This is a longish post.
In June, Calderdale Health and Wellbeing Board yet again nodded through Calderdale Sustainability and Transformation Plan schemes without any real discussion. This time, about setting up the Calderdale Integrated Care System (called Calderdale Cares). (Although they don’t talk about the Sustainability and Transformation Plan any longer – they’ve renamed it the Calderdale Single Plan.)
As a result, driven by the aim of cutting £100m costs by 2020/21, Calderdale is stumbling further into an un-evidenced redisorganisation of our NHS and social care services – even though the Secretary of State and Independent Reconfiguration Panel say the proposals are not in the interests of the public or the NHS. They have given local and national NHS organisations until 10 August to come up with revised plans that include showing how the Care Closer to Home plans will meet NHS England’s 5th consultation requirement of not cutting hospital beds without effective community services being in place.
What the Health and Wellbeing Board said and omitted to say raises urgent questions.
Cuts-driven Calderdale Sustainability and Transformation Plan aims to “moderate demand” for NHS treatments
From the start, the development of Calderdale Sustainability and Transformation Plan was shrouded in secrecy – an issue which Calderdale and Kirklees 999 Call for the NHS and others protested at the August 2016 meeting of Calderdale Health and Wellbeing Board.
Despite the secrecy, a question to the Calderdale Clinical Commissioning Group Governing Body in April 2016 revealed the priority areas for the Calderdale Sustainability and Transformation Plan were all about cutting costs:
- Initial proposals for “demand moderation”, with most of them in the QIPP section of the draft 1 year plan for Calderdale Clinical Commissioning Group.
- Wider productivity changes.
“Demand moderation” means restricting and denying patients’ access to NHS treatments.
The Health and Wellbeing Board meeting in June 2018 avoided any mention of this.
Complacent and desultory meeting in the absence of campaigners
I was the only member of the public present at the meeting and it was clear that campaigners’ absence had a noticeable effect on the conduct of the June 2018 meeting. It was complacent and desultory.
In contrast, two years ago, when campaigners challenged Calderdale Health and Wellbeing Board about the STPs’ draconian cuts and move to American healthcare models that open the NHS door wider to privatisation, this generated some questions and criticisms among the Board.
Cllr Geraldine Carter was driven to protest about the West Yorkshire Sustainability and Transformation Plan Draft Core Narrative:
“I’m worried about CCGs moving to accountable care systems – what does it mean? How can West Yorkshire STP dictate that CCGs are going to morph into something else? I’m worried that there’s no mention of Health and Wellbeing Boards. The document seems to be very heavy handed. It says ‘We will work closely with local communities’ – West Yorkshire STP has no mandate to do this except through Local Authorities. What is this document trying to tell us? I’m not sure I’m happy if this is how West Yorkshire STP is going to work.”
Calderdale Sustainability and Transformation Plan/Single plan is to be updated in the light of West Yorkshire and Harrogate Sustainability and Transformation Plan changes
This time, even when Debbie Graham, Head of Service Improvement at Calderdale Clinical Commissioning Group, told the meeting that the Calderdale Sustainability and Transformation Plan/Single Plan is to be updated in the light of changes to West Yorkshire and Harrogate Sustainability and Transformation Plan (now morphed into an Integrated Care System), no one on the Board asked what these changes are, or how they will affect NHS and social care services in Calderdale.
However, campaigners have some idea of what these changes are, and we are not happy about them.
The updated Calderdale Sustainability and Transformation Plan/Single Plan is to form the new Health and Wellbeing Board strategy, which will mainly be delivered by the Calderdale Integrated Care System (known as Calderdale Cares) and the hospital cuts plan.
Debbie Graham vaguely said they are revising the Health and Well Being Board strategy and will be trying to set out the key things they want to deliver.
Presenting an update from Calderdale Council and Calderdale Clinical Commissioning Group Integrated Commissioning Executive (ICE) , she told the Health and Wellbeing Board meeting that there is a massive number of priorities for the commissioning organisations and they will need to reduce these to ‘key deliverables’.
Many elephants in Committee Room B
The biggest elephant stomped around the final agenda item, Hospital Reconfiguration.
Calderdale and Kirklees Joint Health Scrutiny Committee has referred the hospital cuts and Care Closer to Home plans to the Sec of State and the Independent Reconfiguration Panel, because they are not in the interests of the public and the local NHS.
This obviously has huge implications for the delivery of the Calderdale Sustainabilty and Transformation Plan through the hospital cuts and Care Closer to Home scheme – but the Health and Wellbeing Board completely ignored them.
The Health and Wellbeing Board also ignored the fact that Debbie Graham’s paper clearly states that the Integrated Commissioning Executive is to jointly commission a ‘new Integrated Care Organisation’ – despite an assurance from Cllr Tim Swift at the February 2018 Cabinet meeting that:
“The Calderdale Cares… paper does not propose the establishment of a Calderdale A[ccountable] C[are] O[rganisation].”
NHS England may have rebranded Accountable Care as Integrated Care – as noted approvingly by Cllr Bob Metcalfe at the February 2018 Cabinet meeting – but that changes nothing but the name.
Update 20 December 2018 At the Health and Wellbeing Board meeting in October 2018, ck999 asked why Debbie Graham’s paper says that the Integrated Commissioning Executive is to jointly commission a ‘new Integrated Care Organisation’, despite Cllr Tim Swift’s assurance to the contrary at the February Cabinet meeting. In November 2018 Cllr Tim Swift replied:
“The question refers back to a paper presented to the June 2018 meeting of the Health and Wellbeing Board. The Terms of Reference for the Integrated Commissioning Executive included a graphic that had been “cut and paste” from a document submitted to the STP [Sustainability and Transformation Plan] process in 2017.
The Terms of Reference are being amended to remove the reference to a new Integrated Care Organisation. It is not our intention to establish an Accountable Care Organisation through Calderdale Cares.”
We are now asking to see the amended Terms of Reference for the Integrated Commissioning Executive. End of update
The third blumming elephant in Committee Room B was the total failure to question the “population health management” plans at the heart of the Calderdale and five locality Integrated Care systems.
Calderdale Integrated Care System aka Calderdale Cares
Debbie Graham asserted that the ‘Calderdale Cares’ direction is about moving from bespoke offers to what communities really need. What does this mean – if anything?
She mentioned a meeting the next day with Cllr Tim Swift about what they need to do to take Calderdale Cares forward.
Her paper included an update on progress of Calderdale Cares, including a summary of progress on localities and North Halifax Primary Care Home.
Five Locality Integrated Care Systems for Calderdale – aka Primary Care Home
Primary Care Home is a model of primary care being pushed by NHS England as key to the implementation of Sustainability and Transformation Plans/Accountable Care Systems.
It is a type of large scale GP and Care Closer to Home organisation, to serve around 50k patients through a new care model that will change the relationship between clinician and patient.
It’s remarkably similar to the American “ Patient Centred Medical Home” model for transforming primary care to become:
“accountable for meeting the large majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care.”
- What Dr Margaret McCartney calls ‘a misty belief’ in technology and innovation as the solution to current GP problems – while these ‘solutions’ are un-evidenced
- Only complex patients will see a GP – other patients will see new grades of lower-skilled, lower qualified staff or rely on voluntary organisations
- Behaviour change schemes will attempt to drive patients to self care, as the Commissioners see the current clinician-patient relationship as based on “a dependency model” which they are anxious to move away from
- A new form of contract and payment will introduce financial considerations into clinicians’ and patients’ decisions about what treatment to undertake
Another un-evidenced innovation
The Nuffield Trust Evaluation of Rapid Test Site Primary Care Homes between June 2016 and March 2017 found that:
“the financial and human resources committed to evaluation were limited and most R[apid] T[est] S[ite]s had not yet articulated…how their prioritised interventions would deliver the desired impacts.”
So this un-evidenced version of the Multispeciality Community Provider care model – that was trialled in the Vanguard schemes – may turn out to be nothing more than an example of disruptive innovation.
Will the main beneficiaries be – not the patients and clinicians – but the digital technology companies, whose products are going to be so in demand in the new Integrated Care Systems that a British Medical Journal article has called it ‘a digital gold rush’?
“Gone are the days when a doctor knew you and your family”
St Austell Healthcare in Cornwall (one of the initial Primary Care Home Rapid Test Sites) has experimented with employing a social prescriber to refer around 150 patients to exercise and support them for 12 weeks, co-located two health promotion officers from public health and carried out training 6 week peer led training for GPs, Nurses and admins to improve integrated working of NHS and social care services. But a patient said,
“St Austell Healthcare have approx 33000 patients. I can’t say I’m a fan of such large surgeries – you lose continuity as you don’t see the same doctor twice. You ring for an appointment and someone will ring you back within 5 days, since this system came I have not once had a face to face appointment with a doctor as it’s all done over the phone. I can’t blame the surgery they are under staffed and under great pressure. Gone are the days when your doctor knew you and your family.”
In Calderdale, the Primary Care Home locality integrated care systems are to deliver “care closer to home”, while hospital services are cut.
Mike Lodge, the Calderdale Council Scrutiny Officer, said they will focus on taking Central Halifax forward as the next locality Primary Care Home. He added that Central Halifax Primary Care Home was starting the next day. And some of the other localities are developing Primary Care Home. North Halifax Primary Care Home is moving forward, led by Dr Caroline Taylor.
Cllr B Metcalfe asked if Central Halifax had set up its own vision for Primary Care Home or was there common framework.
Matt Walsh replied that they all have to be aligned to and supportive of the Calderdale Single Plan.
Mike Lodge added that each locality will identify its own priorities. The Officer group on the Integrated Commissioning Executive has a key role to make sure one locality learns from another and doesn’t start from scratch.
Cllr Tim Swift corrected Mike Lodge, saying that the Locality Primary Care Homes have to have overarching goals and priorities, but localities can select within those priorities
Canterbury, New Zealand model of Accountable Care
Mike Lodge said that they were learning from the Canterbury New Zealand model of Accountable Care – a point also made by the West Yorkshire & Harrogate STP Elective Care commissioning standardisation report.
That report decided to standardise clinical thresholds for referral and treatment of Procedures of Limited Clinical Value – including elective orthopoedic surgery and cataracts – so that potentially 10% of patients would be excluded from referral and treatment, saving £50m/year.
West Yorkshire and Harrogate STP justified this on the grounds that it would enable:
“better clinical decisions to be made … Technology and decision making support tools would be targeted at the consulting room, learning from best practice such as the approach from Canterbury, New Zealand.”
The Canterbury technology and decision making support tools are inherent to the HealthPathways programme , which:
“bring[s] together GPs and hospital specialists to agree management and referral pathways for particular conditions….Pathways are available on the HealthPathways website and are designed to be easy to use as part of a patient consultation…Referrals are made via the electronic request management system… If hospital doctors have questions about referrals, they can discuss these directly with the referring GP and GPs receive feedback on their referrals.”
So less money to spend on patients, more money to spend on digitech. And decision making support tools – algorithms of dubious usefulness – replacing clinicians’ decisions made together with patients. Leading to denials and restrictions of patient access to elective care. Funny old world.
What, exactly, is Calderdale STP is learning from the Canterbury New Zealand model of Accountable Care?
Apart from how to restrict patient referrals for elective hospital treatments?
No one on the Health and Wellbeing Board asked. Maybe they all know already. If so, they can tell the rest of us.
Councillor involvement in the five Calderdale Primary Care Homes
Instead, Councillors whittered on about Mike Lodge’s paper.
This reported that two Councillors – one a Cabinet Member with an aspect of health care in their portfolio and one who represents a ward within the locality – should be asked by each Primary Care Home practice to be
“involved in planning and overseeing health and care locality working”.
Mike Lodge warned that GP practices aren’t used to working with councillors in this way and the Health and Wellbeing Board need to have some careful thought about this.
Cllr Megan Swift, – one of the Councillors involved in the N Halifax Primary Care Home – confirmed this. She said:
“It’s very useful having Mike Lodge in North Halifax Primary Care Home. If there’s GP suspicion of Councillors – and there is, there should be some officer there.
There should be an officer from the Integrated Commissioning Executive or Health and Wellbeing Board doing what Mike Lodge does, in the other localities.”
But no one else gave the matter any thought at all and after a bit of whittering, the Health and Wellbeing Board meeting agreed to the paper.
The policeman said it would be good to link to the anti-poverty strategy and Safer Cleaner Greener. Cllr T Swift said that cabinet has commissioned an update on the anti-poverty strategy
Primary Care Home workforce strategy is needed – duh
Matt Walsh opined that they need to bring Clinical Commissioning Group organisational development to talk about this with the Health and Wellbeing Board officers group about how to support Primary Care Home work.
They need to build a workforce strategy.
Have they not done that yet????
The West Yorkshire and Harrogate Sustainability and Transformation Plan Workforce Strategy – finally published in April 2018 after well over a year of us asking to see it – shows Calderdale stating pathetically that they don’t know what staff they need to deliver Calderdale Sustainability and Transformation Plan – which after all is basically the hospital cuts plan and Care Closer to Home plan that the Sec of State says is not in the interests of the public, as it stands.
Nor do they know if Calderdale Employment and Skills Board are the right organisation to help them work out this very basic question. They say,
“discussions are ongoing” about the “potential role” of the Calderdale Employment and Skills Board “in supporting the local system to understand its workforce needs for the future…”
They add weakly,
“…proposals are due for consideration at future meetings of Calderdale Health and Wellbeing Board.”
That’s when they’ve decided if it’s worth asking Calderdale Employment and Skills Board to help them figure out what their workforce needs are, so they can come up with some proposals.
That will hardly go down well with the Calderdale and Kirklees Joint Health Scrutiny Committee, when they look at the Clinical Commissioning Group’s updated proposals for Care Closer to Home before they’re sent off to the Secretary of State and the Independent Reconfiguration Panel.