Calderdale and Huddersfield Hospitals’ Future Plans engagement is invalid

Calderdale and Kirklees 999 Call for the NHS have told Calderdale and Huddersfield hospitals trust their Future Plans public engagement on their revised hospital plans is invalid, because

• There’s no evidence that the planned capacity of the hospitals is going to be adequate to the future needs of the Calderdale and Kirklees population.
• CK 999 is asking the Independent Reconfiguration Panel and Secretary of State for Health and Social Care to direct Calderdale and Kirklees Clinical Commissioning Groups to immediately provide data to Calderdale and Kirklees Joint Health Scrutiny Committee that will allow them to determine if the hospitals’ planned capacity is safe for our future needs.
• When they rejected the 2016 hospitals cuts and centralisation plan, the Independent Reconfiguration Panel told the NHS organisations that from now on they must provide timely information to the Calderdale and Kirklees Joint Health Scrutiny Committee. And avoid repeats of things like withholding the Full Business Case until a last-minute private meeting with the Joint Health Scrutiny Committee immediately before its scheduled meeting in public.
• A requirement that the NHS organisations have persistently refused to comply with, despite repeated requests from this Scrutiny Committee.
• They are making a mockery of the whole consultation process with our elected Councillors’ Scrutiny Committee.

The Secretary of State’s approval of the hospitals Trust’s current plan is only conditional.

A key pre-condition for the Secretary of State to approve the hospital Trust’s revised plan is that the Calderdale and Kirklees Care Closer to Home programmes must provide evidence that the proposed hospital capacity is safe.

The 2019 Strategic Outline Case (p13) assumes that Care Closer to Home services could cut A&E attendance and reduce unplanned hospital bed days by more than 10% over 5 years. This aspiration is not based on data from the performance of the Calderdale and Kirklees Care Closer to Home programmes – but on contentious modelling carried out by global consultancy company McKinsey at a cost of £150K.

This – so far unevidenced – aspiration underpins the hsopitals Trust’s decision in their Strategic Outline Case (p 32), to keep overall hospital bed numbers broadly at the 2019 level, rather than to increase capacity to take account of the forecast increase in hospital usage from demographic growth.

The Strategic Outline Case (p35) forecasts a 2% increase in A&E Attendance, and a 2.7% increase in non-elective (ie emergency/unplanned) admissions. (These increases are presumably yearly, although no time period is stated). These forecasts are based on review of 3-year activity trends.

The public and NHS campaign groups seemingly lost the argument for Two Towns Two A&Es when the Secretary of State accepted the hospitals Trust’s April 2019 revised Strategic Outline Case

Like the first plan in the 2016 public consultation, the revised 2019 plan still aims to centralise our two District General Hospitals into one small planned care hospital at HRI for both Calderdale and Kirklees, and one acute/emergency hospital at CRH, also for both areas.

But we did gain some improvements in the revised plan, thanks to the successful campaigns to say No to the first plans, and Calderdale and Kirklees Health Scrutiny Councillors’ subsequent rejection of them as not in the interests of the public or the local NHS.

The 2019 revised plans are the basis for the current 8-29 March public engagement on the new hospital buildings, before the hospitals Trust submit planning applications to Calderdale and Kirklees Council

The new buildings are for:

• One 162 bed planned care and step-down rehab hospital for both Calderdale and Kirklees at Huddersfield Royal Infirmary, plus diagnostics, outpatients and a downgraded walk-in only A&E – which is better than the Urgent Care Centre in the 2016 plan.
• This downgraded A&E, with 24/7 A&E consultant and anaesthetist presence, is to treat and discharge minor injuries and resuscicate/stabilise self-referring patients with life threatening conditions, before transfer to CRH or other acute hospitals in West Yorks. The plans for HRI’s downgraded walk-in A&E also include 24/7 medical inpatient beds for patients who need to be admitted, but are not unwell enough to need transfer to CRH.
• One 676 bed acute/A&E hopsital at CRH with the only paediatric ward and Intensive Care Unit for both Calderdale and Kirklees

Even with the improvements to the plans that together, we’ve driven, we still think the hospitals cuts and centralisation plans are wrong

This is for reasons of:

• social fairness
• patients’ access to NHS primary care and planned hospital care
• patient safety
• climate change.

There is no evidence that the revised plans resolve these concerns

Even if you accept the planned division of services between HRI and CRH, and the assumptions they’re based on, changes are urgently needed to the plans for the two centralised hospitals, to make them safer for patients, staff and visitors.

These changes are listed in the section ‘Urgently needed changes to the plans’, below.

Consultation on the 2019 revised plans

The 2019 revised plans have not gone to public consultation. This was raised in the 7.9.2018 Calderdale and Kirklees Joint Health Scrutiny Committee meeting. Warren Brown from NHS Improvement threatened that if Councillors thought proposals have changed so much that they need another statutory consultation, that might well put the hospitals trust at the back of the queue for capital funding.

The Secretary of State has been clear that the revised plans are subject to consultation with the Joint Health Scrutiny Committee.

His acceptance of the 2019 revised plans came with 3 caveats:

• The need for further work on out-of-hospital care – this is mainly the responsibility of the NHS Commissioners
• The capacity within the hospitals – so the Trust now commits to retaining beds as they are (until/unless there’s a sustained reduction in demand for hospital beds as a result of Care Closer 2 Home).
• Capital financing – the Dept of Health has now allocated a £197m loan for this development.

He has required the Councillors’ scrutiny committee to tell him if/when the revised plans have addressed his 3 concerns, before he can sign off on further stages in the revised plan’s implementation,.

This makes the Calderdale and Kirklees Joint Health Scrutiny Committee the sole route for consultation on the revised plans.

Progress to date on resolving the Sec of State’s 3 concerns

Capital funding

Of these 3 concerns, the capital funding issue seems to have been only partially resolved because the £177m Department of Health and Social Care loan for Calderdale Royal Hospital’s new buildings doesn’t cover the new multistorey car park.

P44 of the 2019 Stategic Outline Case says that NHS Improvement has “advised” them to develop the additional 546 parking spaces

“ through alternate sources of capital funding via a partnership with either a public or commercial joint venture.”

This sounds like more PFI.

At the 19 March Calderdale and Kirklees Joint Health Scrutiny meeting, the Hospitals Trust and NHS Improvrment need to clarify the nature of this public or commercial joint venture, its rationale and its financial implications for the Hospitals Trust – as well as the issues in the following sections.

Hospitals capacity and Care Closer to Home

The revised plans do not resolve the hospitals’ capacity issues – in terms of A&E attendances and unplanned hospital bed days – and related workforce issues. The plans assume the same level of A&E attendance and unplanned hospital bed days as in 2019, regardless of forecast increases in their use due to demographic growth.

The decision about the hospitals’ capacity depends on reliable, consistent, qualitative and quantitative data about the impacts of the Calderdale, Greater Huddersfield and North Kirklees Care Closer to Home programmes. The decision is unsafe, UNLESS there are data to show Care Closer to Home programmes are on track to cut A&E attendance, as well as reducing unplanned hospital bed days by more than 10% over 5 years.

Commissioners have so far failed to provide these data, despite being responsible for planning, contracting and managing these services.

The missing data are about whether the Care Closer to Home programmes are or are not on track to:

• Reduce A&E attendance and unplanned hospital bed days by more than 10% over 5 years.
• Provide high quality out-of-hospital services AND hospital referrals, that meet the needs of patients, their carers, family and friends, and are based on dialogue between patients and clinicians that respects their respective personal and professional autonomy.

Before CHFT submits its planning application, we need a public consultation on the shift of services out-of-hospital, aka Care Closer To Home

The Care Closer to Home programmes have been running in both Calderdale and Kirklees since 2014 without any public consultation – despite the fact that NHS Commissioners and Calderdal and Kirklees Councils have repeatedly said these programmes are about transformation of local NHS services.

Significant change in NHS services requires public consultation. But the Care Closer to Home programmes were not included in the 2016 Right Care Right Time Right Place public consultation.

Care Closer to Home programmes have not produced any reliable, consistent data that they reduce the number of A&E attendance and unplanned hospital bed/days – or provide patients with a satisfactory alternative to hospital care.

For the past two years, the Clinical Commissioning Groups have evaded every request by Calderdale and Kirklees Joint Health Scrutiny Committee for data that that would provide evidence to support their aspiration that their Care Closer To Home programmes will reduce unplanned hospital bed days by more than 10% over 5 years, and cut A&E attendance.

The Committee Chairs have unsuccessfully made this request in four successive Scrutiny meetings. After the most recent request at the September 2020 meeting, ck999 made a big FOI request to the CCGs and Councils for relevant Care Closer To Home data.

In their Freedom Of Information response on behalf of themselves and the Councils, Calderdale and Kirklees NHS Commissioners again failed to provide the requested data

This failure is perplexing – it’s clear from the Clinical Commissioning Groups’ responses that:

• They know what data they need to collect in order to show the impact of the Calderdale and Kirklees Care Closer to Home programmes on A&E attendance and unplanned bed days.
• They have been collecting this data.
• They have the data analytical skills and resources needed to examine and interpret the data.
• They did not identify any problems marrying data that records innovative clinical and non-clinical activities and their outcomes, with routine data based on existing units of hospital activity.

So why aren’t they producing the requested data? Could their failure to do so be because:

• The data don’t support their “aspiration” Care Closer to Home services will reduce A&E attendances and cut unplanned hospital bed days by more than 10% over 5 years?
• This shows how unsafe is CHFT’s decision to keep overall hospital bed numbers broadly at the 2019 level, rather than increase capacity to take account of the forecast increase in hospital usage from demographic growth?

For reference, all the Freedom Of Information questions, responses and our comments are downloadable here.

jan21_ccgs_foi-response_-final-1Download

Urgently needed changes to the plans for the two centralised hospitals, to make them safer for patients, staff and visitors

The single Intensive Care Unit for both Calderdale and Kirklees needs to be bigger than the combined current ICUs in both HRI and CRH. The Strategic Outline Case does say the new Calderdale Royal Hospital building will include an “expanded” Intensive Care Unit – but doesn’t say how many beds it holds.

And there should be more acute beds at Calderdale Royal Hospital. From the Covid-19 emergency we have seen that compared to other similar countries, the UK is very under-resourced in terms of ICU beds and staff, and acute hospital beds. This has not only meant patients in England have died for want of ICU treatment, it has put enormous pressure on hospitals’ doctors and nurses.

The new centralised hospitals need to be pandemic-proofed. There will be more, and more frequent pandemics because climate change and environmental degradation will cause more social instability, inequality and conflict. These are the conditions where viruses jump species to humans.

Also Covid-19 related – Why does the Strategic Outline Case plan to only use the HRI planned care operating theatres for 2 x 4 hour shifts/day? There is now a huge backlog of waiting lists which NHSE/I has said hospitals must clear – and private “insourcing” companies like Totally Healthcare have recently been set up in order to chase subcontracts from NHS hospitals to reduce these waiting lists.

By insourcing, they mean carrying out medical services/procedures including diagnostics, day-case surgery and outpatients, IN THE NHS HOSPITALS using their NHS premises and equipment during downtime.

West Yorkshire and Harrogate Integrated Care System have told us they have not ruled out West Yorks hospitals’ use of insourcing companies to clear their Covid-19 related waiting lists, as they are considering all opportunities.

It’s not clear from the hospitals Trust engagement on the new building plans whether they include:

• Hospital laundries
• Hospital kitchens for cooking patient and staff meals
• Adequate spaces for staff to don and doff PPE, shower and change before going home, and to rest and recover during breaks and if overwhelmed by their work during pandemic surges or any other emergency

During the Covid-19 pandemic, because of the lack of a hospital laundry, CHFT nurses were having to wash their uniforms at home, with all the worry this created about spreading the virus. Volunteers were sitting at home sewing laundry bags for nurses to put take their uniforms home in to put straight into the washing machine.

Fresh, locally produced food is essential for health, climate change and local economy reasons. When CRH was built, it didn’t have a hospital kitchen. This needs to be remedied in the new build so that CHFT can feed staff and patients healthily as advocated by the Calderdale Assembly on Shaping Food Culture in Calderdale .

How the revised plans sit with the White Paper/ June 2021 NHS Bill on integrated care

The Greater Huddersfield/North Kirklees Clinical Commissioning Groups’ 2019 Care Closer to Home Evaluation Report identified issues that relate to national policy on “integrated “care. The national policy position was that “Integrated Care Provider (ICP) arrangements” should be used to procure/provide Care Closer to Home services. At the time of the Report, the Clinical Commissioning Groupss thought the “market” was not sufficiently developed to procure an Integrated Care Provider, so they decided to extend Locala’s Care Closer to Home/community health services contract until 2022.

Under the new White Paper proposals, ‘Integrated Care Provider arrangements’ will mean statutory Integrated Care bodies. Once all Clinical Commissioning Groups are abolished on 31st March 2022 , these Integrated Care bodies – in fact if not in name, Accountable Care Organisations – will follow a procurement regime that seemingly abandons requirements for open competitive tendering and opens the door to the kind of secretive crony contracts that the government and DHSC have awarded during the Covid-19 emergency. (Proposals on the Provider Selection Regime are currently out to public consultation.)

Already in London, amidst the chaos of all London Clinical Commissioning Groups merging into 5 by 1st April 2020, 13 London Primary Care Commissioning Committees have used murky Covid-19 urgent decision arrangements to secretively agree the Change of Control of around 40 GP contracts from a UK GP contract-holding company to a UK subsidiary of the USA Centene Corporation.

The Integrated Care Provider arrangements that will be put on a statutory basis by the new NHS Integrated Care Bill are based on USA models of managed/ accountable care, which are designed to cut costs to health insurers – whether private or public under Medicare/Medicaid systems. The main cost-cutting mechanisms are:

• Risk/reward share capitated contracts, which have already been introduced for Calderdale and Kirklees Care Closer to Home schemes
• Cutting the numbers of GPs and replacing them with less-skilled and -qualified “alternative roles” and Voluntary and Community Services
• Restricting patients’ access to care
• Replacing clinicians’ professoinal autonomy with requirements to follow clinical decison and referral algorithms

No-one seems to know how Integrated Care System and place-based commissioning will work once CCGs are abolished at the end of March 2022. At the 23.2.21 West Yorkshire and Harrogate Integrated Care System Board meeting, a polite row started up about who is to have power in this new commissioning world – Councillors as representatives of the public, or clinicians.

None of this makes it seem likely that Care Closer to Home programmes are going to be well-planned, well-commissioned and well-provided by NHS organisations. Instead it seems entirely possible that control will be in the hands of private, profiteering companies that are operating in the interests of American parent companies.