Scrutiny Councillors demand hard info on transformation of GP and community health services

7 months late, here’s a report on the 4 July 2019 Calderdale and Kirklees Joint Health Scrutiny Committee meeting about the revised Strategic Outline Case for the hospitals cuts and centralisation.

Although the July 2019 report on the Scrutiny meeting is now outdated, we’re posting it here for the record. It might be useful to come back to, to check if what needed to be done has been done. Particularly the need that this meeting identified for:

• Hard information about care closer to home services, in order to consult the Clinical Senate, Primary Care Networks, Local Medical Committees and the public on definite proposals, not nebulous aspirations
• More info about who exactly will staff the paediatric resuss facilities at the downgraded Huddersfield Royal Infirmary (HRI) A&E
• Info about what the Yorkshire Ambulance Service protocols are for HRI
• GPs’ access to the hospitals’ Electronic Patient Records and vice versa
• More work on travel and transport issues
• Proper funding of the hospitals Trust

What The Committee scrutinised:

• The CHFT Update on their current financial position
• The revised Strategic Outline Case for hospital services reconfiguration
• Plans for stakeholder and public engagement

The meeting was a hard slog and I haven’t been able to make the report any lighter.

ISSUES CLARIFIED FROM THE PREVIOUS MEETING

The Scrutiny Committee clarified two points from the previous (Feb 15th 2019) meeting:

Cuts To Elective Bed/Days – But Not Beds

The hospitals Trust are NOT cutting the number of hospital beds, but are proposing to leave it as they are now. Instead, the hospitals trust said they were proposing to cut the number of elective bed/days in future by 10%. They reckon there will be “ a reduction in demand for bed days because of mitigation from community services”, according to Anna Basford, Director of Transformation.   This is based on capacity modelling in the revised Strategic Outline Case. She added,

“This 10% is in relation to resilience in relation to future demographic demand…existing community services will be more than able to absorb the demographic demand of 10% increase.”

Paediatric Resuss Facilities At Hri Will Not Be Staffed By A Specialist Paediatrician

Dr Birkenhead, the hospitals Trust’s Medical Director, said there will only be a “trained paediatric life support person present who could stabilise child patients before transfer to CRH.” Not a specialist Paediatrician. No one asked what a trained paediatric life support person is, so we need to email him to ask.

Issues raised in public deputations set the agenda for the meeting

These were:

• NHS funding
• The transformation of primary and community health services in relation to the hospitals cuts and centralisation
• Further public consultation
• Travel and transport

It became clear in the process of scrutiny that the NHS organisations had not yet done much work on anything except finances.

ck999 made 2 deputation statements:

There is NO compelling case for change for cutting and centralising our 2 District General Hospitals.

Because the case for change is based on successive governments’ ill-advised political choice to cut public spending, following the global financial crash and the bankers’ bailout.

2 full District General Hospitals remain the best option for the people of Calderdale and Kirklees. We have the money to pay for them. As a country with a sovereign currency, the government creates money by spending it, as it did to bail out the bankers. If it can bail out the bankers, it can and should bail out the NHS.

The transformation of primary and community health services is about cutting hospital costs. 

The Strategic Outline Case says that the only way the hospital can meet its financial control total is to transform hospital and community services.

Without any public consultation – or even consultation with GPs – the Clinical Commissioning Groups have rushed to set up 14 Primary Care Networks in Calderdale and Kirklees. These are to provide cheaper alternatives to a range of hospital services and cut hospital admissions and use of outpatients.

This raises many questions that were not addressed at the Stakeholder Engagement Event on the revised Strategic Outline Case, so we asked the Scrutiny Committee to ask them now.

Acute and emergency services at Huddersfield Royal Infirmary

Colne Valley Cllr Warner and Steve Slator from Hands Off HRI spoke about this.

Cllr Warner said the number one issue for people in Colne Valley, particularly among old people, is the loss of acute services. She asked if there would there be fully staffed acute doctors and said, 

“If there’s an opportunity to look at this again, it should be taken.”

Steven Slator asked if the HRI A&E would be a proper A&E. He said people are expecting nothing less than a fully functioning A&E. But the revised Strategic Outline Case shows that HRI won’t have the required critical care facilities and critical co-dependencies with acute services. Because they will be removed to Calderdale Royal Hospital. He asked the Scrutiny Committee to take this up with the hospitals Trust. Also Yorkshire Ambulance Service clinical protocols were still to be worked out.

Travel and transport

Mike Foster said that the revised Strategic Outline Case relied heavily on the old travel and transport group – how relevant is that now, with the new reconfiguration model?

Has the hospitals Trust set up the joint travel and transport working group yet?

As for roadworks, Ainley Top works have been done but the bottlenecks are worse. Salterhebble works have just pushed the bottleneck a few hundred yards along the road. Other bottlenecks remain including on motorway. How has this been considered and what mitigation is in place?

Does the desktop transport analysis correspond to patient experience?

The Shuttle bus service is not fit for purpose in various ways.

Wider consultation on the revised proposals

Cristina George asked about this. She  said the Calderdale Clinical Commissioning Group Chief Officer had agreed to share data to show the reduction in hospital beds is possible. Has he got it? Do primary care providers agree with the data?

There are improved delayed discharge figures for Calderdale, is it also improved for Huddersfield?

The 5 issues raised in their Judicial Review by the judge need to be fully addressed by Scrutiny and NHS Organisations.

HOW THE SCRUTINY COMMITTEE PICKED UP ON THESE ISSUES

NHS funding and the Hospitals Trust Finances

The Scrutiny Committee ignored the point that there’s no compelling case for change.

Instead, Cllr Smaje said it was important for Scrutiny to consider the financial sustainability of the Trust and Clinical Commissioning Groups.

No one pointed out that:

• Calderdale and Huddersfield hospitals are among the many hospitals across England that now rely on ‘loans’ from the Dept of Health and Social Care to pay staff and suppliers. Our hospitals trust is among the most “indebted” and faces ridiculous interest charges. Its total debt to the Dept of Health and Social Care at April 2019 was £144.9m. This is 39.3% of its turnover and in 2018-19 it paid £2.3m interest on this debt.
• Calderdale and Huddersfield hospitals trust has been drastically underfunded since 2014, which is why it has to borrow money from the Department of Health and Social Care.
• Hospitals’ debts to the Department of Health and Social Care have risen steeply since the introduction of NHS England’s cost-cutting Five Year Forward View 2015 -2020, and the imposition of Sustainability and Transformation Plans. Astonishingly, since 2017-18, these debts have exceeded NHS hospitals’ PFI liabilities.

Given this madness, it would be appropriate for the Health Secretary to write off Calderdale and Huddersfield NHS Foundation Trust’s deficits and its debt to the Department of Health and Social Care.  More info here .

Government and NHS quangos’ carrots and sticks

Kirsty Archer, Deputy Director of Finance at the hospitals Trust, said

• The 2019/20 financial plan was the baseline for the financial modelling for the reconfiguration case.
• There is additional funding of £28.28m cash that they can use to reduce the hospitals trust planned deficit of £39m this financial year.
• The risk levels this year are more balanced than before.
• All efficiency plans will go through Quality Impact Assessment/ Equality Impact Assessment.

Cllr Smaje said that, as the Trust was planning on a £39m deficit this year, that’s supported by £28.28m extra funding:

• What happens if the Trust don’t achieve savings?
• And what happens next year if they don’t meet the £39m target for the deficit?
• Would they lose the additional funding?

Kirsty Archer replied, incomprehensibly,

“The marginal rate emergency tariff [??1] is £6m.  This should come into overall tariff next year and should become normal part of funding.”

No one asked what this meant. Maybe they all understood it. I had to do a bit of digging after the meeting. What I found is at the end of this blog post, if anyone’s interested.

Kirsty Archer added that the other 2 pots are likely to flow because they remain available nationally.  (What 2 other pots?) But if the Trust don’t hit the control total this year, it’s measured on a  quarterly basis.  So if they meet it quarter on quarter they would get some. They would only lose a portion of that funding because it would only be in a portion of the year that they fell short.

Cllr Hutchinson asked how the financial position was looking so far. He was told that the Trust had hit the plan from months 1 and 2 and were on track to hit the quarter.

In terms of the recurrent Cost Improvement Programme (ie so-called efficiency cuts or savings), the Trust had delivered 86% of the savings recurrently – better than the year before and better than the national average. The shortfall has been incorporated into the £11m Cost Improvement Programme for this year.

Surely they didn’t need to set up a company to change the light bulbs and use HRI facilities staff efficiently?

Cllr Hutchinson asked how the Wholly Owned Subsidiary was proposing to meet the Cost Improvement Programme plans it was set up with last year. The answer was with efficiencies through use of energy,  eg low energy lightbulbs, efficient use of staff in the HRI facilities side etc.

Public consultation and transformation of primary and community health services

Kirklees Cllr Simpson asked if the “engagement” should extend to consultation.

Matt Walsh, Calderdale Clinical Commissioning Group Chief Officer, replied,

“Technically speaking that’s not our call. The Joint Health Scrutiny Committee will advise if engagement plans are satisfactory or not.”

Cllr Simpson asked if the NHS organisations expected that a new consultation would produce similar results to the last one. Cllr Smaje added,

“In the last consultation you had a 12 week statutory consultation – you’re saying this time if JHSC wants extra work we can say so, but you don’t think you need 12 week statutory consultation. The last consultation found 80% of Kirklees people thought the proposals would have a negative impact. So how are you going to try and persuade them differently this time?”

The Clinical Commissioning Groups’ engagement officer, Penny Woodhead, lamely said the best mechanism for engagement/consultation depends on the topic.

Where is the hard information about care closer to home services?

Cllr Hutchinson pointed out the need to be clear on the timing of engagement/consultation, so there is specific information for the public to consider and they can get clear answers – not some nebulous vagueness. The Scrutiny Committee want to work with the Trust and Clinical Commissioning Groups about this.

Cllr Smaje added that a specific topic used a lot in the Strategic Outline Case is care closer to home services demonstrating a reduction in hospital care.

She said Kirklees health scrutiny committee needs to look at changes to services and so does Calderdale health scrutiny committee. The Calderdale and Kirklees Joint Health Scrutiny Committee needs evidence to see if plans for reducing hospital services based on care closer to home are sustainable. They need to test their concerns and the Independent Review Panel concerns. The Scrutiny Committee want a specific piece of work on this.

Cllr Hutchinson said the Scrutiny Committee will assess which data they need to test that the local NHS is on a trajectory that makes the planning assumptions valid. An informal workshop with the Clinical Commissioning Groups and the Trust about the data dashboard would be useful,  particularly in relation to the 1st 2 requirements of the Secretary of State.

(These are:

• The need for further work on out-of-hospital care – this is mainly the responsibility of the NHS Commissioners
• The capacity within the hospitals – so the Trust now commits to retaining beds as they are until/unless there’s a sustained reduction in demand for hospital beds as a result of Care Closer 2 Home.)

Matt Walsh said they fully accept that. They need to do that work themselves.

Cllr Smaje asked if there were any plans to discuss the Strategic Outline Case with the Clinical Senate. Jen Mulcahy from the Clinical Commissioning Groups said a panel will be established that includes specialisms from the Clinical senate, clinical people and CHFT and YAS.

Cllr Hutchinson asked at what point that work would be done. Because last time the Clinical senate couldn’t assess risks because of the visionary style of the documents, so this time they need something more hard edged so they can assess it.

Cllr Smaje asked how they were quantifying the Strategic Outline Case proposals for reducing health inequalities – she can’t see how the Strategic Outline Case will make a difference to the rising dementia, rising obesity and rising levels of increased mental illness, that are all aspects of health inequalities.

Matt Walsh said the new model of hospital services described in the Strategic Outline Case can’t be isolated from West Yorkshire and Harrogate Integrated Care System and “place” Systems.

Apparently trying to wriggle off the hook, he added that the Strategic Outline Case can’t talk in detail about improved links between mental and physical health eg mental health workers in A&E.  The Health and Well Being Board is a better forum.

Cllr Smaje persisted that, with all the health inequalities that local “place systems” are trying to address, the reconfiguration has to take into account measures to address them otherwise the reduction in hospital services will not be possible.

Matt Walsh waffled, “ We take account of growth in demand by describing it as demographic growth. And have measures to mitigate this.”

How are the Clinical Commissioning Groups and hospitals Trust interacting with Primary Care Networks and Local Medical Committees?

In response to this question from Cllr Smaje, the Greater Huddersfield and N Kirklees Clinical Commissioning Groups’ Chief Officer, Carol McKenna,  referred to the ck999 comment about Primary Care Networks being introduced without consultation.

She said that the NHS Long Term Plan reinforced local moves to GPs at scale and that Primary Care Networks are a national thing. They were only formally established on 1 July, so are very new.  She added,

“In terms of engagement generally regarding PCNs, we maintain ongoing dialogue with local practices and meet the Local Medical Committee monthly. With PCNs we are talking with them about how we will work together. Each of the 5 Huddersfield PCNS have a clinical director and are expected to work with them on strategy. They will be key partners of the Clinical Commissioning Group.

GPs’ Access To Hospital Electronic Patient Records And Vice Versa

A Councillor asked to clarify whether at the time of the last meeting in February, GPs were able to see hospital  electronic patient records and vice versa? Anna Basford said yes.

The CK999 Chair then told the meeting that at the June Engagement Event in Brighouse, the Hebden Bridge GP Dr Nigel Taylor said that the hospital can’t access GP records because CHFT staff had not been trained how to do that.

The meeting ignored this information.

Healthwatch said they had done work for CHFT about 18 months ago on how Electronic Patient Records was working for patients.

Penny Woodhead had been leading engagement work in Kirklees on the NHS Long Term Plan, including digital NHS She was just writing a report that might be of interest to the JHSC.

Travel and transport

Cllr Hutchinson said that travel and transport info needs to take account of the actual range of travel times from different places, not averages. Especially for public transport users. Scrutiny want input into the design of this info.

Cllr Smaje said that the Joint Health Scrutiny Committee hasn’t considered the independent travel and transport report and needs to. They need someone to come and talk to them about it. Also Highways. They will contact them.

Anna Basford said there was ongoing work around transport infrastructure.

Cllr Smaje asked if it wouldn’t make sense to improve the existing shuttle bus now?

CHANGES IN SERVICE PROVISION BETWEEN SITES

Cllr Hutchinson said the Joint Health Scrutiny Committee would like as much advanced warning as possible of changes in services provision between sites and that extends to diagnostic services. He asked if there there was a proposal to move neurodynamics diagnostics from CRH to HRI. And said

“We would like to look at such proposals before they happen.”

Dr Birkenhead said he would find out. There were no immediate plans for any more interim service reconfigurations.

NEXT STEPS

Need data/metrics already mentioned and the engagement plan by the end of July.

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 [??1]A marginal rate for emergency admissions was introduced in the NHS in 2010/11. The rule saw NHS providers paid 30 percent of the regular Tariff price for emergency admissions above a baseline, which was set at activity reported in 2008/09. It basically looks like a fine for A&E admissions above a targeted number. When the rule was introduced, the Department of Health made clear its purpose:

“The marginal rate will provide an incentive for closer working between providers and commissioners, to support the shift of care out of hospital settings to keep the number of emergency admissions to a minimum.”

Department of Health, March 2010 https://www.nhsconfed.org/-/media/Confederation/Files/public-access/Marginal_rate_for_emergency_admissions.pdf

The way this “incentive” was supposed to work was to punish the hospitals for A&E admissions that exceeded the set baseline, by only paying them 30% of the tariff for each “excess” A&E admission. The stupid assumption was that these A&E admissions were examples of supply-induced demand – in other words, that the hospitals were admitting unnecessarily high numbers of A&E patients in order to increase their income.

Eventually the idiots who came up with that idea had to admit it was false. But the marginal rate continued and the 70% of the tariff that was withheld from the hospitals went to the Clinical Commissioning Groups, who were supposed to spend it on schemes to reduce A&E attendances and admissions.

BUT I think that what Kirsty Ash was talking about was the new so-called Blended Payment for Emergency care: 

“1. Blended payment would mean the marginal rate emergency tariff (MRET) and the 30-day readmission rule would be abolished as national rules”  

https://improvement.nhs.uk/documents/3613/201920_planning_prices.pdf 

So it would help to know what this actually means, in terms of which orgaisations get paid how much money for A&E admissions.