At the Greater Huddersfield Clinical Commissioning Group Governing Body meeting on Weds 11th October 2017, Hands Off HRI campaigners applauded Dr Ashraf’s vote against supporting the hospital Trust’s Full Business Case for the Right Care Right Time Right Place plans. He was the only Governing Body Member to do so.
The public consultation overwhelmingly rejected these plans last year, but the Clinical Commissioning Groups brushed aside this rejection as an emotional, irrational response from people who didn’t understand the issues.
Dr Ashraf explained that there were serious risks attached to the Full Business Case. He warned that he was not sure primary care is ready, or that it will be ready in the next 2 years, to provide the services that will be required as they are transferred out of the hospital.
He pointed out that,
“The gaps in primary care are growing. An an example, in the last 6 months in my practice 3 GPs hve retired. That is a loss of 60 years of medical experience. The replacements don’t amount ot 60 years of medical experience.”
He explained that, as a result, his GP practice are looking to employ practitioners with other skill mixes, and added,
“The shift from hospital to community care may not be as easy as people think. To get specialisms into the community is going to cost, but I can’t see how or where it’s costed. That’s outside the Full Business Case. The targets are aspirational and challenging. To reach them we would have to be in the upper quartile of CCGs. And when they do move, it isn’t going to end up cheaper. This all means there is a substantial risk attached to the Full Business Case.”
(“Aspirational” is the polite euphemism for “wishful thinking” that was used by the Clinical Senate in their 2015 reviews of the Right Care Right Time Right Place clinical models for hospital services and care closer to home. In their reviews, the Clinical Senate said that they could not guarantee that these clinical models would deliver the required standard of patient care.)
Responding to Dr Ashraf’s warning, the Greater Huddersfield Clinical Commissioning Group’s Chief Finance Officer, Ian Currell, said that the 2018/9 plan put £1m into primary and community services, and that grows every year for the next 4 years.
Dr Ashraf replied that it’s a question of capacity as well as money. They need the nurse practitioners and other key staff in place before the hospital services are transferred out to the community – and where are they coming from?
Ignoring everything Dr Ashraf had said, the Greater Huddersfield Clinical Commissioning Group Governing Body Chair Dr Steve Ollerton said that, on the basis of “joint system working” the Full Business Case will contribute savings of £18m/year. (Whatever “joint system working” is – maybe code for “Sustainability and Transformation Partnership” – the scheme forced onto the NHS by NHS England and NHS Improvement in order to push through NHS and social care funding cuts of around £26bn by 2020/21?)
The Chair went on to repeat the questions that the Governing Body needed to decide, in considering whether to support the Full Business Case:
- Is the FBC in line with the model the CCGs consulted on?
- Is the FBC affordable to Commissioners?
- Does the FBC improve and achieve the financial sustainability of the Calderdale and Greater Huddersfield system of care?
And asked for a vote.
All the members except Dr Ashraf voted to tell NHS England the Clinical Commissioning Group supports the Full Business Case.
This was despite the following facts that were revealed in the meeting:
- The resources are NOT in place to develop primary care, nor is baseline data about existing primary care resources, nor have decisions been made about what data needs to be measured.
- Solutions to transport problems have not been identified or the issue addressed.
- The Full Business Case does not solve the under-funding problems across the Calderdale and Greater Huddersfield NHS system.
- Governing Body members who are members of the Huddersfield GP Federation had a clear conflict of interest.
- The ability to “deliver capacity in community and primary care services” that will replace cut hospital services, is based not on the assumptions in the public consultation, but on updated assumptions in line with so-called System Recovery Plans. (These are, to the best of my knowledge, the plans imposed on Calderdale and Greater Huddersfield Clinical Commissioning Groups by NHS England in order to enforce the Sustainability and Transformation Partnership financial control totals, compel them to balance their books and provide a 1% surplus. But I am happy to be corrected if this is wrong.)
Surely the Clinical Commissioning Group must in future make sure that their meetings and reports use language that the public can easily understand.
Conflicts of interest
At the start of the meeting, members declared their conflicts of interest.
A number of Governing Body GPs who are members of the Huddersfield GP Federation said they had been assured by the Clinical Commissioning Group governance person that this did not create any material conflicts of interest.
This judgement seems highly questionable, since members of the Huddersfield GP Federation stand to be directly affected by the transfer of hospital services into the community.
This was made clear by the Greater Huddersfield Clinical Commissioning Group Chief Officer Carol McKenna in the course of the meeting. She said that there will be £1m investment in primary and community services in 2018/19, and that the Clinical Commissioning Group are using the money to build the GP Federation in Huddersfield and are working with the Local Medical Committee on that.
Other Governing Body members who declared conflicts of interest included David Longstaff, the Lay Member for Audit for both Greater Huddersfield and Calderdale Clinical Commissioning Groups, who declared a non-financial professional interest but said the conflict of interest governance officer had told him he was was ok to participate in both discussions and decisions – as were all others, it turned out.
Penny Woodhead, Head of Quality and Safety for both Greater Huddersfield and Calderdale Clinical Commissioning Groups, declared an indirect financial interest via hospital trust roles of a close family member and friends, and a direct non- financial professional interest as a result of her joint employment by both Clinical Commissioning Groups.
Dr Irving Cobden, the Secondary Care Advisor, rents premises from the Calderdale and Huddersfield hospitals Trust, but had been told by the CCG’s conflict of interest governance person that he could participate in both discussions and decisions.
Discussion of recommendation
Before Dr Ashraf warned of the risks attached to the Full Business Case as a result of funding, staff and capacity shortages in primary and community care, other Governing Body members raised some issues.
Changes to clinical model
Dr Steve Ollerton explained that the Clinical Commissioning Group doesn’t have a committee to review the clinical model, so there had been a meeting with secondary care representatives last week to discuss issues with the clinical model such as children’s urgent care and what he called “slight changes to the clinical model” in the Full Business Case, compared to what was presented in the public consultation. He said the meeting was satisfied that the Full Business Case clinical model is still essentially the same.
Members of the public asked him to explain how this could be true, since the Full Business Case halved the number of hospital beds at the Huddersfield planned care hospital, compared to the number given in the public consultation. Dr Ollerton churlishly replied it was a meeting in public not a public meeting and the public were not allowed to ask questions.
I suggested that although it was a meeting in public, that did not mean he could not take the time to explain to members of the public who had gone to the trouble of attending the meeting, the reasoning behind his assertion that the clinical model is essentially still the same.
Dr Ollerton then explained that there is reduction in the number of beds at the Huddersfield “site” because:
- more rehabilitation in the community will be invested in
- high risk patients will be operated on in the “acute care site” – ie Halifax
- they will move more day case surgery to the “planned care site”
He added that the hospitals Trust said 83% of the hospitals’ surgery is day case, and that more complex planned care surgery needs to be done where there’s intensive care – ie at the Halifax hospital.
GP Dr David Hughes backed up Dr Ollerton. He said that the Governing Body needed to look at activity levels, not just bed numbers; and that the change in the clinical model is small. He welcomed 25 beds coming out of the hospital for community rehabilition beds closer to patients’ home or in patients’ homes.
21 step down beds have been moved to Halifax hospital.
10 beds have been moved to Halifax hospital as a result of a change in surgical practice that is about providing complex surgery with good back up
How will the CCG develop primary care?
Nurse Advisor Angela Monagan, identified on the Greater Huddersfield Clinical Commissioning Group website as Chief Nurse (Executive Director) at Harrogate and District NHS Foundation Trust since 2000, said she understood the importance of expanding primary care, but currently primary is under pressure so how will the CCG develop primary care?
Penny Woodhead, the Greater Huddersfield and Calderdale Clinical Commissioning Groups’ Head of Quality and Safety, said,
“I’ve said before that we need to establish a further assurance process to make sure the resources are in place. There will be quality assurance panels to test readiness to make changes in the future.
Up until now this has been associated with CIP* quality assurance and we have taken these CIP quality assurance guidelines to set up a further assurance process, doing Quality Impact Assessments at the service line so the panel can be assured of mitigating actions around negative impacts. We are confident we have the process to do that.
We need parallel work with community and primary services. This will include workforce and how to respond to challenges. We need clear baseline info and the metrics they are using- eg skills and competences not just staff numbers of GPs and ANPs and so on.”
(* CIP = Cost Improvement Programme = cuts.)
The Chair Dr Steve Ollerton chipped in swiftly, before anyone could point out that Penny Woodhead’s reply means:
- the resources are NOT in place
- nor is baseline data
- nor have decisions been made about what data needs to be measured
- there will be negative effects that will need to be dealt with somehow
Dr Steve Ollerton hurriedly said,
“Geriatricians are keen to be out working in the community in care homes.”
He added this is also true of staff who set up intravenous antibiotics, and that the hospital is seeing their role in the community as helping GPs and care homes.
Clinical Commissioning Group Chief Officer Carol McKenna said,
“As I said at the Joint Health Scrutiny Committee meeting in July things are underway that will make a difference in primary care. For example, the Greater Huddersfield primary care strategy that came out last year is in line with the GP Forward View which brings additional money which will come on stream next year. Plus there will be £1m investment in primary and community services in 2018/19.
This is designed to support in making the changes. We are using the money to build the GP Federation in Huddersfield and are working with LMC on that. [So that is conflict of interest right there.]
We need to prioritise work with primary care. I will take comments back to the primary care programme board.”
She did not say that at the Joint Health Scrutiny Committee meeting in July, Councillors were distinctly unimpressed by the lack of information about primary care and whether it would be possible to scale up Care Closer to Home . This was one of the reasons why they decided to refer the Right Care Right Time Right Place plans to the Secretary of State for Health.
Nor did she say that the GP Forward View is designed to destroy traditional family GP practices and replace them with GP superpractices operating “managed care pathways” based on standardised tick box treatments, delivered by less skilled staff who are not qualified GPs, on the basis of models imported from the USA.
Solutions to transport problems have not been identified or the issue addressed
Dr Hughes said the Report’s section on Travel and Transport should probably say that transport issues have been “acknowledged” not “addressed”; setting up a Travel and Transport Group was acknowledging the problems, but the Group hadn’t yet addressed them.
Jen Mulcahy replied,
“Yes, the mitigating issues and concerns regarding transport have not been addressed yet.”
The FBC does not solve the underfunding problems in the Calderdale and Greater Huddersfield NHS system
Dr David Hughes said that under section 8, “Is the FBC affordable to Commissioners? Does the FBC improve and achieve the financial sustainability of the Calderdale and Greater Huddersfield system of care?”, he was slightly confused about the hospitals Trust coming back to financial balance in 2024/5, and the Clinical Commissioning Groups coming back into balance by 2031, but an £18.5m system gap remains in 2021/2.
The Finance guy replied that the financial gap across the system that’s not addressed by any organisation is £11.5m this year (2017/18).
He added that the Full Business Case sorts out the Trust finances but doesn’t address the system gap. Wider work keeps on being needed to close that.
Dr David Hughes asked,
“So does that release money to increase primary and community care?”
The Finance guy said the Clinical Commissioning Group will have increased funding for primary and community care in 2018/19 and added something about addressing the system financial gap that I did not catch.