Questions and Answers from campaigners’ meeting with Calderdale and Huddersfield hospitals trust execs

For the record, here are the questions and answers from the campaigners’ meeting with hospitals trust execs on 6th Feb.

Because most people probably won’t want to plough through them all, I was going to relegate them a downloadable doc from the blog post about the meeting, but wordpress has changed the editing format and now I can’t figure out how to link to a downloadable document.

So this is the only way I can put them in the public domain.

Here are the Q&As.

Revised Strategic Outline Case

Q: Why were there about five different stories circulating among the local NHS organisations and the Calderdale and Kirklees Joint Health Scrutiny Committee about whether or not the hospitals Trust had sent the revised Strategic Outline Case to NHS England late last year ? And which story was true?

Anna Basford said the true version of the story is that CHFT will submit the revised Strategic Outline Case to NHS Improvement in April this year. December 2019 is the deadline for approval by NHS Improvement, the Department of Health and Social Care, Ministers & the Treasury.

Owen Williams said he couldn’t give an explanation about why we’ve had different messages from Calderdale Clinical Commissioning Group and Calderdale and Kirklees Joint Health Scrutiny Committee – but it could be because

“schemes of this size have built in flexibility.”

He added that they are working with the regulators (NHS Improvement and NHS England) about the content of the revised Strategic Outline Case. As part of that work the hospitals Trust have shared a draft document with the regulators that contains information and content that they already have. They are now revisiting that draft to develop it with recently released information about national prices and tariffs.

(In relation to this “draft document”, the notes of the meeting from Nicola Bailey at the hospitals Trust include this, which is more specific:

“Anna Basford advised that in December a draft document had been shared with NHSI that was based on the information that had been included in the Progress Report submitted to the Secretary of State for Health and Social Care in August 2018 (previously published).”)

Owen Williams said that working with NHS England, NHS Improvement and the Department of Health means that it’s not always very clear what the status is of any given document because the contents are not set in stone.

The hospitals Trust is sending these documents to Calderdale and Kirklees Joint Health Scrutiny Committee for the meeting on 15th February:

  • The update for the Secretary of State – downloadable here
  • A report with more info about engagement with the public
  • Renewed Terms of Ref for Scrutiny (but it’s up to the Scrutiny Committee about whether they include this).

Revised hospital cuts and changes proposals

Q: We asked why nurses have been told that they’re not to talk to the public about the proposed changes.

Owen Williams said that he has sent out communications to staff about wanting an open dialogue.

There is a thing called “Ask Owen” on the CHFT computer screens which is a way for people to talk to him.

There are other routes for staff to raise issues of concern.

And failing all else, staff members can talk to the Care Quality Commission.

He said there are no gag orders on staff and he and the other Executives listen to what staff say. He gave as an example surgeons who spoke up at a public meeting in Golcar, and said their points led to changes in the reconfiguration proposals. (But why did the surgeons have to go to a public meeting to get their concerns heard?)

Owen Williams suggested we read the Care Quality Commission report which says the hospitals have an open and inclusive culture.

Anna Basford said that if there are pockets of staff that feel they can’t speak, they want to know.

Owen Williams said they wouldn’t want a situation where somebody couldn’t speak up if they feel what’s happening to patients is wrong. If staff have got reservations it’s important to capture them so the hospitals trust doesn’t introduce inappropriate models of care.

Q: We asked what changes are planned to services provided on the HRI site

Anna Basford referred us to the list in the Trust’s update to the Sec of State:

Owen Williams said there is a significant difference between where the hospital was 4 years ago and where it will be in the future, because of the the electronic patient record and digital technology.

He said that now, for example, a junior doctor on an inpatient ward can look at the same clinical record in real time with the on-call consultant, and have a conversation without the consultant having to come into the hospital. From a patient safety perspective they can always monitor the status of all inpatients.

This is extending further. They are about to pilot work where, for example, after a knee operation doctors will be able to make sure patients are doing their exercises properly, through requiring patients to use wearable technology to be monitored while doing the exercises.

(What crossed my mind was: Is there no limit to the state’s surveillance of citizens? What happens to people’s privacy if our intimate bodily functions are being recorded by the state and its institutions? What happens to this data once it’s been monitored by whoever checks it? Presumably it becomes part of the patient’s (not so) confidential medical record.)

Q: We asked what services CHFT was planning to transfer between the two hospitals in 2018/19 – specifically if chemotherapy was being transferred.

Anna Basford said she wasn’t aware of plans for any service transfers in 2018/19. Owen Williams said there had been three service movements in the last 6 months, that people already know about: Respiratory and Cardiology inpatient services had transferred to CRH and Elderly inpatient services had transferred to HRI.

He added that in 2005/6 a significant reconfiguration consolidated paediatrics in CRH and surgical trauma in HRI. He justified this as avoiding spreading services too thinly across two sites and said it has brought improved quality benefits to patients.

They are consolidating frail elderly care in HRI.

Q: After the meeting, we emailed the Trust to ask what “consolidating frail elderly care in HRI” means. Is this in addition to the post-acute patients transferred from Calderdale Royal Hospital if they don’t need acute care any longer but are not ready to go home?

The Trust replied that in November 2017, some in-patient services were reconfigured to ensure the interim quality and safety of care delivered for patients and their families. These changes were reviewed at that time by the Calderdale and Kirklees Scrutiny Committees and it was agreed they met the criteria for urgent service change in line with Scrutiny guidance and were therefore supported for the Trust to move forward to make these changes rapidly in the interest of patient safety.

This means that currently all in patient services for elderly patients are located together at Huddersfield Royal Infirmary and all cardiac and respiratory inpatient care is provided at Calderdale Royal Hospital.

We also told the Trust that we remember from when the preferred option was for the acute/emergency hospital to be Huddersfield Royal Infirmary, with Calderdale Royal Hospital as the small planned care hospital, that Owen Williams commented that a possible use of the extra CRH beds could be as some kind of care home/hospice. We asked if this the same thing as “consolidating frail elderly care” – but now at HRI rather than CRH?

The Trust said this past option has nothing to do with the consolidation of inpatient elderly medicine services at Huddersfield Royal Infirmary that was implemented in 2017 to ensure the quality and safety of care (as described above).

Anna Basford said that the beds maintained in HRI would not be for A&E admissions as there wouldn’t be any.

HRI A&E will only stabilise patients who need admission to hospital, before sending them on to CRH or another acute/emergency hospital. The beds would be for post-acute patients transferred from CRH if they don’t need acute care any longer but are not ready to go home.

Q: How many of these post-acute patients at any given time are likely to need physician-led inpatient care at HRI, while awaiting arrangements to meet their future needs? How many doctors will this require? Is this what is called “physician led step down inpatient care” in the overview of the proposed service configuration on p 4?

The Trust emailed that detailed modelling work regarding the number of patients and workforce model will be completed as part of the development of the Outline Business Case (OBC) which is due to be submitted to NHS Improvement and published in February 2020.

Q: As in the original proposal, the claim is still that the provision of planned surgery and medical procedures at one site will minimise the risk of disruption to planned surgery from emergency admissions. But what happens to the safety valve for unexpectedly high acute/emergency admissions that’s provided by the ability to postpone planned surgery and medical procedures? How do you plan to deal with surges in emergency admissions without that safety valve?

There are protocols and service continuity plans in place as part of the standard operating procedures within all services to support such situations should they arise. These are regularly reviewed as standard practice to ensure the service can continue to function.

The Trust’s modelling of the acute inpatient bed capacity required at the unplanned hospital will include sufficient flexibility to be able to respond to in-year variation in demand.

Q: We asked about A&E consultants

Anna Basford said they don’t have consultants on site 24/7 now, but there are on-call consultants and they do come in.

Q: We asked how many CRH beds would be cut, if the CCGs realise their “aspiration”, (reported in the CHFT update to the Sec of State) that Care Closer to Home will reduce non-elective bed days for the population by 30% over 5 years.

We didn’t get an answer to that question in the meeting and we forgot to email it afterwards.

Q: What if there is no sustainable reduction in demand for in patient care, once the care closer to home services are in place?

Anna Basford said in that case there would be no acute hospital bed cuts.

Q: Is this possibility being factored into the financial projections?

Anna Basford said yes.

Digital technology

Q: We asked what kind of digital technology will ensure that specialist advice will always be available across both A&Es.

Anna Basford said that currently patient records are fully electronic with real time data. Specialists in CRH will be able to remotely review patients in HRI and provide specialist advice on the phone.

Q: We asked why, if the electronic patient record system is so all singing and dancing, patients were receiving outpatient appointment letters with the wrong information about where they were meant to go, and after the date of their appointment.

Owen Williams said he would look into specific examples we presented, but he had no overall answer.

Q: We asked about data security and what proportion of the £196m will have to be spent on digital data security.

Owen Williams said that during the big cyber breach last year that hit the NHS, CHFT wasn’t affected. NHS Digital has assessed them as robust in cyber security. NHS England commissioned Deloitte to assess CHFT’s digital maturity and they judged CHFT to be the 3rd most digitally mature in the NHS.

Owen Williams continued evangelising for Cerner’s Electronic Patient Record.

He said there are 85 GP practices across the CHFT footprint. The Electronic Patient Record allows hospital doctors to see the GP record of patient data. Also the GPs can now also see the hospital records. CHFT has introduced a digital patient portal for about 10K patients across 8 specialities. Patients will be able to remotely update their data digitally from home, eg blood pressure. CHFT is working hard to make Care Closer to Home work.

(This is all part of the “left shift” of health care which ends up with the patients doing a lot of the work themselves – just as with all this digital stuff in all areas of our lives.)

And what about people who don’t have the internet or smartphones?

Q: What is the regional imaging collaborative? What region does it cover? Is it up and running? If not when will it be?

Nine acute Trusts in Yorkshire & Humberside (as listed below) formed a Regional Imaging Collaborative (RIC) in 2015. Established by the West Yorkshire Association of Acute Trusts (WYAAT) and hosted by Bradford Teaching Hospitals Foundation Trust (BTHFT), the aim of the collaborative was to procure a strategic enterprise imaging solution to replace existing radiology PACS for all RIC member trusts, with a wider vision that the proposed solution would be an enabler to the transformation of imaging and diagnostic services across the region.

The RIC Programme Board was established and completed a procurement exercise which resulted in a shortlist of seven suppliers in March 2016. Following a response and evaluation exercise the trusts agreed to award Agfa with the contract to supply all RIC member trusts. Once the work is complete, all trusts in the collaborative will be on the same imaging platform.

The ultimate goal of the RIC is facilitation of workflow sharing and transformation; to this end, a RIC Yorkshire Transformation Working Group was established which continues to investigate potential transformational elements for the future such as:

  • Capacity optimisation – subspecialty sharing of work & reporting across member trusts (lack of specialist staff nationally means it is difficult to recruit to vacant posts)
  • Supporting patient flow – 24/7 agenda & regional on call
  • Supporting multi-disciplinary team (MDT) working including rapid image transfer
  • Flexible workforce – home or remote reporting; principles for job planning

The Regional Imaging Collaborative member Trusts are:

  • Airedale Hospital NHS Foundation Trust
  • Barnsley Hospital NHS Foundation Trust – exited the Collaborative January 2017
  • Bradford Teaching Hospitals NHS Foundation Trust
  • Calderdale & Huddersfield NHS Foundation Trust
  • Harrogate & District NHS Foundation Trust
  • Hull & East Yorkshire Hospitals NHS Trust
  • Leeds Teaching Hospitals NHS Trust
  • The Mid-Yorkshire Hospitals NHS Trust
  • Northern Lincolnshire & Goole NHS Foundation Trust

Q: What laboratory information management systems are being made interoperable?

Each Trust in the UK has a Laboratory Information Management System (LIMS) and some of these are being configured to link with labs that carry out the testing in order to request and receive results electronically and therefore quicker.

Q: Which ones involve national genomics testing on behalf of NHS England?

There will be 7 main hubs from Genomics throughout the UK, more information can be found here .

Q: Are they going to be taking genomic data from people who have taken part in the scheme whereby you pay £100 to get your genome analysed?

Information on this can be found here .

Q: What is the K2 Athena maternity patient record, why is it a good thing and which organisations have access to it?

K2 Athena is a Trust Maternity Patient Record system which captures all aspects of obstetric care within the Athena and Guardian package. Athena includes all the antenatal and postnatal care in the community, antenatal clinic appointments and inpatients. It ensures that all clinicians involved in a patient’s maternity care pathways have the information they need to provide compassionate care to that patient. Only CHFT have access to this system directly although there is a patient portal where patient information is available.

Q: Why is direct booking of appointments from 111 to GPs a good idea? We’ve heard from primary care clinicians where 111 has trialled booking into their same day afternoon slots that it was always a waste of time; also 111 booked patients who weren’t their patients into a slot, one time with the wrong records attached.

The Trust do not commission the NHS 111 service and so cannot respond to this question.

Q: How will the expanded use of technology provide detailed analytics and reporting to support future improvements to care?

Most of this is covered at a high level in the NHS Long Term Plan

The implementation of electronic systems across care pathways (EPR, K2, Athena etc), combined with the sharing of data across primary care and secondary care settings (HIE/MIG) gives many benefits to both patients and clinicians. It ensures that the clinician has the most accurate, relevant and detailed information possible giving a broader picture of the patients’ needs enabling the trust to deliver the most appropriate compassionate care package to the patient and deliver positive outcomes. Availability of this data gives more depth to reporting and enables more detailed analytics, both of which help to shape the provision of care and set the foundations for future use of digital information.

Risks of extra travel time

Q: We asked why the update to the Secretary of State doesn’t mention the risks to Greater Huddersfield patients of extra travel time to A&E

We said that at a meeting of Calderdale and Kirklees Joint Health Scrutiny Committee, the hospitals trust Medical Director had admitted that there was a trade off between the benefits to patients of centralising A&E and the risk that some patients would die as a result of the extra ambulance travel time time to A&E. But on balance more lives would be saved than lost as a result of the A&E centralisation.

Owen Williams disputed that the Medical Director had said this and asked for our notes from the Scrutiny Committee meeting. We agreed to find and send them.

It turns out that the ck999 notes record that it was Dr Mark Davies, the hospitals’ Clinical Director for Emergency Care, who spoke at the Calderdale and Kirklees Joint Health Scrutiny Committee meeting on 19 April 2016. Not the Medical Director. This is the relevant extract from the notes:

Owen Williams thinks there have been changes to the travel plans and suggested we ask the CCGs for any updates.

Q: There is already extra travel time for outpatients services. This is because GPs no longer seem to refer patients to HRI or even CRH for a variety of treatments. Specifically:

a) Why are Huddersfield patients whose GPs have referred them for dermatology treatment being told they can’t go to HRI but instead must go to either Barnsley, Rotherham, Sheffield or Harrogate – even though there’s a dermatology department at HRI? AND one at CRH. This creates considerable difficulties for patients who have to travel such distances, particularly those who use public transport. How can this be fair or right?

b) And conversely, why are Dewsbury patients being referred to CHFT for heart monitoring, when they wanted to go to Dewsbury District Hospital and there’s a cardiac department at Pinderfields – but GPs said the options were only Halifax or Huddersfield?

The Trust emailed that it complies with the NHS eReferral Guidance issued by the Department of Health and Social Care, NHS England and NHS Improvement regarding patients’ right to a choice of any provider.

The Trust makes all reasonable endeavours to ensure sufficient appointment slots are available within the NHS e-Referral service to enable service users to book an appointment within a reasonable period, however on occasions when there is no availability to receive new referrals into a service, patients may be offered an alternative provider to book an appointment with.

In the case of the CHFT Dermatology service, due to current limited Consultant workforce capacity the Trust service is closed to all new routine referrals and is only able to offer access to 2 week pathways for cancer related referrals. In relation to patient access to the cardiology services at Dewsbury and Pinderfields Hospitals we suggest that this query should be raised directly with Mid-Yorkshire Hospitals Trust.

In relation to wider plans for outpatient services The Trust is working towards the aim of reducing outpatient appointments by one third and is developing new models of outpatient care, enabled by the use of digital technology.

Q: We asked how patients on low incomes could afford to travel further for hospital treatment – whether this was people from Todmorden having to go to Huddersfield for planned care, or people from Huddersfield having to go to Halifax for acute care and children’s care.

We also said that for many patients on low incomes who rely on families for practical and emotional support, the problem is so great that it means they will not call an ambulance for fear of being taken to Halifax or Leeds, where their families would not be able easily to visit them in hospital.

For those who do find themselves or their children in hospital outside Huddersfield, they are unable to receive help from their families that is possible when the hospital is only a short distance away.

Owen Williams said this problem already exists and he knows it’s difficult for people on low incomes when they are in a hospital which isn’t in their own town or area. (He didn’t seem to appreciate that if it’s already difficult for people on low incomes, making it more difficult is not such a great idea.)

He also said that the reason the hospitals trust has a large deficit is because they have prioritised patient care and staff over money. He had just been in a performance review meeting with NHS Improvement and had had to argue with them about that.

We will leave that without much comment for now – apart from objecting that the reason the hospitals trust has a large deficit is because successive blasted governments have persistently underfunded the NHS and, via the quango NHS Improvement, forced hospitals to make spending cuts in order to “balance” their budgets.

However, it is true that in 2014 or 2015 (can’t remember when exactly) the hospitals trust refused to make all the spending cuts NHS Improvement was telling them to make, because they couldn’t do that without endangering patient safety.

And the finance director Gary Boothby has told us that in 2018/19 the hospitals trust refused to accept their control total.

Care Closer to Home

Q: We asked how they hope to persuade the Secretary of State that this is a “development” of the original Care Closer to Home proposals that the Independent Review Panel found lacking. And not just more aspirations?

Because there is no evidence in the update to the Secretary of State that the CCGs’ capacity modelling report has answered the misgivings of the clinical senate about the original care closer to home proposals – broadly, that they were vague, aspirational and unevidenced.

Anna Basford said we need to ask the Clinical Commissioning Groups about the modelling work they’ve had done to show estimated reductions in A&E admissions as a result of their Care Closer to Home plans.

She said the hospital reconfiguration isn’t reliant on Care Closer to Home because the hospital will keep all the CRH beds open if demand isn’t reduced by Care Closer to Home.

Money

Q: We asked if the £20m capital funding loan for HRI extends to equipment such as scans etc. Or is it just to fix the maintenance backlog on the buildings?

Anna Basford said the Dept of Health cash flow means that £22m of the £196m capital funding loan is immediately available – subject to a business/approval process – up to 2022/23. The rest will be available after that – again, subject to a business process.

Because of building issues at HRI, there is an opportunity to access the £22m early, subject to a separate approval process, before the full business case process is completed in September 2022.

The hospitals trust are asking what the process is for getting approval for early access to the £22m.

Q: We asked what are the immediate issues with the building that they wanted to spend the £22m on.

Owen Williams said we would see when we did the walk round the hospital, but there are issues with falling cladding and fire safety. He plonked a broken wall tie on the table and said that recently the cladding had fallen off the wall outside the entrance to Trust HQ and if we’d come then we wouldn’t have been able to get into the building.

Broken wall tie

Chris Davies, head of estates, took us on a walk round the outside of the hospital and through the bowels of the hospital where all the boilers and pipework are.

He said there are three main problems with the building:

  • The cladding is unsafe because it is held onto the building with wall ties that have reached the end of their life. The estimate they’ve had for replacing it is £20m so they’re looking for cheaper ways of doing it.
  • There are not enough fire breaks for current fire safety standards in the long, long corridors that house all the pipework.
  • The 1960s pipework needs updating but this is very costly because they are coated in asbestos and the corridors also have asbestos in the walls behind the pipework that are not really accessible. The risers that house the vertical sections of the pipework are inaccessible to maintenance staff beyond the 2nd floor because of asbestos and heat. To repair/replace the pipework they would have to close wards, which would mean building new wards outside so they could take existing wards out of use during pipework maintenance. They don’t know how much this work would cost.

The £20m earmarked for building maintenance is not enough. Anna Basford said it’s unlikely that more will be available. They don’t how long the maintenance work they can afford in the 3 priority areas will future proof the hospital for.

There were more questions that we didn’t have time to ask so we sent them to the Trust for written answers. You can read the answers

Update: Here’s the April 2019 revised Strategic Outline Case for the Hospital Services Reconfiguration.

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