NHS Commissioners fail to fix Consultation Document errors & omissions (Part 2)

In late April, CK999 and other Save our NHS groups in Calderdale and Kirklees wrote to the CCGs with 38 questions about Consultation Document errors and omissions. They took over 5 weeks to reply. We asked them to pause the Consultation so that the public could have time to absorb and make sense of the CCGs’ responses, but they refused. We asked to meet with the CCGs’ Governing Body patient and public lay reps, to discuss the possibility of extending the consultation period, for the same purpose. They refused.

The consultation is scheduled to end on 21st June. If you think it should be extended, please contact your councillors and MP – and tell the CCGs.

This is the second batch of the CCGs’ answers that we have worked through. It is a time consuming process.

Our comments on the first 12 questions are here. There are still another 17 questions to follow. This blog post deals with questions 13- 21.

Question 13

Ernst & Young’s Strategic 5 Year Plan for CHFT, identifies a “new commercial venture such as private patient wing” as a “significant longer term investment”. Is a private patient wing  part of the 732 beds planned for the reconfigured hospitals? And if so, how many beds would be available for NS patients under the new hospital clinical model?

CCGs’ Answer

A  private patient wing is not part of the current  proposals. In developing CHFT’s 5 Year Strategic Plan, a  long  list of forty initiatives was  devised that  the  Trust  could  implement to improve  future  sustainability.

(The  long  list of initiatives can be  found  n  Appendix  10.4 of the  report on pages 218 -219) This includes reference to ‘new commercial venture such as a private patient wing’ and that this would  require  significant  longer  term investment.

Our Comments

Does the answer imply that a private patient wing may be part of some future proposals?

Question 14

The Consultation Document doesn’t explain the reason for dropping the proposal for an Urgent Care Centre in Todmorden Health Centre, or what provision there will be instead, if any. We need to know why this was dropped and what provision there will be instead. Did you drop it because Ernst and Young’s 5 Year Strategic Plan for CHFT decided the £1.2m costs to run an UCC in Todmorden was unaffordable, given the drive to cut the Trust’s deficit? Or what?

CCGs’ answer

The  future  use  of  the  Todmorden  Health  Centre  is  being  taken   forward  as  part  of  the  Vanguard  proposals  related  to  Care  Closer   to Home.  It  is  not  part  of  this  consultation.  More  information   about Vanguard  can  be  found  at   https://www.england.nhs.uk/ourwork/futurenhs/new-care-models/

Our comments

This answer does not address  the  question,  and seems to  be dismissive  of  patient  and  public  concerns  about  the  lack  of   information.

Vanguards are multi-agency and have no existing patient & public involvement   mechanisms, and appear to bypass the  legal duties set out in the Health &  Social Care  Act  2012  as  they  are  neither  NHS   England  (13  Q  duty)  nor  CCGs  (14Z2  duty).

The Health & Social Care Act 2012 is itself entirely undemocratic as it was not in any party’s 2010 election manifesto.

How can patients  and  the  public  be   involved  in  developing  the Vanguard proposal relating to Todmorden? The Calderdale Vanguard Community Panel, run by Voluntary Action Calderdale – and set up a year after the Vanguard scheme started – is compromised by Voluntary Action Calderdale’s conflict of interest. Voluntary Action Calderdale has received large grants from Calderdale Clinical Commissioning Group to encourage and train voluntary sector organisations to bid for various elements of the Vanguard community health care schemes.

Contrary to the CCGs’ assertion that the Vanguard scheme is not part of the Consultation, it is referred to on p35 of the Consultation Document as ‘a valuable opportunity…to develop new and innovative ways of providing services.’ It is also key to Calderdale’s Phase 2 Care Closer to Home which is a vital part of the consultation, under “Strengthening community services”, Consultation Doc pages 34-38.

Question 15

The Consultation Document claims (p10) that

“over the last two years there have been many discussions involving hospital doctors, nurses and other clinicians working in the Trust as well as with GPs and other healthcare professionals working in GP practices and community health services”.

The Consultation Document claims that CHFT staff have been properly engaged with and support the proposed hospital clinical model but a current Unison survey of all CHFT staff – not just their own members – has found that 93% oppose the proposals and that there has been little or no engagement with the majority of staff. In addition, at the Hands Off HRI public Question Time last night, CHFT General Surgery and Colorectal cancer services Consultant Dr Adrian Smith stated that he and the Department of General Surgery as group have not been consulted. Tamsin Grey, General Surgery consultant Calderdale hospital also spoke against the proposals. Please supply the data you have about how, when and where you have carried out these discussions, with which hospital doctors, nurses and other Trust clinicians, and what the hospital doctors, nurses and other Trust staff told you.

CCGs’ answer

We  would  welcome the submission of the Unison Survey and the responses  as evidence into  the  Consultation  process.  We will ask them to do this.

We have done  significant  work  to  inform  and  engage  staff.  The   engagement  with CHFT  staff  began  three  years  ago  with  the   development  of  the  outline  business case.  A  note  of  that  work  is   attached.

For  CCG  staff, The  Hospital  Standards for  the  Right  Care,  Right   Time, Right  Place Programme  were  initially  developed  by  a  Quality   Assurance Group  comprising  clinical representation  from  both  CCGs. The standards were approved by both CCGs’ Quality Committees  in  August  2014.

Following   approval   of   the   Hospital   Standards,   the   Quality   Assurance   Group   established   the   outcomes   that   we   expected   these standards   to   achieve   and   these,   together  with  the  Hospital Standards  were  subject  to  engagement  at  a Stakeholder  event  in  August 2014,  and  were  approved  by  the CCGs’ Quailty Committees  in   December 2014.

Subsequent  to  the  development  of  the  Hospital  Standards  and  the outcomes,  CHFT worked  with  their  clinicians  to  establish  the  Trust’s baseline and aspiration for the standards  and  the  CCGs  worked  to  develop a dashboard that would enable us to track our performance.

These  pieces  of  work  were  then  used  to  develop  a  narrative  on  the current  position in  relation  to  Quality,  Safety  and  Patient  Experience. This  work,  completed  by the CCGs and  CHFT,  was  used  to  produce  the Quality  and  Safety  Case  for  Change  that has  been  included  in  the  Pre Consultation  Business  Case. The Quality and  Safety Case for Change was approved by the CCGs’ and CHFT’s Quality COmmittees in June 2015.

The  membership  of  the  Quality  and  Safety  Assurance  Group, the CCGs’ Quality Committees and CHFT’s Quality Committees is detailed below.

In  addition  to  the  formal  governance,  the  standards  have  been part of our  developing potential  Outline  Model  of  Care  for  Hospital  Services.

There  have  been  Five  Clinical  Workshops  and  four  clinical  design groups  to  develop the  overall  potential  future  outline  model  of  care for  Hospital  Services.  These groups have met over a period of  ten months between November,  2014 and August 2015. The following paragraphs  outline the work  undertaken by these groups.

Our  first  workshop,  in  November  2014  was  attended  by  clinicians  from Calderdale CCG  and  Greater  Huddersfield  CCG  and  achieved  the  following:
The  development  of  a  common  understanding  of  our  journey  and  where we are  on our  journey.
Agreement  of  the  scope  for  Hospital  services,  the  standards  we  want to  apply  and the  outcomes  that  we  expect  these  standards  to  achieve.
A  shared understanding of  the  different  models  of  Hospital  Care described  in  the Providers’  OBC  and  NHSE  5  year  forward  view.
Started  to  develop  a  common  set  of  assumptions  about  the  optimum configuration of our  future  model  for  Hospital  Services

The  second  workshop  in  January,  2015,  also  attended  by  clinicians from both  CCGs, discussed  Planned  and  Unplanned  Care;  Accident  and Emergency; Specialist Commissioned  Services  and  enabling  changes  (workforce,  estate and  Quality  and performance  management)  and  agreed  that,  as Commissioners  we  should:
Specify  what  we  mean  by  an  Unplanned  Care  offer  on  both  sites  (for both  Accident and  Emergency  and  for  other  Unplanned  Care).
Specify  what  we  mean  by  a  Planned  Care  Offer.
Undertake  work  to  establish  which  elements  of  Specialised  Provision could  be undertaken  locally
Progress  the  work on Hospital  Standards  by  identifying,  baselining  and setting ambition  for  metrics  which  would  allow  us  to  track  our progress  towards  the outcomes  we  want  to  achieve.

The  third  workshop  in  February,  2015  was  a  joint  session  between senior  clinical  representatives  from  CHFT,  Calderdale  CCG  and  Greater Huddersfield  CCG. This   was   a   strategic   session to bring together our collective   thinking   to   date   as   CCGs   and  as a  provider to begin to develop what our ideal model for the  future   provision  of  hospital services could  look  like.
In  doing  this,  we  considered  the  journey  to  date  for  Commissioners and  CHFT; explored  the  different  perspectives  that  have  informed  our thinking,  including  the   collective  views  of  patients  and  the  public; acknowledged  the  level  of  risk  in  the existing  system;  shared  the commissioners’  journey  in  relation  to  Care  Closer  to   Home;  CHFT’s position  in  respect  of  quality  and  finance  and  considered  the changing national  picture.

We  agreed  that  we  needed  to  create  a  place  where  we could continue this  collective dialogue  in  order  to  reach  a  position  where  we  could express  a  consistent   view from the  local  health  economy  on  our  future hospital  services  and  further  clinicians’ workshops  were  organised  for April  2015.

The first April workshop (workshop 4) was attended by CCGs‘ clinicians.  The workshop established our the Commissioners‘ position on the urgent care offer from our Hospital services  and  considered  the  possibilities  for networking specialist  services  in  local hospitals.  The  output  from  this  and previous  workshops  was  taken   into  the  second April  workshop  (workshop five).

Workshop  five  was  a  joint  session  between  senior  clinical representatives  from CHFT, Calderdale  CCG  and  Greater  Huddersfield  CCG. This  was  a  strategic  session to  allow commissioners  to  share  with  the Provider,  their  joint  thinking  in  relation  to  a potential  model  for Emergency  and  Urgent  Care,  and  to  understand the Provider’s initial views in relation to this. The session then went on to explore the detail of the Providers’ Planned Care model   as   presented in  their Outline Business Case. The overall  aim  being  the  further  development  of  a  collective  view  on what our ideal outline model  for  the  future  provision  of  hospital services could look  like.

Following  Workshop  five, we agreed that we needed to strengthen  the arrangements  for how  we  should  continue  this  collective  dialogue  and work  together  in the  future.  To this  end  we  established  a  number  of clinical  design  groups  working  to  a  joint Hospital  Service  Programme Board.

The   Clinical   Design   groups   covered:   Planned   Care; Urgent Care; and Maternity   and   Paediatrics. They   met   five   times in total and were supported by individual   discussions between  Clinicians  from  the  CCGs  and CHFT  and  by  CCG  discussions  in  their Clinical development  forums.

The   Clinical   Workshops and the Clinical Design Groups represent 284 hours of   clinical   time,   supported   by   research and discussion outside of these meetings. Calderdale  CCG, Greater  Huddersfield  CCG  and  CHFT  signed off  clinical  consensus  on  the  potential outline  future  model  of  care for  hospital  services  in  October   2015.

In  addition  to  the  above,  we  have  presented  and  discussed  the  model and  the standards  with  all  our  GP  practices  through  the  Calderdale CCG Practice  Leads   meeting  and  the  Greater  Huddersfield  CCG,  Practice Protected  Time  meeting.

We contend that the process described above demonstrates significant clinical   engagement in the agreement  of clinical   standards and the development of the potential  outline  future  model  of  care  for  hospital  services.

Membership  of  Committees:
Calderdale  CCG,  Quality  Committee  Membership
GP  Governing  Body  Member,  Calderdale  CCG  (Chair)
GP  Governing  Body  Member,  Calderdale  CCG   Head  of  Quality,
Calderdale  CCG  and  Greater  Huddersfield  CCG   PPI  Lay  Member,
Calderdale  CCG   Head  of  Service  Improvement,
Calderdale  CCG   Head  of  Primary  Care  and  Improvement,
Calderdale  CCG   Quality  Manager,
Calderdale  CCG   Consultant  in  Public  Health,  Calderdale  Metropolitan Borough  Council

Greater  Huddersfield  CCG,  Quality  and  Safety  Committee
GP  Governing  Body  Member,  Greater  Huddersfield  CCG  (Chair)
2  x  GP  Governing  Body  Member,  Greater  Huddersfield  CCG
Head  of  Quality,  Calderdale  CCG  and  Greater  Huddersfield  CCG
PPI  Lay  Member,  Calderdale  CCG
Secondary  care  advisor
Required  attendees:
Quality  Manager  Greater  Huddersfield  CCG
Head  of  Practice  Support  and  Development,  Greater  Huddersfield  CCG

Calderdale  &  Huddersfield  Foundation  Trust,  Quality  Committee membership
Head  of  Governance  and  Risk
Medical  Director
Deputy  Director  of  Workforce  and  Organisational  Development
Deputy  Director  of  Nursing/Interim  ADN,  Surgery  &  Anaesthetic Services  Division   Executive  Director  of  Nursing  &  Operations
Executive  Director  of  Planning,  Performance,  Estates  and  Facilities.
Associate  Director  of  Operations  and  Community  Services
Divisional  Director,  Surgery  &  Anaesthetic  Services  Division
Membership  Council  Representative
Assistant  Director  to  Nursing  and  Medical  Directors
Finance  Director
Company  Secretary
Divisional  Director,  Family  and  Specialist  Services  Division
Associate  Director  of  Nursing,  Family  and  Specialist  Services
Division   Associate  Director  of  Nursing,  Medical  Division
Plus  Non-Executive  Director  representation  one  of  which  is  the  Chair of  the committee

Subsequently,  CHFT  have  done  the  following  (the  CCGs  engagement  is detailed  in the  answer  to  Q16  below):
We   encourage   all   staff   to   respond   to   the   public   consultation. Like   any   member  of   the   public   they   can   respond   to   the   consultation   on   www.rightcaretimeplace.co.uk
They  can  also  contact  the  consultation  on  rcrtrp.myview@nhs.net  01484 464212,  or write  to  Freepost,  RTAA-XTHA-LGGC,  Heron  House,  120  Grove Road,   Fenton, Stoke-­‐on-­‐Trent,  Staffs,  ST4  4LX
There is a dedicated ‘Ask Owen’ button on  the  intranet  to  ask  questions or for  support – these  have  all  been  responded  to  promptly
Email  chft.nhs.uk  if  staff  would  like  someone  to  come  along  and  chat to  their department  or  talk  on  a  one  to  one  (but  this  is  not  a substitute  for  them  doing  a direct  response  to  the  consultation)  – as a result  of  this  we  have  attended: – Community  services  in  Brighouse – ward sisters meeting – Quality  team – The  Health Informatics  Service   – Outpatients  team  – Staff  side  – Two  staff  drop‐ins  with  Owen  Williams at  the  start  of  the consultation  –  one  on either  site.
Weekly  Wednesday  walkabout  by  the  senior  nursing  team  has  included discussion with  ward  nursing  staff  about  the  proposed  changes
Held a ‘Big Brief’ presentation on both sites about RCRTRP
1:1  interviews  held  with  consultants  between  August  2015  and  February 2016
Held  13  staff  events  across  our  estates  and  facilities  teams  – catering  /  portering  / engineering  /  switchboard  /  general  office
We  have  held  two  staff  drop  in  sessions  on  29  April  and  4  May, very  similar  to  the public  sessions,  where  staff  can  share  their view. There  is  a  further  one  planned  for 8  June.
There  are  posters  and  leaflets  across  our  sites  advertising  how  to get  involved
There  are  stands  next  to  both  restaurants  advertising  how  to  get involved
There  is  an  update  for  staff  every  Thursday  in  the  e-­‐bulletin
There is a ‘rolling banner’ on the intranet and screensaver advertising the consultation
Owen  regularly  mentions  the  consultation  in  his  blog.
Held  a  meeting  with  surgeons
Listening  Events  on  Wards  3,  10,  15,  19,  20  and  22,  Surgical Assessment  Unit  and the  Intensive  Care  Unit.

We  have  not  taken  notes  at  all  of  these  meetings  and  where  there were  notes  we have  fed  these  straight  in  to  the  consultation meetings. We  have  asked  staff  to   feed directly  in  to  the  consultation.

Our comments

This simply reiterates what we already know; senior staff only have been involved in this project – the  majority  of  the  workshops  and  all  the clinical  design  groups  refer  to the  attendance  of  senior  clinicians.

The  data  supplied  is  of  engagement   activity  and  events,  and  includes no  detail   of numbers,  clinical  roles  etc.

The CCG’s answer fails to acknowledge  the senior staff who gave  reasoned arguments why  they  do  NOT  support the  proposals,  at the first two public consultation meetings.

The  284  clinical  hours  to  attend  these   events,  and  a  further clinical  design  group,   would  account  for  less  than  15  people   attending  10  events  lasting  2  hours  each.

Perhaps  the  Unison  Survey  and  the   proactive  CHFT  engagement  will give a fuller picture  about  what the staff really  think  about  the  proposals.

Question 16

As for the Consultation Document claim that GPs, and staff in GP practices and community health services have been involved in many discussions about the proposals, we would like you to provide evidence of this. From talking with some of these staff, we have found that they didn’t have a clue about what you were proposing and we would like you to back up your claim with documentary evidence of which GPs and other primary and community health staff you discussed these proposals with, when and where and what they told you.

CCGs answer

In  Calderdale  we have  presented  to  the LMC 5 times in relation to proposed future arrangements  for  Hospital  and  Community  health   services.  We presented  to  the Joint  Clinical  Commissioning  and   Practice  Managers meeting  (26  GPs  and  26 Practice managers)  in October  and  December,  2015 and  in  April,  2016.  Information  has   also been  included in the  Jan, March  and  April  2016  editions  of  the   newsletter  which  is distributed to all  GP  Practices.

In Greater  Huddersfield  we  have  presented  to  the  LMC  through   our interface  update every  month  from  September  2015  to  May   2016.

We  presented  a  webinar  on  the  16th  September,  2015  which  was   available  to  all practices  live  and  then  added  to  the  intranet  page.

We  presented  at  Practice  Protected  Time  (PPT)  on  17th  November,   2015 to  all Practice  Nurses,  Practice  Managers  &  GPs  – (approx.   150 people).  RCRTRP  has  been discussed  at  individual  Practice   visits  – May 2014  (previously  called  strategic  review), September   2014,  January 2015, May  2015,  September  2015,  January  2016.   The September  2014  visit referred  practices  to  the  engagement   events  and  the  website. Updates have  been  included in the  newsletter  which  is  distributed  to  all  GP practices and  there  is  a  dedicated  page  on  GHCCG  intranet. The Programme  has been  a   standard  agenda  item  at  Practice  Managers Reference  Group  since   September  2015 (meet  monthly).

We  have  supplied  evidence  as  part  of  the  NHSE  Assurance  process   that  the  four  key tests  have  been  met:

  • strong  public  and  patient  engagement;
  • consistency  with  current  &prospective  need  for  patient choice;
  • a  clear  clinical  evidence  base;  and
  • support  for  proposals  from  clinical  commissioners.

A  copy of  the  letter  from  NHSE  is  attached  as  part  of  the  answer to Question 2 above.

Our comments

There is an extensive  list  of  presentations,  information and discussions but  there  is  no detail of feedback received from GPs,  whether  it  was noted,  discussed  or  fed  into  the development of the  proposals.

The Unison  Survey  findings  (Q.  15)  and  the conversations  reported  in this  question imply  that  the  CCGs  have given out information  but  that they  have  not   actively listened to the staff.

It could be that  the style  of  presentation  and  discussion  may  not  have been inclusive and  clear,  or  it could have used  language  that  was ‘non-management speak’ and with enough  time  for  an  open  and  honest dialogue. There is no way of telling, since they have failed to send the documentary evidence we asked for, about what the GPs and other primary and health care staff have told the CCGs about the proposals, and which GPs they have actually engaged with.

This does not reassure us that the CCGs have properly engaged with and consulted GPs and other primary and community health staff.

Engagement  is  more  about  listening  to  ideas, views and concerns than ‘presenting a case’.

Engagement  is  a  skill  that  is  not  often recognised as such in NHS management   circles. Managers  are  mostly  driven  by policy  and  budgets whereas  staff  will  often  take  a vocational  approach  to  providing   safe  and  good  quality  health  services.

NO  LETTER  ATTACHED  (see  Q  2.comment)

The Kirklees LMC Feb 2016 newsletter reports on the RCRTRP proposals in disenchanted terms:

“A major political Row has emerged following the leak of a proposal to site a major A & E unit in Calderdale despite the inherent impracticality in terms of access for the majority of the population of Kirklees.

The decision lies on the back of the revelation of the binding costs of the PFI in Calderdale. In which there is a commitment to paying a lease at high interest rates for 60 years.

Alongside the proposal lies the proposal to knock HRI down and build a smaller hospital with less than one third of the beds from 360 to 120. The proposal is to extend Calderdale hospital with a multi storey car park and new clinical suite and in the longer term create a further demand to expand the motorway access from Ainley Top all in all throwing good money after bad. We should support the best service for the population developing our
existing resources….”

GP views we have heard on the Right Care Right Time Right Place “engagement” and consultation processes include:

I do not believe that Huddersfield GPs have been appropriately involved in RCRTRP proposals.  I also believe that many local GPs and practice nurses are opposed to the plans.  The culture of the NHS, CCG approach and failure to ballot practices has in effect silenced them.

We were first informed around the time of of the original JHSC meeting at which the “consultation” was launched.

The CCG appears to confuse “consultation” with “meeting attendance.” At mandatory meetings, practice reps. signing an attendance sheet (so that their practice receives the financial incentive) is NOT involving or seeking the views of GPs from constituent practices.

The CCGs do not involve or seek the views of local GPs.

Huddersfield GP federations and individuals were involved in developing a  CCG primary care strategy in late 2015 after CCG was told by NHSE to produce one.  CCG appears to be also using this as evidence of RCRPRT GP “consultation.”

To date there has been no formal consultation with GPs – nothing. Glib brief upbeat sentences in CCG newsletters that the Consultation proceeds.

There have been no formal ballots and none are proposed. My sense is that CCG did not seek our views as too many would be opposed. We were told first at the same time as the public. The LMC has no proposal to ballot members but should do so.

I am totally opposed to Right Care Right Time Right Place proposals. The CCGs should reject and lobby for appropriate NHS funding.

We GPs are on our knees – there is an acknowledged national crisis. Poorly led across the board. Relations with CH CCG are poor – failure to deliver any positive change or impact since inception.

Question 17

The Consultation Document says nothing of the fact that the Clinical Senate, in reviewing the Community Services Specifications for Calderdale, Greater Huddersfield and North Kirklees CCGs (PCBC p 137) says that these specifications contain no evidence to support commissioners’ claims of “extensive engagement with staff” over the last two years. It considers it “likely that there would be workforce issues during such a large scale transformation”  and recommends further work on how “ risks to patient care can be mitigated during the transition period” , that would result from current CHFT “workforce issues getting worse as the morale and motivation of clinicians continues to deteriorate”. This is identified as a “Principal risk”. It also says that there will be “resistance and refusal to change”  in primary care. You need to tell the public about this.

CCGs’ answer

We  published  the  Clinical  Senate  Reports  as  part  of  the  Pre-­Consultation  Business   Case.  The report  does  not  say  that these specifications contain no evidence to support commissioners’ claims of “extensive engagement with staff” over the last two years – rather  it  says that the  Senate ‘is  aware  from  discussions  with  commissioners  of  the extensive  engagement  with  staff  during  the  previous  two  years.  Evidence  of  this engagement was not available within the documentation received.”

The  Principal  Risks  were  identified  by  the  CCGs  and  the  Senate  were asked to comment on  them.
The  summary recommendations  from  the  report,  as  already  published  on the website, are:
The Senate commends the CCGs on their vision for the future of their community services and agree that this has the potential to result in excellent patient care closer to home. In general terms, the Senate review group was very supportive of these comprehensive documents and their values and principles for delivering care closer to home.

2.2 The Senate was given a specific brief in relation to whether particular risks are addressed within the proposals and to appraise whether there are any missed opportunities within the proposed scope of services. The Senate did find it very challenging to assess the risks associated with the service transformation and we have raised a number of questions in relation to the risks arising from the lack of detail regarding workforce, primary care strategy and engagement with partners, for example. We recognise that there have been extensive discussions with stakeholders during the last 2 years which was not detailed within the evidence provided, and that the detail behind the vision will be worked through in competitive dialogue. The Senate hopes that these questions assist with that procurement process. The Senate recommends that commissioners work in partnership with the providers around the development of the service models. This shared approach to the service model development is particularly important in a system undergoing such a large level of change to help mitigate against the risks to service delivery.

2.3 The Senate Review Group has considered the scope of services and agrees that these are comprehensive, with little that could be considered a missed opportunity.

In  addition  the  Clinical  Senate  also  reviewed  the  proposed  future model  of  Hospital   Services  and  the  summary  recommendations  from  the report  –  as  already  published on  the  website  are:

2.1 The Senate commends the commissioners on their vision for the future of hospital services and we support the commissioners’ aspirations for the service. The Senate agrees that the Quality and Safety Case for Change and the baseline position support the need to move towards greater centralisation of services across hospital sites. The Senate agrees that a clear argument is made that the current configuration of services does not and cannot meet national guidance, and that staying the same is not an option.

2.2 The Senate recognises that the documents supplied are a work in progress and the supporting detail regarding activity and workforce will be developed as part of the pre-consultation Business Case.

2.3 As a high level strategic document for whole system change, the Senate agrees with the aspirations outlined in the Model of Care. The Senate recommends however, that as the work develops the commissioners describe the model with greater clarity, particularly focussing on detail about the workforce and activity. The lack of detail at this stage left the Senate with questions regarding the ability of this model to deliver the standards proposed. At this point, the Senate can only endorse the vision and give broad assurance of its potential to deliver a quality service. Following the receipt of further additional information about the Urgent Care Centres, the Senate are broadly content with the proposals but there is always the possibility that a very ill patient will attend the Urgent Care Centre and commissioners need to ensure that staff have the medical and nursing skills, experience and capabilities to safely stabilise that patient. Commissioners are recommended to consider this further as they develop the model.

2.4 The Senate supports the standards proposed in the documentation which are taken from a variety of national documents and reflect the best of national policy. The standards are very generic, however, and could largely apply to any Trust. Commissioners are recommended to include more detail about the level of local clinical engagement in agreeing how deliverable these standards are.

Our comments

Selective quoting from the clinical senate report, ignoring the clinical senate statements we asked them about and refusing to tell the public about them.

The  answer  omits  the  rest  of  the   second  sentence  in  their  quotation from  the clinical  senate  review,  which   reads – in  full:

“The Senate review group considered it likely  that  there  would be workforce issues during  such  a  large  scale  transformation   and  is aware  from discussion with commissioners  of  the  extensive engagement with staff during  the  previous 2  years. Evidence  of  this  engagement  was   not available within  the  documentation   received which  restricted  the Senate ability to  anticipate  the  workforce  issues  that  may   be encountered.”

The  CCGs’ answer  does  not  address  the  risk   regarding primary care ‘resistance and refusal to change’ highlighted  by  the  Clinical  Senate.

The CCGs’ answer doesn’t address the Clinical Senate’s concern  about  how ‘risks to patient care can be mitigated during the transition period.’

On p 138 the Clinical Senate Review is trying to address the “risk of lack of clinical workforce and skills to deliver the services due to inadequate resource, ” identified in the Community Services Specifications for Calderdale, Greater Huddersfield and North Kirklees CCGs. The Specifications said this would cause delays and/or “issues with implementation of the programme.”

The Clinical Senate Review comments that the consequences of lack of clinical workforce and skills will result in a poorer service to patients.

Question 18

The Consultation Document says nothing about any risk assessment of the effects of the proposed hospital cuts on primary care, although the Royal College of Emergency Medicine’s Feb 2016 position statement on Emergency Department Closure says,

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

We need you to acknowledge this publicly and state what risk assessment if any you have carried out of this issue.

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.

Both  CCGs  are  developing  their  Primary  Care  Strategies  and  both acknowledge  that Page  24  of  38 access  to  Primary  care  needs  to  be improved. These  proposals  together with  Care   Closer  to  Home  are complementary.

Our comments

Denial of our points, again saying it’s a change to A&E not an A&E closure. But oh  yes they are closing  an  emergency  department  – our see comments  above.

The  Clinical  Senate  commented  on the  risk  of  not  achieving  the Primary Care Strategy  aims  (a  document  they  had  no  sight  of):

“From the information we have been given, the  link  between  the community services   and  the  primary  care  system  is  under-addressed  in terms of relationships and interactions. Support from the GP’s will be essential  to success;  the  view  expressed  in   the consultation that one size doesn’t fit all mat be a concern for commissions as  to   enable  the model  to  work  the hubs  have  to be  similar  in  order  to  allow  for consistent signposting and referral of patients.”

The CCGs need  to  note  and  act  on  this.

Question 19

Primary health care is underfunded and struggling. The government is cutting public spending and the Consultation Document fails to show that the proposals will maintain the quality of primary and community health care, let alone improve it. Instead, the consultation document (p35) claims that “strengthening community services” is benefitting the patients who need it the most. It provides no evidence to back up this claim. The only evidence given is that admissions to hospital from care homes that received Quest for Quality in Care homes support were 25% lower, in the year to March 2015, than from other Care Homes. Also that the length of stay was reduced by 26% saving £500,000. This was not a controlled trial and doesn’t take account of other differences between the two groups of care homes. By now there should be more data, better evaluated. To present the data in this way is not honest. We need you to publicly produce documentation that shows how you have strengthened community services, how you have determined which patients need these services the most and how they are benefitting these patients.

CCGs’ answer

The CCGs have considered the impacts of the Care Closer to Home Programmes in their Governing Body meetings in public. They have determined that they have confidence that the Care Closer to Home Programmes are improving the quality of Community Care and reducing demand on hospitals. The example given in relation to Quest for Quality in Care Homes does provide evidence that we are strengthening Community Services. The data is correct at the time of publication.

The completion of a controlled trial would take a number of years. The need to improve services is immediate.

Our comments

There is no evidence to back up their reply. We asked for documentation that shows how the CCGs have strengthened community services, how they have determined which patients need these services the most and how these services are benefitting these patients. They have ignored this request.
The  CCGs  may  have  confidence  that  the   Care  Closer  to  Home Programmes are ‘reducing demand on hospitals’ and ‘improving the quality of Community Care’. The public  need  to  be  confident  too.

In terms of benefits to patients, perhaps  CCGS  need  to  ask  patients  and   carers  what their  experience  is  and  if  they   find  services  are better. A  wide  reaching  snapshot engagement  exercise  is  not   expensive  and  may help  create  a  meaningful dialogue with  the  public.

Perhaps  the  CCGs  need  to  have  a  different   approach  to  evidence. They could  be more pro-active  in  collecting   feedback  from  patients,  carers and  the  public  and  less reliant  on  service  activity   data,  national surveys  and  hospital  admissions.

The  priorities  CCGs  talk  about  in  their   communications  are  linked  to budget   control and  meeting  national  targets   rather  than  improving the patient experience and patient outcomes.

This creates a ‘disconnect’ with the people the  NHS  serves,  rather  than  a partnership to improve  services  together.

Strengthening community services is about a lot more than supporting privatised Care Homes to do their job properly – although the Care Home sector is near meltdown and at the Halifax Orangebox drop in, Dr Nigel Taylor said that Calderdale CCG are supporting the “care home market” because “there are huge problems with that – the care home market needs support and development. It needs to be fixed now.” He said Calderdale CCG are working with local authority to make sure they pay what they need to pay, through joint commissioning with the local authority.

On pages 137/138, the Clinical Senate report says that because the Community Services Specifications for Calderdale, Greater Huddersfield and North Kirklees CCGs do not include the primary care strategy, it has “been difficult” to judge whether insufficient capacity and capability to complete and deliver the primary care strategy will scupper the community services programme.

It says that from what they can gather, the link between primary care and community services hasn’t been thought through.

Regarding the question of whether the capacity exists to strengthen community services, at the 22nd March 2016 Joint Health Scrutiny Committee meeting, Cllr Smaje asked if the Clinical Senate and NHS England had looked at the system as a whole in respect of whether the system can cope with these changes, including Care Closer to Home.

A Clinical Senate rep said that the Clinical Senate didn’t look at the resources that are available, because the Clinical Commissioning Groups didn’t invite them to do so.

He said that the Clinical Senate always has concerns about the integration of services – primary care, hospital care and community care. And they identified in their review that this was something that needed work – but whether this was being done or would be done hadn’t been communicated to them.

Cllr Smaje then asked:

“Did NHS England take that into account at all?”

The NHS England rep Brian Hughes said

“In the documentation provided, there wasn’t a detailed analysis of the activity but that does form a part of the consultation.”

Where? We can’t see anything in the consultation about it and when we try and ask the CCGs about it, they deny that it’s an issue.

As retired consultant Colin Hutchinson has told the Joint Health Scrutiny Committee,
Care Closer to Home – done properly – is more costly than care in hospital:

“It takes more staff to deliver care in patients’ homes, because you can only treat one patient at a time, whereas on a ward, you can be treating and supervising the treatment of a number of patients. The staff also need to be trained to a higher level, as they do not have direct access to back up from more experienced nursing and medical staff.”

The CCGs’ answer didn’t acknowledge there is a crisis in General Practice, with insufficient GPs to replace those that are retiring, let alone to meet the increasing population, their increasing health needs and the aim of providing for these outside hospitals.

But the Pre-consultation Business Case seems to think that the way round this is:

“Enhancing generalist and collaborative skills for the Trust’s workforce across primary and secondary care to support delivery of the Commissioners’ QIPP requirements”

At the Lockwood drop in, one of us asked what this means. The CCGs staff didn’t understand the question and therefore couldn’t answer.
Our interpretation follows, based on what we know of the “modern workforce” proposals in NHS England’s 5 Year Forward View, which the Right Care Right Time Right Place scheme  intends to carry out.

QIPP – “Quality Innovation Productivity and Performance” – requirements are to cut spending or deliver more services for the same money, so this means there will be new grades of jobs that will be cheaper than the current ones.

This is about down-skilling. GPs will have a new title of consultant generalist and be supervising a less qualified team so the system will need fewer GPs. Those GPs prepared to work in the system will be providing medico – legal cover for a vastly lower quality service.

Dr Bob Gill, a South East London GP and member of the National Health Action Party, calls it,

“A skid row NHS to drive us to take out private health insurance.”

Care Closer to Home is about cutting costs – but if properly delivered, it would cost more to deliver than existing hospital-based care. So Care Closer to Home is planning to run on far fewer qualified doctors and nurses, and with many more less qualified, new grades of staff like physician associates as well as unpaid family carers and voluntary sector organisations. This is what NHS England’s Five year Forward View calls a “modern workforce”.

What does the Trust’s workforce think of this idea? The Consultation Document doesn’t say.

The CCGs’ answer says nothing about how they will determine which patients most need community services.

The example of the Calderdale Support and Independence Teams– one of the already existing Phase 1 Care Closer to Home schemes – seems worrying in this regard.

These Teams are a hospital Trust/Calderdale Council working arrangement to look after elderly people who need “reablement” after being in hospital, and who may then need further home care after being “reabled”.

Their 2015 Report seems to indicate that the Teams are cherry picking patients that will improve their outcomes. These are about reducing unplanned hospital admissions. It says:

“The targetting of Reablement resource to people who are more likely to benefit – that is to say, applying clear referral criteria – is seen as highly beneficial to the outcomes achieved.”

It also seems that much of their work in 2015 has been figuring out how to accelerate patients’ progress from NHS–funded reablement (which is available for 6 weeks) to an “independent sector provider” (which is means-tested).

The S&I Teams’ 2015 Report says they have been putting more staff to work on services that patients have to pay for – “post-reablement home care waiting” and “rapid access homecare for people who would not be appropriate referrals to reablement”. Their report notes that the more patients who move quickly from reablement to an independent-sector provider, the more money the Council would save.

Rather than determining which patients need these services the most – which is what we asked the CCGs to provide evidence of – it seems that this so-called ‘integration’ of health and social care is funnelling people as quickly as possible from the NHS to means-tested social care, and cherry picking patients in order to improve outcomes – like reducing hospital admissions – that bring financial rewards from NHS England.

Question 20

Where is the evidence that Care Closer to Home can justify the anticipated 6%/year reduction in non-elective medical admissions to hospital? We need this to be publicly available and if there is no such evidence, we need you to state this publicly.

CCGs’ answer

The  Consultation  Document  does  not  state  that  Care  Closer to  Home will reduce non-elective  medical  admissions  to  hospital.

The  Pre-Consultation  Business Case states that one  of  the   assumptions used  in  the activity  and  capacity  modelling  is  that  “ Significant Delivery  of  Commissioner  QIPP will  be  realised   (resulting  in  a  6% reduction  in  non-elective  medical  admissions  per  annum)’.

The  6%  improvement  refers  to  CHFTs  Key  Operational  initiative  to
‘Deliver best in class LOS, DNAs, New to FU ratios and ambulatory care – optimise performance  to  reduce  waste  and  enable  bed  reduction as set out on page 36 of CHFT’s Five year plan’.

Our comments

The CCGs’ answer is essentially admitting that the consultation document and the Pre Consultation Business Case are contradicting each other.

The Pre Consultation Business Case model shows an assumption of a 6% reduction in elective admissions when in actuality they are meaning overall reductions in LOS etc

QIPP – quality,  innovation,  productivity  & prevention  (improve quality/reduce cost) by  managing/reducing  the:

‘LOS’ length  of  stay  in  hospital,
‘DNA’ not  attending  appointments  and
‘New to FU’ – a  new  follow up,  but only if  such an appointment is really necessary.
(Perhaps  explaining  this  would  be  useful)

Again  national  targets  are  the  CCGs’   priority.  Here it is to reduce beds, and   therefore hospital costs. The  reduction of beds is not  a patient, carer  or  public  priority.

In terms of evidence to support the claim in the Consultation that Care Closer to Home can reduce unplanned/ non-elective hospital admissions, a 2014 Health Service Journal review of the evidence for promoting “integrated care” out of hospital found that:

“a close look at the data highlights a dearth of evidence on the impact of integrated care”.

And, reporting on its Commission on Hospital Care for Frail Older People, the Health Service Journal (November 2014) stated:

“There is a myth that providing more and better care for frail older people in the community, increasing integration between health and social care services and pooling health and social care budgets will lead to significant, cashable financial savings in the acute hospital sector and across health economies. The commission found no evidence that these assumptions are true.”

Question 21

The costs of these Care Closer to Home interventions are missing from the Consultation Document, as are the costs of scaling them up to the whole area served by Calderdale Clinical Commissioning Group. This makes it impossible for the public to give an informed opinion on Care Closer to Home. We need you to provide this information.

CCGs’ answer

We  anticipate  that  the  costs  of  these  services  would  be  lower  than   the  provision  of  the  equivalent  services  in  hospitals.  The  costs  of   our  proposals  are  outlined  in  the  Consultation  document  on  page  12.

We are proposing  these changes because  we  think  they  would  save  more lives,  keep people healthy, make services safer and improve quality  of  care.

Our comments

NO –  be  honest  –  most  of  it  is  about   meeting  national  targets  to save  money, reduce  the  Hospital Trust’s deficit and prevent special measures.

Just guesswork on their part but at least they are admitting this in a way.

The costs they refer to on page 12 of the Consultation Document are for building the proposed new planned and urgent care hospital in Huddersfield, expanding CRH to be the single acute and emergency centre for both areas, and supporting the hospital’s deficit position. It doesn’t include any info about the costs of the Care Closer to Home scheme.

As we have already commented (question 20, above), Care Closer to Home, run properly, would cost more than hospital care. The only ways that the CCGs can make them cheaper is to skimp on staffing, by relying on fewer properly qualified staff, introducing new, lower qualified staff grades and relying on voluntary sector organisations, family and friends as carers, and self managed care by patients. And to cherry pick patients and restrict services – as GH CCG is now proposing as result of orders from NHS England, to make sure that it meets the new Sustainability and Transformation Plan requirement to generate a 1% surplus this financial year.

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