Integrated Care System claims it ‘added value’ to Covid19 response

In early July, we asked the West Yorkshire and Harrogate Integrated Care System’s Joint Committee of Clinical Commissioning Groups how their ability to respond to the Covid-19 pandemic had been affected by:

  • the decade-long cuts to NHS funding, hospital beds and clinical staff – including ICU beds and staff
  • the government’s failure to promptly authorise and direct widespread testing and tracing, from the start of the pandemic
  • the government’s failure to source and provide adequate PPE

Their response beggars belief.

How has the Integrated Care System’s ability to respond to the Covid-19 pandemic been affected by the decade-long cuts to NHS funding, hospital beds and clinical staff – including ICU beds and staff?  

Response: Integrated Care Systems, including our WY&H health and care partnership, do not have a formal role in co-ordinating the response of partner organisations to the pandemic. The formal response is co-ordinated through well-established arrangements at national and system levels. These include the NHS command-and-control structure for a level four national incident, the West Yorkshire Local Resilience Forum, and local partnerships, with councils, the NHS, community and voluntary organisations and other partners working together in each of our six places (Bradford district and Craven; Calderdale, Harrogate, Leeds, Kirklees and Wakefield).

However, we are clear that the relationships and ways of working we have established through the WY&H HCP over the past four years add value in supporting the response. The Joint Committee of the CCGs is a key part of the WYH ICS approach.

At the outbreak of the pandemic the Partnership identified four key priorities to focus our collaborative efforts:

  • Supporting an exponential increase in critical care capacity
  • Supporting safe and effective discharge to communities, to free up acute beds
  • Supporting the 1.4m ‘vulnerable’ people shielded from the virus, and other groups e likely to be most affected by social distancing
  • Ensuring continuation of other essential areas of business. The NHS successfully ensured that there were enough hospital beds and staff – including in critical care – to meet the needs of all Covid-19 patients who required them in West Yorkshire and Harrogate. The Partnership has worked closely with West Yorkshire Local Resilience Forum, and with all partner organisations, to ensure that sufficient PPE has always been available to provide the appropriate protection for both staff and patients. We have also supported the implementation and expansion of testing as the pandemic has progressed.

What is the Joint Clinical Commissioning Committee’s view of NHS England’s order to decant loads of people from hospital to care homes without testing, at the end of March, leading to lots of people in care homes dying?

Your report says, “Our integrated teams and primary care networks ensured that safe discharge and support was in place and operating in line with clinical decisions made in each of our hospitals.” Is that really borne out by the evidence of high numbers of infections and deaths in care homes?

Response: In the initial surge phase of the pandemic there was a critical need to free-up enough hospital beds to meet the anticipated level of demand for Covid-19 patients. Many patients were discharged at that stage, including to care homes, on the basis of clinical decisions regarding what was in the patient’s best interests.

Support for care homes across West Yorkshire and Harrogate is a major priority. Working closely with both the NHS regional team and the local place partnerships, we have been ensuring additional support from the NHS is in place and that care homes receive PPE and support for testing. There is a named clinical lead for every care home, training for staff and improved arrangements for multi-disciplinary team working.

How was the discharge of untested hospital patients to Care Homes “safe and effective”?

They claim that one of their four priorities in responding to the Covid 19 emergency was:

Supporting safe and effective discharge to communities, to free up acute beds

But the Huddersfield Examiner reports that:

“Hundreds of hospital patients were discharged to care homes in Kirklees without undergoing Covid-19 tests in the weeks before checks became routine.

A Freedom of Information request made to Calderdale and Huddersfield NHS Foundation Trust, which runs Huddersfield Royal Infirmary and Calderdale Royal Hospital in Halifax, reveals just 88 patients were tested before being allowed to return to their care homes between March 1 and April 15.

It means 302 individuals – or more than three-quarters of patients – were not tested on discharge during those 41 days.”

How was that safe and effective discharge?

We are asking the hospitals Trust and Calderdale Council’s portfolio holder for Adults Social Care how many patients were tested before being allowed to return to their care homes in Calderdale between the same dates.

We will also ask what was the basis for clinical decisions that discharge to care homes without testing was in patients’ best interests.

A COVID update on 20.6.20 from Cllr Scott Archer Patient on the Mytholmroyd facebook group reported 109 Calderdale residents’ deaths from Covid-19 up to 9th June. This showed nearly half the people who died of Covid-19 either died or were living in a care home at the time of death.

I asked for – but did not receive – clarification of this information, which I found confusing:

Most of the deaths took place in hospital, with 30 so far taking place in a care/nursing home and 12 at home. However, of the 109 who died, 42 were nursing/care home residents and 51 either died or were living in a care home at the time of death.

Cllr Scott Archer Patient’s update also shows the dire impact of Covid19 on Calderdale Care Homes:

In addition, from a peak in April when 9 homes were closed to admissions, all homes are now open to an admission which is the first time since the outbreak this has occurred.

Public Accounts Committee: “Our care homes were effectively thrown to the wolves”

The Integrated Care System’s complacency about their drive to discharge patients in order to “meet the anticipated level of demand for Covid-19 patients” is at odds with the findings of the House of Commons Public Accounts Committee’s investigation into “Readying the NHS and social care for the COVID-19 peak“.

The Chair, Meg Hiller MP, said

“Our care homes were effectively thrown to the wolves, and the virus has ravaged some of them.”

The Committee has reported that sending patients into care homes without testing them for COVID-19 was an “appalling error” and a consequence of

“Years of inattention, funding cuts and delayed reforms … compounded by the Government’s slow, inconsistent and, at times, negligent approach to giving the sector the support it needed during the pandemic.”

We are asking West Yorkshire and Harrogate Joint Health Overview and Scrutiny Committee to investigate the Integrated Care System hospitals’ mass discharge of patients on NHS England’s instructions, and any clinical decision algorithms used to determine “what was in the patient’s best interests.”

Stabilisation and Reset of services

The Integrated Care System’s response continues:

As the pandemic progresses, we need to ensure we are developing appropriate and agile responses. Over recent weeks we are seeing fewer people testing positive for Covid-19 in hospitals and care homes, fewer people being admitted to hospital and fewer people dying of Covid-19. We should be in no doubt that the impact on families and friends who have lost loved ones has been significant. This has also sadly included the death of respected and valued colleagues across our Partnership. Our priorities to support the stabilisation and reset of services in the next phase of our response to Covid-19 include:

  • Continuing to provide critical and urgent care for COVID-19 patients, their recovery and rehabilitation
  • Providing essential health and care services during the COVID-19 incident for other population groups
  • Continuing to support people who are shielded
  • Keeping health and care colleagues safe and well, whilst supporting them to manage the impact of the virus.
  • Understanding the wider impact on different population groups, including Black Asian and minority ethnic (BAME) populations, older people, those with learning disabilities, mental health concerns and other vulnerable people
  • Co-ordinating our reset and stabilisation approach to the new ‘normal’– including responding to future peaks.

The Joint Clinical Commissioning Committee discussed the reset of NHS services at their 7th July meeting.

They agreed it would mean cutting elective/planned care operations to 60-70% of pre-Covid-19 levels.

However, since that meeting NHS England has issued instructions that elective care needs to resume at much higher levels than the 60% -70% proposed for the West Yorkshire and Harrogate Covid19 reset – in this Covid19 Phase 3 letter.

NHSE is telling STPs/ICSs to restore:

“In September at least 80% of their last year’s activity for both overnight electives and for outpatient/daycase procedures, rising to 90% in October (while aiming for 70% in August);
•This means that systems need to very swiftly return to at least 90% of their last year’s levels of MRI/CT and endoscopy procedures, with an ambition to reach 100% by October.
•100% of their last year’s activity for first outpatient attendances and follow-ups (face to face or virtually) from September through the balance of the year (and aiming for 90% in August).”

We asked: How does this  instruction from NHS England sit with the Joint Clinical Commissioning Committee’s  reset plan to only provide 60% -70% of pre-covid elective care operations etc?

You can read their reply here.

Every Integrated Care System/Sustainability and Transformation Partnership has to produce an Action Plan for Covid 19 phase 3 and send it NHS England by 21st September

We asked about the costly block contracts with private hospitals that – at least in the case of CHFT- we understand were barely used

Response: We know there will be a number of constraints on the level of services that can be safely reintroduced, including the requirements of social distancing, the availability of PPE, and the resilience of our workforce. In this context the partnerships that NHS hospitals have been able to develop with independent sector providers, as part of the national contract, will become increasingly important as a source of extra capacity to ensure that as many patients as possible can be treated.

Our comment: The benefits of the “partnership” between NHS and private hospitals are far from clear.

The Doctors for the NHS chair, Calderdale Cllr Colin Hutchinson, told the Guardian in June:

“Private health facilities have been very, very quiet over recent months. They have been paid to stand empty, by and large.”

The Guardian also reported a warning from the Federation of Independent Practitioner Organisations, which represents consultants in private practice, that there had been a “gross under-utilisation” of non-NHS facilities and that “the money being poured into the private sector is a total waste”.

NHS England has refused to disclose how many patients have been treated by private providers since March, even though they collect this data each day.

We are asking the Integrated Care System how many NHS patients from each of the 6 hospital trusts in the area have been treated at private hospitals in West Yorkshire and Harrogate, since March 2020.

On 7th August, the Times reported the end of the deal NHS that England struck with the country’s private hospitals in March, to take over 92 per cent of their capacity at cost price, for as long as the health service needed it.

But on July 17th, when Boris Johnson committed an extra £3 billion for NHS winter preparations, he said,

This will allow the NHS to continue to use the extra hospital capacity acquired from the independent sector and also to maintain the Nightingale hospitals until the end of March.

NHS Providers Deputy Chief Executive Saffron Cordery was confused:

“Trust leaders will need urgent clarity about what this £3bn will cover and whether or not it is all new money. Nightingale hospitals and independent sector capacity is already in place, so while helpful, will maintain current capacity.

“Trusts need more than that. They have got to recover the lost ground of the last four or five months and put measures in place to manage the additional activity that always happens in winter.”

According to BrowneJacobson specialist health care law practice,

“The current Covid-19 pandemic fundamentally changed the relationship between the NHS and the independent sector.”

BrowneJacobson recommend that as a result, private healthcare companies should be now included in Integrated Care System planning.

In ending the March 2020 block booking deal with the private hospitals, NHS England plans to give hospitals a share of funding to make their own arrangements, according to the Times. It plans to negotiate a new deal with the private sector in the hope that no longer paying for unused capacity will offset more expensive charges for treatment.

The private sector has given warning that prices will rise, however and The Times report added that while NHS hospital chiefs accept that capacity is going to waste under the March deal, they fear that new terms will be less generous and force them to cut the amount of treatment they can offer.

We are asking CHFT about this. And we are asking the Integrated Care System if they are involving private hospitals – and other private health care companies – in Integrated Care System planning.

Question about the Harrogate Nightingale hospital.

Your report says, “we led the development of NHS Nightingale Yorkshire and the Humber”. But it was a costly white elephant, not used for Covid19 patients, and is now being used for cancer diagnosis. How are patients from the other side of West Yorkshire going to get there?

Response: The NHS Nightingale Hospital Yorkshire and the Humber is part of a wider national response to the Covid-19 pandemic and is an insurance policy for our region. The Nightingale Hospital remains on standby to provide additional critical care beds in our region should our existing hospital critical care provision reach capacity in the event of a second wave of covid-19 over the coming weeks and months. There are still many unknowns with this pandemic and whilst cases have been low, the numbers are beginning to rise with local arrangements already introduced in three areas of our region to try and limit the transmission of this deadly virus. In the meantime, the facility is being utilised to support some hospitals in the region by providing diagnostic and surveillance imaging services to enable us to see patients whose care has been delayed due to the pandemic. More than 1000 patients have now undergone CT scanning at the facility and positive feedback for this service has been received from patients. We believe that the provision of this facility is important in ensuring that we can meet the healthcare needs of our population in the coming months. We hope that the facility is never needed to provide critical care but we are assured that it can be ‘stood up’ to deliver care to local people should it be required.

Question about what work was carried out by the WYH Integrated Care System programme for test, track and trace

As far as I know, apart from Pillar 1 tests in hospitals for NHS staff and patients etc, testing and tracing has been carried out by the hastily set up parallel privatised system – with the exception of recent local outbreaks in workplaces and schools where apparently public health contact tracers have done a high proportion of the work.

Response: In each place in West Yorkshire and Harrogate the Director of Public Health has led the development and implementation of an outbreak control plan, including arrangements for testing and tracing. To support these plans a West Yorkshire Covid-19 Test, Trace and Isolate programme has been established, in partnership between the ICS and West Yorkshire Local Resilience Forum. A co-ordinating group includes Directors of Public Health from councils, colleagues from Public Health England, NHS England and clinical commissioning groups.

Pillar 1 testing is provided by a number of hospital labs, primarily covering NHS staff and patients. Pillar 2 testing has been developed through a national programme led by DHSC to provide additional testing capacity, initially to key workers, and subsequently expanded to the public. Our testing capacity includes regional testing centres in Leeds and Bradford, local satellite sites in Halifax, Huddersfield, Keighley and Wakefield, walk-to testing centres, mobile testing unit sites and the deployment of additional mobile units as requested by the local directors of public health to respond to outbreaks.

Relatedly, what in the JCCC’s view, have been the effects of the failure to follow statutory duties for reporting notifiable diseases?

As you know, these require GPs to notify local Public Health about all patients with Covid-19 symptoms. But the government directed the public to report symptoms to 111, not to GPs; and there has been no process for 111 to pass information to GPs about Covid-19 symptomatic patients. The upshot has been that neither local public health people nor GPs have had any idea about the spread of Covid 19 in their areas. And are now reliant on the new parallel privatised test and trace service that still isn’t giving Public Health adequate data for outbreak prevention and control and still doesn’t give GPs any info.

Response: Arrangements are now in place to update patients’ GP records with the outcome of Covid-19 tests.

As local outbreak control plans have been developed, the data available to local Directors of Public Health and regional Public Health teams has been significantly enhanced, supporting surveillance, the management of outbreaks, and informing targeted prevention activities.

Comment: These baldly disingenous statements about the Integrated Care System’s Covid-19 Test, Trace and Isolate programme require a separate blog post, coming soon. It’s pretty much all snakes and no ladders.

How has the government’s failure to source and provide adequate PPE affected WYH ICS’s ability to respond to the Covid-19 pandemic?

There have been massive problems with lack of PPE, for reasons to do with:

  • the mess created by the 2018 redisorganisation of the NHS Supply Chain,
  • the government’s failure to act on the 2016 Cygnus pandemic planning exercise which identified the need for an adequate stockpile of PPE,
  • the government’s delay in procuring additional supplies of PPE
  • the chaotic and ill informed contracting process when they did belatedly get round to this.

What is the Joint Clinical Commissioning Committee’s view of the impact of these failings on the Integrated Care System’s ability to respond to the pandemic?

Response: There has been widespread disruption to the normal supply chains for PPE across the world as a consequence of the pandemic. To mitigate the impact of this we have established a West Yorkshire and Harrogate Personal Protective Equipment (PPE) Programme Group. The purpose of the group is to ensure PPE supply chain arrangements are in place to maintain, manage and forecast need. The group includes colleagues from across the Partnership, including clinicians, procurement /supply specialists and representation from West Yorkshire Local Resilience Forum and NHS England. The Programme is supported by a Clinical Reference Group. The work also covers primary care and smaller healthcare providers. The aim is to have enough PPE to keep our staff protected and to ensure there are local reserves stored and available to draw upon when needed.

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