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.
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?
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.
Does the answer imply that a private patient wing may be part of some future proposals?
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?
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/
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.
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.
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
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
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
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 email@example.com 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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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’.
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.”
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.
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.
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.