Cost-cutting hospitals Trust contract on the cards

All the talk was about money, when Calderdale Clinical Commissioning Group Governing Body met on 12 October 2017 and rubber stamped the recommendation to tell the NHS England quango that they support Calderdale and Huddersfield hospital trust’s Full Business Case for hospital cuts and changes – that the public consultation overwhelmingly rejected last year.

The Calderdale CCG Governing Body voted that the Full Business Case is:

  • in line with the model they consulted on (which is open to question),
  • affordable to Commissioners (which doesn’t seem to be born out by discussion during the meeting), and
  • improves and achieves the financial sustainability of the Calderdale and Greater Huddersfield system of care (ditto).

Affordability and financial sustainability

Before the vote, the Chief Officer, Matt Walsh, pointed out:

“The Calderdale CCG QIPP gap* gets more challenging whether or not the FBC is supported. But it becomes harder to deliver without reconfiguration. Savings for the CCGs would be halved without this.”

(*ie the difference between the “efficiency” savings (cuts) NHS England has told them to make and the “efficiency” cuts they’re able to make.)

Proposed new contracting arrangement with hospitals Trust to cut costs

The Chief Finance Officer, Neal Smurthwaite, said that both Calderdale and Greater Huddersfield Clinical Commissioning Groups are discussing new contracting arrangements with the hospitals Trust, in order to make savings.

All three NHS organisations are in special measures, as they are not in a position to meet harsh financial controls imposed as a key part of the West Yorkshire and Harrogate Sustainability and Transformation Plan. This aims to cut NHS and social care spending in the region by over £1bn by 2020/21, compared with current spending levels.

The two CCGs and the hospitals Trust are working together on a Health System Recovery Plan, to deal with their “unmitigated” financial risk – that is, the “special measures” cuts that are required, but that they can’t see how to make.

The Calderdale and  Greater Huddersfield CCGs and CHFT Recovery Plan report in the Governing Body meeting papers, says both CCGs and the hospitals Trust  are looking at the Aligned Incentives Contract that is in use in Bolton.

In Portsmouth, where an Aligned Incentives contract has been introduced, instead of being paid for every treatment for every patient, the hospital gets one payment for the year . That has to cover everything that comes through the door. Raising the question of what happens if more comes through the door than the one-off contract can cover.

No Governing Body members asked what this new form of contract was – or what it would mean. So during the tea break I asked about it and was told it was a local variation to the standard contract.

Given the need for both Clinical Commissioning Groups and the hospitals Trust to make cuts which they can’t see how to make, doesn’t it stand to reason that this “local variation” is going to be less than standard contract?

This proposed change to the hospitals contract urgently needs scrutiny

How is paying less than the standard contract going to make our hospitals Trust a more attractive place for people to work? And what effect is it going to have on patients’ access to treatment and patient safety?

Was this part of the Full Business Case financial projections? And if not, what changes now need to be made to them? We are asking the hospitals Trust.

A new business model

In Portsmouth, the Aligned Incentives Contract (AIC) was introduced:

“In preparation for becoming an Accountable Care System (ACS)…

In keeping with the STP principles, the AIC incentivises activity and cost reductions across the system as a whole rather than focussing on hospital income. This will encourage CCG’s and the acute Trust to work together to develop collaborative solutions to address the issues of affordability, rising demand and capacity constraints.”
Accountable Care Systems are a new  business model for the NHS and social care.
Coastal West Sussex CCG says the Aligned Incentives Contract they’ve introduced  allows them and hospital Trust:

“to jointly focus on reducing demand and making sure the system is working efficiently.”

Is the Full Business Case in line with the proposals that were consulted on?

A massive problem was that the Clinical Senate was unable to say that the clinical models for hospital services and for care closer to home were going to deliver the required standard of care, or were any more than “aspirational.”

The report on the Full Business Case to the Governing Body shows that the Clinical Senate STILL can’t tell if the clinical proposals are fit for purpose. The Right Care Right Time Right Place officer, Jen Mulcahy, confirmed:

“The Clinical Senate can’t fully assure the clinical case.”

So the Clinical Commissioning Group has set up a group that includes the Clinical Senate, to look at changes to “individual service lines”.

Problems thrown up by the public consultation about lack of resources for Care Closer to Home (which are to replace cut hospital services) have been resolved by “revising” assumptions about “the pace and scale of delivery of community capacity from the CCGs’ Care Closer to Home programme.”

What does this even mean and what are the revised assumptions?

Jen Mulcahy said that they have reduced the need for Care Closer to Home primary care. How? What have they reduced it to? What are they replacing it with?

None of the Governing Body asked. Is this because they already know or because they can’t be arsed? If your GP is on the Governing Body, please write to them c/o their GP practice, asking them to explain.

And please ask the Calderdale and Kirklees Joint Health Scrutiny Committee Councillors to scrutinise this when they next meet – hopefully soon. You can email the Scrutiny Officer and ask him to forward it to the Scrutiny Committee members.

Jen Mulcahy asserted that they have sorted the problems with the Paediatric Urgent Care proposals – but the Clinical Workshop report shows the same nightmare gobbledygook plus a proposal that an extensive/comprehensive marketing campaign will solve the confusion. And the same failure to provide a doctor’s physical presence 24/7.

The urgent care centres still count amputation as a minor injury, to be treated by an Emergency Nurse Practitioner supervised by the “generalist” doctor who may not be physically present.

“Growing concerns about the safety and sustainability of the system”

After the unanimous “yes” vote, Matt Walsh listed

“many hurdles to cross before changes can happen”:

  • NHS England and NHS Improvement say there will be a lengthy review/assurance of the Full Business Case.
  • It’s been referred to the Independent Review Panel.
  • There’s a Judicial Review challenge to the Full Business Case.
  • There are growing concerns about the safety and sustainability of the system now.
  • There is a set of statutory duties – particularly about safety.

He added that the CCG has a

“commitment to openness and transparency. There is more of this story to tell as we go on.”

So they will readily tell us all  about the proposed cost-cutting contract arrangement with the hospitals Trust then.

Bullsh*t Bingo Dictionary

QIPP – Quality Innovation Productivity and Performance – euphemism for spending cuts, introduced by global consultancy company McKinsey.

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