At Calderdale HWB Board  on 30 October 2014, Jen Mulcahy, the Commissioning Support Unit Programme Manager for Right Care Right Place Right Time, gave an update on the Right Care Right Place Right Time NHS shake up in Calderdale and Greater Huddersfield.

She said this was being carried out through taking forward:

• plans for community care in Calderdale
• plans for community care in Kirklees
• plans for the Calderdale and Huddersfield hospitals.

She explained that Phase 1 for community health care in Calderdale is about strengthening existing services. Ms Mulcahy said Calderdale CCG now had the Phase 1 specification to present to the Calderdale Clinical Commissioning Group (CCG) Governing Body for approval.

(The next Calderdale CCG Governing Body meeting is on 11 December 2014 – 2 – 5p.m., venue to be confirmed.)

Engagement and specification for Phase 2 of Calderdale community health care would be complete by the end of 2014. But approval by the CCG Governing Body will be in February 2015.

In reply to a question from Cllr Tim Swift about Phase 1 and Phase 2 community services, the Chair of Calderdale Clinical Commissioning Group Governing Body, Dr Alan Brooks, confirmed that once the CCG have done the community services specification, there is a process when the CCG recommissions existing services (Phase 1) and then commissions the extended community services (Phase 2).

For the hospitals services, Ms Mulcahy said the CCGs need to set out the potential model for hospital care in CRH and HRI, based on NHS England’s 5 year forward view, which sets out 7 models of care. (For more info, see the last section of this article.)

Ms Mulcahy concluded by saying that both Calderdale and Greater Huddersfield CCGs are running pilots for community paediatric services in Calderdale and Greater Huddersfield. In January 2015 there will be a review of 6 months data with a full evaluation in April 2015.

When will the public be consulted? And what on?

The Health & Wellbeing Board (HWB) Board Chair, Cllr Janet Battye, said that people in Calderdale are worried about the future model of hospital care. She asked what plans the CCG had for public involvement in deciding the model of hospital care and how the HWB Board can be involved.

Ms Mulcahy said that the two CCGs will get together to look at possible models – for example, to include the public’s travel considerations. Once they have narrowed down the possibilities, they can then ask the public what they think of the criteria the CCGs have used and of the CCGs’ recommendations.

In Plain Speaker’s opinion, this seems on the face of it to run counter to the requirement that public consultation must take place on all possible options.

Dr Brooks, the Chair of the Calderdale CCG Governing Body, hastily announced,

“Nothing has been decided and nothing has been hidden from partners.

Calderdale CCG has met with the People’s Commission and is working supportively with CHFT.”

Speaking like one of those Aussie characters from Neighbours? Whose statements always sound like questions? Dr Brook continued:

“We’re trying to sort out the legacy of a system that’s far too focussed on hospital services?

We’re doing everything we can to keep partners engaged in the process?

The People’s Commission started talking about different models of hospital, for example district hospitals and so on?

But now that NHS England’s 5 year forward view has come out, do we need to come back on that to the HWB Board?”

Kath Wyllie, the NHS England West Yorkshire’s Director of Operations and Delivery warned,

“For a big change like a hospital reconfiguration, CCGs have to keep their partners informed.

NHS England wants to see that conversation continuing, but we need to be clear about the difference between an informal conversation and something that’s more than that.

The informal conversation might not always be fully representative.

It’s important not to disrupt a sensitive process by confusing informal and formal conversations with statutory bodies.”

Dr Brook continued – still sounding as if auditioning for a role in an Aussie soap, with his sentences all sounding like questions:

“The CHFT Outline Business Case is not a document on which the CCG would consult.

It gives the CCG a better understanding of the CHFT position, but it needs more work.

The CCG has put the brakes on. The phasing presented in this report is most concrete and up to date.

NHS England’s Forward View is about a national issue – not a local issue – of the demographic timebomb.

We’re not going to put anything to public consultation which we don’t genuinely believe is an improvement to services.”

Cllr Battye said that an important reason for informal conversations was to make people aware of what’s being proposed, so when the formal consultation occurs it won’t be a surprise.

In response to a question from Cllr Tim Swift, Dr Brook reminded the HWB Board that at the Calderdale Council Adults Health & Social Care Scrutiny Panel meeting, the CCG had said that the process when the CCG recommissions existing services (Phase 1) and then commissions the extended community services (Phase 2) will at some stage trigger the public consultation and they need to be careful about that.

It is the job of the Scrutiny Panel to tell the Clinical Commissioning Group when to consult on their commissioning intentions for the Right Care Right Place Right Time NHS shake up.

The Leader of Calderdale Council, Cllr Baines, said that he thought putting the community care infrastructure in place is the right way forward and will make it much easier to convince the public once the consultation occurs.

In Plain Speaker’s opinion, the purpose of a public consultation is to find out what the public thinks, not to convince them to accept a predetermined deal.

Dr Brook said,

“We want the HWB Board’s opinion. We don’t want it to be a political football and there’s the potential for political exploitation. This damages the public’s confidence in the NHS.”

Cllrs Baines and Battye were very keen on saying that this is not political and should not be subject to political debate.

7 models of care in NHS England’s 5 Year Forward View

In order to understand what Ms Mulcahy was referring to in saying there are 7 models of care that Calderdale CCG has to choose from, when planning the potential model for hospital care in Calderdale Royal Hospital and Huddersfield Royal Infirmary, Plain Speaker has checked out NHS England’s Five Year Forward View.

These are the 7 models of care:

• Multi-speciality community providers – extended, larger GP practices that include nurses, therapists, consultant geriatricians, paediatricians and psychiatrists, pharmacists, social workers etc, and  that focus on targetting services on patients with complex chronic illnesses and the frail elderly. NHS England will make it possible for these larger GP practices to form either as GP Federations, networks or single organisations. They would shift most outpatients care out of hospitals & could take over running community hospitals. They would also use volunteers and carers. N Kirklees GPs have already set up as a GP Federation and have awarded themselves a substantial contract.
• Primary and acute care systems (PACS)- “vertically integrated” care systems, modelled on US and Spanish Accountable Care Organisations, that provide GP and hospital services within one organisation. Variants of this system include joint ventures and prime providers which subcontract to other providers, (which is the model proposed for Greater Huddersfield’s Care Closer to Home contract, which is currently out to tender with a 24 November deadline) Link.
• Urgent and emergency care networks – making better use of primary care, community mental health teams, ambulance teams and community pharmacies as well as the 379 urgent care centres throughout the country. These networks will include a “strengthened” triage and advice service.
• Viable smaller hospitals – models for making smaller hospitals “viable” include ‘hospital chains’ which exist in Scandinavia and Germany; specialist hospitals providing services on ‘satellite’ sites in smaller hospitals; use of the PACS model where a local acute hospital and its local primary and community services form an integrated provider.
• Specialised care – greater concentration of care in specialist centres eg stroke units, specialised surgery and some cancer services.
• Modern maternity services – make it easier for midwives to set up their own NHS-funded midwifery services to increase the availability of midwife-led units
• Enhanced health in care homes.

Commission on Hospital Care for Frail Older People blasts the idea that care in community can replace acute hospital care as “magical thinking”

In this context, Plain Speaker thinks it is worth noting that the recent Health Service Journal (HSJ) Report on Hospital Care for Frail Older People blasts NHS England’s latest “Messiah concept”:  that providing more integrated care closer to home for frail older people will solve the problem of poor care. The Report calls this a “myth” and an example of “magical thinking”.

Instead the Report says that – far from cutting acute hospital services, which is the core of the Right Care transformation model –  there is a need to make hospitals a good place for old people.

The HSJ Report is equally sceptical of NHS England’s 5 Year Forward View that the predicted £30bn NHS funding shortfall by 2020 could be reduced to £8bn, on the assumption that rapid structural change would save £22bn in “efficiency savings” ie cuts.

The Report says that there is no evidence that this is possible.

In the absence of adequate NHS funding, the Report says that making acute care hospitals fit for purpose for frail older patients

“will require meaningful changes in the distribution of funding through the system (and disinvestment is always hard.”

It doesn’t say where the extra funding for improving acute hospital care for frail older people will be redistributed from and what disinvestment will be needed — although the obvious source of extra funding would be for the new post-General Election Parliament to enact the 2015 NHS Reinstatement Bill.

By abolishing  NHS marketisation and privatisation the 2015 NHS Reinstatement Bill would save a conservatively-estimated £4.5bn/year – funding which, if  restored to front-line NHS services, will plug the £30bn NHS funding gap that’s predicted for 2020.