This report outlines NHS Organisations’ responses – and failures to respond – to questions raised by the public and councillors at the 15.2.19 Joint Health Scrutiny Committee meeting.
What was the meeting about?
Three months behind schedule, Calderdale and Kirklees Joint Health Scrutiny Committee finally met on 15.2.19 to scrutinise the hospitals Trust’s January update to the Secretary of State. This was about the Trust’s revised proposals for hospital cuts, centralisation and the move of hospital services into Primary Care Networks.
The Secretary of State required revised proposals because he agreed with the Joint Health Scrutiny Committee that the original proposals were not in the interest of the public or the local NHS organisations.
You can find information here about concerns from the public about the revised proposals and what Calderdale and Kirklees Joint Health Scrutiny Committee decided at its 15.2.19 meeting.
Twelve Questions the NHS organisations answered
1.The revised proposal for HRI A&E is different from the previously-proposed urgent care centre in that it would have full resuscitation facilities for patients before transferring them to full A&E. The resus at HRI for walk-in patients will include children
2. It would also have consultant on-call cover. This would be broadly the same as now, plus specialist doctors at HRI. Although they “hope” to extend consultant cover at CRH.
3.But the Hospitals Trust doesn’t know if there will be enough Calderdale Royal Hospital A&E consultants to meet Royal College of Emergency Medicine workforce requirements for 1 A&E consultant per 300 type 1 A&E attendances. There is a shortage of NHS clinical staff in general and apparently no workforce plan to solve the problem.
4.Loss of vascular services from CHFT will mean A&E patients needing this service will have to go to Bradford. For maternity bleeding they would go to the specialist maternity unit. (The one at Calderdale Royal Hospital)
This decision has been made by West Yorkshire and Harrogate Integrated Care System, through the West Yorkshire Association of Acute Trusts. The Association meets in private and doesn’t publish its minutes. Cllr Colin Hutchinson said that when the West Yorkshire and Harrogate Joint Health Scrutiny Committee had discussed it earlier in the week,
“The main concern was about the knock-on impact on other services within the Trust. If you move services and skills from a trust this often affects the rest of the trust.”
He added that the Clinical Senate report identified various areas that could be affected – eg bleeding complications in childbirth and effects on the Hyper Acute Stroke Unit.
Dr Birkenhead, the hospitals’ Medical Director, said he didn’t think there would be an impact on the CHFT Hyper Acute Stroke Unit. So what does he know that the Clinical Senate doesn’t?
September 2019 Update here. It turns out that this is a scheme dictated by the government quango NHS England, that commissions specialised vascular services.
5. They’re not going ahead with the Trust’s previous proposal for a new build hospital on Acre Mill site. The revised update to the Sec of State proposes a £20m capital investment in maintaining the main HRI site. But the capital funding is not enough to sustain HRI in the long term.
6. There’s not enough info from the Trust for Councillors to see if the capital funding’s enough for Calderdale Royal Hospital either. Councillors need to see the info in the funding bid to make sure the capital is enough to meet increased demand for these services at CRH. The £177m for CRH is based on 2017 figures for considerable expansion of wards, A&E, operating theatres and parking. The Trust said it will need refreshing as things move forward.
7. There’s no way of saying the system being designed now will be fit for purpose in 5,10,25 years time – it’s a question of
“a solution that’s affordable given financial and workforce capability”(Matt Walsh, Chief Officer, Calderdale Clinical Commissioning Group)
8. The Trust will keep hospital bed numbers at current levels whilst Care Closer to Home services are developed. Matt Walsh, Calderdale CCG Accountable Officer, said:
“The revised proposal to the Secretary of State takes no beds out of hospital. The proposal is to keep current numbers of beds until/unless we can show a reduction in the requirement for hospital beds.”
9. The hospital bed capacity modelling is the basis for the “aspiration” in the Trust’s Update to the Secretary of State, for a 10% reduction in bed numbers. The update also mentions a possible 30% reduction. This is based on optimal systems nationally and internationally that have the potential to reduce inpatient bed days by 30-40%. According to Matt Walsh, Calderdale Clinical Commissioning Group Accountable Officer, 30% is ambitious enough.
10. There’s so much data that NHS Commissioners can’t see the wood for the trees, but they are willing to identify subsets of data on outcomes for patients, that they will share with the Joint Health Scrutiny Committee. The NHS organisations already report this data to NHS England and the Joint Health Scrutiny Committee also need access to it over a period of time. This will allow them to see if Primary Care Networks are making progress with Care Closer to Home and reducing demand for hospital beds, through achieving reductions in unplanned re-admissions, waits for day case surgery, a&e admissions etc. What next? We will get back to Calderdale and Kirklees Joiunt Health Scrutiny Committee and ask if they have seen this data and what it says.
11. But NHS Commissioners are reluctant to report to Joint Health Scrutiny Committee on Care Closer to Home: tagged onto Matt Walsh’s answer that he was willing to share agreed data sets with the Committee was this stinger:
“A question for Calderdale and Kirklees Joint Health Scrutiny Committee is if hospital changes are not designed to take beds out, then it’s not this scrutiny cttee’s business to scrutinise place-based schemes to reduce hospital demand – but each LA’s scrutiny committees.”
What next? It is vital that Calderdale and Kirklees Joint Health Scrutiny Committee continues to scrutinise the so-called place based schemes to reduce hospital demand – ie the Care Closer to Home schemes for Calderdale and Kirklees. We will write to the Joint Health Scrutiny Committee chairs and members teling them why.
12. Is the Trust being honest with the Secretary of State about the functionality of the Electronic Patient Record? Cllr Hutchinson said that the level of functionality of the Trust’s digital technology reported in the update to the Secretary of State (eg GPs access to hospital patients’ data) was far greater than was evident in the November demonstration, when the Trust Chief Exec Owen Williams showed him and others the system in action. He wants a further visit to see these functions in action.
Dr Birkenhead replied that the Electronic Patient Record system has become far more functional since the Councillors visited and they are welcome to come back and see.
Fourteen questions the NHS organisations didn’t answer – and must!
1.They said nothing about the need for a 24/7 full type 1 A&E at Huddersfield Royal Infirmary.
Councillors didn’t ask about this important point -it was left to Thelma Walker MP and campaigners to make it.
Have Councillors forgotten that at the July 2017 ckJHSC meeting, when the Committee decided to refer the original proposals to the Secretary of State, Paula Sherriff MP for Dewsbury reminded everyone that the continued existence of Huddersfield Royal Infirmary’s full A&E department had been a condition of the Secretary of State’s acceptance of the Mid Yorks reconfiguration plan in 2014?
Thelma Walker MP pointed out that the revised plans provided no social justice for Colne Valley because the proposed Huddersfield Royal Infirmary A&E was really just a walk-in centre for urgent care. Colne Valley Constituents need a full A&E at Huddersfield Royal Infirmary. She knows the need for this from personal experience.
Hands off HRI asked:
Do the Trust consider the HRI proposal to be a full ‘Type 1’ A&E, and if not, what?
CK999 said we still couldn’t see that there’s any socially just alternative to to 2 Towns, 2 full blue light 24/7 A&Es. The revised plans will further disadvantage ordinary people who are short of money, time and rely on public transport.
2. The NHS organisations said nothing about whether there will be a new public consultation on the revised proposals. What next? There must be and we will keep demanding that there is.
3. There was no answer to ck999‘s question: Has the hospitals Trust seen the Clinical Commissioning Groups’ detailed capacity modelling report? Which organisation produced it? Can the public see it?
So we wrote to the hospitals Trust and asked. They said, yes, they’ve seen a copy of the report.
Update 14.9.19 the notorious global management consultancy company McKinsey produced the detailed capacity modelling report
Calderdale Clinical Commissioning Group told us this after we noticed that Calderdale Clinical Commissioning Group’s April 2019 register of private company contracts included this:
Right Care Right Time Right Place Programme Support – open competitive process – New Contract with GHCCG – McKinsey &Co, 1 Jeremy St, London SW1Y 4UH Contract value £150K start date 24.9.18
Decision making process and name of decision making committee Chief Finance Officer and Chief Officer
Calderdale Clinical Commissioning Group told us that the aim of the work they paid McKinsey to carry out was:
To be able to clearly quantify the impact of interventions in primary and community care on reducing demand in acute settings, by being more rigorous about: which interventions work; how we could standardise their application; and the utilisation of underpinning data driven modelling to give confidence in delivery.
McKinsey’s final report has been published on the CCG’s website, here.Calderdale Clinical Commissioning Group FOI Ref: 1920095
Date: 5 September 2019
The £150K contract lasted for eight weeks and McKinsey is no longer providing support to the Right Care Right Time Right Place programme.
They awarded McKinsey the contract through a three stage competitive procurement exercise: Initial triage, Shortlisting, and Evaluation Panel decision. At the end of this process McKinsey was awarded the contract as the preferred bidder, out of seven bidders.
4. Can Primary Care Networks work with a shortfall of trained staff? Cllr Hutchinson said at the West Yorkshire and Harrogate level there are very serious concerns about numbers of staff available to work within the system. The Joint Health Scrutiny Committee need to know the data about that.
The NHS Organisations answered none of CK999‘s questions about Care Closer to Home and Primary Care Networks – nor did Councillors ask them to:
5. The Trust’s January 2019 update to the Secretary of State includes Annex A – Care Closer to Home – Additional Information. In this Annex, is the proposal for one accountable manager per primary care network? How does this sit with requirements of the new GP Primary Care Network Contract? Is it the same as the Primary Care Network Clinical Director?
6. Annex A proposes that the accountable manager would decide how care’s provided by the different partners. Is this through the lead provider deciding which services to subcontract to member GP practices?
7. Would the Primary Care Network contract holder effectively have commissioning powers?
8. Who would be on the Locality Partnership Boards? Would they meet in public?
9. Annex A says the primary care networks would operate within “the proposed Integrated Care System”? Is this a proposed Calderdale and Huddersfield Integrated Care System? Or two separate Calderdale and Kirklees Integrated Care Systems?
10. Either way, what governance and accountability processes would apply?
11. As part of “Care Closer to Home”, the hospitals Trust funds nursing home beds. Where are they? Are they rehabilitation beds? Who provides them?
As the hospitals Trust didn’t answer this question, we emailed it to them. They replied:
The choice and recovery pathway was established as a pilot in 2018 to support patients who require continuing 24 hour nursing care and support to leave hospital earlier.
This pilot enables suitable patients to be transferred from hospital to an existing local nursing home where the patient and their family or carers can engage in full assessment of needs and risks to identify the long term care and support they require. The nursing home works in partnership with members of a Multi-Disciplinary Team including Senior Nursing staff and Discharge Coordinators, GP, Nursing home staff, Trusted Assessor and Social Care.
12. Will the hospitals Trust fund more out of hospital services in future?
Although we also emailed the Trust this question, they didn’t answer it.
13. Annex A says that by 2023 there would be 169 community beds and 13 thousand m2 of estate. Where would these beds be, would the hospitals Trust provide them and if not, who would?
We emailed the Trust this question and they replied that we should ask the Clinical Commissioning Groups.
14. How many community beds are there now, where are they, and do they include mental health beds? Is the 2023 estate footprint significantly different from now?
Six Questions and comments the NHS organisations might have thought they answered, but didn’t really – and must!
1.The Trust’s update to the secretary of State said nothing about prevention and addressing health inequalities – but the NHS Long Term Plan requires this.
Responding to this comment from Cllr Elizabeth Smaje, Carol McKenna, Chief Officer for both Greater Huddersfield and N Kirklees Clinical Commissioning Groups, regurgitated NHS England’s official line – which ck999 regards as bs:
Inequalities and prevention are implicit in the service model for Primary Care Networks and backed up in the Primary Care Network contract.
The benefits should be greater in-depth understanding of 30K–50k population needs in each Primary Care Network area. So they can deliver targetted responses to those who are the highest users of services.
Additional roles in Primary Care Network teams include social prescribers to direct patients to other sources of care and need. This is often used in mental health already.
2. What’s the timeline for development of locality hubs? In Sowerby Bridge have heard very little but it’s more developed in N Halifax. When will we start to see more detail?
Carol McKenna’s answer was too vague to be useful:
- The GP Primary Care Network contract sets out a specific timeline nationally that GPs will need to work to now to deliver.
- By spring this year the Primary Care Networks will be able to submit docs and by Aug 2020 they will start to deliver against national specifications.
- CCGs will also work on it through commissioning.
- It is now a national core requirement that everyone should be delivering on some things at specific dates.
3. How is the hospitals Trust’s revised business case addressing the need for both Mid Yorkshire and Calderdale and Huddersfield trusts to work together for the whole place, not in separate organisational structures?
Bearing in mind that N Kirklees had experiences about the ability of Mid Yorks trust to meet pressures.
Carol McKenna replied defensively that lots of Kirklees Council’s response agreed with the revised plan – eg maximising the use of digital technology, integrated commissioning and integrated work by all providers not just the Trust.
“So this demonstrates we have a Kirklees focus on care, not just on organisational boundaries.”
Anna Basford said the hospitals Trust works with the Kirklees Integrated Provider Board and on how to develop integrated care in Kirklees and right pathways for people who need acute care in terms of blue light access.
4. Access to urgent care in rural areas
Cllr Elizabeth Smaje asked how the revised hospitals model is going to adapt to the LongTerm Plan’s promotion of urgent treatment centres that are supposed to be more local than hospital urgent care centres.
Relatedly, Cllr Stewart-Turner asked if the Locality centres at Tod and Holmfirth are back on the agenda.
Matt Walsh said:
- They will have to keep responding to changes that emerge in the 10yrs of the Long Term Plan.
- The changes the Clinical Commissioning Groups and CHFT are proposing are the ones that are being adopted in NHS England’s Long Term Plan.
- Both Calderdale and Kirklees are ahead of the game. On front foot. They’ve anticipated the changes.
- The Long Term Plan is a framework for “localities” to identify how they will meet challenges.
- They are asking themselves about a locality hub solution to urgent care access.
- The relationship between the emergency hospital, urgent care centres and locality urgent treatment centres will emerge and depend on what workforces can sustain (CK999 comment: FGS. Aren’t they supposed to be producing a workforce plan? In fact weren’t they supposed to produce one in 2016, as part of the Sustainability and Transformation Plan?)
- West Yorkshire out of hours arrangements would be about how to open up access to 111 to dial in appointments to GP practices. (CK999 comment: Wasn’t this meant to be specified in the Integrated Urgent Care Services contract?)
5. Is there a plan in Yorkshire and Harrogate to train up enough interventional radiologists to make sure that there are enough to sustain the proposed 2 vascular services in Leeds and Bradford?
Dr Birkenhead said the shortage of interventional radiologists was very challenging for both Bradford and HRI. There will still be some vascular services at CRH as part of acute services and they will need interventional radiologists for that.
6. Has CHFT had assurance that interventional radiologists would be available through the West Yorkshire and Harrogate hospitals network? Is there any impact on Calderdale and Huddesfield hospitals Trust that Calderdale and Kirklees Joint Health Scrutiny Committee needs to be aware of?
Dr Birkenhead said this is a service at risk because of workforce shortages. Think he said there’s only one interventional radiologist at CHFT?
“The network will help meet the challenge but the workforce challenge is across the network as a whole.”