Local Kirklees impacts of dismantling the NHS

• This is based on a talk about the local impacts in Kirklees of the government’s dismantling of the NHS that Colne Valley Green Party invited me to give to a recent meeting.
• It only scratches the surface of the local impacts of dismantling the NHS – although I tried to go behind the headline news of staff shortages, risks to staff and patients’ safety, and industrial action, which everyone knows about.
• Instead I’ve started to follow the Kirklees NHS money – which is delegated to it by the West Yorkshire Integrated Care Board, set up last year as a result of the 2022 Health and Care Act.

Jenny Holtzer, 2021

Follow the Kirklees NHS money

Like the rest of England, the NHS in Kirklees is in a state of crisis and collapse after more than a decade of cost-cutting and privatising NHS “reforms”.

After over a decade of government underfunding, all parts of the Kirklees NHS, public health and social care services are still being underfunded. So Kirklees Integrated Care Board has to make more cuts in order to avoid ending the 2022/23 year with a deficit that exceeds their “control total” – which legislation forbids.

I’ve not found it easy to see where projected further cuts from September 2022 have fallen, although they identified these would be required. But the January 2023 Kirklees Integrated Care Board decided that the general public needed to be told

“to help themselves to prevent illness and… to manage long term conditions where possible”

Kirklees Integrated Care Board – a non-statutory body – is reviewing and in some instances recommissioning the 400+ contracts that have had to transfer from the Clinical Commissioning Groups to the Integrated Care Board.

In the process it seems to be tightening contract specifications. Locala says that the Integrated Care Board has done this in Locala’s new Care Closer to Home contract, in a way that makes it impossible for all but the most poorly patients to be referred into its Community Nursing Service.

The new Locala contract is for 18 months from July 2022, while the Commissioners develop the ways for Kirklees Community Services (Care Closer to Home) to be delivered in an integrated way, as the basis for a new long term contract.

As things stand, it doesn’t look as if the provision of Care Closer to Home as a key means of reducing A&E attendance and unplanned hospital admissions is working as planned.

The collapse of urgent and emergency services – which the Royal College of Emergency Medicine reports is causing 500 avoidable deaths from long ED waits each week in England – has led to a local charity issuing guidance to the public on how to help themselves when they need urgent or emergency care.

GP practices themselves are not equipped to deal with patients’ emergency healthcare needs, but have found themselves trying to fill the role of paramedics and ambulances, at enormous risk to their patients and themselves. This is causing moral injury to GPs and other GP staff.

Patients are needlessly dying

Calderdale and Huddersfield hospitals trust is still chronically underfunded.

There are staffing shortages at the hospitals.

Other Calderdale and Huddersfield hospitals’ clinical staff shortages are in its stroke services, which are underperforming.

Expanding on those key points

Like the rest of England, the NHS in Greater Huddersfield is in a state of crisis and collapse after more than a decade of cost-cutting and privatising NHS “reforms”

As you’ll know, these reforms were finally cemented in law by the 2022 Health and Care Act.

Successive governments have tried to justify them on the basis of the “austerity” myth – that public spending had to be cut, in order to allow space for the private sector to grow, so that the economy could recover from its collapse due to the misdeeds of the bankers in 2008.

No matter that increasing investment in the NHS would have grown the economy, and the government’s tax take, due to the considerable multiplier effect of such investment.

No matter either, that these cuts and increased privatisation were inevitably going to damage the NHS for both patients and staff; make people sicker; and end in the collapse or dismantling of an effective, universal, comprehensive NHS. With rich pickings for private health, digital technology and life sciences companies.

An exhausted Kirklees GP told me the other week that this predictable and intended end point of these “reforms” has now been reached – the NHS and social care are now well past their failing point:

“10% of the workforce is absent, the workforce is done, they are throwing in the towel. The government has got what they wanted.

“GPs have been sidelined and their practices are not part of the future model, which wants to abandon the GPs’ General Medical Services contract.

“The direction of travel to Accountable Care Systems is very clear, with management of General Practice against outcomes and population funding, and the abandonment of NHS principles.”

How is this collapse playing out specifically in Kirklees? Follow the money

All parts of the Kirklees NHS, public health and social care services are underfunded. So Kirklees NHS seems to be running a deficit that threatens to exceed their “control total” – which legislation forbids.

This is 7 years after the West Yorkshire & Harrogate Sustainability and Transformation Plan was produced, with the stated aim of imposing a balanced budget across the whole West Yorkshire & Harrogate NHS, through a mixture of carrots – called Transformation Funding; and sticks – called variously efficiency savings, turnaround and special measures.

Still the government bashes on with calculated underfunding of the NHS, public health and social care, with impossible consequences: Kirklees Council at the 2nd quarter was forecasting for 2022/23 a net overspend of £24.3m after a £10m drawdown from reserves, closure of services and exhaustion of reserves to mitigate this.

The Kirklees NHS 2022/23 delegated budget from the West Yorkshire Integrated Care Board was initially £786.9m – although it has received some small additional allocations since then.

It had a “control total” of a £1.7m deficit. This is apparently the amount that Kirklees Integrated Care Board is allowed to overspend its delegated budget.

In order to “achieve” their control total, Kirklees Integrated Care Board meeting papers seem to show that originally they planned “efficiency cuts” that included:

• £751 cut to prescribing costs
• £751 cut to Continuing Healthcare costs
• £183K cut to Phlebotomy

But by September 2022 Kirklees Integrated Care Board was having to plan further cuts, in order to make the books balance by the end of the 2022/23 year.

It was still forecasting “achievement of its control total of a £1.7m deficit,” – but only by means of £2.5m additional planned cuts, in order to offset the “risks” to the achievement of the “control total”.

These “risks” included overtrading in the first six months with private companies, for planned/elective care for NHS patients (alongside undertrading with CHFT); increased costs in the use of “discharge to assess” beds; and prescribing costs for a number of drugs.

Without cutting projected overspends on these items, the deficit would increase by between £3.162m to £4.9m.

Scary warning

It’s not easy to see where projected further cuts from September 2022 have fallen.

But the January 2023 Kirklees Integrated Care Board decided that the general public needed to be told

“to help themselves to prevent illness and… to manage long term conditions where possible”

This scary warning was given stark shape by a Locala update in February 2023.

It warns that

• The Locala Community Nursing Service is in OPEL 4 and is managing life critical and essential patients as a priority
• Referrals to Community Nursing will not be accepted if they don’t meet the service criteria, which includes a new definition of “housebound” taken from the Integrated Care Board commissioners’ specification for the new Locala contract as part of the Care Closer to Home review process.
• The new definition of “housebound” is: “A …patient…who cannot leave their home at all, or without significant assistance which cannot be provided, either temporarily or permanently, due to severe physical or mental or illness or disability.” With the exception to palliative care patients who will always be seen in their own homes.”

Care Closer to Home review and new Locala contract

This review and the new Locala contract are important not just in their own right – but because the Secretary of State’s approval of the cuts and centralisation of Calderdale Royal Hospital and Huddersfield Royal Infirmary depends on the Calderdale and Kirklees Joint Health and Overview Scrutiny Committee being able to tell him that the planned hospital beds capacity is safe and adequate, on the basis of firm evidence of the impact of the Care Closer to Home programme on reducing A&E attendance and unplanned hospital admissions.

So far there is no such evidence, as Calderdale and Kirklees Joint Health Scrutiny Committee has repeatedly complained.

And I can’t see where the Kirklees Integrated Care Board review of Kirklees Care Closer to Home is.

But In December 2020 I made a massive FOI request about Care Closer to Home in Calderdale, Greater Huddersfield and Kirklees. The responses in Jan 2021 showed that the Locala Care Closer to Home service was a mess.

New Locala contract is for 18 months while the Commissioners work out how Kirklees Community Services (Care Closer to Home) will be delivered in an integrated way, as the basis for a new long term contract

It would be interesting to know what other Care Closer to Home specifications Kirklees Integrated Care Board has changed in the new contract, in addition to the punitive redefinition of “housebound” which apparently serves to radically reduce patient referrals to the Community Nursing service.

And what other specifications they’re planning to change for the upcoming long term contract. And whether they too will be about reducing Kirklees patients’ eligibility to access Care Closer to Home services.

The new 18 month £59m contract is based on a lead provider model, with the contract holder being responsible to either provide the services directly or in collaboration with other providers of services.

As things stand, it doesn’t look as if the provision of Care Closer to Home as a key means of reducing A&E attendance and unplanned hospital admissions is working as planned.

The collapse of urgent and emergency services – which the Royal Collage of Emergency Medicine reports is causing 500 avoidable deaths from long ED waits each week in England – has led Colne Valley Help charity to issue guidance to the public to contact their GP if they face significant delays in ambulance response to critically injured or unwell patients.

The key message is:

• look after the vulnerable
• if absolutely stuck with a life-threatening emergency call or call into your GP surgery.

This is on a Colne Valley Help webpage under Emergency Ambulance Transport.

NHS England & the government/Department of Health and Social Care have still produced NOTHING of any practical help. I asked a question about this at the West Yorkshire Integrated Care Board meeting on 21st March. Apart from some anxious waffle at the meeting, I am waiting for a proper answer.

GP practices themselves are not equipped to deal with patients’ emergency healthcare needs but have found themselves trying to fill the role of paramedics and ambulances, at enormous risk to their patients and themselves

Although ambulance response delays have been happening more and more often – through no fault of the paramedics or Yorkshire Ambulance Service – neither NHS England nor the Department of Health and Social Care has given patients or GPs caught up in such situations any advice on what to do.

Given the danger to patients, and the risk that GPs may get into trouble too, such advice is needed ASAP. GP Survival warns that,

“The NHS Chain of command has been broken by government. There is little or no evidence of end-to-end clinical risk management of chronic delayed ambulance response and GPs are operating blind in a storm.”

Patients are needlessly dying

GP Survival point out that the number of avoidable deaths due to delayed community 999 ambulance response is as yet unknown.
But they are aware of many cases – nothing to do with industrial action – when critically unwell patients, family members and the public who face significant delays in ambulance responses have contacted local GPs is desperation for advice.

GP Survival has come up with emergency advice for GPs in this situation, on the understanding that,

“General Practice is neither commissioned nor resourced for the provision of emergency response.”

And recognising the risks to GPs of following this advice, should the patient not survive.

Calderdale and Huddersfield Foundation Trust is still chronically underfunded

Calderdale and Huddersfield hospitals have been underfunded and subject to drastic “efficiency cuts” for at least a decade. The trust’s January 2023 Board meeting papers report that for 2022/23, the trust has a £20m “cost improvement programme” (which means spending cuts). There is a risk that it will not achieve its planned £17.35m deficit for the year and there is now an additional “forecast deficit of £1.8m against plan”. This assumes that the full £20m spending cuts will be made.

There are staffing shortages at the hospitals

A review of November 2022 data showed that the combined Registered Nurse and non-registered clinical staff metrics resulted in 23 of the 28 clinical areas having fewer Care Hours Per Patient Day than planned.

This seems to be because the need to open additional beds meant staff had to be moved to cover them and this meant “the ‘base area’ resulted in reduced Care Hours Per Patient Day.

Maybe they shouldn’t have set out in their 2017 Workforce Plan to cut 479 full time equivalent staff over 10 years?

Care Hours Per Patient Day is a controversial measure of staff-patient ratios that was introduced in NHS hospitals as a result of Lord Carter’s 2016 review of Operational Productivity in the NHS.

The 2016 West Yorkshire & Harrogate Sustainability and Transformation Plan (STP) showed that the area’s hospitals were to make Carter programme “operational productivity” savings of £101m by 2020/21.

£2bn of Lord Carter’s proposed £5bn/year savings in the English NHS was intended to come from hospital workforce “efficiency” savings, that included replacing fixed staff ratios with Care Hours Per Patient Day.

Care Hours Per Patient Day includes total staff time spent on direct patient care, and also on activities such as preparing medicines, updating patient records and sharing care information with other staff and departments.

It’s an import from the privatised American health care system, that says nothing about the skills, knowledge and experience of whoever’s doing the caring.  But a 2016 study showed that wards with a higher ratio of registered nurses to healthcare assistants had fewer slips, trips and falls. Those with more Health Care Assistants had a higher than average amount of falls.

The study also showed there were fewer incidents of nausea and vomiting on wards where there was a total establishment of 30 or more whole-time equivalent nurses. According to the research, replacing six HCAs with six registered nurses on the six wards with highest incidents of falls could decrease monthly total falls at the trust by 15%. The study’s author, Professor Leary said the results were a first step to showing causation between the number of nurses on a ward and quality of care.

Regardless, in April 2018 Care Hours Per Patient Day was introduced. NHS England/Improvement Care Hours Per Patient Day Guidance said that since the Carter Operational Productivity Report,

“CHPPD has…become the principal measure of nursing, midwifery and healthcare support staff deployment on inpatient wards. It has now expanded to include all ward-based clinical professionals who are budgeted to the ward establishment and rostered into the 24/7 roster…
“…this updated guidance…includes a wider workforce that includes registered and non-registered allied health professionals (AHPs), and all registered and non-registered nursing associates (NAs).”

Other clinical staff shortages are in the hopsitals’ stroke services, which are underperforming

Calderdale and Huddersfield hospitals trust has identified that staff shortage in specialist stroke teams such as Occupational Therapy, Speech and Language teams and upcoming Consultant retirement will impact the service if new applicants are not attracted into the service.

The Trust has recommended

“Exploration and increasing the development of key roles such as Advanced Clinical Practitioners. The Stroke Matron has now been permanently funded and further exploration of the Thrombolysis nurses and working patterns is planned.”

But

“Stroke performance remains an issue and proposed stroke hub business case not approved – business case for investment in community services being progressed to alleviate bed pressures and thereby enable improved performance at front end of stroke Pathway. – F&P to follow up in March meeting”