NHS commissioners fail to make good Consultation Document errors and omissions

Save Our A&Es campaigners asked the Clinical Commissioning Groups to make good the errors and omissions in the hospital cuts Consultation Document. They took about five weeks to respond and their answers provide almost no new information. They include many denials of the validity of our questions and much splitting of hairs. Here are the first 12 questions we asked. The remaining 26 are here and here.

This is the letter we wrote.

Our questions are followed by the CCGs’ answers, and our comments on their answers.

Reading them will probably make you want to tear out your hair. We will try and boil down the key points in a more accessible way before the end of the consultation.

Dear CCGs’ Chief Officers and Governing Body Chairs,

Having carefully studied the “Right Care Right Time Right Place – Have Your Say” Consultation Document, we find that it is inadequate to the task of properly informing the public about the proposed reconfiguration of hospital, community care and primary care services in Calderdale and Kirklees.

The consultation is not fit for purpose in the questions it asks in the Survey, and in the information it provides in the Consultation Document.

In order to rectify this problem, we ask that you make good the following errors and omissions in the Consultation Document, by sending us accurate corrections to misleading information and producing missing information, as outlined below.

We ask too that you make this new information available to the wider public, well before the end of the Consultation period, by posting it on the Right Care Right Time Right Place website.

We have an absolute commitment to assessing if the Right Care Right Time Right Place proposal is right, once we have all the information about it. We can’t do that until and unless you give us and the rest of the public the information that we need.

The Consultation Document is misleading and uninformative in the following respects, among others:

Question 1

It makes an entirely inappropriate claim that the CHFT’s above-average Summary Hospital Mortality Indicator for the period of the year to July 2015 justifies wholesale change of the hospital’s clinical model. This flies in the face of guidance from the Health and Social Care Information Centre about how to interpret above average SMHI figures – which is to first look carefully at the most obvious likely reasons for it, such as coding errors and case mix. In particular the claim that having senior doctors present in A&E 24/7 would reduce mortality is not a valid extrapolation of the SHMI data, for reasons that are clear from the HSCIC guidance on interpreting SHMI data.

CCGs’ answer

The  Consultation  Document  makes  3  references  to  Mortality.

P5,  Foreword – We  need  to  improve  our  hospital  mortality  rates  which means reducing  the   number of patients who die in our hospitals

P7,  Why  we  are  proposing  changes  –   The  number  of  patients  dying  in our  hospitals is  higher  than  average.
The Trust’s hospital mortality  rates  are  higher  than  the  England average. This  means that   more  people  are  dying  in  our  hospitals  than  would be expected. There  is  an increased   national  focus  on  mortality  which means that  many  more  acute  Trusts  are making  significant   progress.  This brings  down  the  overall  England  average  so  that Trusts  that  are currently   outliers,  such  as  Calderdale  and  Huddersfield  NHS Foundation Trust  have  to  reduce  mortality   even  further  to  move  closer  to  the national  average.

P9,  Why  are  we  proposing  changes   Direction  of  national  policy
There  has  also  been  a  national  drive  for  the  NHS  to  move  towards seven  day working.  In   February  2013,  Sir  Bruce  Keogh  set  up  a  Forum on  NHS  Services,  Seven Days  a  Week  to   address  the  significant variation  in  outcomes  for  patients  admitted to  hospital  at  weekends   across  the  NHS  (a  problem  affecting  most  health  systems across  the world).  This  is  seen  in   mortality  rates,  patient  experience,  the length  of hospital  stays  and  readmission  rates.

None  of  these  references  make  the  claim that the CHFT’s above-average Summary   Hospital  Mortality  Indicator  for  the  period  to  July  2015 justifies  wholesale  change  of   the hospital’s clinical model.  The mortality  references  are  included  as  part  of  the broader  explanation of why  we   are  proposing  changes  in  order  to:  meet  the  needs of  the population;  meet  quality   and  safety  challenges;  and  take  account  of national policy.

Our comments

The  answer  does  not  address  all   the  points  raised  in  the  question.
The  answer  clearly  demonstrates  that   the  key  driver  of  the  proposed changes   is national  policy  rather  than  the  needs   of  the  local population  or  quality  and   safety challenges.

It  also  shows  clearly that the CCGs’ proposals  for  local  reconfiguration adhere faithfully to  the  new  models  of   care  proposed  nationally  in NHS  England’s Five Year Forward View (Oct.  2014).

It is splitting hairs to say that the CCG’s haven’t claimed that the CHFT’s above-average Summary Hospital Mortality Indicator for the period of the year to July 2015 justifies wholesale change of the hospital’s clinical model, and then to say that the mortality references are part of the explanation of why they are proposing changes.

In their verbal submissions at the Joint Health Scrutiny Committee and drop-ins, they do suggest that the changes will reduce mortality rates

Question 2

The joint CCGs didn’t include a Health Inequalities Assessment in their Equality Impact Assessment and the Consultation Document doesn’t refer to the need for one. But the 2015 update of NHSE’s ‘Planning, Assurance & Delivering Service Change For Patients: A Good Practice Guide for Commissioners on NHSE assurance process for major service changes and reconfigurations‘ specifies the Public Sector Equality Duty, to assess the Equality AND Health Inequalities related to the proposals. It also requires a Privacy Impact Assessment, which is nowhere to be seen.

CCGs’ answer

The  Equality  Impact  Assessment  is  Appendix  E  to  the  Pre-Consultation Business Case.  The  Pre-Consultation  Business  Case   has  been  published on the  programme website  and  shared  publicly   with  the  Calderdale  and Kirklees  Joint  Health  Scrutiny Committee.

The  document  referred  to  – the 2015 update of NHSE’s ‘Planning, Assurance & Delivering Service Change For Patients: A Good Practice Guide for Commissioners on NHSE assurance process for major service changes and reconfigurations’  also  states  that  ‘Assurance will be applied proportionately to the scale of the change  being  proposed,  with  the  level of  assurance  tailored  to  the   service change.’

Prior  to  making  a  decision  to  proceed  to  consultation  the  CCGs   were subject  to  the NHS  England  assurance  process.  The  Assurance   panel presented  their  findings  to the Regional  Management  Team   on  18th January  2016  and  recorded  their  findings  in  a letter  to  the   Chair of the  Assurance  Panel  on  19th  January which stated ‘in summary I am  content that  you  support  the  CCGs  to  proceed  to   consultation.’  A  copy  of the letter  is  attached  for  information.

The  Health  Inequalities  considerations  are  taken  from  both  Councils’ Joint Strategic Needs Assessment and referenced in the Pre-­Consultation Business  Case.  A  full  Health Inequalities  impact   would  be  taken  into account  should  the  proposals  proceed  to   implementation.

Our comments

The  answer  does  not  address  all  the  points   raised  in  the  question, and  the assurance  letter  was  NOT  attached.

A  letter  is  on the consultation website.

This  implies  assurance  was  carried  out  at   Regional  level.   NHSE’s ‘Planning, Assurance & Delivering Service Change For Patients’ (PADSCP): Good Practice Guide  states on  P11  that:

“The  Investment  Committee  (IC)  should  review  the  assurance conclusions  and  take decisions  for  all  schemes  where  one  of  the following  conditions applies:” (including) “Impact  on  any  NHS  trust  or NHS  foundation  trust  … where  the reconfiguration  is  in  respect  of services  where  there  has  been  enforcement action.”

Calderdale  &  Huddersfield  NHS  Foundation  Trust  is   under enforcement action  for  its finances,   leadership  and  governance.  Why  was  assurance not  done  by  the  IC?   Why was  there  no  Health  Inequality   Analysis  in the  PCBC  c.f.  the  PADSCP? re: https://www.england.nhs.uk/wp-content/uploads/2015/12/hlth-inqual-guid-comms-dec15.pdf – See  Annex  B  Brown  Principles.

From CCG replies at consultation drop ins, it does not seem that health inequalities is something the CCGs have thought much about. At the Threeways Centre consultation drop in on May 3rd, one of us asked 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. Dr Brook demanded to know the reason for asking these questions. On being told that as Ovenden is a relatively economically deprived ward, we 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.”

On being asked, “What have you done?” another GP, Dr Carsley, said tentatively to Dr Brook,

“There’s Dawn’s work with community champions, and work about travel time.”

Dr Brook then said,

“It’s not for us to address all these fine details. Calderdale Council are aware of the travel problems…”

The fact that relocating services has a disproportionate effect on poorer and more vulnerable people means there is an urgent need for the Consultation Document to include a Health Inequalities Assessment. The Royal College of Emergency Medicine ’s statement on Emergency Department closure and reconfiguration includes the following information


  • Relocating services has a disproportionate effect on the very young, the very old, patients with mental health issues and those with chronic illness or reduced mobility.
  • Relocation also has a greater impact on poorer socioeconomic groups through difficulties with transport.
  • The likelihood of transportation difficulties will be higher in rural areas.

Question 3
The joint CCGs have not met many other requirements for significant service changes, eg the Consultation Document doesn’t show:

  • How you have carried out their statutory duty to involve Service users in the development of their proposals
  • How options would be implemented & safe services maintained in the interim
  • How the Public Health Directors & Local Authority service leaders have been involved in the plans – and the Consultation Document doesn’t say that both Calderdale and Kirklees Councils have unanimously rejected the proposals, in full Council meetings.

CCGs answer

The  information  to  support  the  requirements  in  relation  to  service   change  is included  in  the  Pre-Consultation  Business  Case.     Section  4 of  the  Consultation Document,  Page  9,  sets  out  how  we   have  involved Service  Users  in  the  development of  our  proposals  as  referenced  above in  question  2.

The CCGs successfully completed the NHS England assurance process  prior  to making the decision  to  proceed  to  consultation  at  the meeting of the CCGs’ Governing Body meeting  in  parallel  on   20th  January,  2016.

The  impact  on  local  government  services  is  set  out  in  the  Pre- Consultation Business Case  in  section  4.3  Community  based  Care   proposals.

In  addition  the  period  of  Consultation  also  provides  the   opportunity for  the Councils to  feed  in  their  views  on  the   proposals.
The proposals are also discussed in public at the Councils’ respective  Health and Wellbeing  Boards.

Neither  Calderdale  Council  or  Kirklees  Council  have  unanimously rejected the proposals.

The  decision  by  Kirklees  Council  was  not  unanimous  as  not  all   members  could  vote  e.g.  it  excluded  members  of  the  Joint  Health   Scrutiny  Committee.  Additionally,  the  vote  was  taken  on  16th   March, 2016,  which  was  after  the  launch  of  Consultation  and  the   printing of the  documents.

We  do  not  agree  Calderdale  Council  has  unanimously  rejected  the   proposals.  The Council  expressed  concern,  when  it  met  on  16th   April, 2014  about  earlier  proposals submitted  by  Providers  –  not   the CCGs’ proposals as outlined in Rght Care Right Time Right Place consultation- and agreed to establish the People’s  Commission.  The decisions  by  the  Council from  16th  April  are   reproduced  below.

A key decision was the agreement to establish the People’s Commission  to  take evidence, lead  consultation  and  produce   proposals  regarding  the  future provision  of  integrated health  and   social  care  services  across  the Calderdale  and  Greater  Huddersfield   health  and  social  care  economy.   The  decisions  by  Calderdale  Council  on  9th February,  2015  in relation to the People’s Commission are also reproduced  below.

The  CCGs  are  of  the  view  that  the  proposed  changes  are  in  line   with the People’s Commission’s recommendations. In  particular,  the  recommendations  acknowledge  that:

  •  No  change  is  not  an  option;
  • the  CCGs,  CHFT,  NHS  England  and  the  Council  should  work  together  to  develop proposals;
  • that  people  with  urgent,  life  threatening  conditions  need  access  to  the  best specialist  care  possible;
  • people  who  have  what  they  consider  to  be  urgent,  but  non-life-threatening illnesses  and  injuries  should  have  easy  and  local  access  to  advice  and treatment;
  • alternative  proposals  to  those  put  forward  by  the  Providers  should  be  developed for  public  consultation;
  • we  should  examine  options  to  increase  financial  stability;
  • a transport  plan  should  be  drawn  up;
  • Care  Closer  to  Home  should  precede  any  proposed  changes  to  Hospital  services and  would  need  time  to  bed  in.

The  recommendations  in  relation  to  GP  Access  are  being   progressed separately to this consultation as part of both CCGs’ Primary  Care  strategies.

[The  CCGs  then  quoted  the  Calderdale  Council  minutes  for   meetings  held  on  the    16th  April  2014  and  the  9th  February  2015  where  they  related to  the  proposals.     This  covered  more  than  3  pages of  the  38  page  document  they sent,  that  included    our  questions  and  their  ‘suggested  answers’.]

Our comments

This is just plain denial of our accurate points.

NO  – Section  4  in  the  Consultation   Document  (Ps9  &  12)  only applies  to  the   evaluation  of  the  options,  not  the  development of proposals,  which  was  the  question.

SEE  COMMENTS  at  Q2  about  the  regional   assurance  not  being appropriate.

NO  ANSWER  to  the  point  about  how  options would  be  implemented  & safe   services  maintained  in  the  interim!

NO  ANSWER  to  how  public  health  &  local   authority  service  leaders have  been   involved  in  the  plans.

NO  – there  is  no  mention  of  either  Public   Health  or  local authorities  in  the  PCBC at  4.3  (Ps  45 – 50)  although  the  words ‘prevention’, ‘preventative’ and ‘social c are are mentioned,  twice  each!

INACCURATE  date  given  for  the  Kirklees   Council  vote  rejecting  the proposals. Kirklees  Council voted  on  20.01.16  (NOT   16.03.16)  to:
Oppose  any  proposals  which  leave  Kirklees   without  a  full  Accident and Emergency   provision.

Question 4

For people in search of information who turn from the Consultation Document to The Pre Consultation Business Case, this also fails to meet requirements for significant service changes: eg it fails to:

  • Be clear about the impact in terms of outcomes.
  • Be explicit about the number of people affected and the benefits to them.
  • Explain how the proposed changes impact on local government services and the response of local government – neither the PCBC nor the Consultation Document says that both Calderdale and Kirklees Councils have unanimously rejected the proposals, in full Council meetings.
  • Summarise information governance issues identified by the privacy impact assessment -which is conspicuous by its absence. This is particularly bad since the proposed Care Closer to Home scheme requires “integrated care” delivered by a wide range of providers from the public and private sectors as well as voluntary organisations, family and friends, which means patient consent will be required for sharing confidential medical data, entailing considerable information governance issues. The Care Closer to Home and Vanguard schemes also rely on risk stratification of patients most at risk of unplanned hospital admissions – which requires shared access to patients’ confidential medical records.
  • Demonstrate affordability and value for money.
  • Demonstrate proposals are affordable in terms of capital investment, deliverability on site, and transitional and recurrent revenue impact. This omission is particularly glaring since the PCB and the Consultation Document, far from showing that the proposals are affordable in terms of capital investment, says that if Treasury won’t come up with the money, the proposals can’t happen. And there is no clarity that the proposals for expanding CRH are deliverable on the site, given the PFI contract and the shortage of additional space on the CRH site, which is leased to the PFI consortium/special purpose vehicle.

CCGs’ answer

The  information  to  support  the  requirements  in  relation  to  service   change  is included  in  the  Pre-Consultation  Business  Case.

The  impact  in  terms  of  outcomes  contained  in  the  Quality  Impact   Assessment  -­‐ Appendix  D  of  the  Pre-­‐Consultation  Business  Case.

The  number  of  people  affected  is  included  in  the  Context  section   of  the Pre-Consultation  Business  Case  and  the  benefits  for  patients   are  set  out  in  section 4.5  Future  Model  of  Care – Outcomes  for   Patients  and  Section  5.1.2.  which  is  a summary  from  the  Quality   Impact  Assessment  at  Appendix  D

The  impact  on  local  government  services  is  set  out  in  The  Pre- Consultation Business Case  Section  at  section  4.3  Community   based  Care  proposals.

In  addition  the  period  of  Consultation  also  provides  the   opportunity  for  the  Councils  to  feed  in  their  views  on  the   proposals. The proposals are also discussed in public at the Councils’ respective  Health  and  Wellbeing  Boards.

In  relation  to  rejection  of  the  proposals  by  the  Council,  please  see   the  answer  to Q3  above.  In  summary:  We  do  not  agree  that  either   Calderdale  Council  or  Kirklees Council  have  unanimously  rejected   the  proposals.  Additionally,  the  motion  passed  by Kirklees  Council   was  taken  on  16th  March  which  was  after  Consultation  had     started.

A  Privacy  Impact  Assessment  is  not  required  to  be  completed  at   this  stage  because we  are  consulting  on  proposed  changes  and  no   decisions  have  been  made,  therefore  it  is  not  possible  for  it  to  be   completed  in  a  meaningful  way.  A  Privacy  Impact Assessment   would  require  the  detail  of  the  specific  information  which  would   be used,  the  name  of  the  provider(s)  who  will  use  it  and  how  they   would  process  the data.

Affordability  is  set  out  in  the  financial  situation  on  Page  4  and  in   the  Pre-­‐Consultation  Business  Case  at  section  7.2.  This  is  supported   by  the  CHFT  five  year plan  which  has  been  completed  in  line  with  Monitor’s guidelines and is available on the CHFT website.

Value  for  Money  is  one  of  the  criteria  used  to  appraise  the   alternatives  and  is  set out  on  pages  12  and  13  of  the  Consultation   Document.

CHFT  have  submitted  to  the  Department  of  Health,  what  we   believe  to be the  best case  for  financial  support,  in  that  it  would   provide  the  least  expensive  way  to deliver  the  requirements  of  our clinical  model.

We  have  been  clear  that  progression  of  the  proposed  changes  is   dependent  on additional  funding  being  secured.     We  will  not  know  if  our  submission  has  been successful  until  after   the  consultation  has  finished.  If  the  conclusion  of  the  public   consultation  process  was  that  we  were  to  proceed  with  the   proposed  changes  this could  only  be  a  recommendation  pending   the  successful  outcome  of  the  request  for funding.

Update: On 8th June the CCGs amended their answer in response to our request for clarification of the above 2 paras – we couldn’t tell who had submitted the case for financial support to the Dept of Health – CHFT or the CCGs. This is their update:

Monitor has applied to the Treasury for funding on behalf of CHFT. Should the
application be successful, CHFT would have responsibility for repaying the loan (or PFI
debt if PFI2 were to be used for the capital funding).

Both CHFT and the CCGs believe the submission to be the best case for financial support,
in that it would provide the least expensive way to deliver the requirements of our
clinical model.

We  do  not  agree  that  providing  clarity  on  the  space  requirements   at  CRH  should  be part  of  the  Consultation  Document.

As referenced above in question 2: the CCGs successfully completed  the  NHS  England assurance  process  prior  to  making  the   decision  to  proceed to consultation at the meeting of the CCGs’ Governing  Body  meeting  in  parallel  on  20th  January,  2016.

Our comments

They claim the info is in the Pre-Consultation Business Case but it clearly is not. Again and again throughout their responses they keep referring to the NHS England Assurance process and claim they are compliant with it which we have shown they are not.

AGAIN  the  specific  points  raised  in  the  question  are  not  answered.

The  question’s point  being  that  specific   information  is  not  as “clear”, “explicit” or even included ,  as  required  by  the  good   practice  guide  mentioned  above.  (see PADSCP at  Q2.  comments)

The impact  on  patient  outcomes  needs  to   be  CLEAR –  i.e.  easily  found.

The  numbers  affected  and  benefits  for   them  need  to  be  EXPLICIT  –  not  just  a   repeat  of  the  aims  of  the  proposal   assuming  these  will  be  achieved.

See  comment   at  Q  3.  re.  inaccuracy  of   the  answer  about  Kirklees  Council.

A  privacy  impact  assessment  should  be   INCLUDED  in  the  proposal,  and  how  the   issues  about  information  governance   identified  will  be  addressed  should  be   INCLUDED  in  the  Pre-Consultation Business Case.  See Annex 5 Information Commissioner’s Guidance on privacy.

The Consultation ‘financial situation’ is on P8  (not  P4)  and  outlines  pressures  that  are   not  about  to  change,  i.e.  will  continue   after  the  reconfiguration.

The  financial  case  made  is  not  very  convincing,  certainly  not  clearly  explained. The Trust  runs  a  current  deficit  and  the  plan  is to  borrow  money,  £179  million,  to reduce this for  them!   The  CCGs  say  there is a need  to  borrow  a   further  £291  million  of capital  to  change   CHFT  premises  and  the way the Trust  delivers  service!

Where will the risk for this debt sit? WHY  take on further  debt  when  the  information clearly   says  the  Trust  will  still  be  in  deficit  for   years?  (Q  12.)

We have been very puzzled about these questions and the CCGs’ answer doesn’t help. It is ambiguous. It refers both to CHFT’s submission to the DoH of the case for financial support and “our submission” for additional funding – which implies that the CCGs applied for the funding. (Update: The CCGs’ 8 June update to their answer confirms that Monitor has applied to the Treasury on behalf of CHFT.)

But Katherine Riley, CHFT Assistant Director of Strategic Planning, said at the Orangebox drop in on 18 May that Monitor applied to the DoH/Treasury for the funding before the Consultation started. So it wasn’t CHFT’s or the CCGs’ submission. It was Monitor’s.

Monitor did that on behalf of CHFT, which it has in “enforcement measures” because CHFT breached its licence conditions by going into deficit, because it couldn’t make the required efficiency savings and safeguard patient safety.

Before the 6th June Huddersfield public consultation meeting, one of us asked Owen Williams to explain this further. He said:

  • contrary to what Katherine Riley (CHFT Asst Director of Strategic Planning) said at the Orangebox drop in, Monitor did not apply for the £490m hospital development money before the consultation started.
  • Monitor had sent them notice that this is what they’ll be asking them for IF the CCGs decide to go ahead with the proposals.
  • if the DoH/Treasury does approve the money, it would probably be delivered through a programme board of DoH/NHS Improvement/CCGs/CHFT/NHSE.
  • in terms of who will have to repay the money and take the risk – will it be CCGs, CHFT or both? – Owen Williams later emailed ‘We are in an ever changing world so my response may be invalid at a point in the future. That said, based on previous examples and what I know today, then I suspect that the borrowing requirements in whichever form they would take would largely sit with the Trust. If you look at the attached link you will see how this has happened in an example from elsewhere. All of this subject to consultation.’

As the Chief Executive surely he should know who is borrowing the money, Trust or CCG. This statement beggars belief. The BBC article he sent is  about PFI 2. Is that the most likely source of the money?  Update: See CCGs’ 8 June updated response, which clarifies that:

Should the application be successful, CHFT would have responsibility for repaying the loan (or PFI debt if PFI2 were to be used for the capital funding).”

There are inconsistencies in the stories various organisations and individuals have told about this money.

At the Calderdale and Kirklees Joint Health Scrutiny Committee (JHSC) on 21 October 2015, the Monitor rep said that there was uncertainty about whether the Treasury and Department of Health would agree to cough up capital funding for the hospital service changes and for double running costs, while the Care Closer to Home system is set up. He continued:

“Some factors are beyond our control… We’ve started conversations with the Department of Health and the Treasury but can’t say when they will decide. If funding isn’t forthcoming, we can’t consult.”

At the 29 Jan 2016 JHSC meeting, Calderdale Cllr Martin Burton asked what “develop” means, in the draft survey question that says they’re proposing to develop the hospital.
Matt Walsh replied,

“Development will be required on both hospital sites. In terms of detail, we need to consult on the hospital services model and be prepared to flex and change in response to the consultation and then reflect on what that means for the estate and discuss this with the Treasury. We won’t have that information until we’re out the other side of consultation.”

Cllr Molly Walton asked how realistic the prospect of a new planned care hospital was, given the current government and its finances. Carol McKenna, GHCCG’s Chief Officer, said:

“We can’t give a definitive answer on the time frame for hospital development because we haven’t had a definitive answer from the Department of Health, although the Department of Health said we have made a strong case.”

Owen Williams, Chief Executive of the hospitals Trust (CHFT) said that regarding how realistic a new hospital is:

“A lot of national policy narrative in the 5 Year Forward View is that there is a need to transform how health & social care is provided in future. That can’t be done on a cost neutral basis. This model that we’ve contributed  to – the development of a planned care site & urgent care centre – is absolutely business-critical to CHFT and the broader Calderdale & Huddersfield system. Those elective services are critical not just to patient care but to CHFT financial survivability. It can’t physically go on the CRH site, so without it CHFT and the wider system sustainability is in doubt. So this is the acid test of whether the government is going to invest.”

At the 9 March 2016 JSHC meeting, Monitor said that it had, with “some caveat” put in an application to the Department of Health for “extraordinary funding of £470m for a single Trust reconfiguration” – extraordinary in that it compares with £300m that it cost for a Northern Trust to build a whole new hospital.

Monitor also said that the Department of Health is liaising with the Treasury and that there is no indication of the time frame “or what they’ll stomach”. In the meantime, Monitor were working with the hospitals Trust to review in detail the work that Ernst and Young did to come up with the cost of the “reconfiguration”. This was to reassure themselves and the Treasury that all that money is needed and will increase quality and safety.

Also at the 9 March 2016 JHSC meeting, the hospital Trusts Finance Director said that if they can’t get the capital to rebuild the hospitals, the proposed changes can’t happen and the big current deficit will be ongoing.

Dr Brook, the Chair of Calderdale Clinical Commissioning Group Governing Body, told the Joint Health Scrutiny Committee on 9 March no one will fund it without the consultation results. So it seems the consultation is the hoop the Clinical Commissioning Groups and Hospital Trust have to jump through to have a chance of getting £470m.

There  is  no  reason  given  why  space issues  shouldn’t be part of the consultation. It is vital that they are, given the complexity of the PFI contract and the impact of this on any capital development of CRH.

There seems to be a significant conflict of interest involved in CHFT’s employment of Lendlease Consulting  to advise on the Estates requirements for the hospital cuts/reconfiguration, since it is part of Lendlease corporation which is a major shareholder in the CRH PFI consortium/special purpose vehicle. At the Orangebox drop in, one of us asked Katherine Riley, the CHFT assistant director of strategic planning, about whether CHFT had considered this conflict of interest when they decided to employ Lendlease Consulting and she said no.

The Ernst and Young (EY) 5 Year Strategic Plan for CHFT states that Lendlease Consulting has advised on the Estates requirements for the hospital cuts/reconfiguration. This advice has led to the decision to make CRH the acute/emergency care hospital and to knock down HRI and replace it with a planned/urgent care hospital of 1/5 the size.

Lendlease Corporation has been involved in CRH PFI from 1998, when it bought 50% of the equity in the CRH PFI deal. As of 2012 it held 40% of the equity in Calderdale Hospital SPC Holdings Ltd, via Lend Lease PFI/PPP Infrastructure CIHL Holdings Ltd (Jersey). In other words an offshore company that pays next to no tax.

P167 of EY’s 5 Year Strategic Plan for CHFT states that figures comparing the costs of different options for the planned/unplanned hospital sites were obtained from a Lendlease “Lifecycle Costing CHFI Cost Model” Report.

So Lendlease Consulting has come up with capital costings for development of HRI and CRH, according to the new clinical model, that reverse the Trust’s earlier decision that the most cost effective option would be to make HRI the acute/emergency hospital and CRH the smaller planned care hospital.

On p 226, the EY Plan states that Lendlease Consulting has undertaken “more comprehensive assessments of the capital costs at CRH”.

The EY Plan also 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
  • expanded pathology space
  • multi-storey car park.

The EY plan says that any works within the PFI site owned by 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).

Question 5
The Consultation Document lacks any assessment of the risk of increased patient deaths that would result from the proposed Huddersfield A&E closure, due to increased ambulance journey distances to the proposed Calderdale Emergency Centre. We need to see this risk assessment.

CCGs’ answer

We  are  not  proposing  to  close  services  –  we  are  proposing  to   change  the  way  we treat  people.  Under  these  proposals,  both  A&E   departments  would  be  replaced  by Urgent  Care  Centres  to  deal   with most  ambulant  patients,  with  a  single  more specialised   Emergency Centre supporting  both  Urgent  Care  Centres.  Instead  of   all people  going  to accident  and  emergency  and  waiting  to  be  seen,   only  people  who are seriously  ill  or  have  life-­‐threatening   emergencies  would  go  to  the Emergency Centre in  Halifax.  People   who  need  urgent  medical  help would go  to  an  Urgent  Care Centre   at  either  Calderdale  or  Huddersfield.

The  risk  assessment  is  included  as  section  3.4  of  the  Quality  Impact Assessment which  has  been  published  as  part  of  the  Pre-­‐ Consultation Business  Case. Specifically,  the  risk  assessed  is:
‘increase in average ambulance journey time due to the requirement  for  some patients to be  transported  further  to  the  single Emergency Care Centre.’
Both  the  prior  risk  level  and  the  risk  level  should  the  proposals go ahead are assessed  as  low.

The  mitigating  action  is  as  follows:

‘Maintenance of an Urgent Care Centre on the planned site which will  support the majority  of  urgent  clinical  needs.  For  blue  light   patients, evaluation  undertaken  to date  indicates  an  average   increase  in  journey time  from  16  to  22  minutes.  The  6 minute   increase  is  more  than out-weighed  by  the  benefits  of  being   treated in the most clinically appropriate setting.’

Our comments

Again they state that they are not closing A&E simply changing it. A service  IS  being closed  – the  specialist  emergency  service  currently sited  in   Huddersfield  will  not continue  and  local   residents  will need to  travel  to,  or  be   transferred  to,  Halifax  if they  are  ‘seriously ill  or  have  life-threatening emergencies’.

AGAIN  the  points  raised  in  the  question   are  not  answered.

The CCGs say that the risk assessment is included as section 3.4 of the Quality Impact Assessment in the Pre Consultation Business Case. We are aware of that and consider that this “risks evaluation” table is not in any way, shape or form a risk assessment. This is why we asked this question. Referring us back to the document that we have already found wanting is pretty pointless.

There is no mortality reference in the Quality Impact Assessment (app D in the PCBC, 3.4, just a simplistic risk evaluation).

The  Pre-Consultation Business Case  is  not  the  consultation   document.  It would  have  been  helpful  if   the consultation  document  referred  to  the document  names  as  well  as  the  web  site   address  on  P39.   The  risk quoted  does  not  include  the   assessment  criteria  that  put the  risk  as ‘low’.

The risks evaluation table (Pre Consultation Business Case p182) in the Quality Impact Assessment identifies as a low (green) risk “increase in average ambulance journey time due to some patients to be transported further to the single emergency care centre”. It says this risk will be mitigated through “maintenance of an urgent care centre on the planned hospital site that will support the majority of urgent clinical needs” and “For bluelight patients, evaluation undertaken to date indicates an average increase in journey time from 16-22 minutes. The 6 minute increase is more than outweighed by the benefits of being treated in the most clinically appropriate setting.”

No evidence is given to support the judgement that this is a low risk. Is there any evidence? And if so, where is it?

Isn’t the risk inadequately defined anyway?

Isn’t a risk assessment about working out the risk related to a well defined situation and a recognised threat or hazard? If this is correct, then the risk in question is increased emergency patient mortality, the situation is going to A&E by ambulance and the recognised threat or hazard is the increased distances Kirklees patients would have to travel to A&E in Halifax. So the risk evaluation table doesn’t even name the risk. It conflates the risk and the hazard. Why?

The mitigation actions beg questions. Urgent care patients are by definition not suffering from a life threatening condition, so how is an urgent care centre in the planned care site going to reduce the risk of increased emergency patient death due to increased distance to A&E?

As for the blue light patients – who in fact are the only patients who are at risk in this situation – there is a question about the average increase in journey time of 6 minutes.

The use of an ‘average’ travel time is meaningless  in  these  circumstances, where  a  large area  currently  having  a  two   site  emergency  service is to change to a single  site  service that  is  not  centrally   placed.

The  new  single  site  is  to  be  placed  at  one   of  the  two  existing sites  causing  no change   for  the  population  currently  served  at  that   site.  The  other  population  group will  have   significantly  more  travel to  access  the  new   service  that  currently  is  local to  them.

It seems from the Consultation Document (p 20) that this average is for emergency patients from both Calderdale and Kirklees. If this is so, then the average increase in ambulance journey time for emergency patients from Kirklees would be 12 minutes, if each area has roughly the same number of emergency patients. This is because there would be no increase in average journey time for the Calderdale half of the emergency patients.

For Kirklees blue light patients, there is then the question of whether a 12 minute increase in journey time would still be outweighed by the benefits of being treated in the most clinically appropriate setting.

There is also the question of the extra ambulance response time that would result from so-called ambulance drift, when ambulances are found near A&Es. Since there will be no A&Es in Kirklees, ambulances will have to get back to Kirklees from whereever they are. the 19.4.2016 JHSC meeting found that this was not including in the modelling for ambulance journey times.

And there is the question of whether and how the benefits of being treated in a single emergency centre have been quantified.

And then there is the point raised by the Clinical Senate, that there is no evidence in the proposed hospital clinical model, that clinicians at the hospital have been sufficiently engaged with, to determine whether the resources exist to realise these benefits.

  • Plus the Royal College of Emergency Medicine’s statement on Emergency Department closure and reconfiguration:
  • Increased travel times are associated with worse outcomes for some patient
groups with time critical illness.
  • The increased demands on ambulance services brought about by longer transport times are seldom properly modelled.

Question 6
There is no risk assessment of increased patient deaths at Calderdale Royal Hospital following the proposed HRI A&E closure, despite the identification in a big Californian meta study of increased inpatient mortality in hospitals retaining their A&Es when a neighbouring A&E closes. We need to see this risk assessment.

CCGs’ answer

We  are  not  proposing  to  close  services  –  we  are  proposing  to   change  the  way  we treat  people.  Under  these  proposals,  both  A&E   departments  would  be  replaced  by Urgent  Care  Centres  to  deal   with most  ambulant  patients,  with  a  single  more specialised   Emergency Centre supporting  both  Urgent  Care  Centres.  Instead  of   all people  going  to accident  and  emergency  and  waiting  to  be  seen,   only  people  who are seriously  ill  or  have  life-­‐threatening   emergencies  would  go  to  the Emergency Centre  in  Halifax.  People   who  need  urgent  medical  help would  go  to  an  Urgent Care  Centre at either  Calderdale  or  Huddersfield.

The  CCGs  and  CHFT  do  not  support  the  assertion  that  the  proposed   future arrangements  for  hospital  and  community  health  services  would lead to ‘ increased patient deaths’.

The  risk  assessment  is  included  as  section  3.4  of  the  Quality  Impact Assessment which  has  been  published  as  part  of  the  Pre- Consultation Business  Case.

It is not  clear  from  your  description,  which  Californian  study  you   are  referring  to. However,  our  proposals  are  not  about  closing  or   retaining  A&Es.  We  are  changing the  way  that  we  treat  people-­‐  we are  not  closing  services.  Therefore,  from  the description  of  the   study  that  you  have  provided,  the  outcomes  of  the  study  are  not   relevant.  Our  proposed  changes  would  provide  Urgent  Care   Centres  on both  Hospital sites  and  a  single  Emergency  Centre  on   one  site.  Only those  who  are  seriously  ill  or have  life  threatening   emergencies would go to the  Emergency  Centre.

Our comments

The  CCGs  need  to  be  honest  –  there  will  be  no  Emergency  Unit   in Huddersfield, there  is  now,  to us that is a ‘closure’!

The  consultation  is  clear  that   emergency  services  will  not  be   provided  at  an  Urgent Care  Centre,  so   the  existing  emergency  care service  in   Huddersfield  will  not  exist, which  is  a  ‘closure’ of that service.

The study is “California a Emergency Department Closures Are Associated With
Increased Inpatient Mortality At Nearby Hospitals”, Charles Lui AB, Tanja Srebotnjak PhD, and Renee Y. Hsai MD, (2014). The full abstract with appendixes and bibliography is available to view .

“The CCGs and CHFT do not support the assertion that the proposed future arrangements for hospital and community health services would lead to ‘increased patient deaths’.” But Matt Walsh conceded at the Joint Health Scrutiny Committee meeting on 19 April 2016 that there is a point at which risk tips between improved outcomes from 1 specialist ED and increased patient mortality associated with longer travel times.

This was in response to Cllr Marchington’s questions:

“What is the impact of longer travel times on clinical outcomes? Not just emergency patients but midwifery and gynecology? And what is the balance of improved outcomes from 1 ED against increased patient deaths/ worse clinical outcomes?”

Matt Walsh said:

“We are working with YAS to make sure first response is good. It’s right that there is a point at which risk tips. eg stroke reconfiguration in London – and here, heart patients directly to Leeds to be stented – we can show gains from mortality rates here.

There is an application of the assumption that – given that evidence exists that we can deliver speciality services – there is consensus around 45m accessibility to ED time after stabilisation. But there are evidence gaps and we will need to fill them

At the 19 April JHSC meeting, Cllr Smaje ascertained that no Yorkshire Ambulance Service (YAS) modelling had been carried out to take account of the need to get to the patient and get the patient to treatment in one hour – given that ambulances for Kirklees patients will have to get there from other areas, due to ambulance drift which sees most ambulances in areas where there are A&Es.

The YAS guy said that the North East Commissioning Support Unit travel analysis just gave the 10K extra hours/year ambulance journey time based on getting from A to B, not getting ambulances back from outside the area. They will need to model that.

At the Hebden Bridge drop in, a member of the public asked what risk analyses had been undertaken re increased ambulance journey times and was told there were no studies showing increased risk. But of course there are. At the Shelley drop in, Dr Ollerton told another member of the public that the Sheffield Uni study led by Prof Jon Nicholl was outdated. We emailed Prof Jon Nicholl and he said as far as he knows no study has superseded it.

None of this is reflected in the Consultation Document or pre consultation business case and the CCGs’ assertion that they are not proposing to close services does not hold up. They are proposing to close a type 1 A&E department in Huddersfield and replace it with an urgent care centre, and to send all emergency patients with life threatening ailments to a single ED in CRH. This fits the model of service changes that the Californian meta study looked at.

Question 7

The Consultation Document lacks any quantification of the likely reduction in patient mortality from the centralisation of acute and emergency services in Calderdale Royal Hospital.

CCGs answer

It  is  not  possible  to  accurately  quantify  the  likely  reduction  in   patient  mortality prior  to  the  changes  taking  place.  However,  we   know from  other  reconfigurations, for  example  the  centralisation   of  Stroke services  in  London,  that  the  centralisation of  specialist   services leads  to  improvements  in  patient  mortality.

We  also  have  data  to  show  that  surgical  outcomes  improved  after   acute  surgical services  were  centralised  at  HRI  a  few  years  ago,   reducing  mortality  associated  with gastrointestinal  perforation  and   obstruction  from  approximately  12%  to  6%. Additionally,  In   2005/06  a partial  reconfiguration  of  some  hospital  services  in   Halifax  and Huddersfield  was  implemented  to  concentrate  acute   surgery  and  trauma services  at  Huddersfield  Royal  Infirmary.  The   clinical  evidence  base for  this  was recognised  and  supported  by   Commissioners  at  that  time. Data  published  by  Dr Foster  shows   that  there  has  been  a  significant reduction  in  surgery  and  trauma   service  mortality  rates  (i.e.  General Surgery  mortality  has  reduced   from  97  to  64, and  Trauma  and Orthopaedics  mortality  has   reduced  from  90  to  53).  A  full reconfiguration  of  all  the  acute   specialities  and  emergency  services on  a  single hospital  site  could   enable  even  more  people  to  benefit from  similar  improved  safety and  reduction  in  mortality  (more  lives saved).

Our comments

The  answer  implies  the  CCGs  are   making  guesses  and  assumptions   rather  than  basing  the  proposals  on   clear  clinical  evidence. Their reply is just an assumption.

The  use  of  a  service  reconfiguration  (as   recent  as  a  decade  ago) as evidence  for ‘doing it all  again, but differently’, does not strengthen  the case  for   change,  or  confidence  in  the  decision-making.

See Matt Walsh’s comment at the Joint Health Scrutiny Committee meeting on 19.4.2016, above, in q 6. He says there is data from relevant reconfigurations in Leeds and London that can be used and that there are evidence gaps that need filling.

A 2014 study of centralisation of acute stroke services in 2 metropolitan areas (London and Manchester) showed a reduction in patient deaths after 90 days of 1.1% in London. There was no reduction in Manchester. The study was carried out because

“it is unknown if centralising acute stroke care to a small number of high volume specialist centres produces better clinical outcomes. In addition, the wisdom of focusing on hyperacute stroke care has been questioned”

Question 8
The Consultation Document lacks any indication of the tipping point where the risk of increased patient deaths is outweighed by the reduction in patient mortality.

CCGs answer

The  CCGs  and  CHFT  do  not  support  the  assertion  that  the  proposed   future arrangements  for  hospital  and  community  health  services   would ‘lead to increase patient deaths’.

The purpose of these proposals  is  to  save  more  lives,  keep  people healthy,  make services   safer  and  improve  quality  of  care.

The  risk  assessment  is  included  as  section  3.4  of  the  Quality  Impact Assessment which  has  been  published  as  part  of  the  Pre-Consultation Business  Case.

Our comments

The  answer  gives  no  reason  why  the  CCGs   are  certain  that  the  proposals  will  NOT ‘lead to increase patient deaths’.

The  risk  evaluation (NOT assessment)  only  mentions  time,   not  potential death,  as  a transfer  risk. The  Clinical  Senate  review  says  (P12)  that Urgent Care Centres need “correct  medical   and  nursing  skill  mix  and experience to safely  stabilise  a  very  sick patient.”

A further point raised by the Clinical Senate, is that there is no evidence in the proposed hospital clinical model, that clinicians at the hospital have been sufficiently engaged with, to determine whether the resources exist to realise its benefits.
The Royal College of Emergency Medicine’s Feb 2016 position statement on Emergency Department Closure says,

“Secondary, though important, are the consequences for services at sites that would be required to absorb the diverted patient flows.”

Question 9

We want you to publicly acknowledge the Royal College of Emergency Medicine position statement on Emergency Department Closure and state what you think the consequences would be for CRH – and other hospitals like Barnsley and Pinderfields – of having to absorb patients who could no longer attend HRI and Dewsbury A&Es. And what data your assessment of the consequences is based on.

CCGs’ answer

The  proposal  for  the  local  reconfiguration  is  not  comparable  with  the Royal College’s statement from February 2016.

We  are  not  closing  an  emergency  department.  We  are   reconfiguring  our urgent  and emergency  care  so  that  there  is  one   Emergency  Care  Centre support  by  two  Urgent Care  Centres  which   between  them  will  take  the majority  of  the  patients  that  are   currently  seen  at  the  two A&Es.

The  benefits  of  this  proposal  extend  far  beyond  just  those   anticipated  in  emergency care.  We  are  reconfiguring  the  whole  of   our un-planned  in-patient  services  for which  the  emergency   department  is the  front  door,  so  that  we  have  a  centralised pool  of   expertise  on a  single  site  with  all  the  relevant  clinical  adjacencies.

The implications of activity  shift to neighbouring  providers is set out in the Pre‐Consultation Business Case at Section 7.1.6.

Our comments

They have totally avoided the question. It still needs answering.

They deny the point we make because they say they’re making “change” not “closure”. But there  will  be  no  specialist  emergency   staff  or emergency scans and  surgery at Huddersfield, as now, after  the changes. So the Emergency service in Huddersfield is  closing.

The  section  7.1.6  does  not  include   Barnsley  in  its  modelling and has no evidence base.    The  four  Tables  (Ps  92  &  93  in  7.1.6)   are embarrassingly  inaccurate:    Table  7 should  total  1590  not  1589!   Table 8  adds  8+1  and  gets  10!   Table  10  adds  7+2  and gets  10!

Question 10
The CCGs’ assessment of the likely consequences for CRH needs to take account of the following facts:

  • The Consultation Document claims that 54% of patients who currently use A&E would be treated at Urgent Care Centres following the hospital cuts/changes, meaning that the new Emergency Centre would only treat 46% of patients who would otherwise have gone to A&Es in Halifax and Huddersfield.
  • But the Royal College of Emergency Medicine’s 14.4.2016 press release says that 20% of patients who attend A&E would be as well or better served by clinicians other than A&E doctors – meaning that if this is correct, the new Emergency Centre would have to treat 80% of patients who would otherwise have gone to Halifax and Huddersfield A&Es.
  • This amounts to 113,600 emergency patients/year instead of the proposed 65,320 emergency patients/year. (Consultation Doc p28).This would mean that the currently proposed Emergency Centre would be dangerously overcrowded. We need you to publish the College of Emergency Medicine information and say what the CCGs and CHFT are going to do about this.

CCGs answer

The  analysis  supporting  the  figure  of  54%  is  based  on  actual   attendances  over  a  12 month  period: The  assumptions  used  are  set  out in  section  7.1.1  of  the  Pre-­ Consultation  Business  Case.

Urgent  Care  Centre  Assumptions
The  Clinical  Director  for  Emergency  Services  agreed  a  list  of   treatment  codes  to  identify  patients  who  were  suitable  for   management  in  an  urgent  care  centre  (UCC).  These  are:

  • Adults  with  minor  injuries  and  /  or  minor  illnesses
  • Children  over  the  age  of  5  years  with  minor  injuries

The categories of  minor  injuries  and  minor  illnesses  are  highlighted   below

categories minor injuries & illnesses

All A&E  diagnosis  fields  that  matched  the  above  criteria  were used for modelling purposes.

-Walk  in  patients  who  met  the  UCC  criteria  are  assumed  to  be   treated  at  the  site  they  present  at.
-Walk  ins  who  do  not  meet  the  UCC  criteria  are  assumed  to  firstly   attend  the current  site  at  which  they  are  treated,  but  then  are   moved  to  the  future  unplanned care  site  (if  they  need  to  be   moved) and  hence  they  would  appear  as  2  attendances in  the   modelling  work. In  other  words,  these  people  attend the UCC and then attend the ECC.

The  Royal  College  of  Emergency  Medicine  paper  you  have  linked  to   is describing primary  care  provision  which  does  not  have  access  to   appropriate  diagnostics  and reporting  and  is  not  open  24  hours (see para  3  under  the  discussion  heading).  The urgent  care  centres will have access  to  diagnostics  and  other  equipment  and facilities which are routinely  used  now  by  our  emergency  care  practitioners,   who will continue to  provide  care  in  our  proposal  in  addition  to  the   medical resource referred  to  the paper.  They  will  therefore  be  able   to  care for  a  higher  percentage  of patients.

We  understand  the  hub  referred  to  in  this  instance  to  be  a  primary care centre  not an  urgent  care  centre.  The  difference  being  that   the RCEM looked  at  those  cases that could  be  seen  by  a  GP  only.   Our urgent care  centres  will  have  Emergency Nurse Practitioners   who  will also  be  able  to  see  minor  injuries  and  who  look  after,  on   average, significantly  more  than  22%  of  the  patients  who  come  to   our existing A&Es. We  are  aware  that  in  other  parts  of  the  country   where this  model  has  been implemented,  such  as  Northumbria,  they are  able  to treat  more  than  the  54%  we  are forecasting.

Our comments

Who  is  more  reliable  on  figures – the  Royal   College  of  Emergency Medicine  or  those  planners  who  think    7+2  =  10  and    8+1  =  10?

The  question  about  the  implications  of  the  Royal College of Emergency Medicine (RCEM)  figures  compared  with  the  Trust’s   figures  has  not been answered.

This  description  assumes  that  the  UCC staff  have the skill  mix  and experience  to safely   stabilise  a  sick  patient  before  transfer  – a   concern  raised  by  the  Clinical Senate  in   their  report  (P12).  (A point that  is  not   addressed  in  the  consultation document.)

The information about the modelling for patient flows to urgent care centres is extremely cursory, in no way matches the detail of the RCEM research and is impossible to verify.

Although the CCGs’ answer to our question says “The  analysis  supporting  the figure  of  54%  is  based  on  actual   attendances  over  a  12  month period”, information CHFT sent to the Joint Health Scrutiny Committee says otherwise: it refers to p 131 of the CHFT 5 Year Strategic Plan which says that all modelling has used forecast activity for 2015/16 (as at month 6) as the baseline.

Why did this modelling use forecast activity as the baseline – not actual activity, as shown in attendance information? And why do the CCGs claim that the modelling was based on actual attendances over a 12 month period? Which is right? CHFT? Or the CCGs?

And the info under Urgent Care Centre assumptions gives no actual data for how A&E attendance over a specific period, or at a particular point in time, broke down by treatment codes or diagnosis fields.

In the absence of raw data and an explanation of how the data was analysed, it is impossible to verify these assumptions.

There must be better data than this and if there isn’t we can’t see how the 54% figure has any credibility.

Despite us asking for it, CHFT has not sent us the raw data used to derive the figure that 54% of current A&E patients could appropriately be treated in urgent care centres, and CHFT’s analysis of the data. We are still waiting for this information.

NO it is  a  press  release,  not  a  ‘paper’,   that  was  referred  to  in the  question,  and  it   makes  no  mention  of  Primary  Care  provision that ‘does not have appropriate diagnostics  and  reporting  that   is  not  open 24 hours’.

On  the  contrary  the  press  release  we referred  to  goes  on  to  say that:

‘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.”

The two paras in the CCGs’ reply that start, “The Royal College of Emergency Medicine paper you have linked to is describing primary care provision which does not have access to appropriate diagnostics and reporting and is not open 24 hours (see para 3 under the discussion heading)…” is a copy of an email that Vicky Pickles at CHFT sent to Jenny Shepherd, in response to Jenny’s email to CHFT’s medical director David Birkenhead, with the link to the RCEM paper.

Jenny’s email asked:

“You said that the figure of 54% of CHFT A&E patients who could appropriately be treated in urgent care centres is based on an analysis of CHFT A&E patient codes. Please will you send me the raw data and the analysis of it?

I would like to see how it can be so different from the Royal College of Emergency Medicine figure of 22% of A&E patients who could appropriately be treated in urgent care centres.

As you may remember, at the Threeways Centre consultation drop in, Dr Brook told me the RCEM data was old and didn’t refer to “wonderful new urgent care centres”.

I have checked this with the Royal College of Emergency Medicine and they have told me this 22% figure is for A&E patients who could be appropriately treated at  Urgent Care Centres. Here is the link  to the research that generated this finding – although I am sure you are already familiar with it.”

With regard to that paper, we disagree with the CCG’s statement that

‘The Royal College of Emergency Medicine paper you have linked to is describing primary care provision which does not have access to appropriate diagnostics and reporting and is not open 24 hours (see para 3 under the discussion heading).’

That section of the paper says that 15% of A&E patients could be treated by primary care provision without access to appropriate diagnostics, reporting and 24 hour services. The next sentence says:

‘However, this figure rose by nearly a half to 22% of patients who it was thought could be seen immediately by a GP working on site. Such a doctor would, of course, have complete access to all the considerable facilities available in a major emergency department.’

When we contacted the RCEM to ask about this, the RCEM replied as follows:

‘The idea of a hub is that these services are co-located on the same site as an A&E department – a triage nurse could then direct the patient more appropriately to these services. As we mentioned in the statement we believe that around 20% of patients from A&E could be redirected to these on-site services and reduce the pressure on the A&E.

With regards to the 20% figure, our studies have shown that 15% of patients were thought to be suitable for delayed management (but within 24 hours) by a primary care practitioner; this figure increased to 22% for immediate care by a GP working in the emergency department.’

We don’t think it is right to say that the RCEM A&E hubs would be primary care centres that are only staffed by GPs. From talking with the RCEM, it is clear that the A&E Hub model that the RCEM launched on 20 May 2016 is far more than a GP in a primary care centre. It is co-located with a full A&E department and has a range of health care professionals and services that includes frailty teams, community pharmacies, out- of-hours primary care, occupational therapists, mental health teams and others. The RCEM launched the A&E hub concept with the Royal College of Nursing, that is quite supportive of Emergency Nurse Practitioners and wouldn’t exclude them from A&E hubs.

The RCEM A&E Hub would be co-located with an A&E in order to help with the flow of patients, but it is not a substitute for or a downgrade of a full A&E centre, as the Huddersfield urgent care centre would be.

Regarding Urgent Care Centres, the RCEM position statement on Emergency Department Closure says,

“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.”

The RCEM A&E Hub concept is central to its STEP campaign, which to our way of thinking offers a much better approach to the problems of understaffed, overcrowded A&Es than the Right Care Right Time Right Place proposal to centralise A&E services in a single Emergency Centre and replace HRI with a small planned care hospital and urgent care centre.

In addition, new research by academics at Imperial College London into two UCCs in London has found that 25 per cent of the total patients who came to the UCCs could not be treated there. But among over 70s the proportion was even higher, at 40 per cent.

Question 11

We don’t think you have adequately thought through the services and resources needed at CRH, if it is to absorb 80% of patients who would have gone to CRH and HRI A&Es, not 46% as you have planned for. We need you to do this.

CCGs’ answer

As  above.  Our  research  shows  that  no  more  than  46%  will  go   through the Emergency  Centre.

Our comments 

See comments above on CCGs answer to q 10. The Cramlington hospital in Northumbria that they referred to, that has an Emergency Centre while neighbouring hospitals have urgent care centres, has been in the local newspaper with overcrowding in its Emergency Centre  and patients on trolleys in the corridor. Further, an article about Cramlington Hospital in the Health Service Journal (behind a paywall, unfortunately) reports that emergency admissions have fallen by 14% since it opened but ambulance delays have surged.

Screen shot 2016-06-08 at 11.00.00

Question 12

The Consultation Document says that there will be 732 hospital beds after the cuts – down from around 800 beds at the moment. It doesn’t say that this means Calderdale and Huddersfield will have 1.61 beds per 1000 population.  Only Indonesia, India and Columbia have fewer hospital beds per 1000 population than this. But the Consultation Document claims (p5) that the proposed hospital clinical model will progress the future shape of hospital services ensuring that they are high quality, safe, sustainable and affordable. We would like you to explain how you have traded off the requirement for “high quality and safe” hospital services with the requirement for “sustainable and affordable” hospital services, and what data you have used to determine that you can provide high quality, safe hospital services on the basis of1.61 beds per 1000 population

CCGs’ answer

The  figure  of  732  beds  is  correct.  The  population  of  Greater Huddersfield  and  Calderdale  is  estimated  to  be  452,000  as  stated  in the  Consultation  Document.  This  would  provide  1.72  beds  per  1000 population.

The  number  of  beds  per  1,000  population is not  a  recognised   indicator of the quality and  safety  of  care.

We have not ‘traded off the requirement for high quality and safe hospital services’. The model of care was developed based  on   clinical  evidence.  We then  looked  at  a  number of  alternatives  to   deliver  this  model.  These are  outlined  in  the  Consultation   Document.

Value  for  Money  is  one  of  the  criteria  used  to  appraise  the alternatives  and  is  set out  on  pages  12  and  13  of  the  Consultation Document.

CHFT  have  submitted  to  the  Department  of  Health,  what  we   believe  to be  the  best case  for  financial  support,  in  that  it  would   provide the least  expensive  way  to deliver  the  requirements  of  our   clinical  model.

We  have  been  clear  that  progression  of  the  proposed  changes  is dependent  on additional  funding  being  secured.

Our comments

The  correct  figure  is  1.62  beds  per  1000   population  (732  ÷  452  = 1.619)

These  Consultation Document pages  (12  &  13)  merely  compare  the   ongoing  deficit positions  of  the  two   potential    sites  for  the  single site  EC,  and   gives  the  preferred option  as  the  lower   potential deficit!

How can this demonstrate  value  for   money  after  such  a  large investment that will incur  ongoing  loan  costs?

About the CCGs’ claim that the bed no/1000 population is not a recognised indicator of the quality and safety of care,  Chris Hopson, chief executive of the Foundation Trust network, which represents NHS hospitals, said OECD figures about the low number of UK hospital beds/1000 population (ie 3/1000) show they are operating near full capacity. He told the Daily Telegraph:

“There is no slack in the system and trusts are constantly juggling their resources to meet patient demand. We must avoid situations where elderly people are moved from one bed to the next, or forced to endure long waits on trolleys, but it’s not easy because of the pressure the system is under.”

A data briefing on bed occupancy by John Appleby for the BMJ,  reported that more intensive use of hospital beds could be a problem. High occupancy rates of above 90% reduce the time available for cleaning between patients and increase the chances of infection. A Health Quality Improvement Fellow, commenting on the report, said

“ It is known that high bed occupancy diminishes quality of care, increases stress for staff and increases waiting times.”

Claiming that the “value for money” criterion provides data to show that the CCGs have determined that they can provide high quality, safe hospital services on the basis of 1.62 beds per 1000 population completely misses the point. Using the value for money criterion  does not identify the highest quality, safest option or show that these bed numbers would provide that.

At the 25 March 2015 Joint Health Scrutiny Committee meeting  the Monitor Regional Director Paul Chandler said that delivering two hospitals’ worth of services is “the right thing for access to patients, but expensive to do.” He continued,

“Finances are one issue compelling the clinical case for looking at whether two sites is in the best interest of patients or whether it would be better to consolidate services in one bigger specialist hospital.”

At the same meeting, Dr Matt Walsh, Calderdale CCG’s Chief Officer, said that the Right Care Right Place Right Time hospitals “reconfiguration” won’t deliver the funding cuts that are needed, but it will provide a clinical rationale for the hospitals shake up. He said there will have to be compromises and these will have to be talked about in the consultation.
So why aren’t the CCGs talking about them?


  1. Thanks Jenny


    > On 08 June 2016 at 01:00 Calderdale and Kirklees 999 Call for the NHS > wrote: > > Green__Jenny posted: “Save Our A&Es campaigners asked the Clinical > Commissioning Groups to make good the errors and omissions in the hospital > cuts Consultation Document. They took about five weeks to respond and their > answers provide almost no new information. They include” >


  2. What a fantastic piece of work! Thank you so much for this. No surprises that they can’t actually provide complete answers and it just goes to show that they do not have sufficient information or correct information to make the decision – oh, and their maths is dreadful!!!


  3. Thank you Jenny for all your hard work. Friends of HRI have tried to get everyone to look at you advice and will continue to push this for the next few hours as the clock ticks by.


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