going to encourage long term partnerships with the private sector in setting up an Accountable Care Organisation (ACO) for the Calderdale Vanguard scheme? And does Wainhouse Healthcare Ltd – the Pennine GP Alliance – count as the private sector?
A: Dr Nigel Taylor, Hebden Royd Group Practice GP and member of Calderdale CCG Governing Body, said:
No – Pennine GP Alliance is not private sector, it is a GP Federation. Calderdale CCG are not necessarily committed to an ACO, they’re considering if an ACO is a useful organisation and looking at its merits as a potential model. The Vanguard will be given a cash envelope to provide the service. This shifts the emphasis from commissioner to provider.
We discussed the idea of an ACO at a Development Forum last week but didn’t come to any conclusion. It’s a working idea. There’s no fixed agenda or timetable for a decision.
Vanguard has become entangled in Care Closer to Home. What’s come out at the end of the process is reduced support compared to what NHSE had offered. We will push ahead even if no money is available. It’s blue sky thinking about what model to use.
Dr Taylor didn’t know how much money has been taken from the Vanguard scheme and put in the Sustainability and Transformation Plan fund.
Calderdale CCG got some Vanguard money from the first allocation. He didn’t know if they’re getting anything from the second allocation via the Vanguard Value Proposition. He said he’s not close enough to know – ask Matt Walsh, Calderdale CCG Chief Officer. Update: It has been cut by 94.3% in 2016/17.
Q: I asked about the shift from the original plan for a Multi-speciality Community Provider (MCP) Vanguard – which according to a Calderdale CCG presentation to the March Health & Wellbeing Board, is now seen as an MCP/Primary and Acute Care Systems (PACS) Vanguard. I asked if this means that a likely endgame would be that the lead provider/ACO will end up running the (downgraded) Calderdale Royal Hospital, which has had many of its services hived off to large specialist regional centres by the time the Sustainability & Transformation Plan has done its work?
Katherine Riley said she doesn’t know about PACS.
Dr Nigel Taylor said they’re working on the Vanguard as an MCP scheme. He is not aware of a decision about a switch to MCP/PACS. He said that if they went for the ACO model, someone would be the main partner in the organisation, for example in Northumberland the Acute Trust is the main partner in the ACO. They had some discussion in last couple of weeks about where they wanted to be in 5 years time – this was one option.
Katherine Riley said:
This is a niche question – we’ve not been briefed to answer these questions. But ask the Governing Body.
“STP has happened to us.”
Dr Nigel Taylor said,
We’re still in the process of writing Sustainability and Transformation Plans – they have to be submitted by the end of June, the CCG are writing the STP for Calderdale.
Q: Money for bailing out Trusts in deficit will now come from the STP fund and will be conditional on the STP “footprints” eliminating the NHS deficit in 2016-17, and meeting other criteria. Money for bailing out Trusts’ deficits will not come from the Dept of Health/Treasury. But the £490m that Monitor has asked the Treasury for, to pay for the Right Care Right Time Right Place hospitals reconfiguration, includes £179m for the CHFT deficit. (Consultation Doc, p 9.) What if the Treasury says no, this has to come out of the STP fund?
Katherine Riley said:
This Consultation started in good faith. If circumstances have changed and we can’t deliver that model, there’d be further consultations. Ask Matt Walsh about how the STP would affect the Treasury’s backing for the Plan.
Q: 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?
A: Katherine Riley – Not briefed on that.
Q: What about EU Competition Law? eg the mental health trust is alive to the fact that EU competition law poses problems for the rollout of NHS England’s 5 Year Plan for new care models. Its Strategic Plan 2014-2019 states that the only way it can survive financially is:
“…to be part of a bigger entity with critical mass as a specialist mental health and community provider”
But it identifies as a Strategic Risk:
“Commissioners and regulator concerns – potentially re competition impact.”)
A: Dr Nigel Taylor said :
I can’t answer this. Martin Pursey would advise on this.
Q: Will diagnostic capabilities need upgrading for the Emergency Centre & the urgent care centres and if so will these been done through the private sector?
A: Katherine Riley said, There’s no level of detail about this. There’s a 3rd MRI scanner approved and there will need to be a 4th. Send in these questions in writing.
Q: At the Textile Centre drop in, Dr Ollerton said that the Urgent Care Centres could feasibly be provided by the private sector. Do the CCGs plan to put the contract for urgent care centres out to competitive tender?
A: Dr Nigel Taylor said,
“This is news to me. In the model, they’re GP-led. There are no detailed proposals about who would provide it. It would be providing services that are provided by the out of hours GP service – more integrated urgent primary care centres are currently provided by walk in centres. That’s Local Care Direct. Would you call them a private provider? I don’t know who will be the ultimate provider.”
Q: What long term partnerships with the private sector if any is Calderdale CCG and the Trust thinking of for hospital groups and acute care collaborations?
A: Katherine Riley: West Yorkshire acute providers meet and discuss how to work together to improve the clinical offer.
Q: The GP member practices of Wainhouse Healthcare Ltd are the same as the GP member practices of the Calderdale Clinical Commissioning Group governing body. This presents the interesting prospect that the commissioner and lead provider for almost all Calderdale’s health services – bar some specialist acute hospital care and A&E – will be one and the same.
Is this ethical?
A: Dr Nigel Taylor:
There is an inevitable conflict of interest to deal with in everything we do. So GPs would have to excuse themselves from that decision about awarding any contract to Pennine GP Alliance. We have been careful as a CCG to deal with this.
Financial case for change
Q: Who asked the Treasury for the money for the hospitals reconfiguration and deficit reduction? Was it Calderdale & Huddersfield NHS Foundation Trust (CHFT)?
Katherine Riley: The proposal was submitted to the Treasury by Monitor before the consultation started. Money is not the root of it (the hospitals reconfiguration), it’s about clinical safety and making CHFT an attractive place to work and to recruit to.
Dr Nigel Taylor: Calderdale CCG is not like other CCGs that are privatising everything, it has a commitment to work with existing providers as first choice, although they have to work within rules about procurement.
Q: When will the hospital Trust’s deficit be eliminated, if these proposals are carried out? We know that for the 1st 5 years of the new hospitals clinical model, there is a projected deficit of £9.5m/year, meaning a cumulative deficit of £49.5m by 2025/6.
A: Katherine Riley – Don’t know.
Dr Nigel Taylor: Matt Walsh (Calderdale Clinical Commissioning Group Chief Officer) expects it to happen, but he doesn’t know if MW has date.
Possible conflict of interest in role of Lendlease Consulting
Q: The Role of Lendlease Consulting in costing the capital costs of both options for hospitals reconfiguration and advising on the decision to make CRH the acute/emergency care hospital seems at odds with the role of Lendlease Corporation as a major (40%) shareholder in the PFI Special Purpose Vehicle Calderdale Hospital SPC Holdings Ltd – which would stand to benefit financially from developing CRH as the acute/emergency site.
The Ernst & Young 5 Year Strategic Plan for CHFT says that any proposed capital works that fall within the CRH PFI site that is owned by the PFI provider will be subject to their own procurement procedures that take longer and cost more – within the PFI contract there is an identifiable 12/5% overhead cost. Programme costs may also increase because of the longer period to procure the works. The type of contractors used may increase the tender prices. The capital cost at CRH may be greater than at HRI. Should the works at CRH be added to the annual PFI costs, this will significantly increase the differential between HRI and CRH over the remaining 47 years of the PFI contract (Ps 226/7).
Who decided to employ Lendlease Consulting?
A: Katherine Riley – CHFT
Q How much were they paid? Whose budget did this come out of?
Katherine Riley – CHFT’s budget. Put in FOI request about how much they were paid. It may be subject to commercial confidentiality – CHFT would ask LendLease Consulting if they are happy to provide info.
Q: In deciding to employ Lendlease Consulting, did CHFT consider their conflict of interest as Lendlease Corporation holds 40% of CRH PFI equity & so stands to benefit from a decision to make CRH the acute/emergency hospital?
A: Katherine Riley – Can’t answer that.
Q: The decision to make CRH the acute/planned care hospital could bring a lot more money to the PFI Special Purpose Vehicle, which Lendlease Corporation has a sizable share in. The EY Plan states that if CRH is the acute site, it will need:
- a new ward block with around 100 extra beds
- a bigger ICU that can take level 3 care
- an expanded A&E with a dedicated children’s A&E
- Additional diagnostic services including MRI and CT (will these be privatised?)
- expanded pathology space
- multistorey car park.
Which of the proposed capital works would fall within the CRH PFI site that is owned by the PFI provider? I forgot to ask this question, will write and ask CHFT
Proposed A&E closure/downgrade
Q: At the Huddersfield public meeting, Head of A&E Mark Davis said he goes to bed crossing his fingers that everything will be ok in the A&Es overnight. At the 3ways centre drop in, the Trust medical director said that having 2 A&Es open at night was a waste of money. Which statement is true? That A&Es are dangerously understaffed at night? Or that it’s a waste of money keeping both open – which implies there isn’t much patient throughput?
A: Katherine Riley: It just takes one person to come in who doesn’t get the right treatment.
Dr Nigel Taylor There’s not enough staff on site at both of them.
Q: The Consultation Document says that 54% of current A&E patient numbers would go to the 2 Urgent Care Centres (UCCs). At the Textile Centre drop in, Dr Ollerton said that 80% of A&E patients would go to the 2 UCCs. Which one is right?
Katherine Riley: CHFT did an analysis – it was being cautious. In time, there could be more patients going to the UCCs.
Q: 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”?
A: This is about ambulance travel times – this is what’s desirable.
Q: When are the Clinical Commissioning Groups going to quantify the risks of increased emergency patient mortality associated with increased distances to A&E?
A: Katherine Riley:
“No work is going on to quantify this.”
Q: 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?
A: Katherine Riley:
“The whole population lives within 45 minutes ambulance travel time and there will be an improved service model. I’m confident that increased journey time isn’t an increased risk.”
Hear See and Treat
Q: Does Hear See and Treat relies on paramedics being able to prescribe?
Dr Nigel Taylor: Don’t know if any paramedics can prescribe. If a paramedic needs to prescribe, they will contact primary care to come and prescribe.
Q: Re Hear See Treat, what about emergency care practitioners (ECPs) -mainly paramedics, with extended skills. Is the plan that ECPs with extended skills will attend as first responder and perform the whole episode of care assessment / diagnosis and treatment? So either they are going to need to prescribe or carry a drug cabinet in the car. Are they allowed to prescribe?
Dr Nigel Taylor: We often work under group directives that allow certain drugs/medicines to be delivered when they are prescribable, by people who can’t prescribe. This is in hospitals and primary care, so non-prescribers can administer some prescription medicines. The group directives are developed by the relevant organisations.
Q: A big question has got to be around the pathways in place ie can they gain follow up if required from GP after initial diagnosis / treatment? Is there a pathway into hospital if deemed necessary?
A: Dr Nigel Taylor said that at the moment a paramedic will ask primary care to see patient if they don’t need to go to hospital. Will develop that more. There will be much better access to primary care, through the improving access to primary care agenda.
Hospital bed cuts
Q: 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?
A: Dr Nigel Taylor: Can’t comment on how CHFT have calculated what the number of beds should be. But they are moving to shorter lengths of stay, and more treatments on a day case basis. Whenever bed numbers have been planned in the past, clinical advances have meant that not as many as planned have been needed.
Katherine Riley: Calderdale CCG Quality Innovation Productivity and Performance (QIPP) plans for Care Closer To Home etc are behind the hospital bed numbers. [QIPP = efficiency savings = cuts.]
Dr Nigel Taylor: Calderdale CCG are supporting nursing home providers. There are huge problems with that – the care home market needs support and development. It needs to be fixed now.
Dr Nigel Taylor: We are supporting the care home market – working with local authority to make sure we pay what we need to pay, through joint commissioning with the local authority.
The privatisation of nursing homes (64% of residential and nursing homes were provided by local authorities or the NHS in 1979; by 2012 it was 6%) has been accompanied by growing role for large companies with 50+ homes at the expense of small, family-run businesses. Privatisation has had a bad effect on the workforce, and this in turn affects the quality of care staff can deliver.
The sector is at breaking point, but why should NHS and local authority money be funelled into business models that are often based on private equity buyouts and offshore ownership? A report from the Centre for Research in Socio-Cultural Change shows that calls from private companies for a ‘full cost’ fee level are based on a return on investment of 12%. The report proposes a maximum of 5%.
Social care should be renationalised but until that happens, the Centre for Research in Socio-Cultural Change suggests 4 tests that could improve the situation:
- transparency – private providers should be subject to full openness and transparency with no “commercial confidentiality” let out, subject to FOI and local political scrutiny processes.
- ownership/taxation test – the ownership of all companies providing public services under contract to public sector should be available on public record and private companies with public services contracts should show they are domiciled in Uk and subject to UK taxation.
- comply with national minimum wage levels including paying travel time between visits and not using tracking devices that pay people by the minute.
- accountability test.
Q: 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?
A: Katherine Riley:
Calderdale CCG has looked at the acute medical admissions profile compared to national bench mark. Confident that benefits outweigh risk.
Questions I didn’t get round to asking
What is the reason for dropping the proposal for an Urgent Care Centre in Todmorden Health Centre ? On p144, Ernst and Young’s 5 Year Strategic Plan for CHFT 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?
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.)