Best laid plans – Commissioners haven’t yet looked at Trust’s business case for NHS shake up

At Calderdale Council Adults Health and Scrutiny Panel meeting on 28th July,
Cllr Adam Wilkinson doggedly took the lead in questioning NHS chiefs about their confusing proposals for hospital bed cuts in both the 2014-16 Balanced Plan, and in the Strategic Outline Case.

If you don’t want to read a lot of detail about the scrutiny, you can could read the idiots’ guide to the Scrutiny Panel meeting instead.

The Balanced Plan, which the Scrutiny Panel only found out about through reports leaked in local media,  aims to make cuts and generate new income in order to cope with the Trust’s £20m funding shortfall this financial year and a £19m shortfall in 2015-16.

The Strategic Outline Case proposes to cut acute and emergency hospital care from 2016-17, and replace it with an as-yet unspecified system of care in the community.

Cllr Wilkinson hacked his way through the NHS chiefs’ barrage of smoke and mirrors to get answers about

  • the bed cuts in the Balanced Plan,
  • bed cuts proposed in the Strategic Outline Case (and now in the Outline Business Case)
  • whether and how these cuts relate to each other.

This matters because the issue is whether the Trust is trying to slide through significant service changes without holding a public consultation. The public has a right to have an input into decisions about significant service changes, such as substantial numbers of hospital bed cuts.

NHS chiefs passed the buck by saying that anything that happens with significant bed reduction depends on the Clinical Commissioning Groups being “comfortable” with the Trust’s Outline Business Case for the Right Care proposals.

Clinical Commissioning Group bombshell: it hasn’t looked at Trust’s business case or decided whether to take it to consultation

Julie Lawreniuk, the Clinical Commissioning Groups’ Chief Finance Officer, passed the buck back by saying that Calderdale Clinical Commissioning Group hasn’t formed an opinion about the proposed bed cuts or decided to go to public consultation, because it has not yet looked at the Trust’s Outline Business Case.

Julie Lawreniuk said,

“The reason is because the CCG has been working on future models of care. This is to decide if care closer to home is the right clinical model. Then we will look at the Outline Business Case, to see if it’s right. We haven’t made a decision to go to consultation on it.”

Ms Lawreniuk said that the 14th August Calderdale CCG Governing Body meeting will make a decision about whether they’ve done enough work on future models of care to be able to make a judgement of the Trust’s Outline Business Case.

That will determine whether they now look at the OBC.

Cllr Dave Draycott asked,

“Are you saying you don’t know what sort of services care closer to home would look like?”

Julie Lawreniuk replied,

“There are two parts to the work – looking at what care closer to home would be, and what kind of hospital services that would require.

The CCG is developing a care closer to home strategy based on its Strategic 5 Year Plan. We don’t know how that will be delivered and what standards CCG expect for patients.”

She also said that all NHS providers will have to to make so-called Cost Improvement Programme (CIP) savings of at least 4% because of tariff changes.

In other words, they have to find ways of meeting this funding shortfall. This is because  the government is cutting the rates of payment to NHS providers for the services and treatments they give patients.

Julie Lawreniuk said,

“The CCG knew that CHFT would have to face £20m efficiency savings. We have to quality assure all their plans including CIP savings. They have to make these year on year. In the end, this will lead to the need for large scale change.

As Commissioner, we haven’t made any decision about bed reductions and are not committed to these plans.”

Councillor Wilkinson said,

“The CCG hasn’t made decisions on the Trust’s plans, but most CIP savings are between now and September.”

Ms Lawreniuk replied,

“Every Trust we work with will be making small savings to make cuts for government efficiency programmes and this is an example of short term small changes year on year and the CCG has a role in quality assuring that.”

Cllr James asked if the CCG was content with proposals in the Balanced Plan.

Julie Lawreniuk said that the CCG was content and had quality assured all the efficiency savings in the Balanced Plan.

Are Balanced Plan bed cuts a significant service change? It depends if you believe Trust assurances that it can make these cuts without changing the service

Cllr Wilkinson asked,

“We should expect this is a normal change year in year and is nothing to do with the Strategic Outline Case?”

Mags Barnaby, the management consultant hired by the Trust to work out the Balanced Plan, said they had assumed normal levels of activity and found more efficient ways of delivering them.

Which didn’t really answer Cllr Wilkinson’s question, unless you accept Mags Barnaby’s implication that the efficiency-saving bed cuts won’t change normal levels of activity.

Owen Williams deflected further questioning from Cllr Wilkinson by making the patronising observation that he wasn’t surprised that people were confused  – but that regardless of the Strategic Outline Case/Strategic Review, the Balanced Plan “is exactly what we’ll be doing” and that with the comprehensive spending review coming up in 2015 “the ask of efficiency savings year on year is going to increase.”

After a long detour through Scrutiny Panel members’ questions that had little or nothing to do with the Balanced Plan and its relation to the Strategic Outline Case, Cllr Wilkinson dragged the questioning back to the question of how “normal” the Balanced Plan cuts really are.

He said,

“Have there been other years where beds have been cut by 110 over two years?”

Owen Williams said that the bed baseline shifts. Ten years ago the hospitals operated 1000 beds.

Earlier questions had yielded information from Owen Williams that at some times of the year bed numbers increase and at others they decrease, depending on demand. In winter demand would have been higher, hence the 870 bed base in the SOC, which was published in February. But by the summer, when the Trust published its Strategic 5 year plan,there were only 802 beds.

Asked whether this was a typical seasonal reduction in any year, Owen Williams said that the hospital is currently operating fewer than 800 beds, but in the last two years the Trust has to extend the higher level of beds beyond the normal high winter period.

Armed with this information, Cllr Wilkinson said,

“In the previous 10 years there’s been a reduction of 200 beds and now you’re proposing a reduction of 110 beds in two years.”

Julie Lawreniuk chipped in that this reduction was quality-assured by the CCG, which didn’t answer Cllr Wilkinson’s question, unless you accept Ms Lawreniuk’s implication that this means that the bed cuts won’t affect the quality or the amount of services that are available for patients who need hospital.

But Cllr James clearly accepted Ms Lawreniuk’s implication, asking:

“The 110 bed cut has been agreed by the CCG.”

Julie Lawreniuk said yes.

Cllr Wilkinson continued,

“The Trust is already reducing beds at a rate that hasn’t been made before, before the outcome of consultation.”

Chair Cllr James intervened to give his version of the NHS chiefs’ view that the Balanced Plan bed cuts were nothing to do with the Strategic Outline Case, so the lack of SOC consultation had no bearing on the current bed cuts.

This muddied the point that Cllr Wilkinson was trying to establish, of whether the Balanced Plan bed cuts were big enough to count as a significant service change, in which case there would need to be a public consultation before the Trust could carry out the cuts.

Cllr Wilkinson persisted with his questioning.

Owen Williams said that last year the Trust had aimed at a 30 bed cut but couldn’t meet it because it wouldn’t have been safe.

Which didn’t answer Cllr Wilkinson’s question.

But  Cllr James took Owen Williams’ bait and swam off with it, saying:

“So the 66 bed cut this year may not happen.”

Owen Williams agreed.

Cllr Geraldine Clarke said that this was not clear and she didn’t want to see things getting out of hand for lack of clarity.

Mags Barnaby said,

“What I’m hearing in the room is how to cut 66 beds in 2014-15. We’ve looked at the amount of time patients are waiting in bed for something to happen, for example diagnostics. Patients are waiting in bed unnecessarily. We’ve achieved a 20% reduction in unnecessary waiting for necessary processes to happen.”

Cllr Wilkinson asked if patients and the public have had the opportunity to say if this is what they want.

Owen Williams said,

“We’re looking at increasing efficiency, not changing care.”

Which didn’t answer Cllr Wilkinson’s question, except obliquely by assuming that it was taken as read that these efficiency savings are possible without reducing the amount or quality of care. And so the Balanced Plan bed cuts wouldn’t need any public consultation before the Trust can carry them out.

NHS chiefs say the bed cuts efficiency savings won’t affect the amount or quality of the service patients receive and staff provide, but most people don’t believe this assertion can possibly be true after years of cuts have pared the system to the bone. And NHS chiefs aren’t forthcoming with evidence for their claim.

NHS chiefs deploy smoke and mirrors to evade questions about staff engagement

Cllrs McAllister and Draycott asked questions about staff engagement in Balanced Plan proposals to little effect, despite raising questions about the lack of anonymity for staff who completed the staff bit of the “Family and Friends” survey, and issues of staff sickness and poor morale.

By this stage of the meeting Owen Williams and his posse had perfected their dance of evasion to the point where he was able to say, unchallenged, that,

“…this is the best relationship between management and Trade Unions.”

Management consultant and director of operations for the Balanced Plan Mags Barnaby skipped in to add that the Trust has a staff absence management policy and are not changing that. She also claimed that open staff briefings are generally supportive.

Shortly afterwards, the Chair drew the meeting to a close with the anodyne observation that it had been a useful session.

Owen Williams pleads ignorance of plans to raise extra money from private and overseas patients

The Scrutiny Panel ran out of time before it got round to asking questions about the Balanced Plan proposals for raising extra income, so immediately after the meeting I asked Owen Williams these questions:

  • Of the £6.55m proposed additional income for 2014/15, how much is planned to come from an increase in the number of private and overseas patients? (Please give the indicative numbers in each category.)
  • Given that the Balanced Plan shows that the Trust is planning to increase income from private patients and has discussed the Plan at at least one Executive Board meeting, why has the Trust responded to an FOI request for information about this by saying that the Trust has not discussed exploring opportunities for private patient income?

I had to ask Owen Williams the first question three or four times, because he kept answering questions I hadn’t asked him.

Eventually he said he didn’t know how much of the planned £6.55m income was planned to come from an increase in the number of private and overseas patients, because the
Trust hadn’t started working that out.

So I asked him when they were going to start working that out and he said he didn’t know that either.

Then I asked him about the FOI question and he said without detailed knowledge of my question he couldn’t give me an answer but said he would look into it. I told him that I was asking for a review of the Trust’s FOI refusal and would copy him into my request for the review.

Unison regional health organiser Gary Cleaver told the Trades Council public meeting that Owen Williams had sent Unison a 3 page letter saying there were no plans at present to increase private patients.

This was after Unison had raised its fears that Strategic Review plans for a vastly reduced “planned care” hospital, with only 87 beds compared to the current 400+ at each hospital, would mean that the surplus beds would be used for private patients.

Gary Cleaver told the Trades Council meeting,

“The Trust’s Communications Department threatened Unison with an injunction for claiming that there were plans to increase the number of private beds.

Then the Balanced Plan came out, with information about plans to increase private care.”

One thought on “Best laid plans – Commissioners haven’t yet looked at Trust’s business case for NHS shake up

  1. Well done to Adam for persisting but obviously the CHFT management don’t feel that our opposition is meaningful. Where is their obligation to defend our services?

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