Two members of the public – Anna Best and Calderdale 38 Degrees NHS member Dr Chris Day – report here on the 9th June Hanson Lane drop in session about the future of Calderdale and Huddersfield NHS.
Anna said that the representatives at the Hanson Lane drop-in event gave out leaflets and information, listened to her concerns and wrote down a number of her questions and suggestions. She thought they may have better prepared than those at previous drop ins, judging on previous reports.
Ruth O’Hare, a public relations person on a six month contract with the Commissioning Support Unit, told Chris Day that she had written answers to all the questions in Plain Speaker’s “Right Care” Drop In flyer – she didn’t say what her answers were, but said she would email them.
Chris Day reported that 18 members of the public attended the Hanson engagement. He said,
“The four who left between 5 and 7 pm. took Calderdale 38 Degrees NHS leaflets and were very keen to hear what I had to say.”
Anna Best was at the drop-in from 2.30 to 4.45. As she left, she asked how many people had attended and was told it was about 15.
“I spoke first to the Quality Manager of the CCG. I asked her how many local people had
been consulted for the views represented in the Right Care leaflet. She referred the
question to another woman who was “meeting and greeting” who said that around 5,000
people had had their views taken over the last three years and that although the data
wasn’t in the public domain she could forward it to me if I let her have my email address.
“I asked if the Right Care proposals were a money saving exercise. She said that was
definitely not the case – it was about targeting the pot of money in a way that would
produce better clinical outcomes. I queried the huge amount of money this would require
and while she conceded it would be massive, she felt it was a wise investment because to
carry on as at present was not feasible as we did not have the capacity for the projected
hospital beds we would need in the next five to ten years. She stated that to do nothing
wasn’t an option – which seems to contradict page 9 of the Right Care leaflet which
places it as the first one – “Continuing with the existing hospital and community model,
so there are no changes to the service you get now.”
“I expressed concern that the proposed integrated health and community service model
looked as if it would need considerable technological support and that technology
sometimes breaks down and she agreed there would need to be a back up to the technology.
“I also pointed out that not everyone would be willing or able to self- help and she
admitted the model would not suit everyone.
“She was not very forthcoming on the proposed closure of A&E apart from saying it was by no means a done deal and this was something to discuss with the CHFT representatives.
“I then spoke to those representing the CHFT. They said they had made their preferred
option public because they felt this was something the CCG and other interested parties
would want to know. They also said that the CHFT own 28 acres of the Huddersfield site
and only 18 acres of the Calderdale one and that many services have already transferred to Huddersfield – implying this is why they prefer to keep Huddersfield’s A&E open.
“I pointed out that the greater length of time ferrying casualties to Huddersfield is
likely to result in an increase in fatalities, but was told the increased time isn’t
enough to be significant and heart attack patients are already taken straight to Leeds
and this has seen survival levels rise (they didn’t have figures for by how much).
“Apparently an analysis on the time journeys to Huddersfield take has been carried out but the results haven’t been made public yet, but the claim is that the time of the journey is not a problem. I was also told that the Yorkshire Ambulance Service (YAS) support the proposed changesand were part of the consultation (they referred me to the National Clinical Advisory Team report.) Regarding YAS’s plans to downgrade the qualifications of ambulance crews, they said the idea was to team a skilled paramedic with a less highly qualified partner.
“All three were adamant they were not in favour of privatisation and did not feel the
strategic plan would make this more likely to happen. They said that there were
integration models that had been looked at – one from Sweden and one in England – Torbay that showed how the Right Care model worked well.
“The Locala representative described in some detail how he envisioned the integrated
model working and pointed out that some parts were already up and running. He did concede, however, that it would certainly require a great deal of retraining and redeployment to make such a wholesale radical change and agreed that there would be real challenges in getting it up and running.
“They said there would be more evidence-based information in the outline business plan.”
Little or no evidence for claims that integrated care is a cost-effective way to reduce acute and emergency hospital costs
Chris Day discussed the lack of evidence for the cost-effectiveness of integrated care models with a Hospital’s Trust consultant cardiologist. Chris reports:
“He was unaware of the World Health Organization (2014) policy summary review of the existing evidence on the economic impact of integrated care approaches. This shows clearly that there is almost NO evidence on the cost-effectiveness of integrated care, although if enough money were made available it might improve quality of care, health outcomes and patient satisfaction.”
Chris Day also spoke about this with Ruth O’Hare, a public relations person who has been recently employed by the Commissioning Support Unit as the “Right Care” Seniro Communications and Engagement Lead.
“Ruth O’Hare enthusiastically talked about the cost-effectiveness of integrated care and was unaware of the World Health Organization (2014) policy summary review of the existing evidence on the economic impact of integrated care approaches. This shows clearly that there is almost NO evidence of cost-effectiveness.”
Although staff at the drop in told Anna that there is evidence that the Right Care model works well, this seems not to be a general opinion.
So far there seems to be little or no evidence about whether this model of integrated health and social care, as trialled in South Devon and Torbay, is a cost-effective way to reduce rates of emergency bed use or length of stay. A Kings Fund study says that evaluation for several years is needed to see what impact it has.
The integrated care pilots in South Devon and Torbay were jointly funded by NHS England and Devon County Council. Some good results are tempered by the heavily increased workload (not fully matched by extra staff and funding), meaning not all the co-operation and meetings could take place. The pilot also ran into problems with data sharing, which has become a political hot potato as the NHS becomes increasingly commercialised.
Changes brought in by the 2013 Caldicott review of NHS information governance meant that in Torbay and South Devon, GP practices had to rely on local intelligence, rather than shared confidential patient data, to identify patients to include in the virtual ward.
(This is a ward that exists on the computer as a list of patients at a high risk of admission to hospital for acute and emergency care. These high risk patients are identified by use of a “risk stratification” computer model that analyses identifiable, confidential patient data. The virtual ward allows “care in the community” multidisciplinary teams to direct extra care towards the patients in their homes, in order to improve or better manage their health with the aim of reducing hospital admissions.)
The Caldicott rules specify that the flow of confidential patient data between GPs, community healthcare staff and organisations and hospitals, for the purpose of risk prediction and stratification of identifiable patients remains impossible, unless there is explicit patient/service user consent. This raises questions about Locala’s current use of risk stratification and virtual wards, as well as the wider use of risk stratification and virtual wards in the Right Care model.
Meanwhile the virtual ward idea appears to be expanding. In April 2014, NHS England announced a new, one year Enhanced Scheme that will pay participating GPs up to £2.87/patient to introduce the “risk stratification” model, identifying at least 2 percent of their patients as being at risk of an unplanned hospital admission and putting them on a pro-active risk management register. But GPs have been underwhelmed by this proposal and recent reports found that only 51% were planning to take part in it.
As well as the Torbay and South Devon integrated care pilot, the Calderdale and Huddersfield Strategic Outline Case refers to a Swedish integrated care model from Jönköping county council. A Royal College of Nursing briefing reported that although Jönköping is undoubtedly an example of good practice – with a 20 per cent reduction in hospital admissions and a redeployment of resources to the community, a 30 per cent decrease in length of stay for heart failure patients and reduced waiting times to see specialists – it is not necessarily easy to transfer to England. A key reason for this is the lower numbers of community nurses in England compared to Sweden. The RCN reported:
“In spite of the urgency of the matter, evidence from the RCN’s Frontline First campaign show that provision of care in the community has declined and community workforce numbers are struggling to meet increasing health demands. There is a continued disconnect between rhetoric and reality on the ground as NHS providers struggle to meet efficiency savings targets.”
Lack of evidence of the cost-effectiveness of integrated health and social care is mentioned in the Local Government Association’s Adult Social Care Efficiency programme Interim report 2013, summarising the results of the programme’s first year (2012-13). 54 councils -including Calderdale – have taken part in the programme, which aimed to find ways of saving money and increasing productivity in Adult Social Care. This was driven by Coalition government cuts to Council’s Adult Social Care funding. The Report found that,
“Those places that hoped to achieve that [sic] efficiency savings through health and social care integration have so far been disappointed that they are not able to evidence the savings.”
There is no demographic time bomb waiting to blow up the NHS
A consultant cardiologist who Chris Day talked to said that the Strategic Outline Case proposals for the future of the NHS and social care in Calderdale and Huddersfield are not about privatisation – they’re about about better services.
“He gave anecdotes from his own experience, for example, that his elderly patients take longer to discharge than younger ones. From these examples, he concluded that effective care in the community could help counter the government’s NHS funding cuts by providing cheaper services than hospitals could provide.
“I explained that the evidence is that an aging population only has a small effect on increasing health expenditure. Studies show this is in the order of an annual growth rate of 1.5%, rather than the much-publicised notion that the NHS is facing a “demographic time bomb” .
“He was unaware of this.
“Right Care” “engagement” and Calderdale Council’s People’s Commission on Health & Social Care
“I also talked to Ruth O’Hare, a Public Relations contractor with the Commissioning Support Unit who talked about Calderdale Council’s proposed ‘People’s Commission’.
“Ruth told me ‘We have been hiding away’, but said that things are changing. She had just returned from discussing communications about the “Right Care” proposals with the Calderdale Council communications team, who are involved with “Right Care.”
“She is meeting with communication leads from CHFT on Wednesday, with the same purpose.”
The Calderdale Council Leader, Cllr Tim Swift, told Plain Speaker,
“I can assure you that the Council will be deciding what we say to the public about the People’s Commission. I am
determined to ensure that the commission’s work is kept entirely separate from the various engagement events being organised by the commissioning groups and / or the provider trusts.”
Calderdale Councillor Janet Battye said,
“I’m determined to make sure, if I can, that the work of the People’s Commission is as open as possible.”
What next for public consultation
Chris Day reported.
“Ruth O’Hare will send me statistics and a programme document for the engagement process.
Briefly, these will apparently tell me that information from the CSU-led engagement will be passed on to the CCGs and providers.
“Each will then produce their own proposals.
“However the providers cannot act on their proposals without the agreement of the CCG, which is responsible for commissioning NHS services.
“The outline business case draft is due to be ready by mid June (about now).”
Updated 11th June to clarify Chris Day’s report of Ruth O’Hare’s recent meeting with Calderdale Council officers involved in “Right Care”.
Updated 12th June with comments from Cllrs Tim Swift and Janet Battye.