No community services staff plan in Full Business Case

It’s very strange that Calderdale & Huddersfield hospitals Trust Full Business Case for moving hospital services into the community says nothing about a community services workforce plan.

How are they going to move hospital services into the “community” and provide “Care Closer to Home” when there’s no community services workforce plan in Calderdale & Huddersfield hospitals Trust Full Business Case?

And do the Clinical Commissioning Groups think the numbers of highly qualified district nurses and community matrons that will be needed are going to fall like manna from heaven? We need a local training plan.

Here is the bit of CK 999’s report to the Independent Review Panel that’s about this failing.

We are asking them to investigate it, and also the related issue of the Clinical Commissioning Groups’ lack of a primary care strategy that has the backing of GPs and other primary care workers.

There is next to nothing on community services workforce plan

Calderdale and Huddersfield NHS Foundation Trust (CHFT) is a hospital AND community services provider, but the workforce plan section of the Full Business Case says almost nothing about the community service workforce implications of the proposed reconfiguration.

The failure to include community service staff in the workforce plan is a gaping hole. Why? Particularly when we have come across this advice (that we think may be from the Independent Review Panel, although we did not remember to bookmark the link):

  • The focus on acute care provision should not overshadow the need to strengthen primary care
  • Local discussion often centres on beds as a representation of investment and capacity – the debate should focus more on creating a viable workforce for primary and community services

The omission is particularly dire given the overstretched and understaffed community services in both Greater Huddersfield – where Locala’s community health services need improvement, according to the recent Care Quality Commission report – and in Calderdale.

District nurses need to account for every minute of their time – every activity is allotted time, from accessing notes to patient care and travel. It is demoralising and time consuming. Their laptops are poor and as they are out and about, the notes they are supposed to write end up as home work, with nurses reporting that they often are writing notes at 9.30pm.

Recently-retired Calderdale Community Matron Anne Marie Hutchinson said,

“Working with vulnerable clients with inadequate resources is hell on earth. You cope initially by doing unpaid overtime then you burn out. I was lucky, my retirement date came and I took the opportunity to get out. Still feel guilty about those left behind!”

It is essential to have the right numbers of staff with the appropriate levels of training and skills in the community to care for sicker patients with more complex care needs. Qualified District Nurses need to be a key element in this work-force, co-ordinating and supervising other less qualified members of the Community Nursing Team.

Nationally, there are only half the number of District Nurses there were in 1997, and a third of those remaining are over 50 years old. The numbers being trained nationally are inadequate, and in 2016 12% of the training places were unfilled, with Health Education England citing “a reduced calibre of students and availability of placement capacity”, presumably as a result of lack of Community Practice Teachers within the stripped down Community Nursing Teams. (Understanding Quality in District Nursing, King’s Fund August 2016)

There is no evidence that Clinical Commissioning Groups have embarked on a locally-driven process of training up sufficient District Nurses to support the massive changes planned in the numbers of sicker patients in the Community. It will not be possible to attract ready-qualified District Nurses from other areas – Calderdale and Greater Huddersfield will need to grow our own – and that takes time, so the gearing up needs to start now. But it doesn’t seem to be.

Recently-retired Calderdale and Huddersfield NHS Foundation Trust consultant Colin Hutchinson told the Calderdale & Kirklees Joint Health Scrutiny Committee,

“Do not be reassured that larger numbers of less qualified staff will make up for the shortage. There is very good evidence that the levels of qualified graduate nurses makes a very big difference to hospital death rates and to the speed of patient recovery, the most recent being published this month in the BMJ Quality and Safety, ‘Nursing skill mix in European hospitals, by Aiken L.H. et al..

When such patients are being cared for in their own homes, there is every reason to believe that the close involvement of graduate nurses would be even more critical.”

Disregarding these vital points, the Full Business Case limits itself to:

  • a claim (p74) that the proposed reconfiguration will improve recruitment and retention of clinical staff within key hospital and community specialties; and
  • a key workforce planning assumption that an outpatient services review will help deliver new models of care and reduce follow-up appointments for existing patients with long-term conditions, while CHFT works with mental health, primary and social care and other local provider services to “develop efficiencies in service provision.” (Full Business Case p 76)

Lack of a primary care strategy

At its July 2017 meeting, the Calderdale and Kirklees Joint Health Scrutiny Committee rubbished the Clinical Commissioning Groups’ lack of a primary care strategy and the Kirklees Local Medical Committee (LMC) secretary Dr Bert Jindal complained that the LMC had not been involved in any discussions about the reconfiguration proposals or the Full Business Case. Among their many concerns, the LMC are worried about the impact of a greater workload on GP services and community nursing. There is a workforce crisis in General Pratice nationally and not enough staff to run existing GP services and primary care.

On top of all this, we are worried that the omission of community services workforce planning from the Full Business Case may mean that CHFT are assuming that they will lose the community services contract/s when the Calderdale Accountable Care System is set up (Full Business Case p26; October 2016 Calderdale locality Sustainabiity and Transformation Plan, slide 13)

We ask you to investigate:

  • the community workforce requirements of the Calderdale Care Closer to Home scheme,
  • the local community service staff training needs for both Calderdale and Greater Huddersfield,
  • the lack of a primary care strategy that has GPs and other primary care staff backing

And to tell the hospitals Trust to include community staff requirements and associated costs in a revised version of the Full Business Case,  before going any further with its reconfiguration plans.

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