At the West Yorkshire and Harrogate Integrated Care System Board virtual meeting on 1st September, four NHS campaigners asked questions about issues on the Agenda relating to the Integrated Care System’s response to the Covid-19 pandemic.
We’ve received some responses from Stephen Gregg, the Integrated Care System’s Governance Lead:
“Many thanks for your questions to the Partnership Board. In line with current practice, I read the questions in red text out at the meeting and members of the Partnership Board responded verbally. The stream of the meeting is available here.”
(Before getting into the Q&A, in case of interest this blog post gives some background to the questions we asked about:
- The utilitarian ethical framework for clinicians’ decisions on who gets critical care and community care.
- The Harrogate Nightingale Hospital.
- The results of decade-long cuts to NHS funding, hospital beds and clinical staff.)
Questions about the West Yorkshire & Harrogate Clinical Forum’s Ethical Framework
Question 1 (This was the question in red text read out at the meeting),
The West Yorkshire & Harrogate Clinical Forum’s Ethical Framework states that:
“community care is facing limited resource in the sense of inaccessibility of usual treatment pathways and consequent impact on wider population health due to the reconfiguration of hospital care to focus very heavily on providing capacity for treatment of COVID-19.”
Which community care treatment pathways are inaccessible as a result of the reconfiguration of hospital care for Covid-19? For how long are they likely to remain inaccessible?
- With reference to these specific community care pathways, what care, if any, will be available for patients who are deemed unfit for usual treatment pathways, on the basis of utilitarian ethics? Please answer pathway by pathway.
- With reference to these specific community care pathways, what percentage of patients are likely to be deemed fit for and given the usual treatments? Please answer pathway by pathway. d) What are the likely clinical consequences for patients who are refused the usual treatments in these specific community care pathways? Please answer pathway by
Response (this conflates the responses to similar questions from both Jenny and Christine about the ethical framework)
The Partnership developed its Ethical Framework at a time when the extent of the impact of the pandemic was unclear. It was important as a health and care partnership that we provided a framework to help staff to make the best decisions around care for our patients and the people who use our services.
It supports, but does not replace, decision-making by individual clinicians. Responsibility for ensuring that patients have access to the most appropriate treatment will remain, as now, with individual clinicians. These decisions will continue to be made within the context of available resources.
The Framework supports our wider aim of ensuring that we can continue to deliver the best possible care to people who most need it, even under the most difficult circumstances.
Unfortunately, the experience of some other healthcare systems across the world in responding to COVID is that sufficient resources are not always available to meet exceptional peaks in demand for healthcare. The utilitarian principles have not been required as our response to the pandemic in West Yorkshire and Harrogate has meant that we have been able to provide care to the standard expected. Our aim as a Partnership is to continue to do everything within our power to ensure that we avoid the circumstances when we would need to employ utilitarian principles.
It is not the role of the Partnership to determine the detail of specific community care pathways in each of our places. The Ethical Framework sets out broad principles to be applied in managing demand and capacity for services. How those principles are applied to specific community care pathways is a matter for local places to decide, in line with the health and care needs of their local populations.
Comment on response – it cannot be truthfully said that the Integrated Care System has been able to provide care to the standard expected during the pandemic
Unlss the standard they expected was pretty dire:
- Why did almost all elective hospital care stall for months during the initial months of the pandemic?
- Why did many people find themselves unable to ask GPs for advice and referrals?
- Why did so many hastily-discharged patients die in care homes?
- Why is there such a backlog of cancer patients who didn’t get seen?
- Why did the ‘excess death’ rate rocket, beyond the numbers of people dying of Covid-19?
- Why has NHS England/Improvement sent out the directive on the Phase 3 Covid-19 response, instructing Sustainability and Transformation Partnerships and Integrated Care Systems to restore routine NHS services?
- Why did the Clinical Forum recognise the “inaccessibility of usual treatment pathways and consequent impact on wider population health due to the reconfiguration of hospital care to focus very heavily on providing capacity for treatment of COVID-19”
Question 2 – About critical care availability
The West Yorkshire & Harrogate Clinical Forum’s Ethical Framework also states,
“There is also the potential for resource limitations if a surge of infections impacts on critical care availability.”
Regarding critical care availability:
- Where does this ethical framework for Covid19 critical care sit with the NICE guidelines?(Covid-19 rapid guideline: Critical Care in Adults, last update as far as I know 27 March 2020.)
- And where does the Harrogate Nightingale Hospital fit in? Wasn’t that set up in order to significantly increase the number of critical care beds?
The West Yorks and Harrogate Integrated Care System has already told us:
“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.”
So why does the Ethical Framework identify “the potential for resource limitations if a surge of infections impacts on critical care availability”? Isn’t the “insurance policy” Nightingale hospital enough? If not, what further resources would be needed to provide critical care for all who need it, on the basis of the NHS ethics of equality of access?
We believe that our Ethical Framework is entirely consistent with current NICE guidelines. Both have as their aim the provision of the best possible care for patients, taking into account their individual needs and circumstances.
Our previous response reflects the current position in relation to NHS Nightingale Yorkshire and the Humber. The Nightingale Hospital remains on standby to provide additional critical care beds in our region should our existing hospital critical care provision reach capacity. Unfortunately, we cannot rule out the possibility that a future surge of infections may impact on the total availability of critical care. Our Ethical Framework provides guidance on how we can provide the best possible patient care in such a situation.
Update: At the West Yorkshire Joint Health Scrutiny meeting on 30 September, the NHS quango boss Anthony Kealey gave a completely different account of ‘the current position in relation to NHS Nightingale Yorkshire and the Humber’. The Integrated Care System Director could only agree with him, despite the fact that it negated the response the Integrated Care System gave to the question we put to the Board meeting. More info here. Can they tell their arse from their elbow?
Question 3 – About the need for adequate NHS resources after decade-long cuts
CK999 has already asked West Yorkshire and Harrogate Integrated Care System about the effects on its ability to respond to the Covid-19 Pandemic, of decade-long cuts to NHS funding, hospital beds and clinical staff – including ICU beds and staff, and the government’s failure to promptly authorise and direct widespread testing and tracing, from the start of the pandemic. Your answers were evasive.
Did the West Yorkshire & Harrogate Clinical Forum consider whether it would be more ethical to demand adequate resources to meet patients’ needs, rather than having recourse to utilitarian “ethics” of weighing up one patient’s claim on scarce resources against another’s? If not, why not? And if so, why did they reject this course of action?
Question 3 Response
The Partnership does not see this as an ‘either/or’ issue. We believe that we have a responsibility to both make the case for adequate resources and at the same time to put in place contingency plans to deal with exceptional circumstances.
The Partnership, and the individual organisations of which it is comprised, have a strong track record of advocating at national level for funding to meet the health and care needs of our population. This has led to significant additional investment in WY&H and we will continue to advocate on behalf of our population. However, we know from the experience of other healthcare systems across the world that sufficient resources may not always be available to meet unprecedented demands for healthcare. We consider that it is our responsibility as a Partnership to ensure that we have a framework in place to guide decision making even in the most difficult circumstances.
Comment on response
The admission that the Integrated Care System has a responsibility to make the case for adequate resources is a bit of a change of tune. We have not heard any such view when we’ve raised this question before – for instance at the 2016 public consultation on proposed cuts and centralisation of Calderdale and Huddersfield hospital services.
At the angry public meeting in Huddersfield on June 6th 2016, the hospitals trust Chief Exec Owen Williams spoke critically of the government’s policy of withholding funding to improve existing services, while approving huge investment in “different models of care”:
“No one on the panel wants this, no one in the room wants it.”
But he wouldn’t act on this – instead he said this is a democratic country and it’s the responsibility of the public to use democratic channels to influence the government. And Greater Huddersfield Chief Officer Carol McKenna told the meeting the NHS organisations see themselves as having to make the best of the circumstances they find themselves in.
We are also mindful of the whole cuts agenda of the Sustainability and Transformation Plans, which the West Yorkshire and Harrogate Sustainability and Transformation Partnership (now the Integrated Care System) has never publicly challenged. It has also carried out the cost-cutting “transformations” with every appearance of enthusiasm and cheerleading.
So we can’t place too much importance on the ICS claim to “have a strong track record of advocating at national level for funding to meet the health and care needs of our population.” Because in our view the purpose of the transformation funding it has sought and gained is to introduce new cost-cutting care models that will turn the NHS into a UK version of Medicare/Medicaid – the USA rump public health service that provides limited health care for those who are too poor or ill to get private health insurance.
Question 4 – about the proposed virtual elective care hub for West Yorkshire
Where does this Ethical Framework sit in relation to the proposed virtual elective care hub for West Yorkshire?
- Has NHS England/Improvement approved the Integrated Care System’s bid for £1.2m for this virtual elective care hub?
- We understand that 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. Will the clinical panel be using the utilitarian ethical framework?
- And is this just a backup for computer algorithms that say yes or no to patients’ getting planned care? What ethical considerations have been programmed into the algorithms?
Question 4 Response
We have not heard whether the bid for funding for a virtual elective hub has been successful. We do not currently know what the timescales are for hearing about the outcome of this bid.
The purpose of the virtual hub, if created, would be to support collaboration between organisations to make sure that patients across West Yorkshire and Harrogate receive the interventions and or care required according to clinical priority and need. There is no plan to use algorithms to determine clinical priority. Our Ethical Framework provides guidance on how we can provide the best possible patient care should a need for prioritisation occur.
Update 6 September 2021
The Integrated Care System told us in August 2021 that,
‘NHSEI provided funding of £271,947 for a “virtual elective hub”. The funding was used to provide capacity to share data, understand system level waits and ensure equity of access.’
Response to questions and statements from Christine Hyde – N. Kirklees NHS Support Group
Question 5 – What people, bodies, institutions and/or companies make up the West Yorkshire Clinical Forum?
The purpose of the Clinical Forum is to provide clinical leadership, advice and challenge for the work of the Partnership. It is made up of clinicians from across our Partnership. The current list of members is attached (as at 10 September 2020):
- Dr Bryan Gill, Chief Medical Officer, Bradford Teaching Hospitals NHS Foundation Trust (Co-Chair)
- Dr James Thomas, Clinical Chair, NHS Bradford District and Craven CCG (Co-Chair)
- Dr Adam Sheppard, Clinical Chair, NHS Wakefield CCG
- Anthony Kealy, Locality Director – West Yorkshire and Harrogate, NHS England and NHS Improvement (North East and Yorkshire)
- Dr Bruce Willoughby, GP Clinical Lead for Primary Care and Population Health at NHS North Yorkshire CCG
- Dr Danielle Hann, YOR Local Medical Committee representative
- David Melia, Director of Nursing, Mid Yorkshire Hospitals NHS Trust
- Dr David Sims, Medical Director, Bradford District Care NHS Foundation Trust
- Dr Jackie Andrews, Medical Director, Harrogate and District NHS Foundation Trust
- Dr Jason Broch, Clinical Chair, NHS Leeds CCG
- Jill Asbury, Director of Nursing, Airedale NHS Foundation Trust
- Justin Tuggey, Chief Clinical Information Officer, WY&H Digital and Interoperability Programme
- Kerry Warhurst, Deputy Director of Nursing, NHS England and NHS Improvement (North East and Yorkshire)
- Dr. Khalid Naeem, Clinical Chair NHS North Kirklees CCG
- Michelle Turner, Strategic Director of Quality and Nursing, NHS Bradford District and Craven CCG
- Maureen Drake, Professional Lead for AHPs, Leeds Community Healthcare NHS Trust
- Dr Peter Davies, Royal College of GPs Ambassador for WY&H
- Dr Philip Wood, Medical Director, Leeds Teaching Hospitals NHS Trust
- Ruth Buchan, Chief Executive, Community Pharmacy West Yorkshire – the Local Pharmaceutical Committee for West Yorkshire
- Representative from Calderdale and Huddersfield NHS Foundation Trust
- Representative from the Yorkshire and Humber Academic Health Science Network
- Dr Sal Uka Clinical Lead for the West Yorkshire Association of Acute Trusts
- Dr Steven Cleasby, Clinical Chair, NHS Calderdale CCG
- Dr Steven Dykes, Deputy Medical Director, Yorkshire Ambulance Service NHS Trust
- Dr Subha Thyagesh, South West Yorkshire Partnership NHS Foundation Trust
- Suzannah Cookson, Chief Nurse, NHS Wakefield CCG
- Dr Yasmin Khan, Associate Medical Director (North East and Yorkshire), NHS England / NHS Improvement
Question 6 – About the West Yorks and Harrogate BAME Network and health inequalities
With reference to the Paper ‘Supporting our BAME Staff and Communities’, how will the work of the WY&H BAME Network help with decisions for ‘scarce resources’ in real live situations, eg 2 people with severe Covid-19 in hospital, with similar prognoses and of similar age but only one supply of oxygen, when one is BAME and has to return to an overcrowded and damp residence, and the other has to return to a spouse with a warm dry home?
The WY&H BAME Network has set up a COVID Research and Health Inequalities Group which has a targeted focus on reducing the gaps in health outcomes that have become apparent during the pandemic. This group is working with the WY&H Health Inequalities Network to further understand local data and insight and identify racial inequalities which impact on population health. The Group will provide evidence to the wider WY&H BAME independent review into the impact of COVID-19 on health inequalities and support for BAME communities and staff, which will be published in Autumn 2020.