What do we want? Public scrutiny! When do we want it? 3pm July 6th, Huddersfield Town Hall

Here is an email from Calderdale and Kirklees 999 Call for the NHS members to Councillors on the Calderdale and Kirklees Joint Health Scrutiny Committee, which meets on July 6th. Sorry it’s a bit long – but a lot has happened over the past year since they referred the hospital cuts plans to the Secretary of State.

The meeting seems set to be a pathetic travesty of public scrutiny of the local NHS Organisations’ proposals for phased implementation of 3 areas of the hospital cuts plans. These proposals – which are not described in the Scrutiny Committee meeting papers – are a response to the Independent Reconfiguration Panel’s comments in May that the NHS organisations had 3 months to come up with proposals that are fit for the Calderdale and Kirklees public.

Here’s Jenny Shepherd’s deputation statement to the meeting.

Dear Calderdale and Kirklees Joint Health Scrutiny Committee Councillors

At the 6th July meeting, you MUST make public the proposals for phased implementation of the hospital cuts plans, that the local NHS Organisations intend to send to the Secretary of State and the Independent Reconfiguration Panel on 10th August.

AND the public must have access to the planned workshop in late July between the Joint Health Scrutiny Committee and the local NHS organisations, when the proposals are to be discussed before being sent off the the Secretary of State/ Independent Reconfiguration Panel.

Without public information about the NHS organisations’ proposals, the Scrutiny meeting will be a travesty of scrutiny and democratic accountability.

We do not agree with the Independent Reconfiguration Panel’s acceptance of the inevitability of one emergency care hospital and one planned care hospital. Two towns, two 24/7 full bluelight A&Es is what we’ve campaigned for from the start. We see no good reason to abandon that goal.

We can’t see how the Right Care Right Time Right Place proposals can be made to work on the basis of a phased implementation of out of hospital care, hospital capacity and availability of capital.

We are particularly disappointed that the Independent Reconfiguration Panel ignored our request to review the Right Care Right Time Right Place plans in the context of their wider context and drivers:

  • the governmentʼs “austerity” policy and its effects on the NHS and social care; and
  • the Sustainability and Transformation Partnership that the Right Care Right Time Right Place plans are a key part of

Both issues surface in the Full Business Case for the Right Care Right Time Right Place reconfiguration, particularly in The Economic Case for Change and in The Strategic Context, respectively. They are not about to go away. And they have a considerable bearing on whatever phased implementation plans the NHS Organisations have been able to cook up.

Despite the government’s recent promise of an additional £20bn NHS funding, “austerity” NHS funding continues. Teresa May’s speech at the Royal Free Hospital made it clear that the extra money is not to pay for extra hospital beds, doctors or nurses – but for the digital technology and related gizmos needed to deliver the Accountable Care models and harvest the wealth of patients’ medical data for profiteering life sciences corporations.

Sustainability and Transformation Partnerships and Plans have morphed into Integrated Care Systems in Calderdale, Kirklees and West Yorkshire and Harrogate. These cost-cutting transformations of our NHS, public health and social care services have not been subject to any public consultation, but they will radically affect the Right Care Right Time Right Place proposals for phased implementation of out-of- hospital services, hospital capacity and capital availability.

Please consider these wider issues in your response to the Secretary of State and the Independent Reconfiguration Panel – particularly in the light of developments we drew your attention to in December 2017, and further developments since then that are outlined below.

The Integrated Urgent Care Service for Yorkshire and the Humber

Due to start in April 2019, the Integrated Urgent Care Service will be based on a revamped NHS 111 service that hands patients off to a phone- and digital-technology based Clinical Advice Service, with the aim of completing the consultation without referral to other services.

This cost cutting “all hours” Integrated Urgent Care Service will control and restrict patients’ access to A&E and ambulance services – as well as to their own primary and community health services. It fails to provide any continuity of care for patients, and focusses largely on algorithm-driven phone consultations followed by self care.

There is considerable criticism of Clinical Decision Support Systems – the algorithms that will drive the Clinical Advice Service:

“There is a large gap between the postulated and empirically demonstrated benefits of [CDSS and other] eHealth technologies … their cost-effectiveness has yet to be demonstrated”. doi:10.1371/journal.pmed.1000387

Clinical Decision Support Systems seem to be about tying clinical decisions to data about cost and outcomes that are required for Accountable Care payment methods.

With its reliance on algorithm – based remote consultations, the Integrated Urgent Care Service not only de-personalises the relationship between patient and clinician – it will deskill and deprofessionalise our clinicians, by reducing their role to ticking standardised care protocol boxes.

It also pushes more responsibility for self care on patient, family and friends. This comes with considerable clinical risks.

There is little or no evidence of the effectiveness of this model, either in financial or patient care terms. A 2017 external evaluation of the West Yorkshire Urgent and Emergency Care Vanguard, by the Yorkshire & Humber Academic Health Science Network company  basically said it produced no usable evidence.

Kirklees and Calderdale Integrated Care Systems and the large scale ‘Primary Care Home’ GP practices they are setting up

Risks to patient safety are arising from putting specialist hospital services such as scans into GP practices. The quality of the outsourced provision is uneven and it’s unclear where responsibilities lie for overseeing the scan and report – is it just the sonographer/ radiologist or a consultant?

There are also problems with how the results are reported back to the GP. Information from a West Yorks GP practice is that radiology reporting is no longer being automatically referred on to the GP practice or reported in terms of follow up advice – now only the findings are reported on without clinical next step advice.

GPs are realising their work is increasing because of the fallout from changes to radiology, cataract surgery and bloods; there are problems with cataract follow up as the result of a decision by the West Yorkshire and Harrogate Sustainability and Transformation Partnership (now Integrated Care System), that post-op outpatients’ follow up appointments will “no longer be the norm” – but “will be preserved for those whose clinical needs rely on the technology or skills of the secondary/tertiary care environment”.

Additional risks include the blurring of the boundary between social care and NHS services, with the likelihood that this will lead to some NHS continuing care services ceasing to be free at the point of use.

Hyper Acute Stroke Services reconfiguration

It is not clear that centralisation of hyper acute stroke services should be happening or what the effect would be on CHFT and Calderdale and Kirklees patients.

The Case for Change, presented at the July 2017 West Yorkshire and Harrogate Joint Clinical Commissioning Committee, claimed that the status quo is not an option and that the reconfiguration and centralisation of stroke services in London and Greater Manchester had provided:

“Strong evidence that stroke treatment is better concentrated in specialist centres.”

However, Prof Graham Venables, the Clinical Network Clinical Director at Yorkshire and Humberside NHS England, said he fully agreed when CK999 presented evidence that this is not the case, from Peter Trewby in the NHS Consultants Association March 2014 Newsletter.

He then struggled to build a plausible case by saying that that the overall gain from centralising hyper acute stroke services is not because of access to thrombolysis – for which he agreed there is no evidence – but because care is much better organised in hyper acute stroke units – eg assessment of swallowing, better positioning, better hydration.

But this should & could be done properly anywhere and doesn’t need centralised hyper acute services.

In addition, if hyperacute stroke services were to be cut from CHFT, there would be an opportunity cost in terms of the de-skilling of A&E generalists that would result.

The WYH ICS plan to cut the number of elective treatments by 10% in 2018-19

The Joint Clinical Commissioning Committee plans to cut £50m spending on elective care in West Yorkshire and Harrogate this financial year, by:

  • Paying for fewer operations – particularly elective orthopoedics and cataracts – as a result of raising the clinical threshold for treatment.
  • Paying for shorter hospital stays.
  • Not paying for outpatients followup (with a few exceptions).
  • Paying for an “industrial scale” patients’ behaviour change programme, called “Supporting Healthier Choices”

This has not been scrutinised – but it will radically affect CHFT and Calderdale and Kirklees patients. It is a ploy to encourage patients who can afford it, to go private.

Creating a two tier private/ public service for elective care can erect a major barrier to the provision of high quality comprehensive NHS services.

For example, because cuts to hospital funding caused waiting lists for cataracts etc to build up, NHS commissioners have been sending large numbers of clinically uncomplicated patients Calderdale, Kirklees and Wakefield eye patients to the private eye hospital SpaMedica  in Wakefield.

These patients are cheaper to treat and so more profitable, while the NHS is left with the more complex patients who cost more to treat. CHFT has lost a lot of income to the private eye hospital – and the ability to use this income to support emergency eye services and the treatment of less common, but often more serious eye disease, which are not adequately paid for by the tariff system of payments.

Pinderfields and Calderdale and Huddersfield hospitals are now underutilised and finding it hard to train up new eye surgeons.

The Supporting Healthier Choices “proactive behaviour change programme” is a development of contentious schemes in Kirklees and Harrogate that refused surgery for between six and twelve months to patients who were obese, smokers or drank too much, until they stopped smoking or reduced their Body Mass Index to an acceptable level.

Opposition from hospital clinicians and others led Kirklees NHS Commissioners to scrap the scheme,  which did not generate any recorded financial  savings.

The “Supporting Healthier Choices” scheme is being instructed by the Yorkshire and Humber Academic Health Science Network company in behaviour change, including how to apply advertising industry techniques.

Quite apart from its dubious ethics, this is a neoliberal absurdity: it requires individual solutions to collective public health problems such as air pollution, an unregulated junk food industry, as well as poverty, precarity and growing inequality. These public health problems are only amenable to public solutions.

Aligned Incentives Contract with CHFT

For the financial year 2018/19, we understand that the contract both Clinical Commissioning Groups have with CHFT is an aligned incentives contract. We hope you are scrutinising the effect this will have on CHFT.

In Portsmouth, where an Aligned Incentives contract has been introduced, instead of being paid for every treatment for every patient, the hospital gets one block payment for the year and 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.

If our CCGs are paying CHFT less than the National Tariff on the NHS Standard Contact, surely we will end up with a second class hospital.

Was this part of the Full Business Case financial projections? And if not, what changes now need to be made to them?

CHFT deficit/underfunding 2017-18

The government’s continued underfunding is setting up CHFT to fail. We urge the Joint Health Scrutiny Committee to tell the Secretary of State and Independent Reconfiguration Panel this is unacceptable.

We can’t keep up with all the figures, but the last time we looked, Calderdale and Huddersfield hospitals trust papers showed that in February 2018, (month 11 of the financial year 2017 -18), it had a year to date deficit (or rather, government underfunding) of £35.27m.

The Trust was forecasting an end of year deficit (or underfunding) of £31.34m, which was £15.4m off target. This was made up of an £8m overshoot of the control total and loss of £7.4m Sustainability and Transformation Funding.

In January 2017, CHFT appealed its unrealistic 2017-18 Sustainability and Transformation Plan control total (spending limit), which allowed it to run a deficit of £15.9m. This required it to cut £20m costs, after years of already making huge so-called efficiency savings (ie cuts). The trust estimated that it could only make £17m cuts.

To punish the Trust for failing to meet the control total since month 7, and for not meeting A&E targets in Q1 and Q2, the carrot of sustainability and transformation funding was snatched away.  When we last looked at the 2017/18 figures, the government had withheld £6.22m Sustainability and Transformation Funding.

There is only a month before the NHS Organisations send their proposals for phased implementation of out of hospital services, hospital capacity and capital availability to the Secretary of State and the Independent Reconfiguration Panel. The public has no idea what these proposals are – or whether or how they take into account the developments just outlined, as well as those we brought to your attention in December 2017.

Please make sure you bring them to public scrutiny at the 6th July meeting and open the workshop in late July to the public.


CK999 members:

Andrea English

Katherine Horner

Christine Hyde

Chrissie Parker

Jenny Shepherd (Chair)


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