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.

Update: Calderdale Clinical Commissioning Group replied to my questions in writing. I have added each reply to the relevant question, below. You can also download their complete response here:

Questions to Governing Body

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

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?

Response

The CCG recognises the financial risks of being part of the West Yorkshire & Harrogate Integrated Care System (ICS) as noted in our report. We currently are not in a position to answer direct questions on the ICS financial position as we report the CCG’s individual financial position. We will however provide your questions to the ICS to respond on the overall position. Please confirm you are happy for the CCG to share your contact details with the ICS for the purpose of providing you with a response.

Comment on response

a) How come they can’t comment on the Integrated Care System’s financial position when the Clinical Commissioning Group’s own finances are increasingly tied into it, and they know enough to say that because various provider trusts are having problems meeting their financial targets, the financial position of the whole Integrated Care System is at risk?

b) I did agree that the Clinical Commissioning Group could send my contact details to the Integrated Care System but due to various kinds of chaos I can’t find if the Integrated Care System ever gave me the info I asked for. Will keep looking.

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?

Response

  • Further guidance on 26 weeks waits is currently awaited.
  • The CCG has set up a routine monitoring report for patients waiting over 26 weeks at specialty and provider level. Until further guidance is published it is not possible to quantify any financial and/or activity risks.
  • The increase in expenditure [on acute providers other than CHFT] is mainly links to increased levels of activity and cost at Spamedica in respect of the cataract surgery pathway.
  • Planned levels of activity at Calderdale and Huddersfield NHS Foundation Trust (CHFT) are only marginally below plan for elective activity and more so below plan for non-elective activity and therefore this is deemed to be a positive position. The increase in non-contract activity is not related to non-elective activity.
  • [Re: Why couldn’t Calderdale and Huddersfield NHS Foundation Trust provide the acute services that have been carried out by other providers?] In addition to the positive position in respect of non-elective activity, activity at other acute providers is as a result of patients exercising their right of choice of elective provider and where the use of provider is determined by a clinical requirement i.e. referral from secondary to tertiary care.
  • Not really [anything to do with the Aligned Incentives Contract (AIC)]. The AIC allows the CHFT and the CCG to manage the risk of fluctuating demand and/or activity levels. If anything it incentivises both parties to recognise pressures on both sides and seek to identify solutions.
  • The increase in referrals to BMI Huddersfield relates to patient choice as required by the NHS Constitution.
  • Yes.[These are for planned operations.] BMI Huddersfield is commissioned to only provide elective i.e. planned services.
  • As stated above, the increase in referrals is linked to patient choice. There may be a number of reasons why an individual will select a particular provider, relative waiting times for Referral To Treatment is likely to be one of these factors.
  • The increase [on spending on private cataract operations and related outpatient activity] is linked to patients exercising choice of elective provider once the need for referral for cataract surgery is confirmed. The choice of provider will be informed by a number of factors e.g. waiting times for first outpatient appointment and subsequent treatment.

Comment on response

Section “Redisorganising eye surgery” in this Feb 2018 Ck999 blog post provides some background to the West Yorkshire and Harrogate Joint Clinical Commissioning Group decisions that led to the increased spending on private cataract operations and related outpatient activity.

What, if anything in addition to shorter wait times, is driving the choice by patients, for SpaMedica? A Dewsbury resident tells us the waiting room in her optician has glossy brochures advertising the clinic. North Kirklees Clinical Commissioning Group pays on a case by case basis for treatment at SpaMedica in Wakefield.

Optometrists have been able to refer patients directly for cataract surgery for many years, without having to go through a GP. We don’t know if it is still the case, but at one point, optometrists received a higher fee from performing a pre-operative assessment for patients that ‘chose’ to be referred to SpaMedica, than was being offered by CHFT. We are not suggesting that that would have any influence over their decision of provider service, of course.

It’s clear NHS England is driving patients to the private sector under the patient choice banner and Long Term Plan provision (as we know). One question raised by Paterson/Walsh is who is responsible when things go wrong, in relation to work done in private sector but paid for by NHS? Both Paterson and Walsh operated on private patients, and NHS patients sent to private sector. Spire would not take responsibility saying they were not direct employees and the NHS would not take responsibility either! This needs urgent clarification,

On 3rd March 2020, Dr John Puntis, Chair of Leeds Keep Our NHS Public, asked this question about cataract surgery at the West Yorkshire and Harrogate Integrated Care System Board meeting:

The West Yorkshire and Harrogate Elective Care and Standardisation of Commissioning policies has developed a clinical pathway for cataract surgery. I am pleased to say that this does follow NICE guidance. Cataract surgery is the most common operation performed by the NHS, but increasing numbers of patients are having the procedure formed in the private sector and paid for by the NHS. Figures over the last 5 yeas show for West Yorkshire a fall in cataract operations in the NHS from around 15,000 to 14,000, and an increase from around 1,000 to 11,000 in the private sector. This striking trend will have negative effects on staff training and future recruitment for the NHS. The Ian Paterson and Michael Walsh cases have also raised serious concerns about the business models of private hospitals, their avoidance of scrutiny, and some serious safety concerns including who is responsible when things go wrong, as the surgeons are not direct employees. Does the board know who is in fact responsible when things go wrong with NHS patients who have been sent to the private sector for surgery? Will the board look are reversing this trend and building NHS capacity?

This is the Response – which conflates NHS-funded services with NHS-provided services and misses the point of the question. This must surely be wilful obfuscation. The Response also implies that expanding the number of cataract operations by NHS hospitals would mean spending scarce capital funding on NHS estates to create additional capacity. Why? Finally, by focussing on insurance and indemnity in the event of things going wrong, the response ignores evidence of the risks associated with private hospitals’ business models, clinical governance and Care Quality Commission regulation.

“With increasing demand for healthcare interventions and increasing complexity of the interventions available, the demand placed on the NHS estate and resources is considerable. Capital funding for estate growth and development is limited, although the WY&H Partnership has been extremely successful in securing national funding for development. When available this funding is used for specific projects which address clinical care in areas where the estate and/or resources are in need of modernisation or where there is inadequate provision to meet the health needs of the population. Provision of NHS funded cataract surgery is sufficient to meet the demands of the WY&H population and so it would be inappropriate to invest funding into the development of additional capacity when there are other clinical specialties with greater need. All Independent Sector providers of NHS funded services are required to have full insurance for all their interventions, and this is checked by the CCG on award of a contract to provide services. Surgeons also have their own medical professional indemnity cover which is checked by the Independent Sector providers for whom they work. The liability for any harm experienced by a patient receiving NHS funded care in an Independent Sector provider remains with the provider of the care.”

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?

Response

The CCG is awaiting formal written confirmation of the outcome of the national processes that took place at the end of last year regarding consideration of CHFT’s Strategic Outline Case.

Comment on the response

The revised Strategic Outline Case for the hospitals’ “reconfiguration” was approved by the Dept of Health and NHSEngland/Improvement in January 2020. More info here.

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?

Response

Calder Community Practice Will become a member of the Upper Calder Valley Primary Care Network from the 1st April 2020.

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. 

Response

The CCG is not in position to recommend this formally; however, we recognise the concern raised and we will pass on your comments to Calderdale Council’s Director of Public Health for their consideration.

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?

Response

  • The CCG continues to work with the ICS partners and regulators to understand demand and capacity across West Yorkshire and Harrogate (WH&H).
  • The CCG is committed to the delivery of resilient primary and community care services. As reported to the Secretary of State in September 2019: The current plans, and those of the wider system, for out-of-hospital care, could reduce acute hospital bed days by 10% over five years, if they reach their full potential. This would more than absorb the forecast 5% increase in hospital usage from demographic growth. The modelling work presented evidence that the best integrated care systems in both England and internationally have 20-40% fewer non-elective bed days per head of population than Calderdale and Greater Huddersfield CCGs. The CCGs have therefore set an aspiration to reduce non-elective bed days for the population by 30% over 5 years. This would make Calderdale and Greater Huddersfield CCGs some of the best- performing areas in the UK for this measure. This modelling, the NHS Long Term Plan Implementation Framework and the five-year framework for GP contract reform are informing CCG investment decisions in primary and community services to address demand pressures, enable workforce expansion, and develop new services to meet the needs of the population. The Strategic Outline Case confirms that the total number of hospital beds will continue to remain broadly as they are now whilst integrated services are developed in the community and demonstrate a sustainable reduction in the demand for in-patient hospital care.
  • [Re: the development of Primary Care Networks and the 2020/21 Directed Enhanced Services specifications] The CCG is not in a position to comment and awaits the response from NHS England following the engagement they have undertaken on the draft outline Network Contract DES service specifications.
  • [Re the elective care pilot] As part of the national clinical review of standards, CHFT are one of 12 pilot sites looking at moving to an average waiting time rather than 92% of patients treated within 18 weeks. The theory being that this ensures focus on those patients who currently have a very long wait i.e. once they have breached 18 weeks, as the very long waits have more of an impact on average waiting times that the current 92% standard. The evaluation period for this work has been extended because 4 months, for elective pathways is insufficient and therefore we will be continuing with this into 20/21.

Comment on response

We found this response inadequate. As the Calderdale and Kirklees Joint Health Scrutiny Committee have been trying and failing for years to get data about the ability of Care Closer to Home to reduce the need for CHFT beds, we have put in a Freedom of Information request which we are still waiting for an answer to as, understandably, pressures of dealing with Covid19 mean the Clinical Commissioning Groups have a lot on their plate at the moment.

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?

Response

Please see attached extract “Calderdale Workforce Strategy Development – Requirements” from the procurement documentation which sets out the requirement in full.

You can download “Calderdale Workforce Strategy Development – Requirements” here:

Comment on the response

The procurement documentation shows that all they’ve done since 2018 is define what they don’t know, as the basis for a bid for funding for someone else to come up with the answers for them.

As a layperson, I would have expected that a workforce strategy for Calderdale’s “place based system” for health and social care would aim to identify what NHS and social care staff are needed (along with voluntary and community sector staff, since so much of NHS and social care is being handed over to the charity/voluntary sector), how the different grades and categories of staff are to work together, and how to recruit, retain and train these staff. But this is not so. Instead, a key focus is on Organisational Development and how staff from different organisations can work across organisational boundaries (which I suppose does cover how different grades and categories of staff are to work together).

Accordingly they have given the contract for the consultancy to Pinnacle Performance Development, a company run by an Occupational Psychologist, Coach & Organisational Development,Workforce/HR Specialist whose speciality is

“OD Consultancy and change management – Diagnostics, design, interventions/delivery and evaluation including organisational culture”

No mention of any skills or experience in workforce strategies for NHS and social care organisations.

Also there is no time frame for the stages of delivering the workforce strategy.

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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