The Clinical Commissioning Groups have added two extra drop in sessions to the hospital cuts and community health service consultation. The first was at Lockwood Rugby Club on 9 June.
Andrea English, Chrissie Parker, Sheila Elson and Terry Hallworth asked a bunch of questions, here is their account.
Chrissie: I knew where the venue was, but for people who didn’t, there was no sign at the end of the road, most out of the area would not realise there was anything along that road other than a gym.
Outside the building there were no signs at all, I assumed we would go in the main entrance, but it was via a side door due to there being a lift by that entrance, there was a CCG person outside to guide us, otherwise we may have given up.
The room was stifling so we sat outside.
Andrea: The most positive thing I noticed was that something has started to change in their expression regarding how comfortable they are that these plans are fit for purpose – there was a shift from “This is all about improvement and I completely believe this will improve patient experience” to “Yes underfunding is a big problem and we too are worried about our patients but this is the best we can do we are providing the best with what we’ve got.”
Repaying the £490m loan
The hospitals Trust Assistant Director of Strategic Planning, Catherine Riley, said that the hospital trust would be responsible for the £490m loan it could come from the government it might come from elsewhere or be PFI 2.
She believes repaying it will have been factored into the projected deficit of £9.5m/year after 2020/21 but didn’t know how this had been costed and could not say whether or not it had been factored in for sure. The person with this information is the head of finance who was not there and they therefore suggest we email the question.
Sustainability and transformation plans
STP is sinking in for sure. This is where I got the biggest impression they were doubting.
There is the bombshell that Greater Huddersfield Clinical Commissioning Group has to cut £8.5m of NHS services this financial year, on the orders of NHS England. This is because under the controversial new Sustainability and Transformation Plan edict, Clinical Commissioning Groups have to make a 1% surplus this financial year and GH CCG isn’t going to be able to do it without making cuts.
Many of the likely cuts are in the area of Care Closer to Home. They include:
- mental health, prescribing, community equipment, high-cost drugs, care home support and other areas.
- the prevention and treatment of falls, respiratory infections, urinary tract infections, heart disease and skin disease together with flu and pneumonia.
Andrea asked how these cuts are going to affect the plans for Care Closer to Home Phase 2 (ie the bit that hasn’t yet been implemented and that is being consulted on now as part of the so-called Right Care Right Time Right Place cuts and changes.)
The nurse, Jackie Murphy, was very honest, and fairly open in her agreement that it was a big concern that plans were pushing ahead without adequate alternative provision in place and functioning to meet need.
She couldn’t do other than silently agree when I spoke about STP and that no matter how I understood that many patient needs were best community-managed, but unless the services are up, running and proven to meet the gap before the current pathways are closed we have a major problem – the timescale the CCGs are under is much tighter than they envisage transforming community service.
My simple point: what price a life, and the NHS needs to be funded properly and cost should not be an issue, and all services should be funded and run by the NHS. I mentioned someone I know who now works for Locala and he is leaving as he feels he cannot give the care he wants or needs to.
Community nursing logistics
I spoke about community nursing logistics and how if I as a clinician am placed in a clinic I can see one patient after another. Put me in the community and my clinical time is reduced. This has not been fully explained in the proposals.
Jackie Murphy spoke of the need to utilise and embrace new ways of working such as voluntary sector and social and defibrillator response training. I spoke about how both she and I had been trained all our lives to recognise the need for joined up care and tackle inequalities, how previously the NHS was the NHS and our managers were clinically motivated. That the problem with things such as Macmillan and breast care is responsibility for quality. That now the parity and control of quality is disjointed and inequality of service much worse than ever before.
The logistics of the plans are definitely where the strategic planner and I differ – it is not that there isn’t an element of possible improvement to be gained via inventing new ways to work and bringing these things into the community, but with a purely business-based focus the results are catastrophic – in the past the small hospital admissions avoidance pathways were very specific, our team had focused referral criteria and clear start and end points as did the walk in centres; as time has gone on and teams have been taken on by social enterprise I noticed that standards dilute as, with procurement of service, new things are grouped into a contract and not necessarily aligned to team role, skill mix and the nature of team purpose or based on needs assessment.
Box ticking instead of making a real difference
The arbitrary standard setting in Quality and Outcomes Framework (QOF) and money available for enhanced services such as the prediabetes targets in referral to diet and exercise are too removed from understanding what will actually provide patient improvement. I’ve no idea what the answer is but it is very frustrating to be ticking boxes instead of making a real difference and being allowed to individualise care considering all those things that go into optimising outcomes – the problem is constant however we address it.
Do specialist centres remove the need for ordinary A&Es?
They are arguing a flimsy line, basically ( on a night ) the number of consultants in the two A&Es doesn’t meet guidelines and docs won’t stay and are not happy with our working patterns. They struggle to get staff and retain them, at the moment there are A&E 7 consultants in post and 5 locums.
“Specialist centres reap better results” is their quote – well that stands to reason but people are not specific, so those centres of cardiology are not going to, say, help the person with a ruptured appendix, so what is the comparison worth?? How do they know that just because major trauma centres and specialist cardiology centres etc do better at dealing with that which they are intended for than ordinary A&E, that this will compare to not needing as many little A&E’s??
Problems with urgent care model
I said that basically now instead of patients filtering through two imperfect accident and emergencies we will have x amount of patients we hope have been directed based upon being more important in an emergency care centre and the rest spread between urgent care and community, with all the consultants in the bit with the patients we hope are the most poorly.
Hope isn’t really good enough and unless 111 are up to the job of coping with increased workload ( and patients aren’t waiting ages for call back ) and triaging is improved ( with lots ending up in A&E or higher or lower priority than necessary), surely all we’ve done is lump the problem in a different place and create a massive problem .
Basically in some ways they will have managed a different problem – the emergency centre will indeed less frequently see less urgent things, so its time will be better spent. However the urgent care centres ( run by GPS and Advanced Nurse Practitioners (ANP’s ) and the community with less than perfect provision will now be full of patients caught in a waiting game of filtering through 111 telephone triage or being seen by me to decide is this urgent or not. Well if the system works and it’s not a four hour wait to sit in front of me who then thinks “Shit you don’t need me, you need them,” that’s fine. But if it doesn’t, the time to get to the right place massively increases so care standards are worse regardless of a more impressive A&E.
If they cannot staff two properly they need to ring fence services, downsize call them something else that is gauged by a lower staff level and turn away by triage at the point of rocking up.
Andrea: I asked about staffing and why they have said that redundancies have not been factored into the equations. They believe that they can account for redundancies in natural wastage – the answer was very non-forthcoming as to how reduced manpower was going to address the same problem of lack of staffing that they have in A&E, in these new ways of working.
The nurse lady believed that in her time as a nurse, improvements had been made – she spoke of early days as the only qualified nurse for a ward, she spoke of the time-old problem of nurses’ subservience and the need for change. Asked would she have chosen differently in the past, given the belief that things were less than safe, she said probably not.
Although I said I got what she was saying, I didn’t agree – not only do unsafe staffing levels such as she spoke about still occur (she contests this) but also the very nature of the role has developed in such a way a nurse’s role now is nothing like it was in the days when one qualified nurse was on a ward. When I first qualified I would have usually half a ward I’d be responsible for the drug rounds and ward rounds, admissions and discharge planning but also with a lot more washing dressing, feeding core cares . Now the well patients who were able to take their own Meds, wash and dress themselves are unlikely to be on that ward for sure and many of the junior doctor duties are the nurses remit.
Sheila: The consultant and the Assistant Director of Strategic Planning kept trying to convince me this was the best deal to achieve ‘Clinical Safety across more areas of care due to recruitment difficulties being down to shift patterns restrictions not lack of salary levels’ which the consultant said ‘were across the board in the NHS’, when I said that ‘recruitment problems were due to them not offering competitive salaries to attract staff’.
Lack of engagement with nursing home residents
Sheila: When I was inside the room a consultant – tall lady, blond bob and dark rimmed glasses – can’t remember her name, came to ask if I had any questions.
“Can you tell me how many Nursing home residents had been consulted?”
She was stood with the Planning & Strategic Manager lady, Catherine Riley, who said
she couldn’t answer that question but knew someone who could.
A tall Asian man called Sal came and he said that:
“‘Assets’ had consulted with groups who represented the elderly population – like Help the Aged, Age Concern etc who had contacts with Nursing homes , had held Open Days for families and residents to attend to ask questions about the consultation, but hadn’t directly been to any Nursing homes to ask individual residents.”
“That didn’t really add up to proper consultation then.”
He said if I felt there was a gap there I should email the CCG about it.
I thanked him and he went off.
Care Closer to Home
Sheila: I talked about our families’ experience with both mine and Anthony’s dads having had to go in Nursing homes before their passing away and the circumstances leading up to us having to make those decisions. I expressed concerns about Care in the Community – staff not being given long enough with each client to properly meet their needs, that greater levels of training were needed to meet Clinical Safety in the community if more people’s care was going to be delivered that way. They said that was what I should put in the boxes on the Survey, which gave me the impression they thought this too but as they were based in hospitals couldn’t comment on that side of things.
Andrea: They told me to put down my concern about timed “episode of care” too, in the Survey box.
Q: Which organisation currently provides Therapies – speech and language, occupational and physio therapies?
A1 : Locala in Kirklees the CHFT in Calderdale
A2 The nurse lady said that all the physios and ots are employed by hospital trust. She spoke about being uncertain whether this would continue to be so in the community and didn’t know about if there were any projected changes in therapist numbers under plans.
Q: How will Care Closer to Home work to deliver these outpatient services in a community based setting?
A Similar to as they are in Todmorden Health Centre. Unable to give other locations but suggested GP surgeries or forming other locality hubs?
Q: How will the proposal work to deliver children’s services as primary/community based service, rather than as an acute- led hospital service?
A: As above.
Q: How will the proposal work to deliver outpatient children’s therapies services in a community based setting?
A: As Above
Q: Ditto for rehab bed days – how does the system work at the moment in hospital, and how will it work in a community setting rather than in hospital?
A: Locala provide it in Kirklees and CHFT in Calderdale.
Q: Is GH CCG planning to introduce job coaches into GP surgeries and/or community health care hubs?
Q: Why hasn’t the CCG ballotted GPs to ask their views on the Right Care Right Time Right Place proposals, as part of the consultation?
A: They have been told via Protected Time meetings with GP’s, 3 times a year. (Which doesn’t answer the question.)
Q: What is the Greater Huddersfield CCG primary care strategy and how were GPs who are not on the CCG Governing Body involved in developing it?
A: GP’s have their say via the consultation as the rest of the population. The GP’s have already voted for the GP CCG members. (Which doesn’t answer the question.)
There was a common theme to most of the answers given:
The information is in the PCBC or 5 year plan
We won’t have the answer until we do a full business case after the consultation.