Calderdale NHS Commissioners meeting Jan 23rd: Inadequate funding, shortages of clinical staff & capacity, and risks to patients

Calderdale Clinical Commissioning Group Governing Body Meeting Jan 23rd, 2pm, Elsie Whitely Innovation Centre, Hopwood Lane, Halifax. This meeting is open to the public, who can ask questions.

From trying to make sense of the 580+ pages of the documents for the meeting, I’ve pulled out what look to me like some issues for questions to the Governing Body and for info to the public.

These are about:

  • Inadequate NHS funding
  • Increasing control of local NHS organisations’ finances by the West Yorkshire and Harrogate Integrated Care System (aka Health and Care Partnership)
  • Shortages of NHS clinical staff and capacity and consequent risks to patients’ safety and experiences -particularly a Red risk to patient safety, quality and experience at Out of Hours GP services provided by Local Care Direct and a Black (critical) risk of compromised patient care and experience from a failure to meet the 4 hour A&E target. (More info in Additional Issues section, below.)
  • Privatisation of NHS services through commissioning and contracting
  • The need for Calderdale and Kirklees Joint Health Scrutiny Committee to scrutinise these issues

Questions to Governing Body

1. West Yorkshire and Harrogate Integrated Care System risks not achieving its financial targets, because various provider trusts have not met, or are forecasting they won’t meet, their own financial targets. 

Because of the government’s carrot/stick approach to fund the NHS, this risks the loss of Provider Support Funding of at least £1m and possibly £8m across the Integrated Care System, and also the loss of transformational funding. At month 7 the Integrated Care System’s reported position had deteriorated as more provider trusts were financially pressured. This means a greater risk that the ICS won’t meet its control total. The papers note that “the CCG is increasingly being tied into the performance of ICS partners.”

  • What is this risk level and how much money might the Integrated Care System lose?
  • How would that affect Calderdale Clinical Commissioning Group and Calderdale and Huddersfield NHS Foundation Trust?
  • Is the government’s real terms NHS funding pledge of an extra £20.5bn by 2023/4 going to make it any easier for  West Yorkshire and Harrogate Integrated Care System to achieve its financial targets from 2020/1-2023/4?
  • Did Airedale Trust and/or Bradford Teaching Hospital end up not meeting their financial targets for Q3?
  • If so, how much Provider Support Funding has been lost and how has that affected Calderdale and Huddersfield NHS Foundation Trust and SWYPFT?

2) Contracting 

  • What is the planned choice process across Yorkshire and Humber that is required by the NHS Long Term Plan for all patients who reach a 26 week wait? 
  • And what are the results of the work undertaken by Calderdale Clinical Commissioning Group into the financial and activity risks for Calderdale?
  • Chief Finance Officer’s Report –
  • What is the non-contracted activity with acute providers other than Calderdale and Huddersfield NHS Foundation Trust, that has caused a £0.5m overspend?
  • Which are the other providers?
  • How does that relate to the lower than planned acute activity levels at Calderdale and Huddersfield NHS Foundation Trust?
  • Why couldn’t Calderdale and Huddersfield NHS Foundation Trust provide the acute services that have been carried out by other providers?
  • Is it anything to do with the Aligned Incentives Contract between the local Clinical Commissioning Groups and the Foundation Trust that incentivises “demand management”, by allowing both Clinical Commissioning Groups and the hospitals to “reward” themselves with the money saved by reduced “demand”?
  • Why have referrals to the private BMI Hospital in Huddersfield increased by 97.4% compared to 2018/19?
  • Are these for planned operations?
  • Is it to do with Calderdale and Huddersfield NHS Foundation Trust’s long waiting times for Referral To Treatment (that are currently not being measured because the Trust is taking part in an elective care pilot about waiting times?)
  • Also why has the Clinical Commissioning Group’s spending on private cataract operations and related outpatient activity increased significantly over recent years and is set to increase by 33% in 2019/20 compared to 2018/19?

3). Revised strategic outline case for hospitals and GP/community health services transformation

Re: 83/19 Right Care, Right Time, Right Place – Update To Secretary Of State – Has the Sec of State, Dept of Health and Social Care etc accepted the revised strategic outline case?

4) Locala GP practice in Todmorden

Re the High Level Risk Register and the expiry date for APMS contracts – now that the Locala APMS contract for Todmorden Calder Community Practice has been extended for 2 years while the CCG looks for another GP practice to take it on, will this GP Practice become part of Upper Calder Valley Primary Care Network?

5) The Director of Public Health’s report on health and work

The Introduction to this report refers glancingly to the damaging effects on health of precarious, low wage and zero hours contracts and includes statements about the importance of Good Work. But it doesn’t identify the proportion of jobs in Calderdale that come into the categories of “bad work” (precarious, low wage work and zero hours contracts), or what public bodies can and should do to make sure that such bad work is replaced by good work.

Please will the Governing Body recommend that this should be a key focus of  public health programmes about work and health?  And that they should take into account:

  • work by Mark Fisher in Capitalist Realism, on the relationship between the capitalist economy and mental illness,
  • Ted Schrecker and Clare Bambra’s How Politics Makes Us Sick – Neoliberal Epidemics, and
  • the recent research report in the Journal of Epidemiology & Community Health, which shows a widening in health inequalities by income now compared to people born in the 1920s. 

6) Primary Care Networks and West Yorkshire Integrated Care System discussion on how to measure demand and capacity in General Practice

(Info source: Item 7 Appendix 2 – letter to CCCG from NE and Yorkhsire NHSE/I re CCG Improvement and Assessment Quarter 2 Review Meeting)

  • What has been done about the quangos’ recommendation for a West Yorkshire and Harrogate Integrated Care System discussion on how to measure demand and capacity in general practice?
  • How does this affect the ability of Care Closer to Home to reduce the need for hospital beds?
  • With regard to the development of Primary Care Networks, what is the likely impact of GPs’ recent mutiny over the 2020/21 Directed Enhanced Services specifications and the widespread perception that Primary Care Networks are not the solution to the problems of under-resourced and struggling GP and community health and social services?
  • What is the elective care pilot about waiting times that CHFT is participating in?

7. What is the scope of the  £36K Calderdale CCG contract with Pinnacle Performance Development Ltd to come up with a Workforce Strategy for the Calderdale “Place based system”?

This is nearly two years after the West Yorkshire and Harrogate Sustainability and Transformation Plan Workforce Strategy was finally published in April 2018 – after well over a year of us asking to see it. That showed Calderdale stating that they didn’t know what staff they need to deliver the Calderdale Sustainability and Transformation Plan – now apparently renamed as the Calderdale “place based system”.

Is this what Pinnacle Performance Development Ltd is supposed to come up with?

Additional issues

These are issues in the Governing Body papers that I’ve not asked questions about.

Cuts to elective/planned operations

The so-called “Evidence Based Interventions” scheme to withdraw routine NHS funding for 17 elective (planned) operations has contributed to a reduction in both operations and outpatients activity. There’s been a 4.1% reduction in elective “spells” to date in this financial year.

Cataracts “pathway” contract

Calderdale Clinical Commissioning Group is in the process of confirming commissioning and contracting intentions re the Cataracts “pathway”.

The number of GPs on the Governing Body has been cut from 7 to 4

So it is no longer possible to have or require a clinical majority in decision making

Red risk to patient safety, experience and quality of Out of Hours GP care delivered by Local Care Direct

(High Level Risk log and report, Risk Cycle 4, 2019-20 p506, Calderdale CCG Governing Body Papers).

Local Care Direct is the company that provides the Out of Hours GP service for the West Yorkshire Urgent Care Contract.  The “red” risk is because NHS England has required NHS 111 to pass on more referrals of high acuity patients, and also because of an increase in the number of one hour call backs.

This means that Local Care Direct lacks the capacity to meet patients’ needs. But surely the Joint Clinical Commissioning Committee should have known about this when they procured the contract?

West Yorkshire Clinical Commissioning Groups are “managing the risk” through “strategic…actions”.

A red risk is the second highest risk level, just below the black “critical” level of risk.

Calderdale and Kirklees Joint Health Scrutiny Committee surely need to look at this at their next meeting, which is still to be scheduled. If the out of hours GP service for urgent care isn’t working, that has big implications for the ability of the Care Closer to Home plans to reduce the need for urgent and emergency hospital attendances and admissions.

This is one of the big issues the Secretary of State has said needs resolving before the plans for Calderdale and Huddersfield hospital cuts and centralisation can be approved. It is down to Calderdale and Kirklees Joint Health Scrutiny Committee to make that judgement, on the basis of evidence it extracts from the local NHS organisations, in order to inform the Sec of State.

Black risk of not delivering the 4 hour A&E target next quarter

(Also in High level risk log and register).

This would result in patient care and patient experience being compromised and an inability to assure NHS England of the stability and resilience of the system.

The Chief Officer’s report says that the A&E four hour wait performance has deteriorated, ie more people are waiting longer than 4 hours to be treated in A&E.

Delayed transfer of care has worsened

This is about being unable to discharge hospital patients who no longer have a medical need for hospital care, but who need continuing health and/or social care after leaving hospital.

Update – the Guardian reports that between Dec 2018-Dec 2019 the number of days of delayed hospital discharge from Calderdale Royal Hospital rose almost 5 times. But reducing delayed discharge is crucial to plans for Huddersfield and Calderdale hospital cuts and centralisation. What now?

Diagnostic “pressures” resulting from a shortage of radiographers

Translated, this means patients who need diagnostic scans are waiting too long, because there aren’t enough radiographers to do them.

In October 2019, Calderdale and Kirklees Clinical Commissioning Groups awarded a public/private group of providers a £3.44m contract (not sure of the duration) for a Non-Obstetric Ultrasound Service.

The contracted providers are: 

  • BMI Healthcare Ltd,
  • Calderdale and Huddersfield NHS Foundation Trust, 
  • Diagnostic Healthcare Services Ltd,
  • Direct Medicare UK Ltd,
  • Kleyn Healthcare Ltd,
  • Mediscan Diagnostic Services Ltd,
  • Yorkshire Health Solutions,
  • Curo Health Ltd,
  • This Is My Healthcare.

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