The papers for the Calderdale and Huddersfield NHS Foundation Trust meeting show the toll taken from the hopsitals by government under-funding and the top-down Sustainability and Transformation Plan redisorganisation imposed by the government’s quangos.
“Extreme risks” that the hospital cuts reconfiguration will not go ahead (because of health and social care partners’ inability to agree a way forward) and the “very likely” failure to deliver the 2017/18 financial plan (due to inability to carry out the Cost Improvement Programme – ie spending cuts), mean that if these risks aren’t averted, it is “highly likely” that the Trust will:
- not be able to deliver safe and effective high quality care and experience for patients
- have reduced activity and increased expenditure on additional capacity
- low staff morale.
- face compromised viability and competitiveness
There is a “likely” risk that the Trust will not achieve full compliance with NHS Improvement over its 5 Year Strategic Plan, which would bring
- Risk of further regulatory action
- Reputation damage
- Financial sustainability
The Trust also risks failing to achieve local and national performance targets and levels required for Sustainability and Transformation Funding. The impacts of this would be:
- Poor quality of care and treatment
- Poor patient experience
- Regulatory action
- Reputational damage with stakeholders
- Sustainability and Transformation Funding withheld and financial issues
What are the Sustainability and Transformation Fund standards? And why has the Trust failed to put in place controls / systems for performance against these standards? (Info from Board Assurance Framework, p 115)
To top it all, the Board papers show that the hospital cuts Full Business Case has not been signed off internally or by NHS Improvement. This not only makes it impossible for the Joint Health Scrutiny Committee to decided whether or not to refer the proposals to the Secretary of State, it is a cause of many of the extreme and highly likely risks.
Here are some of the key things that we need to find out from the 6th July Calderdale and Huddersfield NHS Foundation Trust Board Meeting.
Sign off of Right Care Right Time Right Place (hospital cuts) Full Business Case
Has the Right Care Right Time Right Place Full Business Case now been signed off by the hospitals Trust? (It hadn’t when the papers for the meeting were published)
Has Calderdale and Huddersfield NHS Foundation Trust now received clarification from NHS Improvement about their sign off process for the Full Business Case? If not, why not? And if so, has NHS Improvement now signed it off – and if not, when will it?
Has the Treasury signed off the Full Business Case? If not, why and when is it going to?
Have Calderdale and Huddersfield NHS Foundation Trust and the two Clinical Commissioning Groups sent their responses to Calderdale & Kirklees Joint Health Scrutiny Committee’s 19 recommendations?
Has Calderdale and Huddersfield NHS Foundation Trust sent the Full Business Case to Calderdale & Kirklees Joint Health Scrutiny Committee? (They had previously told the Committee this would contain most of the answers to the 19 recommendations.)
What other papers and information has the Trust sent to the Joint Health Scrutiny Committee, to enable it to properly scrutinise and contextualise the Full Business Case? (These additional documents were listed by the Clinical Commissioning Groups and Calderdale and Huddersfield NHS Foundation Trust in their report to the Feb 23rd meeting as:
- Update of the Benefits and Outcomes in line with any updated clinical standards and any changes to the proposed model.
- Update of the Ambulance Travel Analysis
- Activity modelling for Community Services
- Update of Integrated Quality Impact Assessment across hospital and community
- Update of the Public Travel Analysis
In addition, the Reconciliation consultant advised that the Joint Health Scrutiny Committee should consider:
- the wider context of other, parallel strategies and plans
- the development of partnership arrangements and a whole system approach
- any barriers to achieving this across health and social care
- workforce capacity, taking into account the pressures and risks that exist in the current system
- the relationships between health and social care and the pressures and risks that exist in the current system.
The report on the reconciliation process between the Joint Health Scrutiny Committee and the NHS organisations is clear that the Joint Health Scrutiny Committee wants assurances that there is evidence to demonstrate that Care Closer to Home can pick up the increased demand that will be generated by the reconfiguration. They want more detail on this and the work to reduce demand and improve outcomes, as well as having their concerns addressed that the Clinical Senate had been unable to provide assurance to the proposals. Is all this included in the Full Business Case and/or any other documents Calderdale and Huddersfield NHS Foundation Trust and the Clinical Commissioning Groups have sent to the Joint Health Scrutiny Committee?
What is the Trust doing about “insufficient capacity and capability across the organisation to manage the many schemes (Electronic Patient Records, Cost Improvement Programme, Care Quality Commission preparation and service reconfiguration) while keeping the base safe”.
Workforce modernisation and efficiency savings
The Board papers say the national shortage of qualified staff and the recent level of vacancies pose “significant risk to the workforce.”
“Sustainable recruitment & retention to the nursing workforce is a priority alongside workforce modernisation.”
Work force modernisation is the replacement of highly qualified, skilled clinical and therapeutic staff by new grades of less skilled, less qualified staff.
£2bn of Lord Carter’s proposed £5bn/year Operational Productivity savings in acute hospitals is from hospital workforce “efficiency” savings – through reviewing new nursing roles, e-rostering, “Safe Care”, and “better use” of nursing staff.
The West Yorkshire & Harrogate Sustainability and Transformation Plan (STP) shows that the area’s hospitals are to make Carter programme “operational productivity” savings of £101m by 2020/21: £8m from Estates, £93m from “all other”.
The Trust is proposing to set up Carter’s “Safe Care” systems – what are they?
And is the Trust applying Lord Carter’s “Operational Efficiency” recommendations that it should review new nursing roles and replace fixed staff ratios with Care Hours Per Patient Day?
This is an import from the privatised American health care system. Care Hours Per Patient Day says nothing about the skills, knowledge and experience of whoever’s doing the caring.
But a recent study showed that wards with a higher ratio of registered nurses to healthcare assistants had fewer slips, trips and falls. Those with more Health Care Assistants had a higher than average amount of falls.
The study also showed there were fewer incidents of nausea and vomiting on wards where there was a total establishment of 30 or more whole-time equivalent nurses. According to the research, replacing six HCAs with six registered nurses on the six wards with highest incidents of falls could decrease monthly total falls at the trust by 15%.
So let’s hope that replacing safe staffing ratios with Care Hours per patient day is not part of Calderdale and Huddersfield NHS Foundation Trust’s application of the Carter recommendations. Is it?
Can the Trust explain the muddle over whether its workforce strategy for medical staff has or has not been developed?
The Board Assurance Framework bit on p118 identifies a level 20 (Very likely) risk of not being able to deliver safe and effective high quality care and experience for patients due to inability to attract, recruit, retain, reward and develop clinical workforce. To deal with this, it says:
“Workforce strategy for medical staff to be developed”.
But confusingly, the Report on the 1 year Plan says (p133) that the Trust is on track with implementing the 5 Year Workforce Strategy, as its Workforce Strategy and implementation plan was approved by the Board in January 2017 and a Workforce Modernisation Group is in place to manage delivery of the plan.
And then on p134 the Report on the 1 year Plan says the Trust is off track but with a plan to develop workforce roles and service models that enable the Trust to deliver care within planned resources and minimise use of agency and temporary staffing. Work is underway on Right Skills, Right Time programme. Recruitment of 14 Physician Associates to our services. Agency spend in month was below planned levels.
So what is really going on with this workforce strategy for medical staff, to reduce this “very likely” risk of “not being able to deliver safe and effective high quality care and experience for patients?”