After two and a half years of scrutiny, Calderdale and Kirklees Councillors are still in the dark about whether so-called Care Closer to Home services are meeting patients’ needs and reducing the need for unplanned hospital admissions.
They have repeatedly asked NHS bosses for hard facts about this, after the Health Secretary directed Calderdale and Kirklees Joint Health Scrutiny Committee to let him know if the new model of GP, community NHS and social care services is in a fit shape to allow the revised plan for cuts and centralisation of Halifax and Huddersfield hospitals to safely go ahead.
This plan for the cost-cutting hospital and community services “transformation” is based on shifting a lot of services out of hospital and limiting the need for unplanned hospital admissions, by providing care closer to home for the frail elderly and patients with chronic health problems. Between them they are the most costly group of patients, because of repeated hospital stays.
Back in February 2019 Matt Walsh (at the time the Calderdale NHS Commissioners’ boss) agreed to give vital data to Calderdale and Kirklees Joint Health Scrutiny Committee.
But the September 2020 Scrutiny meeting was the fourth in a row when NHS bosses failed to produce these data. So the co-chairs had to remind them again.
Scrutiny co-chairs’ reminder ignored by NHS bosses
Kirklees Cllr Elizabeth Smaje affirmed that the Committee has the task of identifying whether and how the capacity is there in community services across the whole footprint of the hospitals trust, in order to make it possible for hospitals changes to go ahead.
And Calderdale Councillor Colin Hutchinson also pointed out,
“The Committee need to be assured about the capacity of community and primary care services and the impact of that on the hospitals’ design.
“The Committee has heard quite a lot from the NHS Commissioners about organisational redesign – but we need to know the outcomes of these organisational changes.
“What would be the best sources of info about outcomes? Actual detail of whether changes put in place are achieving what they need to achieve.”
Concerns about lack of coordination between primary, community and public health services
Cllr Hutchinson added,
“There are definite concerns in Calderdale that since the pandemic, coordination between primary and community and public health services is not working as it needs to.”
Neil Smurthwaite, Acting Chief Officer of Calderdale Clinical Commissioning Group, rejoined
“It’s interesting and disappointing to hear these services are not joined up,
“It’s not what I’m hearing elsewhere about links between joined up social care, community and primary care, particularly regarding End Of Life Care.”
“I want more information before we can address this.”
Cllr Hutchinson said he would get back to Neil Smurthwaite outside the meeting with information about lack of coordination between primary, community and public health services.
Neil Smurthwaite asserted that capacity issues will be taken care of by NHS England/Improvement investment in new roles in community care, such as social prescribing, physiotherapists and pharmacists.
What are these ‘new roles in community care’ ? Info dump
Across England, this investment amounts to £173m/year (rising to £1.4bn in 23/24) to allow Primary Care Networks to employ a wider range of additional staff
NHS England/Improvement information about the Additional Roles Reimbursement Scheme is on pages 19-31 of this pdf document.
This is key to the Primary Care Networks’ Directed Enhanced Services, that the Health Secretary’s Directions require them to provide on top of their core services. Complying with these Directions is the only way for GPs to get extra funding, which they are in dire need of after at least a decade of under-funding where their share of the NHS spend fell drastically.
He said that Calderdale Clinical Commissioning Group had done some updates to Calderdale scrutiny and he was not going to repeat that.
Updates to Calderdale scrutiny – info dump
Here are Care Closer to Home updates to Calderdale Adults Health & Social Care Scrutiny Board since May 2018, in reverse chronological order : Integrated Approach to Procurement, August 2020; Update on Primary Care Networks, 14 November 2019; Update on Care Closer to Home, 14 November 2019 (which says “We can confirm that where service change continues we will exercise our engagement and consultation duties as Commissioners, including consultation with local scrutiny arrangements.” So where’s the data they need to provide, in order to exercise their engagement and consultation duties?); Continuing Healthcare, 11 July 2019; Mental Health Services – Innovation Hub, 13th June 2019; Personal Budgets and Personal Health Budgets, 28 March 2019; Integrated Commissioning Executive Terms of Reference, 28 March 2019;Integrated Commissioning Executive Priorities, 28 March 2019; Local System Reviews 26th November 2018; Joint Commissioning with Calderdale Clinical Commissioning Group, 18 October 2018; Transforming Outpatient Care, 6 Sept 2018; Calderdale Cares Update, 6 Sept 2018
Why the secrecy?
Why did Neil Smurthwaite ignore the request to provide data the Scrutiny Committee needs and instead just talk about organisational matters?
And why did Matt Walsh before him also fail to provide data he had promised to the Scrutiny Committee?
In February 2019, Matt Walsh told Councillors,
“There is so much data that NHS Commissioners can’t see the wood for the trees.”
But he added they were willing to identify subsets of data on outcomes for patients, that they would share with the Joint Health Scrutiny Committee. He said the NHS organisations already report this data to NHS England.
At the time, Cllr Hutchinson told Matt Walsh the Joint Health Scrutiny Committee would need access to it over a period of time, so they could see if the Primary Care Networks were making progress with Care Closer to Home and reducing demand for hospital beds, through achieving reductions in unplanned re-admissions, waits for day case surgery, a&e admissions etc.
So what’s going on?
After the meeting on September 25 2020, Cllr Hutchinson confirmed that Matt Walsh would not agree a dashboard that would show how close they were getting to being “best in class”. He added,
“It has been a constant tussle to get them to accept that the Joint Health and Overview Scrutiny Committee should scrutinise the performance of Care Closer to Home, rather than the separate Adult Health and Social Care Scrutiny Boards in the respective boroughs.”
Relatedly, there’s nothing about Care Closer to Home in the NHS organisations’ schedule for engagement/consultation over the next year or so. This would require production of the data, as the only way for the public, the Local Medical Committees and the Clinical Senate to see if the plans are workable and will meet patients’ and their families’ needs.
Could this be the problem?
Calderdale’s organisational resdesign of primary care, social care and community services
In his presentation on Care Closer to Home at the 25 Sept 2020 Joint Health Scrutiny Meeting, Calderdale Clinical Commissioning Group’s Acting Chief Officer Neil Smurthwaite limited himself to the organisational redesign of primary care, social care and community services. He said,
- There is a Care Closer to Home Memorandum of Understanding for all partners to sign up to. (But it’s not on the Calderdale Clinical Commissioning Group Key Documents webpage – I looked.)
- Primary Care Networks have come on leaps and bounds via digital first.
- Primary Care Networks have started to deliver the care homes Directed Enhanced Service ahead of schedule. (For info, GPs were ordered to do this by Directed Enhanced Services Directions from the Health Secretary.)
- There has been some really good work and safe discharge of patients throughout the pandemic ensuring patients have remained safe at all times.
- ‘Digital first’ is a thorny issue – what’s the balance between digital and face to face? They are working with Healthwatch on community engagement on this balance. It’s a priority to get this right over next 6 months. (We have asked Calderdale Healthwatch for information about this engagement. So far it’s not listed in their 2020 work .)
- They are doing quite a lot of work round making sure GPs are open even if only by phone.
Greater Huddersfield NHS Commissioners are moving services out of hospital
Greater Huddersfield NHS boss Carol McKenna told Councillors that the Clinical Commissioning Group had a strategic commitment to moving services out of hospital and that’s in the budget.
But she too provided no data to show the capacity of these out of hospital services to meet patients’ needs and avoid unplanned hospital admissions.
She said the Clinical Commissioning Group finished last year in surplus and is not strapped for cash. They have invested in Locala for extra community health staff to work with Primary Care Networks.
They have also invested in a Kirklees Council quick response service to help people stay at home rather than be admitted to hospital.
The Clinical Commissioning Group boss did not address questions about the rapid response function that the Clinical Senate raised when they reviewed the Care Closer to Home plans in the 2015 Pre-Consultation Business Case. They’d wanted to know:
- What was meant by ‘therapist’ in the rapid response function
- How commissioners were going to deal with shortages of specific therapy skills.
Who knows if the Clinical Commissioning Group has worked out solutions to these issues?
Carol McKenna reported that they are developing the Primary Care Networks , and NHS England/Improvement have awarded the Clinical Commissioning Group acclerator status for an urgent community response scheme. The aim is to avoid hospital admission and provide a quick and timely response to discharge. This will start in November.
Covid-19 pandemic has enabled NHS bosses to accelerate NHS Long Term Plan changes
The Greater Huddersfield Clinical Commissioning Group boss also told Councillors,
“When the pandemic hit, we had to transform primary and community services rapidly. It made it possible to quickly make some long-discussed changes – for example, GP services have transformed via phone and video consultations as well as face to face where essential.
“They’ve been very flexible – Primary Care Networks and the Community Plus Service have worked together to deliver support and contact to vulnerable patients, socially prescribing.
“GP Federations have been working with Locala community service on covid assessment centres and a home visiting service for people with covid 19 symptoms who couldn’t leave home.”
GP Helen Salisbury, writing in the British Medical Journal, is not so sure that all this is such a good thing.
She added that they had just reported on Care Homes partnership work to the Kirklees scrutiny committee and they were doing a lot of work to support care homes to not send patients to hospital.
Urgent Community Response Service – info dump
This is what I’ve been able to find out about this service.
The aim is to set up a new rapid response community service to support older people in their homes and keep them out of hospital.
Teams will work to put in place tailored packages of “reablement” support for individuals in their own homes within two days of the referral. And they are expected to act within two hours to prevent vulnerable patients being taken to hospital, as part of efforts to provide more care closer to home.
A national roll out of the Urgent Community Response service began in the spring, with the first teams launched in April across seven “accelerator” sites – West Yorkshire and Harrogate Integrated Care System (Kirklees) among them.
Backed by £14m of investment from the commissioning and oversight quango NHSEngland/Improvement, the intention is that the teams will standardise how urgent community services will be delivered across the country.
But the Nursing Times has reported that nursing and social care trade union leaders have warned that the plans cannot act as a substitute for having enough nurses and a well-resourced social care system.
Dame Donna Kinnar, chief executive and general secretary of the Royal College of Nursing, warned of a loss of nurses from local community services over recent years:
“The evidence shows it is district nurses and health visitors who provide high quality holistic care in people’s homes.
“There can be no substitute for having enough nurses in communities, social care and hospitals too.”
Christina McAnea, assistant general secretary of the union Unison said the rapid response teams could not replace a well-resourced social care system.
“If the social care system wasn’t underfunded to the point of collapse, older people could be helped before they hit crisis point.”
The urgent community response service is a development of the urgent and emergency care Vanguard schemes – which included the West Yorkshire Urgent and Emergency Care Vanguard. An evaluation found there was not enough data to see if it had reduced admissions to A&E.
Overall, the various different Vanguard schemes did not reduce unplanned hospital admissions, although they were shown to limit their increase, compared to areas without Vanguard funding and status. The July 2018 National Audit Office Report concluded that “it is still too soon to be conclusive on the impact of vanguards on the demand for hospital services and patient outcomes overall.”