The Clinical Commissioning Groups – who should be defending the NHS – are betraying it, and us the public, by going along with the government’s “austerity” mission to cut public spending and privatise public services. This is what the proposed hospital cuts and the replacement of hospital services by community care is about, as the second public meeting in Huddersfield on June 6th made clear.
Here is a slow news report on the justifiably angry public meeting in Huddersfield last week.
On the panel: Greater Huddersfield Clinical Commissioning Group (GHCCG) Governing Body Chair Dr Steve Ollerton. GHCCG Chief Officer Carol McKenna, Calderdale CCG Chief Officer Matt Walsh, Calderdale CCG Governing Body Chair Dr Alan Brook, Calderdale & Huddersfield Hospitals Trust (CHFT) Chief Exec Owen Williams, GHCCG Gov Body Urgent Care lead Dr David Hughes, Dr Mark Davis, CHFT A&E head honcho, Jane Middleton CHFT Nurse director, surgery and anaesthetics.
Chair Richard Horsman, Journalism lecturer, Leeds Trinity college.
Around 270 members of the public, according to CCG figures.
The CCGs had pre-selected questions that the public had sent in when booking tickets. They chose loads about travel and transport, which led to a Groundhog Day feeling. It seems this is something they’re happy to discuss – rather than the clinical models for hospital services and community health services, and the workforce implications, ie the key issues. The travel and transport issues have been endlessly rehashed and nothing new came out of this meeting about them.
Apart from travel and transport, key issues at the meeting were:
- the consultation is phony (because it’s done deal)
- NHS underfunding and what to do about it
- Calderdale Royal Hospital PFI
The public was clearly angry with the proposals, the consultation and panel members’ frequent evasiveness and lack of clarity.
The panel don’t seem to understand how vulnerable illness makes us when it hits our friends and families, how important it is to have a reliable NHS for when we are in this vulnerable position, and how central this is to our pride in ourselves as a society, that we make sure this is there for everyone.
The panel just seem to see it as some technocratic deal, and the crux of the issue is that the panel see themselves as having to make the best of the circumstances they find themselves in, as Carol McKenna said. While the public want them to tell the government to stop its under-funding of existing services and its insistence on throwing money at “new clinical models”. Clinical models that we the public can clearly see are tied into the government’s “austerity” agenda – of cutting public spending and privatising public services.
We the public feel betrayed by the Clinical Commissioning Groups’ refusal to recognise this and to stand up to the government. But this is hardly surprising in bodies that have no democratic mandate to exist, having been created by the stealth -privatising 2012 Health and Social Care Act that was not in any party’s 2010 election manifesto. The CCGs were brought into being to privatise the NHS by enforcing competitive tendering of contracts. For this reason alone we should have no confidence in them.
But Owen Williams seems to have heard and understood the public’s message – speaking of the government’s policy of withholding funding to improve existing services, while approving huge investment in “different models of care” he said:
“No one on the panel wants this, no one in the room wants it.”
But he won’t act on what the public is saying. Because he says this is a democratic country and the public needs to use democratic channels to influence the government.
On the “ done deal” issue, members of the public shouted down Dr Brook when he said,
“We haven’t heard much from the consultation that changes the fundamental argument.”
Matt Walsh said what he has said before, that “we will listen to you to some extent” – but not to the extent of calling into question the proposed clinical models for hospital services and Care Closer to Home.
He has said before that in response to consultation feedback, the CCGs may “flex the details” of the proposed new clinical models.
In response to an almost unanimous show of hands from the public, that they did not support the consultation proposals – preceded by the question, “Is this a genuine consultation?” he said:
“We will listen to you to some extent. There are some limits. The limits in relation to clinicians is that we think we can deliver something better [than the present system]. Public input will go into the business case and how this will affect our plans.”
Owen Williams said that only two trusts in the country are now without a deficit. He went on:
“The money situation is absolutely unprecedented – it’s not like it’s been before.
The people in the room want the same services with more money. People want CHFT to go back to government and ask for more money.
Money for paying for the existing model of care isn’t there.
We’ve asked for £274m capital costs in an envelope of £500m. £215m is to support CHFT though this change eg by paying staff wages etc.
That’s a big amount of money when the government has no money for existing services.
But the government has the money for different models of care.
No one on the panel wants this, no one in the room wants it.
We can’t influence the government – we’re a democratic country and there are opportunities to influence the government.”
He suggested people could do this by talking to their MP.
Matt Walsh said,
“Are we investing enough as a nation in the NHS? More should and could be forthcoming. Compared to other OECD (Organisation for Economic Co-operation and Development) countries, we are not at the same level. The panel and audience agree about this.”
Calderdale Royal Hospital PFI
Owen Williams said that CRH PFI was the main “challenge” behind the decision to make CRH the acute/emergency hospital site. In normal English, this means PFI is the reason they made this decision.
Dr Brook said that Monitor (the hospitals regulator – now NHS Improvement) has told them in no uncertain terms that the CRH PFI hospital must be fully used by the NHS.
Asked by a member of the public if the panel could provide evidence that the proposal hasn’t been based around PFI rather than human needs, Carol McKenna said:
“Owen Williams has been frank with regards to PFI.
She went on:
We have a job to do to make the best of the circumstance we find ourselves in. If we went to the Treasury to ask for HRI as the acute and emergency centre, that would be an extra £30m that has to be repaid that would come from services that are currently provided. It would mean a cut to £30m of services to deliver a service that wouldn’t be better than the current proposals.”
Here is an account of the meeting as it unfolded. (My notes are not entirely complete.)
It started with panel statements.
Ollerton: have heard many concerns about Care Closer to Home and have taken these on board. We will make sure that CC2H is ready to implement before it is implemented.
Dr Hughes: We are consulting on emergency and acute services – an entirely new model of providing urgent and emergency care. At least 60% of patients who currently go to A&E will go to urgent care centres. He presented the proposals for:
- acute and emergency care
- planned care
- maternity services
- community services.
At this point he said
“We are in the early stages of the Care Closer to Home debate”.
There was general uproar and shouts of
Dr Hughes aroused more wrath by saying:
“You won’t find a better advocate for the NHS than me.”
He ignored the Locala issue – that Greater Huddersfield CCG has their Care Closer to Home contract in improvement measures because of Locala’s failure to answer calls to the Single Point of Contact quickly enough.
Carol McKenna said the public had asked why the CCGs are only consulting on one option.
She said they started with the clinical model.
She didn’t say that they started with NHS England’s Right Care Right Time Right Place template.
She said that key issues that the public were questioning through the consultation process are:
- Emergency Centre location
- The CCGs have already decided what they’re doing (predetermination)
- Potential options
and a couple of others that I missed.
What about the substantial public opposition to the entire proposed clinical model for hospital services, that includes moving services out of hospital into the community?
1. What if you don’t get the £500m for the hospital development and deficit support?
Carol McKenna: Without the money couldn’t progress with capital changes. CHFT would have to look for any alternative means of funding.
(Like what? She didn’t say.)
2. What is the sequence of development?
If decide to go ahead there will be a full business case with all the steps. Haven’t yet done order of how they will proceed.
3. Dr Brook was on Liz Green’s BBC Radio Leeds programme this morning saying it’s a done deal.
Dr Brook: The CCGs won’t decide until October. We haven’t heard much from the consultation that changes the fundamental….AUDIENCE shouted him down.
Don’t tell us you haven’t heard anything that undermines your argument. Is this genuinely a consultation?
Member of public:
Come on Judas.
Another member of public:
- A consultation is two-way, if you’re listening to us. Will people please put their hand up if you agree with these proposals?
About 4 people put their hands up.
That’s a fair question. We will listen to you to some extent. There are some limits. The limits in relation to clinicians is that we think we can deliver something better [than the present system]. Public input will go into the business case and how this will affect our plans.
4. Natalie Ratcliffe: You’ve not consulted with front line staff.
Dr Ollerton: On the back of surgical colleagues, have been to meetings with them in the last 2 weeks on the basis of what’s come up in the consultation.
5. Question about the increased risk of death due to increased distances to A&E
Dr Ollerton: We have heard this many times before. More than 50% of A&E patients can be seen by urgent care centres. We have involved Yorkshire Ambulance Service in many conversations. Calderdale Council is investing £millions in improving roads.
6. What about getting patients to A&E in busy traffic hours?
Mark Davis: Ambulances get from Huddersfield to Halifax faster than by car. Emergency care begins the moment the ambulance gets to patient. Care in A&E isn’t as good as it could be.
Member of public: Tell the government to address the underfunding.
Another member of public: Improve them both.
How about people being able to visit patients in more distant hospital?
Member of public: A family member was told they can’t go on the shuttle bus, that it was for staff. The shuttle bus is crap.
Jane Middleton: Planning to set up travel group for people to resolve these problems.
Member of public: Need to sort it now.
7. How will there be prompt access to the Emergency Centre from places like Denby Dale etc
Dr Brook: It will increase average travel time by a small amount. Most important thing is the time the ambulance takes to get to the patient.
Andy Simpson,Yorkshire Ambulance Service: The panel is right – we have advanced/specialist/critical care paramedics, all trained to deliver care in ambulance. Elland Road is a bottleneck but a blue light ambulance doesn’t have a problem negotiating it.
8. The travel analysis in a theoretical model, wouldn’t it be good to test it with actual journey times?
Carol McKenna: The modelling was validated with actual 12 months real ambulance journeys.
Member of public: It took an ambulance 1 hour to reach her then 1.5 hours to get to A&E. Another time when she was in labour it took 1 hour 40 minutes to travel 6 miles (not in ambulance).
Member of public: There is no independent study. We need one.
Carol McKenna: The studies have been commissioned from independent consultants. Have recently commissioned another study to see how these proposals overlap with Mid Yorkshire Trust.
Chair asked YAS if they’re confident they can deliver the extra 10K ambulance journey hours/year.
YAS said it would need 10 extra staff and 2 extra ambulances.
Someone said there are variable times that ambulance takes to get to patient in same location on different occasions. Need better data.
Owen Williams: People have raised good points. It’s not just patients who are travelling but also families and friends. We have to take that on board and come up with some good responses.
Dr Ollerton: Still a lot of work with these proposed changes, will have a travel working group. Have to make sure that whatever we propose in future, travel has to be safe and we will make sure it is.
9. Will YAS have enough paramedics and vehicles to cope?
Dr Hughes: Looking at extra 10K ambulance journey hours/year – ie 33 hours/day. Significant amount.
Doing lot of work with YAS to reduce the numbers of patients who go to A&E but don’t need to go there. 30% of patients transported by ambulance leave A&E without treatment. Working to increase treatment of patients in home by YAS.
10. Member of public: Can you on panel guarantee that no one will die as a result of increased distances to A&E?
Mark Davis: No but I can guarantee that when you get there the service will be better.
Members of public: Lots of shouting “It’s underfunded”
11. Member of public: I have some sympathy with benefits of scale. But consultation should happen when plans are at formative stage, not on something on which the clinicians have a decided view.
YAS increased costs are not included in the CHFT costings – the total costs to the taxpayer haven’t been considered. Extreme journeys have been excluded from the travel analysis docs. By his calculations, having the single A&E at HRI requires 50% less ambulance time than A&E at CRH. So how can you justify this?
And what about urology? I thought all planned care was to be in Huddersfield but the consultation doc says urology will be at CRH. – Owen Williams said: If there is lack of clarity about which services are in which hospital, let him know.
Owen WIlliams: We won’t know some of the extra YAS requirements until it happens. We have some work to do on this, including the CCGs. He went on:
There have been questions about poor management and I should answer them.
Only two trusts in the country are now without a deficit. The money situation is absolutely unprecedented – it’s not like it’s been before.
The people in the room want the same services with more money. People want CHFT to go back to government and ask for more money. Money for paying for existing model of care isn’t there.
We’ve asked for £274m capital costs in an envelope of £500m. £215m it is to support CHFT though this change eg by paying staff wages etc.
As an example, Smethwick hospital is spending £370m of a 674 bed hospital and has more than £500m funding overall.
That’s funded by PFI 2.
That’s a big amount of money when the government has no money for existing services. But the government has the money for different models of care.
No one on the panel wants this, no one in the room wants it.
As for, this is a “done deal”: I’ve been face to face with front line colleagues talking about this. We have to come to changes but I don’t think your input will be ignored.
Members of the public raised “Bullshit warning” signs and shouted:
Address the underfunding.
Owen Williams: We can’t influence the government – we’re a democratic country and there are opportunities to influence the government, eg by talking to your MPs.
12. Member of the public: CRH PFI takes 10% of Calderdale CCG’s annual budget.
Owen Williams: There are 3 routes to the funding we need:
- direct loan from Treasury/DoH
- permission to borrow on commercial market
- PFI 2
Public shouts: No there won’t
13. Member of public: Why should A&E transfer to Halifax with a smaller population than Huddersfield?
Owen Williams: We’re trying to develop a different way of providing A&E. The Trust boundaries cover 210k population in Calderdale CCG area and 250K population in Greater Huddersfield CCG area. CHFT serves that populace.
We’re proposing a new different model of care, with urgent care centres to deal with at least 54% of what currently goes to A&E. If it’s an emergency that turns up at Urgent care centre, there has to be a protocol to transfer patients to the Emergency centre.
Questioner: You didn’t answer my question.
Owen Williams: The fundamental challenge is PFI. Whatever decision was made in the past, we have to deal with it.
14. Without planned care beds open to being turned into emergency beds, how will the acute and emergency hospital cope when there are loads of extra patients and can’t can’t planned care?
Jane Middleton: This happens every single day. We have to look at doing things differently so there are not so many people coming to hospital, eg through Care Closer to Home.
With locum doctors in A&E there is a greater influx of emergency admissions because the locums don’t know what services are available in the community so they are risk averse and don’t want to send patients home.
[Ed: Duh, why don’t they give locums a list of services available in community?]
15. The CCGs have admitted that the impact will be greater on vulnerable and poor groups so what are they going to do about this?
Dr Brook: Nothing here will impact very much on any groups. Care Closer to Home will benefit vulnerable groups more. I believe we are addressing the needs of all groups.
16. Care Closer to Home will rely on charities so why put a strain on them that are already at breaking point?
Dr Brook’s answer missed the point.
17. Unison rep for Calderdale & Huddersfield Natalie Ratcliffe: There’s been no real formal consultation with front line staff. Don’t their views matter?
Dr Mark Davis: All consultants were invited to be part of the engagement. Every member of staff has been invited to drop in sessions and I’ve addressed those meetings.
Dr Brook: Monitor has told us in no uncertain terms that the CRH PFI hospital must be fully used by the NHS. Centralising everything in a new hospital wouldn’t be funded.
18. Member of public: Can evidence be provided by the panel that the proposal hasn’t been based around PFI rather than human needs?
Owen Williams has been frank with regards to PFI.
We have a job to do to make the best of the circumstance we find ourselves in. If we went to the Treasury to ask for HRI as the acute and emergency centre, that would be an extra £30m that has to be repaid that would come from services that are currently provided. It would mean a cut to £30m of services to deliver a service that wouldn’t be better than the current proposals.
Member of public:
But you own HRI. Sell that site and it’s gone.
There’s a significant maintenance backlog in the state of the building at this time.
Members of public:
Good point. There’s been Board commitment to get what investment that we can into HRI eg fire safety etc.
If we don’t use CRH, the PFI “mortgage payment” is £10m/year until 2060. CHFT/DoH own some of the site. Government is demanding that estates/assets come under central control. We are balancing competing demands.
19. Lots of figures are bandied about. How much is the entire project going to cost, including Care Closer to Home and Yorkshire Ambulance Service costs for the extra journeys? What’s the contingency plan for when this proposal busts the budget?
Matt Walsh: the high level numbers are £270m capital funding for hospitals estate, £200m to reduce the deficit.
There is more detailed work to do for the final business case to address a big challenge -that this won’t close the deficit.
We will have to map out extra capacity in YAS including staffing.
This ask is alongside the CCGs’ allocation to purchase services of approx £300m/year.
Are we investing enough as a nation in the NHS – more should and could be forthcoming. Compared to other OECD (Organisation for Economic Co-operation and Development) countries, we are not at the same level. The panel and audience agree about this.
We are designing how we use that money, including redirecting it to Care Closer to Home, investing in community services. Final business case will have figures.
Re contingency plan – no determination about cutting services.
Member of public: How many less nurses?
Matt Walsh: will have to redesign workforce and take nurses out of hospital into community care.
Member of public: How can we give you feedback on something that looks like a finger in the wind?
Matt Walsh: it’s not a finger in the wind.
Member of public: Surprised that there’s no contingency plan for bust budget. The mood of this meeting will carry on and you will face angry public if you have to come back and say you’re going to cut services.
20. It doesn’t look as if Care Closer to Home will be available for Huddersfield people.
Dr Hughes: This new model of care will increase spending on Care Closer to Home. The Care Closer to Home contract with Locala is an enormous project and just Phase 1.
Other workstreams will look at Care Closer to Home where appropriate. Some of what’s needed is money, some is staffing. In regard to Unison’s question – it’s disgraceful that staff are working for minimum wage on zero hours contracts.
21. 1,000-3,000pharmacists across the UK are going to close. Then there is NHS 111 and GPs – but people will go to A&E only out of frustration, because they can’t get GP appointments. How and why will you bring blood tests and x rays into community?
Dr Ollerton – not intending to move X rays out of hospital. But blood tests in community will come in as costs come down.
Re pharmacies – his surgery has brought in pharmacist to do some work that GPs do. Pharmacists will be used fully in new system.
Member of public: Don’t think you’ve answered question. People are turning up to A&E because of panic because there’s no clarity about where to turn in community for advice. Services of district nurses and home care are difficult to arrange. My question was: how is this going to be rectified? And how will we know when this has been done.
A: CCGs will measure it, it will be fed to Board by GP practices who can report it to CCGs.
Re Key Performance Indicators that Locala has to fulfill – when the Care Closer to Home contract first started it was far from ideal but it’s now better than it was 6 months ago.
Member of public: fragmented NHS is cause of this problem.
The meeting ended without this being addressed.
About 2/3s of the way through the meeting, Natalie Ratcliffe called on everyone to walk out. About a third to half of those present did.