The West Yorkshire and Harrogate NHS Commissioners meeting on July 7th was over in one hour with very little discussion taking place.
The meeting was basically the same old cuts stuff the Commissioners have been talking about since the Committee formed – but now lack of hospital capacity through the effects of Covid 19 is going to drive rationing even more.
There was no comment on the Integrated Care System’s response to Covid 19, even though huge questions need to be asked about PPE, testing, care homes, the Nightingale hospital in Harrogate etc.
Planned operations “reset” – ie “dialled right down”
The NHS Commissioners’ representatives discussed proposed changes to the planned operations, as a result of the Covid-19 crisis. The proposal, oddly named “Improving Planned Care”, focussed on addressing (in their words):
- access to diagnostic testing and elective surgery
- referral and proactive approaches to managing planned care
Since the proposed changes mean 30%-40% of planned care operations that would have been carried out pre-Covid19 won’t happen – according to comments made during the discussion – it’s hard to see where the “improvement” to planned care is coming from. More like “Slashing and Privatising Planned Care”. Or – in their code – “managing” planned care.
This is not being left to the judgement of doctors, or even to individual hospitals. Instead, an Improving Planned Care Alliance board now oversees “planned care transformation” across the whole West Yorkhire and Harrogate Integrated Care System. It had its first meeting in June.
The Alliance Board brings together the cuts-based “evidence based interventions” programme, (which West Yorkshire NHS campaigners have been objecting to strenuously since the public consultation in 2018) and the West Yorkshire Association of Acute Trusts (WYAAT) Elective Surgery programme (which no one knows much about because WYAAT meets in private).
The planned care “transformation” means that patients needing planned operations can no longer expect to be operated on in their local hospital – or even at all! Only patients who are a clinical priority will get planned operations – and they will be sent to whichever hospital in West Yorkshire has an operating theatre slot and the staff to run it. Although the proposal does say,
“as far as possible patients will be treated in their usual local hospital”
Why? The long term reason is because District General Hospitals are being run down.
The short term (Covid 19) reason is that because of the pandemic, the lack of planned care resources in District General Hospitals has got worse.
Planned care was more or less shut down in late March as hospitals cleared out patients in order to make space for Covid-19 patients. In late April, the head of the Bradford Institute for Health Research, Dr John Wright, reported that,
“At present, half the hospital is empty, while the other half has become a Covid-19 Red Zone; in time it will contain two parallel universes, Covid and non-Covid…and this has some important consequences.”
£1.2m funding bid to set up virtual elective care hub for West Yorkshire
In response to an invitation from NHS England/Improvement, the Integrated Care System have bid for £1.2m to pay for a virtual Elective Hub until March 2022. (This is the current pandemic planning period.)
If the funding is approved, this data crunching IT centre will trawl through planned operations waiting lists and determine who are priority patients and where in West Yorkshire NHS and private hospitals capacity exists for planned care operations at a given time. It will then direct patients accordingly.
Clinical prioritisation of patients
“would primarily include surgery for cancer, high priority non-cancer diagnoses, and those who are ‘long waiters’”.
“A clinical panel will be convened, if necessary, to support patient prioritisation at WY&H level.
The virtual Elective Hub will also carry out financial modelling, to work out how hospitals should be paid. At the moment they are paid by their local Clinical Commissioning Groups for treating local patients, on the basis of risk-sharing Aligned Incentives Contracts.
How to get GPs not to refer patients to hospital
The “Improving Planned Care” paper for the meeting also hinges on “prevention” (in the contested Improving Population Health sense), “conservative management approaches” and “rethinking the concept of referral”.
These are all part of the move to US-style “accountable care”, which requires GPs and Primary Care Networks to take responsibility for keeping patients at high risk of unplanned hospital admissions, out of hospital; and to manage “population health” – based on data analysis that identifies patients suffering from modern epidemics of obesity, respiratory and cardiovascular disease, who are prescribed participation in large scale behaviour change schemes.
Discussion during the meeting focussed on prevention, shared decision making, shared responsibility for care. This sounds very much like how to get GPs not to refer to secondary care.
- Primary care is not that keen on taking on all this extra work (!)
- It sounds like we are handing more work to hard pressed GPs who will not want it (Ed: quite right!)
- Secondary care has to change as well – secondary care does not have capacity to cope – we have to have willing partners.
Tim Ryley Chief Executive, NHS Leeds CCG said planned care is not about prevention.
This seemed to be a challenge to comforting group think that somehow demand can be decreased through preventive strategies that are supposed to be integral to the planned care programme, like the Sustainability and Transformation Plan documents that anticipated a rapid fall in cancer rates.
Other comments included:
“The health of our population has to be at the centre of all our plans” ( meaning that we have to keep saying everything we are doing is for the best).
“Strategy has to be outcome based – population health management embedded in whole approach.”
“This is our top priority – a fundamental transformation…”
Why does the Improving Planned Care: Programme Refresh require cuts to planned operations?
I have read the Improving Planned Care Programme Refresh paper and can’t see reasons in it for the reduction in planned care activity.
I gather – admittedly from hearsay – that many hospital wards are currently either empty or with low occupancy, so I am wondering what the obstacles are to resuming planned operations at or around the same level as before Covid-19.
So I asked Catherine Thompson, Director, Improving Planned Care, West Yorkshire and Harrogate Integrated Care System. This is her explanation:
“Delivering safe care, whilst working alongside the patient for their improved health and wellbeing is a priority to us all. There are safe and effective alternatives to hospital care and as we restart planned care services we have a real opportunity to reassess and try new approaches which may add much greater benefits to the person.
“Going back to how things were before Covid-19 would be a missed opportunity to take a more holistic approach to planned care and make a real difference to people’s lives.
“The programme will make sure that we are helping all of our hospitals to deliver as much planned care as possible, where best for people.
“There are additional infection prevention and control procedures that are required to maintain safety during elective procedures during the coronavirus pandemic. This includes measures such as allowing more time between procedures in an operating theatre to allow for a complete change of air within the room.
“Many procedures are done as day cases in a separate part of the hospital from the main wards, and people return to the ‘day case’ ward after their procedure to recover before they go home. To maintain the required physical distance between patients while they recover we are no longer able to have people in every bed, which reduces the number of people who can attend for a procedure on each day.
“Whilst many appointments will be done virtually, some people will need to attend where a physical examination or procedure is required. The size and layout of the waiting area dictates the number of people who can be waiting at any one time to attend their appointment. This varies from department to department, based on the physical layout of their department.
“We also have to plan for the likelihood of local outbreaks of coronavirus and future periods with high numbers of people requiring hospital admission and intensive care.
“All of these factors, and others, for example planning for winter pressures, have led us to predict that we will have less capacity for elective care than prior to the outbreak of the pandemic and our work will be to mitigate this impact wherever we can.”
I also asked, regarding the proposed virtual Elective Hub: would its data about the various hospitals’ capacity be drawn from the NHS Covid-19 Data Store?
Catherine Thompson’s reply:
We work together on providing the best care for people, following data protection guidance / rules – this includes any new areas of work developed to deliver this.
Reckon that’s a “yes” then.
You can find out about the NHS Covid-19 Data Store here – please scroll down to the section headed “Secretive NHSx Covid-19 data store”.
Info about NHS Covid-19 Data Store from the US Consumer News and Business Channel here .
Updated 24.7.2020 with information from Catherine Thompson, Director, Improving Planned Care, West Yorkshire and Harrogate Integrated Care System, that “current restart plans are to have a 60-70% of pre-COVID activity levels. This would mean a 30-40% reduction compared to pre-COVID.” And with her answers to my questions after the meeting.