How is West Yorkshire and Harrogate ‘Sustainability and Transformation Plan’ going to affect Calderdale & Huddersfield hospital cuts plans?

Calderdale & Kirklees 999 Call for the NHS sent this information (below) to the Calderdale & Kirklees Joint Health Scrutiny Committee members, before their Reconciliation meeting on Monday 12th December with Calderdale and Greater Huddersfield Clinical Commissioning Groups.

The meeting was an attempt to resolve the problem that the CCGs have ignored all the Joint Health Scrutiny Committee’s recommendations on the Right Care Right Time Right Place plan to cut acute and emergency hospital services, move many outpatients and community services out of hospital into the community and set up “new models of care” for primary and community services, called “Care Closer to Home”.

If the reconciliation process is unsuccessful, the Joint Health Scrutiny Committee may refer the Right Care Right Time Right Place proposals to the Secretary of State for Health in February 2017.

The impact on Right Care Right Time Right Place of West Yorkshire & Harrogate Sustainability and Transformation Plan

It looks as if the Sustainability and Transformation Plan means Calderdale & Huddersfield hospitals Trust (CHFT) is gearing up to losing specialisms – it is rumoured that Owen WiIliams has said that any elective specialism that needs locums to run it would be closed. And a Health Service Journal reporter recently tweeted:

“NHS trusts have been told to close services that rely on locum doctors on more than £150K/year. This includes many A&E units.”

When asked if this is what CHFT is facing,  the Health Service Journal reporter replied:

“Yes that one is confirmed and has been used as an example to follow by national leaders.”

We hope that the  Joint Health Scrutiny Committee can get to the bottom of this.

There is also info in the West Yorkshire & Harrogate Sustainability and Transformation Plan (p42) that indicates “rationalisation” of acute hospital services through creation of a  “foundation group” for the hospitals in the West Yorkshire Acute Hospitals Allliance.

At the 8th Dec Calderdale CCG meeting the engagement officer Penny Woodhead said:

“There will be some conversations falling out of Healthy Futures reconfiguration [ie at West Yorkshire & Harrogate Sustainability and Transformation Plan level] that haven’t been talked about in Calderdale”.

The first part of that sentence is typically vague and coded but the second part is very clear. Taken together my guess is that she means that there are going to be service reconfigurations that will affect Calderdale but that they haven’t told Calderdale about. For whatever reason.

We hope the Joint Health Scrutiny Committee can get to the bottom of this issue of the rationalisation of acute hospital services across West Yorkshire and Harrogate.

Other impacts of the West Yorkshire & Harrogate Sustainability and Transformation Plan on the Right Care Right Time Right Place scheme emerged at the Calderdale Clinical Commissioning Group Governing Body meeting on Dec 8th.

It seems that Calderdale Clinical Commissioning Group is now in dire straits.

The Chief Officer said resistance and suspicion of Sustainability and Transformation Plans nationally is based on fairly solid ground. There needs to be a conversation about working within resources allocated by Parliament. It’s not happening at the West Yorkshire level, but they have tried in Calderdale.

His concern is: how will all this be stitched together nationally when the answer comes back – eg about capital ask?   West Yorkshire & Harrogate Sustainability and Transformation Plan’s capital ask is £1bn – multiply that by 44 [the number of Sustainability and Transformation Plans across England.] “The  Country hasn’t got the money the STP is driving us to need.” He said there is a need for a  better conversation with West Yorkshire and a need to move at pace on primary and community services.

Calderdale Clinical Commissioning Group Governing Body say the Right Care Right Time Right Place and Care Closer to Home schemes have put them in a “good place”  but it is “a big challenge to mitigate gaps”. Deficit-mitigating actions are “hugely challenging.”

Calderdale CCG will be in turnaround soon and “NHS England will have conversations about this.”  [My note: ie NHS England will take control and probably parachute in KPMG or another consultancy to tell them what to do- as has happened with the Vale of York CCG which NHS England put into turnaround and brought in Price Waterhouse Cooper]

After being static at 16 for 2 risk cycles,  the risk that the CCG fails to deliver the 2016/17 planned financial surplus has gone up to 20, critical. The 2016/17 financial plan includes a number of pressures/risks that will need mitigating to ensure delivery. It was reviewed and further mitigating actions are required to close the gap and a recovery plan was developed and went to the October governing body.

The forecast surplus should have been £4.6m. But facing cost pressures of £11m; there is mitigation for some of that but the CCG is reporting to NHSE a reduced surplus of £3.7m.  Knock on effect on financial position = reduced surplus next year.

There is a huge QIPP (efficiency cuts) increase to £6.4m 2017/18 – up from £2.5m+ so far this year.

This is a challenging situation – it has brought a challenge into the contracting round due to be signed 23.12.16 [These contracts are to deliver the STP from 2017-19 – see Stop STPs Protest info here.]  If can’t achieve efficiencies,  deteriorates fast. Biggest risk is acute contract with CHFT. Overspend around £8m & other hospitals have increased too but not at same rate as CHFT.

In West Yorkshire at least 3-4 other CCGs are in similar position. Calderdale CCG is planning for breakeven if not deficit next year & overspend in acute hospital.

The CCG is working through a recovery plan. £17.5 -£10m opportunities recognised, “just up to us to take it.”

Matt Walsh said:

“We need to bring the recovery plan into the public forum and talk about how we make challenging decisions about how to use resources.”

He added that there is pressure from the regulator about investing in Primary Care and Mental Health Forward View.

[My note: This is the Vale Of York CCG’s Turnaround Action Plan – just to get an idea of what a turnaround plan does. One of the things ck999 have noticed is that a few months ago the Vale of York CCG came up with a contentious proposal to restrict access to elective care for some categories of patients, but NHS England told them they couldn’t do this. Recently Vale of York CCG again announced they are going ahead with this and NHS England hasn’t stopped them this time. This is very worrying because it shows that one of the effects of the STPs and the financial control totals they entail, is that this undermines the basic NHS principle of equal access to all approved treatments for any patient who has a clinical need for them.]

Calderdale Clinical Commissioning Group needs a new Governing Body Assurance Framework (GBAF) because the old one no longer tallies with reality.

(This is about how Calderdale Clinical Commissioning Group shows it is managing the risks it faces.)

Matt Walsh told the 8th December meeting of Calderdale CCG Governing Body that the world has changed significantly in the last 6 months. Conversations about health and change are not reflected in the GBAF. Challenges and approaches to risk mitigation are not as clear as might be about what’s not in the CCG’s gift.

The current way of listing risks and controls in the Governing Body Assurance Framework (GBAF) doesn’t work in face of new system risks & partners etc. [from the West Yorkshire Sustainability and Transformation Plan.]

Calderdale and Greater Huddersfield CCGs have now made the decision to reconfigure community and hospital services over 5 years. There are significant challenges in shifting resources and activity from hospital to community. This doesn’t come through clearly enough in GBAF.

There’s a lot of risk in the system about achieving the CCG’s statutory duties as an organisation – but the GBAF risks are a lot of green, a bit of amber and no red.

Need more depth to dive into risks and therefore what mitigations are – eg things outside CCG control, partners etc. Need more acute assessment to reflect what’s going on & what feel about it.

Risks the CCG are facing are not mitigatable – they are big strategic risks. Need to reframe assurance framework to say: what are provider risks? What about the role of regulators & what they’re imposing -social care, austerity, integration agenda? (The CCG say this is the only hope in that regard).  All these things need addressing and how to deal with them and start the conversation.

Calderdale CCG is not meeting the referral to treatment times target and doesn’t think they can afford to, because it would mean more patients to pay for.

Although the CCG isn’t meeting the referral to treatment times (RTT) target, referrals over- perform and are costing the CCG £4m. (I think that’s what the CFO said, but all this discussion was in code.)

The Chief Finance Officer definitely said if Calderdale CCG want to improve or maintain their position re RTT, they have to pay for that. RTT improvement means that people being seen more quickly can increase demand and costs.

There is a perverse incentive not to achieve the RTT target. ( I think that’s what he said.)

RTT is a constitutional requirement but they have to assess the implications – demand as system needs to be addressed.

Nigel Taylor said: Demand needs to be the right demand  in terms of looking at outcomes and quality of NHS £. [My note: this is picking up what they talked about in the Aug 2016 meeting  – cherry picking patients and restricting elective procedures.] Need to meet RTT Targets.

Vice chair Dr Cleasby said re RTT: they’ve been discussing triage systems to reduce referral to hospital – without this he can’t see how the CCG can manage demand in Calderdale.

Matt Walsh: Not interested in applying arbitrary thresholds to care, eg restrictions on smokers etc – but how to make sure elective care patients improve their health? [My note: this is what he was first saying in August – cherry picking patients who will most benefit].  There could be some interventions between GP referrals to hospitals. [My note: Is this Cleasby’s triage proposal?]

Neil Smurthwaite (Chief Finance Officer): As a CCG we can’t deliver all constitutional requirements on our own – we need to work with partners providers etc. Need to be clear with public about challenges we’re facing.

[Note: NHS Birmingham Cross City CCG put out a tender for a referral triage pilot from April 2016. This includes:

“Have mechanism to provide GPs with education/feedback which includes high quality feedback to GPs proposing a management plan that ensures that the GP can effectively care for the patient outside of a hospital as part of the requirements of the NHS GP contract, agreed shared care protocols with secondary care or through the CCG Aspiring to Clinical Excellence Scheme.”

This is surely a conflict of interest – the GPs on the Clinical Commissioning Group Governing Body are the GPs on the GP Federation who will care for patients outside of hospital and get paid for it instead of hospital getting paid for it. (But not paid so much, because it is meant to cut costs. So what care can they provide for less money?)

Also for background info on “referral management” systems:

The governance structure is not in place for the West Yorkshire & Harrogate Sustainability and Transformation Plan

The aim is to set up a joint committee arrangement between all the Clinical Commissioning Groups and the formal Memorandum Of Understanding for that, which should have come to the Calderdale Clinical Commissioning Group Governing Body meeting to discuss sign off, risks and opportunities, was not available for some reason. The Clinical Commissioning Group Governing Body needs to see it to understand what power the Clinical Commissioning Group is ceding. It will come to the Feb 2017 Governing Body meeting. This will allow time to set it up for April 2017.

There were other points too but these are the main issues we hope the JHSC will be able to get proper answers about during the reconciliation process.


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