NHS Commissioners fail to fix Consultation Document errors & omissions (final part)

This is the final batch of the Clinical Commissioning Groups’ answers to the questions Calderdale & Kirklees 999 Call for the NHS (CK999) asked them, in order to fix errors and omissions in the Consultation Document about proposed hospital cuts and changes to community services.

Their response is hugely disappointing. Our questions were an opportunity for the CCGs to show that they take seriously the views of members of the public who question their proposals. They passed up that opportunity.

We explained to the CCGs that the reason for our request is because:

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

The first batches of CCG answers to our questions are here (Part 1, Questions 1-12) and here (Part 2, Questions 13- 21).

This post covers questions 22-38.

Now we have reviewed and commented on all the CCGs’ answers, it is clear to us that the CCGs have provided hardly any new information.

Where they have provided new information, this is lists of “engagement” events with NHS staff – both hospital staff and GPs – and a justification their payment of “engagement champions”.  None of this has shown that they invited or took notice of the views of the staff they “engaged” with – their answers are all about “presentations” they made.

But 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.

It is absolutely clear, from this new information and from the generally dismissive tone of their answers to our questions, that this is in no way a formative Consultation. Many of their answers deny the validity of our questions, avoid answering our questions and repeatedly deny that they are proposing to close Huddersfield A&E.

Here are the last 16 questions and answers, with our comments on the CCGs’ answers

Question 22

The Consultation Document fails to mention that the Clinical Senate stated that there is no evidence in the proposed hospital clinical model, that clinicians at the hospital have been sufficiently engaged with to determine whether the resources exist to realise the claimed benefits of the cuts and changes. The Clinical Senate said that the hospital’s clinical model is based on national policies and guidelines, and that there is no evidence of informed local clinicians’ assessment about how and whether these are capable of being applied locally, given the available resources, in order to produce the required quality of care. We need you to acknowledge this publicly.

CCGs’ answer

Please  see  answer  to Q17 above.

Our comments

No – Q  17  relates  to  the  Clinical  Senate  Review   of  Community  Service Specifications or Calderdale, Greater  Huddersfield  and North  Kirklees CCGs.  In their answer, the CCGs  quoted that Review  but did not  address Q22.

This  question,  (Q  22)  refers  to  the  Clinical   Senate  Review  of  the Future  Model  of Hospital Services for  Calderdale  and Greater  Huddersfield CCGs. These  are  two different  documents  about  different  Clinical  Senate Reviews.

The Clinical  Senate  repeated throughout their Hospital Services Review  their concern about the lack  of evidence of ‘informed local clinical assessment’ of the deliverability of the proposed hospital  model.

The CCGs have not addressed Q22 at all  and  have ignored the  need  to acknowledge the Clinical  Senate’s  repeated  concern  about  this ‘informed local clinical assessment’.

Question 23

As a result, the Clinical Senate review said that they could not vouch that the proposed hospital clinical model would generate the required quality of care. The consultation document makes no mention of this. On the contrary, it asserts (p13) that the proposed model of care would enhance quality of care. We need you to tell the public about this statement by the Clinical Senate and to provide data that shows how the proposed model of care would be of the required quality. If this is not available, you need to say so.

CCGs answer

Please see answer to question 17 above

Our comments

NO  – AGAIN  the  question (Q  23)  is  talking about a different Clinical Senate  Review  to that referred  to  in  Q  17.

Q  23  therefore  has  not  been  answered. The  consultation  document repeats many aims  of the proposal  as  if  they  are  definite   outcomes. This  is not  helpful.

The  Clinical  Senate  States:

“At this point, the Senate can only endorse the  vision  and  give broad  assurance  of  its   potential  to  deliver  a  quality  service.  The   proposed  model  needs  to  be  described   with  greater  clarity, particularly  detail   about  the  workforce,  in  order  to  answer   questions  regarding  the  ability  of  this  model to deliver the standards proposed.”

Question 24

Claims about engagement with the public and key stakeholders are flawed and statements about public and stakeholder support for the proposals are exaggerated. We need the CCGs to publicly acknowledge the limitations of their public and patient engagement and the criticisms of this by Calderdale Adults Health and Social Care Scrutiny Panel Chair, who told the CCGs when they presented their engagement review in August 2015, that they “should seek a wider basis of opinion about their plans” – instead of confining their “engagement” to “people inside the goldfish bowl.” When we decided to provide a wider basis of opinion at the CCGs’ Stakeholder Engagement Event, we had to protest vocally in order to gain admission.  Once inside, we found that invited “stakeholders” – many of them the CCGs’ “community assets” – were saying that they didn’t agree with the proposals and didn’t understand them. We would like the CCGs to make public all the documentation relating to their public and stakeholder engagement events so we can see exactly what the CCGs base their claims on regarding public and stakeholder support for their proposals.

CCGs’ answer

We  have  supplied  evidence  as  part  of  the  NHSE  Assurance  process  that the  four  key tests  have  been  met. One  of  these  tests  is:  strong public  and  patient  engagement.  A copy  of  the  letter  from  NHSE  is attached  as  part  of  the  answer  to  Question  2  above.

We  do  not  agree  that  our  claims  about  our  engagement are  flawed.  We have published  reports  of  all  our  stakeholder  sessions   on  our  website and  a  composite report  of  all  our  engagement  has   been  produced  by Healthwatch  Kirklees  and published  on  our   website.(  Link)

The Consultation  Institute  have  signed  off  the  scoping  stage of  their Compliance process  – part  of  which  assesses  the  quality  of the pre-consultation  engagement.

I can  find  no  reference  in  the  August  minutes  of  the  Calderdale   Adults  Health  and Social  Care  Scrutiny  Panel  Council  minutes  to   support  the  statement  attributed  to the  Chair  of  the  Scrutiny   Panel. The CCGs’ Engagement report was not presented to that meeting, The  minutes can be  found  here:  (Link)

The  Engagement  report  was  presented  to  the  August  meeting  of  the Calderdale  and  Kirklees  Joint  Health  Scrutiny  Committee  on  13   August. I  can find no  reference  in  these  minutes  to  support  the   statement attributed to the  Joint  Chair  of  the  Scrutiny  Panel.  The  minutes  can be  found  here:  (Link)

A full report  of  findings  in  relation  to  the  August  event  has  been published  on  the Programme  website.

Our comments

No  –  there  was  no  letter  attached

Again denial and an over-reliance on the NHS England Assurance process report. Bear in mind that NHSE are driving these changes through across all of England.

See  comment to Q 2, that  the  Investment  Committee  and  not the  Regional DCO should  have  undertaken the Assurance as  CHFT  is subject to  enforcement   action.

How  can  CCGs  reconcile  the clear   difference  between  the  engagement   claims  and the  public  disapproval  and   anger  demonstrated  at  the  Huddersfield  Public Consultation   Meeting  on  18th  April  2016?

The CCGs are correct that Cllr Malcolm James’ comment wasn’t made at the Calderdale AHSC Scrutiny Panel. It was made at the August 13 Joint Health Scrutiny Committee meeting, where Cllr Malcolm James said,

“In formulating future questions, the CCG should maybe take a wider basis of opinion as a basis for the formulation – not just from people inside the goldfish bowl.”

The fact that his comment is not minuted doesn’t mean he didn’t make it. It gave rise to some merriment and led us to produce the following graphic:

fish for jenny(1)

CK999’s report on the August stakeholder engagement event meeting is here
Question 25

We would like to know why and at what point the mental health Trust (South West Yorkshire Partnership Foundation Trust), stopped being involved as a Right Care Right Time Right Place partner. SWYPFT was one of the 7 original partners in the Strategic Review and the Strategic Outline Case, but it does not seem to have taken part in the “Right Care Right Time Right Place” engagement processes and it is not taking part in the current consultation. We need you to clarify what the relationship is between the CCGs and SWYPFT, why mental health services are not included in the current consultation and in particular what the relationship is between Calderdale CCG and the SWYPFT Arts Psychotherapy Service in Calderdale. Does Calderdale CCG commission this service from SWYPFT? Does it have a view on whether SWYPFT should go ahead and cut this service entirely, as it was planning to do before legal action caused it to withdraw staff redundancy notices and engage with service users about the future of the service?
CCGs answer

The  Strategic  Review  was  established  to  bring  together the seven  partners  across Calderdale  and  Greater  Huddersfield  to  develop   proposals  for transformational change across  the health and social  care  economy  of  Calderdale  and  Greater  Huddersfield.

The  programme  produced  the  overall  Case for  Change  which  identified that significant  change  is  essential  because  we  want  to   ensure  that everyone  gets  the right  care  at  the  right  time  and  in   the  right place  whilst  responding  to  the challenges  of:

  • An  ageing  population  with  increased  needs;
  • National  shortages  of  key  elements  of  the  workforce  that  mean  new  service  models are  required
  • Continuing  to  meet  ever  increasing  external  standards
  • Significant  financial  pressures  facing  commissioners  and  providers.

In response to the case for change, three of the CCGs’ existing Providers (CHFT,  SWYPFT and  Locala)  produced a jointly developed  proposal  for changing  the  way  community and  hospital  services  in  Calderdale  and Greater  Huddersfield  could  be  provided.  They described  their  proposals in  the  form  of  a  draft  Strategic   Outline  Case  (SOC),  which was presented  to  members  of  both   CCGs’  Governing  Bodies  in  January,  2014.

It  was  presented  to  both  the  Kirklees  and  Calderdale  Health  and   Wellbeing  Boards (HWB)  and  Overview  and  Scrutiny  Committees   (OSC)  in February  and  March,  2014.

The  Providers  subsequently  developed  the  Strategic  Outline Case into an Outline Business  Case  (OBC).  This  Outline  Business  Case   was  lodged with  the  NHS Procurement  Portal  Bravo  in  June  2014, but was  not accessed  by  Commissioners until  September  2014.

In  May,  2014  the  scope  of  the  programme  was  revised  and  the partnership  of  seven was  set  aside  as  part  of  the  transition   arrangements.  In  order  to  signal  the transition,  the  name  changed   from  Strategic  review  to  Right  Care,  Right  Time,  Right Place.  The   revised  scope  and  phases  were  established  as:
Phase  One-­ Strengthen  Community  Services,   Phase  Two -­ Enhance  Community Services   Phase  Three – Hospital  Services

The  CCGs  have  a  commissioner/provider  relationship  with  SWYPFT.

Mental  Health  Services are not  included  in  the  current  consultation   because  we  do not  intend  to  change the services as  part  of  this  programme.

The  SWYPFT  Arts Psychotherapy  Service  in  Calderdale  is not part  of   this consultation.

Our comments

There  is  no  reason  given  why  mental   health  is  not  included  in  the proposals,  or   the  consultation  paper.

Or why mental health was abandoned when the CCGs decided to set aside the providers’ Outline Business Case and make the “transition” to developing their own proposals.

YOU  ARE  changing  the  services  for  people   with  mental  health problems. They  are members  of  the  public who  have  emergencies and  accidents  like everyone else.

  • WHAT  mental  health  liaison  services   will  be  available  at  the  Urgent  Care   Centres?
  • WILL  the  use  of  Section  136  suites   increase  if  the  Emergency  Centre  does   not  take people in mental health  crisis?
  • &  WILL  people  end  up  in  police  cells   again?

Have  the  CCGs  discussed  the  future  of  the   Arts  Psychotherapy  service with  SWYFT as  the commissioners,  given  the  public   concern  about  this service  closure? Both CCGs  have  commissioner/provider  relationships  that are  the  same  with  both:

CHFT  (for  acute  services)  and  SWYFT  (for  mental  health and community health services).

SWYFT’s Summary Strategic Plan 2014-2019  is clear that it has a “transformation focus” which seems to carry on seamlessly from its proposals in the Strategic Review.
It says it aims to:

“support integrated team working closer to communities – in line with the transformation vision of the Trust and of our partners.”

In addition it says:

“…the vision for inpatient services is for high quality in- patient facilities at geographically strategic locations within the Trust area delivering single room en suite accommodation designed to support cost effective staffing models.”

Here is a list of the mental health services it intends to transform:

SWYPFT service line strategic intent_summary stratgeic plan 2014-19

It seems odd that when the acute hospital provider, CHFT, wants to “transform” its clinical model, the CCGs run a public consultation on the proposals – but when the mental health trust provider, SWYPFT, wants to “transform” its clinical model, the CCGs don’t see any need to consult the public about the proposals. When you read SWYPFT’s summary strategic plan, the proposed changes seem massive. Why hasn’t there been any public consultation about them?

Question 26

The Consultation Document mentions the recent public engagement on maternity services. Clinical Commissioning Groups carried out this public “engagement” late, and as an afterthought. The maternity engagement survey was filled in by all kinds of people without the remotest interest in maternity services, but who wished to support a community group in need of money. This was because the CCGs paid £5 per completed survey to cash-strapped community groups who promoted the survey. This was widely advertised on social media by well-meaning members of the public who wanted to support these community groups. This must surely invalidate the outcome of the engagement. We need you to explain why it is right that you fund cash-strapped voluntary organisations in this way, in exchange for them promoting your engagement activities, and how you assess as valid responses to the engagement that are made in order to benefit the cash-strapped voluntary organisations.
CCGs’ answer

The  pre-consultation  engagement  was  carried  out  as  planned  and  as reported  to  the  Calderdale  and  Kirklees  Joint  Health  Scrutiny   Committee in  August  2015.  Link  to  minutes  above.

It  is  not  possible  to  comment  on  the  reason  why  or  the  interest   level in  maternity  services  of  those  who  completed  the   engagement survey.

The  actual  value  of  payments  is  not  promoted  outside the  programme.  Engagement  Champions  are  representatives  of  local  communities. They  are trained to  talk  with  people  about  local  health  services.  They  give local  people  the chance  to  influence  the  way  services  are  delivered.

The  CCGs  are  responsible  for  buying  local  health  services  in   hospital  and  in  the community.  They  need  to  talk to  all  communities when  they  are  considering changes to  local  health  services. We  purchase this  resource  to  reach  an  audience  we   would require  extra  capacity to reach –  this  would  include  staff   time,  additional  resources such  as interpreters,  venue  hire  and   administration  including  marketing  and promotion.

The  reimbursement  acknowledges the  time  facilitation  and  administration costs of delivering  in  house activity.

Engagement Champions ask  questions so  that  when  changes  to  services  are being considered  the  views  of  local  people  can  be  taken  into  account.
Our comments

In a long-winded way they are admitting the payments made to “engagement champions”.

It  is  not  best,  or common,  practice  to  pay  organisations  for quantities  of  surveys   completed.  Such  organisations  should  be  encouraging  patient  involvement  within   their  role  as  service  providers and  within  their  ethos  as  community  interest  bodies.
It  is  not  best, or common,  practice  to  make  payments  to  volunteer Engagement Champions,  unless  they  take  up strategic representative roles requiring specific skills.

See NHS England’s policy on this.

There  are  Employment Law implications for paying volunteers,  minimum  wage etc., and  payment  is  counted  as  income  for  tax and  benefit purposes. CCGs  are obliged to  inform  people  about  these  implications.

Such  payments  to  individuals affect their independence  which  is  the reason  that  the  making  of  payments  needs  to  be  according  to procedures  that  are  in  the  public  domain.

If  the  CCGs  are doing this  payment for engagement they are compromising the validity of the process and are taking action that has serious legal implications.

It is true that pre-consultation engagement was reported to the August 2015 Joint Health Scrutiny Committee meeting. But the CCGs do not admit that at that meeting, the engagement officer Penny Woodhead reported that they hadn’t got round to maternity and paediatrics engagement, as the CCG had been focusing on urgent and emergency care and Care Closer to Home. She said,

“We want to do young people’s engagements with children and young people when we have done the clinical model on paediatrics and maternity.”

Cllr Elizabeth Smaje asked why the CCG wasn’t ready with the clinical model for paediatrics and complex maternity.

The Calderdale CCG Chief Officer Matt Walsh said:

“Getting to agreement on the clinical model hasn’t been straightforward. We’ve only gained some consensus in the last two weeks or so, so we haven’t yet been ready to consider paediatrics and maternity.”

Question 27

Some if not all of these groups are also serving the Clinical Commissioning Groups as “community assets” aka “community engagement champions”. Their role now is to act as a mouthpiece for the Clinical Commissioning Groups and to encourage people to respond positively to the consultation. This seems entirely unethical. At least one member of the public has complained to the Consultation Institute about inappropriate social media messages that include downright disinformation about the hospital cuts proposals provided by one of these “community assets” and rude dismissals of members of the public who have questioned the false information that the community asset has put on their fb page. We need you to explain: how and whether you monitor the accuracy of the information put out by your communuity assets and the ways in which they communicate with the public; and how you justify the ethics of paying cash strapped voluntary organisations to be your mouthpiece.

CCGs’ answer

Please  see  the answer above in  relation  to  the  use  of  Community   Asserts.

We  do  not agree  that  they  act  as  a  mouthpiece  for  the  CCGs.

We  are aware of the  complaint  that  has  been  submitted  to  the   Consultation  Institute and we  have  agreed with the  individual  that  this will be dealt with through the CCG’s complaints process.

Our comments

It  is  not  what  the  Community  Engagement  Champions are and actually  do that  is the  issue here. It  is  how  their role is  perceived  by the patients,  carers  and  the public.

E.g.  Most  Healthwatch  groups  around  the  country are seen as ‘mouthpieces’ for NHS commissioners  and  providers  by  the   general  population.
One  reason  being  that  most are run  by   organisations  with  limited understanding,   or proven  track  record,  in engagement,  involvement  and participation. It doesn’t help that under the terms of the 2012 Health and Social Care Act, that created them, they are not allowed to criticise government policy.

Independence,  accountability  to  the   participants  and  an ability  to challenge  are   essential  to  engagement facilitation.

The  answers  to  questions  so  far,  and  the  clear  difference  between the engagement claims and the  substantial  public  opposition to the proposals demonstrate  that  the CCGs  are  not  tuned  in to  the  general  feeling  of the population  they  serve.
Question 28

It is unclear from the Consultation Document that the CCGs have properly considered alternatives to the Right Care Right Time Right Place proposals. We need full access to all relevant papers concerning the consideration of all alternatives. The lack of disclosure of all the documents relating to all the alternatives the CCGs considered makes it impossible to see if there’s anything in the other options you’ve rejected that shows you’ve made the wrong decision, or if there’s an alternative that deserves to be considered that is worth raising.

CCGs’ answer

The  consideration  of  alternatives  is  set out  in  the  Pre-Consultation   Business  Case. We do not  agree  that  there  has  been  a  lack  of   disclosure.

Our comments

Denial, simply relying on the options table in the Pre-Consultation   Business  Case.

It  is  unclear  from  the  Pre-Consultation  Business  Case  that  the CCGs have properly   considered  alternatives to the  Right  Care  Right  Time Right Place  proposals.   We  need full  access  to all  relevant  papers  concerning the  consideration  of  all  alternatives.  The lack  of  disclosure  of   all the documents  relating  to  all  the alternatives  the  CCGs considered makes  it impossible to see if there’s anything in the other options they’ve rejected that shows they’ve made the wrong decision, or if there’s an alternative that deserves  to  be considered  that  is  worth  raising.

One of us asked for the planning data the CCGs used for the Right Care Right Time Right Place proposals, received an extremely vague and useless reply and has asked again for the planning data.

Again it  is how  people  are  perceived  by  the  public.  People  see  the CCGs’ leaders as really enthusiastic  in  their  belief  that the proposals are the right thing to do. However, this comes across as having closed  minds  and being led by  national   policies,  (as  stated repeatedly  in  the   Clinical Senate  (Hospital)  Review.)

Have there  been any blank sheet discussions  with  staff,  patients  or  the public?
Question 29

As far as we can see, the Consultation Document doesn’t say anything about the extra 10,071.86 hours/year of ambulance journeys that would result from the closure of Huddersfield and Dewsbury A&Es. We need to know what assessment has been made of whether YAS can cope with this. And if no assessment has been made, we need you to make one well before the consultation period ends. Otherwise, how can the public comment on whether or not they agree with your proposals, or comment on how these proposals will affect us? We also need to know how this figure was calculated, on the basis of what assumptions.

CCGs answer

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

The assessment of  additional  ambulance  hours  is  summarised  in   the Pre-Consultation Business  Case and the  full  report  detailing   how  these figures  were  determined  is also  available  on  the   website.

YAS  NHS  Trust  has  been  fully  involved  and engaged  with  the programme and therefore fully informed of the potential  changes  within  the  local health  economy. The  subsequent  travel  analysis   was  designed  around  YAS NHS  Trust  specification  as well  as  the programme board’s requirements.

YAS  has  identified the  additional  resource  that  would  be  required   to meet  these hours  and  this  was  presented  in  public  to  the   Calderdale and  Kirklees  Joint  Health Scrutiny  committee  by  YAS  on   19th  April, 2016

Our comments

The public see the Emergency  service  at Huddersfield  as  closing,  as  it will  no  longer  be  there,  and  emergency  services  will  only  be accessible  at  Halifax.

We know where the information about additional ambulance hours is – our question was about why there is nothing about this in the Consultation Document, in terms of whether and how YAS will be able to cope. This is a major worry for the public. We know how over-stretched YAS is already.

We attended the 19 April JHSC meeting, where we learned that although the travel analysis may have been designed around YAS specifications, it does not include an analysis of the extra time ambulances may take to reach Kirklees patients, given that ambulance drift to areas near A&Es means that it will take time for ambulances to return to Kirklees – where there would be no A&Es.

See also our comments on questions 5 and 6.

Why  did  the  CCGs  not  include  a sentence  or  two  to  say  that  they will  commission these extra  hours  from  Yorkshire  Ambulance  to  account for  the extra journeys transferring  patients  etc.?

Question 30

There is no proper equality impact assessment in the Consultation Document. You need to address this.

CCGs’ answer

You referenced the  availability  of  the  published  Equality  Impact   Assessment  in Question 2 above.  The Equality  Impact Assessment is  published  as  Appendix  E  of  the Pre-Consultation  Business Case

Our comments

An Equality Impact Assessment  is not even summarised  in the  Consultation Document.  Please  see  our Q  2 comment  re  the  Public Equality Duty and Health Inequalities.

Question 31

Neither is there any adequate information about how people who rely on public transport would cope with having to travel further for planned care and to visit family and friends in either the planned care or acute/emergency care hospital. At the 19th April JHSC meeting, Neil Wallace, Bus Services Manager for West Yorkshire Combined Authority said that he had had no involvement in plans for transport between the 2 hospitals and there had been no consultation from the CCGs on the issue. The 2014 transport document by Jacobs identified a disproportionate effect on public transport users, but Mr Wallace said that he doesn’t know what to do to improve this because that would depend on the issues and but the CCGs haven’t consulted him, so he doesn’t know what the issues are. He wants to talk about the options, but the CCGs need to talk about where the money would come from. We think the CCGs need to explain these facts to the public and say if they have money to commission bus services to improve travel for people who will have to travel further to hospital using public transport and if so, how much.

CCGs’ answer

The  Travel  analysis  has  been published  on the  programme  website.  We have committed  to setting  up  a  travel  group  to  give  further   consideration to travel matters  – this  is  detailed  on  page  39  of  the consultation  document.

The  minutes  of  the  Calderdale  and  Kirklees  Joint  Health  Scrutiny   committee  on  19th April,  2016  have  not  yet  been  published.  The purpose of  Consultation  is  to  provide the  opportunity  for   people  and organisations  to  contribute  their  views.  This includes  the  West Yorkshire  Combined  Authority.

Additionally,  the  West  Yorkshire  Combined  Authority  is  launching  a 12 week  public consultation  on  23rd  May  in  relation  to  their  Bus   Strategy.  We  will  feed  into  that work.

Our comments

The  key  points  raised  in  the  question  have   not  been  addressed.

Are  you  including specific  patient  representatives  in  the  travel  group, e.g.  people with  sight or  hearing  loss,  mobility   problems  etc.?

It  would  be helpful  to  clearly  name,  in  the   consultation  document, the  travel   documents  on  the  website.

Question 32

The Consultation Document (p 20) talks about people’s worries about travelling further to A&E and says that the average ambulance journey time to the “Emergency Centre” at Calderdale Royal Hospital would be 6.48 minutes longer than the current average ambulance journey time to A&Es at both hospitals. This is misleading. For people in Calderdale, the average ambulance journey time would stay the same – not increase by 6.48 minutes. So since roughly equal numbers of patients travelling by ambulance to A&E in both areas, this would means that for Kirklees people, the average increase in ambulance journey times would be 13 minutes. The Consultation Document misinformation needs to be corrected.

CCGs’ answer

We  do  not  agree  that  the  consultation document  is  misleading.

The  document  states  that:  We understand that  some  people  are   worried about  the extra travelling time if they need to  go  to   hospital  as an  emergency.

We have had  some independent analysis done of ambulance journeys over a  12 month  period.

This shows  that  the  average  journey  time  now  for  patients  being   taken by ambulance  to  their  local  A&E  departments  is  15.94   minutes.

For a  single  Emergency  Centre  at  CRH  the  average  journey  time   would be  22.13 minutes  compared  to  21.51  minutes  if  the   Emergency  Centre was  at  HRI.

Although  the  ambulance  journey  is  a  little  longer,  all  of  the   specialist  services needed  would  be  available  at  the Emergency Centre at CRH,  which  would  give patients  a  better  chance  of  a   good recovery.

Travelling  to the  Emergency  Centre  is  the  same  as  happens  now  for   patients  who need  specialist  care  because  they  have  had  a  heart   attack  and  need  to  be  taken  to Leeds  or  very  serious  burns  and   need  to  be  taken  to  Wakefield.  (The  travel  analysis is  available  at www.rightcaretimeplace.co.uk).
Our comments

Denial of the validity of our question and refusal to address our points.

Please  read this question  (Q  32.)  and  the  comments  we made  at  Q 5.

Both  Q  32,  and  our  comments   made  at  Q  5,  explain  that  the  use of ‘average’ journey times in these  circumstances  has  no  relevance  and  is meaningless.
Question 33

Further, by only reporting average journey time, the Consultation Document avoids telling people in the most remote parts of Kirklees what their actual ambulance travel time would be. The Consultation Document should report actual distances and ambulance journey times to the proposed Emergency Centre from the main towns and villages in Kirklees.

CCGs answer

It  is  not  possible  to  tell  people  what  their  actual  journey  time   would  be.  The ambulance  takes the  most  direct  route  to  the  most   appropriate  place  depending  on the  care  needed and  the  state  of  the roads  at  the  time  the  journey  is  made.  For example,  as  per  current arrangements,  people  with  serious   multiple  injuries,  heart attacks  or burns  would  go  to  a  specialist   emergency  centre,  such  as  Leeds  or Wakefield.

In  addition,  the  most  important  time  is  the  time  taken  for  the  ambulance  to  reach the  patient.  The  ambulance  staff  will  then   spend time  stabilising  the  patient  and then  taking  them  to  the place where the  required  specialism  is  in  place  to  provide the required  care.

Our comments

The  answer  describes  a  few  scenarios,  it  would  be  a  simple  task  to give  journey   times  for  these,  and  at  different  times  e.g.  early hours  and  peak  commuting  times.

As already mentioned in question 29, the travel analysis does not include estimates of the extra time ambulances may take to reach Kirklees patients, given that ambulances drift to areas near A&Es means and it will take time for ambulances to return to Kirklees – where there would be no A&Es. This is worrying, since the CCGs say that the  most  important time  is  the  time taken  for  the   ambulance  to  reach  the  patient.
Question 34

The Consultation Document (p6) makes the inaccurate claim that the proposed hospital clinical model would close the financial gap that the system is facing. We know from what Monitor told the Joint Health Scrutiny Committee, that although the proposed changes would reduce the “financial gap”, CHFT would still be £9.3m in deficit by 2020/21, when the proposed changes would have been implemented. And the Consultation Document says on p 12 that in the five years following the changes, if CRH were chosen as the Emergency Centre, the cumulative deficit at CHFT would increase by £47.5m. This gives the lie to the p6 claim that the proposed changes would close the financial gap – £47.5m is rather a large financial gap. Please explain to the public that while these proposals may narrow the financial gap the system is facing, it will not close it for at least a decade from now.

CCGs answer

The  claim  on  Page  6  of  the  Consultation  Document  is  accurate.  It states that: “That these developments would cost more than £291m but would generate efficiencies to close the financial gap the system is facing.’

The  breakdown of these costs  is  provided  on  page  8  and  9  which  clearly  state:     ‘The local savings challenge across the NHS in Calderdale and Greater  Huddersfield  is  forecast  to  be  £270m  by  2020.  This  is   broken  down  as  follows:
CCGs’ financial gap £60m
Calderdale  and  Huddersfield  NHS  FT  £193m
Other  providers  £17m

Such  significant savings  can  only  be  made  by  designing  and implementing major changes  to  services  and  patient  pathways.  Without  change  our local  NHS  would  not be  financially  sustainable  in  the  future  and  the Trust  would  have  an  underlying deficit  of  £27.5m  (despite  having  made the  required  efficiency  savings  of  £75m, most of  which  relate  to services  commissioned  from  the  Trust  by  our  two  CCGs).

To bring  about  the  level  of  change  needed  would  require  some   considerable  investment.  We  would be seeking  funding support from  HM Treasury  of  £291m to  redevelop  CRH  and  build  a  new   hospital  on  the Acre Mills  site  at  Huddersfield.

In  addition  we are seeking  £179m  from  HM  Treasury to  support the hospital  deficit position. Our  proposed  changes  cannot  go ahead if we don’t get the money from HM Treasury.

And  on  page  12  we  state:   ‘While money raised in the way at HRI would not cover the cost  of  the  investment  needed  for  both  hospitals  going forward  it  would   mean  we were  better  placed  to  seek  the  additional funding  that   would  be  needed.  This  would help  us  to  invest  in  both hospitals  so  that  CRH  could  be  further  developed  to become  the  state of  the   art  Emergency  Centre  and  the  Acre  Mills  site  at Huddersfield  developed  to  become  a  state  of  the  art  planned  care  hospital.

‘The total funding required, including the funding to develop CRH as  the Emergency Centre  would  be  £470m,  compared  to  £501m  if   we  were  to develop  HRI  to  be  the Emergency  Centre.  These  figures   (£470m  and £501m)  include  £179m  that  is  needed to  support  the   hospital  deficit position. In  the  five  years  following  the  changes,  if   CRH  were chosen as  the  Emergency  Centre  the  cumulative  deficit   at  Calderdale  and Huddersfield  NHS  Foundation  Trust  would   increase  by  £47.5m,  if  HRI were  chosen the  cumulative  deficit  would increase by £108m’

Our comments

Why  does  the  answer  just  repeat  the  extracts  from  the  consultation   document  that the  question  describes   as  misleading,  but  not  address the main  point  made  in  the question?

Why  cannot  the  CCGs  change  one  word  to  be  more  honest  i.e.  change ‘close’ to ‘reduce’?

(It  has to be  said,  throughout  the CCGs’ response,  the  suggested answers given have refused  to  use  the word ‘close’ in another  context.)

Question 35

At the Hebden Bridge consultation drop in, Dr Alan Brook told a member of the public that CHFT expected to go into surplus at some point after the whole Care Closer to Home scheme had kicked in. Please provide the modelling for this expectation and show when the surplus is expected to occur.

CCGs’ answer

Dr  Brook  cannot  remember  the  exact  details  of  the  conversation  but it was  a conversation  which explained  that  the  financial   projections  are based  on  current activity  but  when  we  succeed   moving  Care  Closer  to Home  then  the  numbers should look  even  better.

Our comments

Is this a retraction? Their reply is hopeful but without evidence.
Question 36

The Consultation Document says that “These proposed changes would secure the future of health services for both areas for the next 20 years.” But according to Monitor, it isn’t true that the proposed changes would secure the future of health services for both areas for the next 20 years. Monitor told the Joint Health Scrutiny Committee on 9 March that “Running a £9.5m deficit/year that can’t be funded by the Trust or the Clinical Commissioning Group, that’s not a sustainable position.” And that at the end of the 5 year period of the proposed hospital cuts and changes, the hospitals Trust will: “obviously be unsustainable in the longer term unless the government changes its funding policy.” The Monitor rep continued, “We’re heading into an unprecedented phase of the NHS, with many Trusts going into deficit this year. We’re looking at wider footprints now than individual Trusts.” We need the CCGs to spell out Monitor’s warning that these proposed changes won’t secure the future of health services for both areas for the next 20 years, and your reaction to it.

CCGs’ answer

The  £9.5m  deficit/year – is  outlined  in the Consultation document on Page 12 – where it is  stated  as  a  cumulative  deficit  (i.e.  5  x  9.5):

The  total  funding  required,  including  the funding  to  develop  CRH  as  the  Emergency Centre  would  be  £470m,  compared  to  £501m if we were to develop  HRI  to  be  the Emergency  Centre.  These  figures   (£470m  and £501m)  include  £179m  that  is  needed  to  support  the   hospital  deficit position.  In  the  five  years  following  the  changes,  if   CRH  were chosen  as  the  Emergency  Centre  the  cumulative  deficit   at  Calderdale and Huddersfield  NHS  Foundation  Trust  would   increase  by  £47.5m,  if HRI were  chosen the  cumulative  deficit   would  increase  by  £108m.

The  full  meeting  of  the  Calderdale  and  Kirklees  Joint  Health  Scrutiny Committee, outlined the full extent of Monitor’s comments  is  available  as  a webcast  here:   http://www.kirklees.public-i.tv/core/portal/webcast_interactive/215866/start_time/3000

Our comments

The  answer  does  not  address  the   question,  again.

Monitor  clearly  states  that  carrying  an  annual  deficit that  cannot  be funded  is   unsustainable.

The  answer  does  not  comment  on  this.

Monitor  goes  on  to  say  that  after  all  the  changes,  the  hospital Trust  will  be   unsustainable  in  the  longer  term unless  the  government changes  its  funding  policy.

The  answer  does  not  comment  on  this.

Question 37

Monitor’s comment about “looking at wider footprints than individual Trusts” seems to be a reference to Sustainability and Transformation Plans. The CCGs need to explain these Plans to the public as part of this Consultation, since they are going to determine the future of our local services. The implications for the likely future of our hospitals need clarifying – particularly the implications of the fact that each STP “footprint” will have to make sure that the sum of plans for individual areas stick within the allocated budget – meaning it will not be possible for a “footprint” go into deficit. Given that the hospital cuts proposals will not return the Hospitals Trust into the black even by 2025/6 (when a cumulative deficit of £47.5m is predicted), this surely has to put a question mark over whether the proposed hospital clinical model will be acceptable under the terms of the STP; and if it is, what other service will have to be cut to carry that £47.5m deficit – let alone the current deficit. The CCGs need to explain this to the public.

CCGs’ answer

We  cannot  answer on  behalf  of Monitor  or  speculate  on  what  they   were thinking  at the  time  they  made  their  comments.

In relation to Strategic  Transformation  plans  (STPs),  we  can  confirm that the  CCGs are  closely  involved  in  the  conversation  and   planning  in relation  to  STPs.
This  is  a parallel process  to these  proposals  and  the  CCGs  are  briefing  in  public  at their Governing  Bodies  and  Health  and  Wellbeing Boards as  those plans  become  clearer.

Our comments

Are the  CCGs  making  arrangements  for  the   patients,  carers  and  members of  the public  in  the  populations they  serve  to  be  involved  in  the drawing  up  of  the  STP  for  the West Yorks and Harrogate ‘footprint’ the two CCGs belong to?

CCGs  have  a  legal  responsibility  to  involve   the  people  they  provide  services  for  in the   commissioning  of  those  services.

The  STP  will  impact  on  commissioning   decisions  that  both  CCGs  will make  in  the   near  future.

There is a  moral  duty, if not yet a legal one, for both CCGs to involve –  not just ‘brief’ – people who will be directly affected  by  the implementation of the  STP.

The inability of the STP ‘footprint’ total budget  to  go  into  deficit  is  a significant risk  to  the  implementation  of  this  proposal.

The  CCGs  need  to adjust  their  plans  to   account  for  these  new circumstances  and requirements

Question 38

Without accurate financial information, the public cannot possibly judge whether this proposal represents good value for money. But the Consultation Document doesn’t provide this. It says (p 12) that the total funding required to develop CRH as the Emergency Centre and HRI as a new planned care hospital would be £470m, and that that figure includes £179m to “support the hospital deficit position.” So £179m of the “financial gap” reduction would come from outside funding – not from any “efficiencies” generated by the proposed hospital clinical model. £291m would be needed to cover the capital costs of the hospital changes (Consultation Document p 6).

The Consultation Document is vague about the sources of finance for the £470m. It says (p12) that the sale of either the HRI main site or the Acre Mill site wouldn’t pay for the capital costs of the hospital changes, but it would make it easier to get the extra funding needed for this. The Consultation Document (p9) says that HM Treasury is the intended source of the £470m additional funding and that if this isn’t forthcoming the proposed changes can’t go ahead.

It doesn’t explain that Monitor has, with “some caveat” put in an application to the Department of Health for what it considers to be “extraordinary funding of £470m for a single Trust reconfiguration” – extraordinary in that it compares with £300m that it cost for a Northern Trust to build a whole new hospital, according to Monitor. Monitor told the Joint Health Scrutiny Committee on 9 March that the Department of Health is liaising with the Treasury and that there is no indication of the time frame “or what they’ll stomach”. What is this “extraordinary funding” from the Department of Health? There is nothing in the Consultation Document about this. And how confident are the CCGs that this funding will be forthcoming, and why?

The Pre Consultation Business Case (p97) identifies these sources of the £470m external funding:

  • loan funding to support the capital requirement
  • non-recurrent reconfiguration revenue costs funding
  • non-recurrent deficit support funding

The public needs to know on what terms and conditions the Department of Health would provide “extraordinary funding”. Is it from a loan and/or Public Dividend Capital? https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/365134/SofS_Finance_Guidance_under_Section_42A.pdf

What is the rate of interest and how long would it take to repay the loan and interest charges?

At the Halifax public consultation drop in, Owen Williams said there are 3 potential funding sources:

  • A capital pot between the DoH and the Treasury, which would require repayments
  • The DoH/Treasury could give CHFT a borrowing limit to get the loan on the commercial market and the DoH would pay the interest
  • PFI 2 – could be required to go down that route.

The CCGs need to provide clear, accurate financial information that makes sense.

CCGs’ answer

We  cannot  answer  on  behalf  of  Monitor or  speculate  on  what  they  were thinking  at the time they  made  their  comments.

In  relation  to  Strategic  Transformation  plans  (STPs),  we  can  confirm that  the  CCGs are  closely  involved  in  the  conversation  and  planning in relation  to  STPs.  This  is  a parallel  process  to  these  proposals  and the  CCGs  are  briefing  in  public  at  their Governing  Bodies  and  Health and  Wellbeing  Boards  as  those  plans  become  clearer.

The  financial  information is as  accurate  as  it  can  be  at  this  stage. As  detailed  above, the  purpose  of  these  proposals  is  to  save  more   lives,  keep  people  healthy,  make services safer and improve  quality  of care.

The  Consultation Document  is  clear  that  the  bid  for  additional  funding includes £179m  to  support  the  hospital  deficit  position.  The  remainder of  the  £470m  would be  used to  implement to  arrangements  proposed  as part  of  this consultation.

As  referenced  earlier,  we  believe  that  the  proposed  clinical  model, that  we  are proposing  would  configure  services  in  a  way  that   would enable  us  to  generate efficiencies  to  close  the  financial  gap.
CHFT  have submitted  to  the  Department  of  Health,  what  we  believe  to be the best case for financial  support, in that it would provide the least expensive way to deliver  the  requirements  of  our   clinical  model.

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

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

The further  detail  in  relation  to  the  terms  and conditions  provided  by the Department  of  Health  is  not  known  at  this  stage.

Our comments

It is pretty incredible that the CCGs sat through a meeting and don’t know what Monitor meant by what they said at the meeting. Do you expect us to believe that you can’t speculate on what they meant? Surely a failure to find out what Monitor meant is negligence of your duties. If you didn’t understand what Monitor meant, you should have asked them.

Why  are  the  CCGs  not advocating the involvement of  patients  and  the public  in   the STP, rather than just ‘briefing‘ them?

The financial  information  given  presents  a  very weak  case  for  value for  money.

The  CCGs  still  maintain  they  will  close  the  financial  gap,  not reduce it,  but this  will be by borrowing  the  money  (£179m),  not  by ‘efficiencies’.

The funding  information IS very  vague. Some simpler explanations  are needed, not just repeating the vague  statements,  yet again.

The figures  repeated in the suggested answer do not make  it  clear exactly what  the extra  £179m  is  intended to cover.
QUESTIONS END – HERE IS THE SIGN OFF TO OUR REQUEST FOR INFORMATION ABOUT CONSULTATION DOCUMENT ERRORS AND OMISSIONS

As stated above, we have an absolute commitment to assessing if the Right Care Right Time Right Place proposal is right, once we have all the information about it. We can’t do that until and unless you give us and the rest of the public full, accurate information that is currently missing from the Consultation Document.

Kind regards

Paul Cooney, Huddersfield Keep our NHS Public
Nora Everitt, Barnsley Save Our NHS
Terry Hallworth, Huddersfield Citizen
Rosemary Hedges, Calderdale 38 Degrees NHS Campaign Group
Christine Hyde, N Kirklees Support the NHS
Jenny Shepherd, Calderdale & Kirklees 999 Call for the NHS

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One comment

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

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