Calderdale and Kirklees Joint Health Scrutiny Committee met on 7 September to consider what to do with the revised zombie proposal for the ‘Right Care Right Time Right Place’ hospital cuts/centralisation and the related move of hospital services into “Care Closer to Home”.
The Scrutiny Councillors also questioned a proposal from Kirklees Council for a new hospital to be built in 10 years time somewhere in Kirklees.
Both proposals have been sent to the Secretary of State in response to his requirement for revised proposals, after the Independent Reconfiguration Panel told him the plan cooked up after the public consultation was not fit for purpose in various ways.
Capital funding bid has gone to Secretary of State
Dr Birkenhead, the Calderdale and Huddersfield hospitals trust Executive Medical Director, said that to finance the capital cost of turning the 2 District General Hospitals into a planned care hospital and an acute hospital , West Yorkshire and Harrogate Integrated Care System had put in a bid to the Secretary of State for capital funding. If successful, the hospitals Trust would have no need to pursue PFI for financing.
Warren Brown from NHS Improvement said a number of capital funding bids are working though the system. This application has landed on the Secretary of State’s desk and he will look at it in competition with other bids across country.
The Secretary of State should say yes or no to the capital funding bid this calendar year.
If it gets the go ahead, the Trust will do work around clinical and financial sustainability. He said it would be an iterative process, and added,
“There’s been consultation so that’s an advantage, but it may need more consultation.”
Matt Walsh, the Calderdale Clinical Commissioning Group Accountable Officer, said
“I believe we will get an indication from the Secretary Of State that capital will be available if the local system is so minded to take it. So we have to do more work on what the system can afford and commissioners can afford.”
In response to a question from Cllr Julie Stewart Turner, Matt Walsh said the Strategic Outline Case about “ the shape of hospital proposals and interface with Care Closer to Home” should be ready by October.
The Scrutiny Committee Co-Chair Cllr Wilkinson pointed out that it’s up to the Scrutiny Committee to decide on further consultation on whatever proposal the NHS organisations finally come up with. He asked the local and national NHS organisations about their thoughts on further consultation
Warren Brown from NHS Improvement said his organisation want
“consultation engaged in the widest sense with scrutiny, councils, iterations and engagement.”
NHS Improvement threat
He then threatened that if the Joint Health Scrutiny Committee thinks proposals have changed so much that they need another statutory consultation, that would raise question marks in the Secretary Of State’s documents about bids for capital funding. This would lose the current advantage Calderdale and Huddersfield hospitals trust has over other bids, of having already concluded the public consultation.
Cllr Smaje said that, regarding consultation, the Full Business Case said there wouldn’t be a need to consult if the proposal improved affordability. But the revised model will cost more and overrun the timescale. She said she was concerned about the short and long term. They have a proposal for a short term solution but there is a need for a long term solution too. She asked how all that is going to come together.
Anna Basford, the hospitals Trust Director of Transformation and Partnerships, said that the revised model won’t cost more than the hospitals Trust currently spends on healthcare services, it will reduce that amount. It just costs more than the original model.
Warren Brown (NHSI) replied that in the long term we’re all dead. He added,
“In terms of detail, how do we know if we’ve got the right clinical plans? It will be an iterative process that will feed into the business case. The risk is, if we wait for all the answers we won’t get there.”
It is quite incredible to me that they’ve been talking about this for around five years and still don’t know if they’ve got the right clinical plans.
The “iterative process” line was spun by the then-Chair of Calderdale Clinical Commissioning Group, Dr Alan Brook, three or four years ago. Just how many iterations do they need? It sounds more like endless bullshitting than an iterative process.
All about shortages of funding and workforce – the public should really be out on the streets shouting against this.
Under questioning from Councillors – mostly Cllrs Hutchinson, Smaje and Stewart-Turner – it became clear that the zombie proposal from the NHS and Calderdale Council is – like the previous rejected hospital cuts and centralisation plan – expediently cobbled together without evidence or detail, in order to shrink NHS and social care services in line with serious levels of underfunding in Calderdale and Kirklees and national workforce shortages.
The upshot of the 7th September meeting was that:
- The Co-Chairs would write to the Secretary of State with an update on plans for further scrutiny.
- The Scrutiny Committee would meet again in November to review clinical and financial sustainability documents and more detailed proposals from the Strategic Outline Case, which was due in October.
Why has it taken the Hospitals Trust 4 years to recognise concerns that have been raised about the hospital cuts?
Dr Birkenhead, the Calderdale and Huddersfield hospitals trust Executive Medical Director, said that the revised proposal retains key principles about the planned/unplanned care model, and this is
“strongly supported by senior nursing members at the Trust, but they recognise the concerns that have been raised.”
It’s a pity they didn’t recognise these concerns when we raised them years ago. It would have avoided a massive waste of time, money and energy. Not to mention the opportunity cost of not working out better proposals.
Dr Birkenhead said that in the revised proposal both Huddersfield Royal Infirmary and Calderdale Royal Hospital will have 24/7 A&E with consultant presence on both sites, and when a consultant is not present there will be consultants on call.
Cllr Elizabeth Smaje asked if the A&E consultant presence would be in the day and on call at night? And would that be at both sites equally?
Why has detailed work about A&E staffing not been completed?
Dr Birkenhead said the detailed work’s not been completed. There is currently consultant presence at both sites for 14 hours/day. There will be consultant presences at both sites in the day.
There would be 24/7 anaesthetic cover at Huddersfield Royal Infirmary for resuscitation of any patients who came in under their own steam, before transferring them to Calderdale Royal Hospital.
This is because although ambulances would take all emergency patients to Calderdale Royal Hospital (or whichever full blue light A&E is nearest), some emergency patients might be taken by family or friends to Huddersfield Royal Infirmary and need resuscitation there.
Huddersfield Royal Infirmary would transfer patients needing admission from A&E to CRH.
Why are they bullshitting about the A&E workforce?
Anna Basford, the hospitals Trust Director of Transformation and Partnerships claimed there was
“an enhanced ability to recruit and retain clinical workforce as a result of consolidating acute services. This will mitigate current risks to the system.”
Cllr Smaje objected that the previous plan said the hospitals Trust couldn’t recruit clinical staff for A&E at Huddersfield Royal Infirmary and that it wasn’t workforce-viable or finance-viable. So what’s the difference now with the revised proposals?
Dr Birkenhead said it will cost more and require more staff. Unless they recruit enough to keep both A&Es open it will be a challenge but there will be benefits not just for A&E but around A&E, in a more resilient acute service.
Cllr Colin Hutchinson challenged the idea that operating acute services on 2 sites is the sole determinant of the attractiveness of working at the hospitals Trust. He said there were many other factors.
For example, the trust is withdrawing the skin cancer service because they can’t recruit dermatologists because there’s shortage of 100 nationally because they’re not training enough. Also in terms of job plans for prospective consultants, rigidity within the Trust is influencing its ability to recruit staff.
Anna Basford said that the hospitals Trust was protecting dermatology and skin cancer patients as best they could.
Why aren’t NHS England and NHS Improvement doing anything useful to improve national workforce numbers?
Cllr Hutchinson pointed out that the Francis Report led to the need to recruit safe numbers for nursing – but the country as a whole has not met that challenge to train up and retain nursing staff. He asked NHS Improvement and NHS England:
“So what are you planning to do to address that?
“There are 1500 more medical places next year, but this is starting from a much lower baseline than other OECD countries. We need a fully motivated national drive to redress the situation because what’s happening here is going on across the country.”
Helen Dowdy, Head of Intervention and Support, NHS England North Regional Team, said nothing.
Warren Brown from NHS Improvement said they recognise national workforce challenges. They are working closely with Health Education England in getting the right workforce. But this is long term.
Cllr Hutchinson said that Health Education England has had their funding kept flat which doesn’t suggest great willingness to develop an effective workforce for the future, particularly given the aging workforce .
Cllr Julie Stewart Turner asked NHS Improvement what’s being done to address the clinical staff shortage
Warren Brown waffled that they are working with trusts around reducing agency use to release funds to increase the staff head count. They are working with the Care Quality Commission and NHS England to have the right workforce in the right place. A number of things are going on to increase the quantity and quality of staff.
Cllr Stewart Turner rightly pointed out,
“That doesn’t give a clear picture of what’s being put in place.”
The Calderdale Clinical Commissioning Group Accountable Officer, Matt Walsh, said he agreed with the need to sort out the national workforce, adding the disclaimer:
“But we have to deal with the now. If we’re not careful, we’ll run out of time and see services fail in the system. We have to deal with it now by reconfiguration…Where we are in the proposals will get the system to where it needs to be in next 10 years – to hold system safely while long term training works through…We have to deal with now.”
Cllr Hutchinson observed,
“We have people in the room who have some leverage on this.”
Those people said nowt.
Only a short term fix not a long term solution
The House of Commons Health Select Committee report on Integrated Care: organisations, partnerships and systems found such short term thinking in the face of systemic funding and workforce shortages to be typical.
In the section “Inadequate response to system pressures” (p46) the Health Select Committee Report notes that:
“Sustainability and Transformation Partnerships, and the more advanced integrated care systems …are no substitute for effective solutions to funding and workforce pressures, but if well designed and implemented they can represent a better way to manage resources in the short term.”
However under questioning from Councillors, it didn’t look as if the claim that this plan is a better way to manage resources in the short term can stand up.
Why did the hospitals trust say one thing about hospital bed numbers to the Scrutiny Committee and another to the Secretary of State?
Dr Birkenhead said there would be 24/7 medical care for inpatients at Huddersfield Royal Infirmary.
Beds will be maintained using the Huddersfield Royal Infirmary “facility.” He said there would be no Huddersfield Royal Infirmary bed cuts now. Bed numbers would flex up and down, as now, according to need.
Cllr Smaje asked Dr Birkenhead to confirm there’s no requirement to reduce beds – because the letter to the Secretary of State seemed to indicate that Huddersfield Royal Infirmary would keep its beds until it could be proven they could be taken out and the number could then be reduced to 105 as they had initially planned. So which is it?
Dr Birkenhead said they were still committed to Care Closer to Home work that will reduce hospital beds and they will flex up and down as needed. He expected as Care Closer to Home kicked in there would be a requirement for fewer hospital beds.
So it seems that he’s talking about double running existing hospital and new Care Closer to Home services for a transition period.
Why is there no evidence in the public domain to support assertions about reduced demand on the hospitals?
Matt Walsh said there were plans to cut 44 beds at Calderdale Royal Hospital.
He said that they have created the potential for beds to come out and they can demonstrate the basis for that.
This boiled down to Calderdale’s significantly improved delayed transfers of care from hospital, along with rehabilitation and other work, which he said showed the system could work with fewer hospital beds.
Cllr Colin Hutchinson said
“This has been going on for a long time, but the material that’s been produced is not clear and evidence that should support it is not in public domain. To scrutinise proposals properly, we need evidence behind your assertion of reduced demand on the hospital, and Dr Birkenhead’s A&E proposals to be produced for scrutiny.”
Matt Walsh wriggled that there was no nationally mandated guidance on the 5th test
(ie the bed closure test to prove there are still going to be sufficient hospital beds to provide safe, modern and efficient care locally). And no template for evidence. He added
“We are going to work hard over the next 2 months to get clear currencies to demonstrate evidence. The hospital’s still full despite everything. We’ll do work on it and share in detail.”
Cllr Hutchinson reminded the meeting that the Clinical Senate had said there was not enough detail in the previous proposals to be sure that they’d work. He asked if the revised proposals, when adequately worked up in detail, would be put in front of the clinical senate to see if they can improve what we’ve got now?
Matt Walsh said yes.
Cllr Smaje asked how the Councils are working to reduce hospital demand and whether they think the projections for reduced hospital demand are achievable.
Richard Parry from Kirklees Council said there are real constraints to being able to manage demand – not just money but the workforce issue. For example home care staff is a real challenge. Registered nursing care is the biggest gap in Kirklees. He added that this is why West Yorkshire and Harrogate Integrated Care System is talking about left shift, which he explained as the only way to manage, by getting people to care for themselves.
Cllr Hutchinson said it was an issue of faith that IT would transform the interaction of people with care services – for example comparisons had been made with the banking sector. He continued,
“But look at what’s happened with bank branches’ closure, leaving no ability to interact face to face. So that’s not a good analogy. It’s introducing a new inequality between the digitally enabled and not digitally enabled – particularly since the digitally disenfranchised are among most vulnerable. So don’t rely too much on IT for patients’ access to services and delivery of services online.”
Matt Walsh replied
“You can’t get care and compassion from a computer, but IT can help people with signposting and how to do more for themselves.
If your argument is the need to build the workforce, that’s a political decision and we have to deliver within what we’ve been given by politicians. I’m absolutely certain that’s not going to happen.”
If it didn’t work in Wakefield and Dewsbury, why is it going to work in Calderdale and Huddersfield?
Cllr Smaje said,
“In N Kirklees we’ve had a similar reconfiguration, and growth in demand has not reduced as expected. This is in situations where there are also workforce constraints too. So how have you accounted for expected growth in demand from increased multiple conditions, reductions in family care and increased pressures. In N Kirklees, services can be temporarily not there when there are not enough staff and lot of pressures on the acute hospital because of demand and staff shortages. I’m worried about pressures on the acute system here.”
Carol McKenna waffled that they were
“able to share learning from the Mid Yorkshire situation across both N Kirklees and Greater Huddersfield. We can take learning from the Mid Yorkshire system for Greater Huddersfield.Those discussions happen on a regular basis.”
She said they have also done work across Calderdale and Greater Huddersfield. They have “listened to concerns.”
“We can point to comparators that show demand is being held to a level that’s better than other systems. Basically things are not as bad as they could be if we weren’t managing demand.”
Cllr Smaje replied that it’s about better outcomes. She appreciated that they were controlling hospital admissions better than other systems but was concerned whether they would achieve the outcomes. She pointed out that capacity and workforce are key things particularly with dual running of hospital and care closer to home services.
The elephant in the room: Cuts and Accountable Care
The elephant in the room was Accountable Care – now called integrated care.
Accountable Care Models are designed to “manage demand”, replace costly hospital services with cheaper out-of-hospital care provided by huge multispeciality GP practices, and undermine the key patient-doctor relationship – both by introducing financial considerations into decisions about which patients get which treatments and by replacing doctors with cheaper less qualified grades of clinicians.
Matt Walsh, Calderdale Clinical Commissioning Group Accountable Officer, outlined what’s happened in the “Calderdale system” since the referral of the original proposals a year ago. He said,
“There have been significant steps forward since then with primary and community care.”
He described Calderdale Cares (the Calderdale Integrated Care System) as:
“A shared vision for Integrated health and social care services across 5 localities in Calderdale. There is real work going on particularly in 2 localities – Halifax North and Haifax Central – around the relationship between health and social care services and the voluntary sector.”
They are investing £6.2m into access to GPs and primary care. But he didn’t say what this is paying for. Is it this?
“NHS England are making extra funding available to CCGs for use in order to improve access to GP services, by offering more appointments with GPs and Nurse Practitioners.”
Ian Baines, Calderdale Council Head of Adults Social Care described Calderdale Cares – the Calderdale Integrated Care System – as:
“a Calderdale Council initiative that aligns and supports the out-of-hospital proposal.”
Carol McKenna, Chief Officer for Greater Huddersfield and North Kirklees Clinical Commissioning Groups said some waffly confusing things – I think the gist of it was that the Kirklees Health and Wellbeing Board plan had been sent to the Kirklees Health Scrutiny Committee the day before.
Huge cuts to Kirklees NHS and Council spending
She didn’t say that the Kirklees Health and Wellbeing Board Plan is about NHS organisations in Kirklees cutting spending by £70m in 2018/19 and Kirklees Council cutting spending by £83m between 2017-2020. This includes a £4m cuts target for 2018/19 in adult social care, alongside an expected increase in the volume of adult social care that will cost £3.6m. (p 8, Kirklees Health and Wellbeing Board Plan).
Most of the Plan is platitudinous waffle distracting from the reality of shrinking NHS, social care and other council services.
The Plan has segmented the population into 4 categories:
- people who need acute or urgent care services,
- people with complex health needs,
- people who are independently managing their health problems and
- people who are well.
They will use risk stratification tools and impact modelling to identify population cohorts that are “at risk” – at risk of what is not specified, but usually in this context it means at risk of unplanned hospital attendance and/or admission. They will then direct “interventions” towards them. The interventions are mostly about that infamous “left shift” – getting people to look after themselves.
Carol McKenna said that the Kirklees Health and Wellbeing Board Plan was about a “place based system of care”. Primary care practices would serve 50K patients and would bring GPs, Kirklees Council and mental health services to deliver care differently. They are initially setting up in 2 localities but bringing others on asap. CK999 has already blogged about this.
So this is basically the same as the Calderdale Integrated Care System. And all the other so-called primary care homes across England. And the 50 that are due to be set up across West Yorkshire and Humberside by the West Yorkshire and Harrogate Integrated Care System.
According to Carol McKenna, the Kirklees GP Federation supports vulnerable GP practices through a new model.
And a national GP retention fund encourages GPs not to retire.
Carol McKenna also said Kirklees had “an extended access model to GPs including physiotherapy” and that they were strengthening the workforce in primary care – additional pharmacy support was freeing up GPs’ time.
Pharmacist doing the job of GPs is not on
According to unsuspecting patients who have turned up to the new urgent/same day walk in clinic in Mytholmroyd expecting to see a GP, only to find they are talking to a pharmacist – this is NOT strengthening the workforce in primary care.
The pharmacist has given prescriptions to patients after apparently following a diagnostic pathway and asking what seemed to be irrelevant questions. Pharmacists doing a minor ailment clinic in a pharmacy are one thing, as that is patient-instigated. But pharmacists actually consulting and prescribing for GP same-day appointment patients is another and we don’t like it.
Pharmacists doing the job of GPs is NOT part of the “emerging model of care delivery”, according to the Royal Pharmaceutical Society.
Why is there no clarity and evidence about connectivity between the hospitals’ and GPs’ patient care records?
Dr Birkenhead said they were enhancing connectivity via the hospitals’ Electronic Patient Record to support Care Closer to Home work.
Cllr Colin Hutchinson pointed out that NHS England and NHS Improvement say the enhanced summary care record is being used now, the Clinical Commissioning Groups and hospitals Trust say they plan to implement it. Which is correct?
Dr Birkenhead said they were currently testing the 2 way interface between GPs and hospital.
Cllr Hutchinson said, so it’s still in planning to be rolled out? And added,
“We need evidence of its effectiveness from people at the front line who are using it. Should we be looking for that now or in the near future?”
Dr Birkenhead said that the links from GPs into the hospital are functional, the links from hospital to GPs are being tested.
Cllr Hutchinson asked if there was adequate network coverage for use by mobile people in the community, so systems don’t crash
Matt Walsh replied,
“Some things we can deliver, some we can’t. The hospital is very up to date with the Electronic Patient Record but there are lots of other partners, so it’s not all in their hands.
Digital technology is one of the opportunities to work with the workforce numbers we are likely to have over the next few years.”