NHS bosses’ failure to consult on proposed hospital cuts and A&E closure is not in the public interest

A Calder Valley member of the public who was confused by Craig Whittaker’s recent comments on her facebook page about the proposed NHS shake up in Calderdale and Huddersfield asked Plain Speaker for clarification about the following issues.

Here is the Plain Speaker view. Just to be clear, the reporter Jenny Shepherd is also the Green Parliamentary Candidate for Calder Valley

Who decides whether to go ahead with the proposals in the hospitals Trust’s Outline Business Case?

Calderdale and Greater Huddersfield Clinical Commissioning Groups are the organisations that decide whether or not to go ahead with the proposals in the Outline Business Case (OBC).

Calderdale CCG told Calderdale Council Adults Health and Social Care Scrutiny Panel that they looked at the OBC on 27th October.

On 30th October Dr Alan Brooks, Chair of Calderdale CCG Governing Body, told Calderdale Health and Wellbeing Board that the CCG had decided not to consult the public about the OBC because ” it needs more work”.

But in a letter to me on 12th December, the Calderdale CCG Chief Officer Dr Matt Walsh said that the CCG is setting up the “Care Closer to Home” community health care system in three phases over the next 5 years.

This community health care system is a key aspect of the OBC.

Dr Walsh told me that,

“It is our intention to make these changes in partnership with the hospital – working together.”

When are the Clinical Commissioning Groups going to consult the public?

The public consultation issue is extremely contentious. The Clinical Commissioning Groups initially planned to hold the legally-required formal public consultation on the OBC plans (also called Right Care Right Place Right Time) in July-September 2014.

But in early August 2014, both Greater Huddersfield and Calderdale Clinical Commissioning Groups announced that they had decided to go ahead and set up the care in the community aspects of the proposed Calderdale & Huddersfield NHS transformation without any public consultation – while postponing the formal public consultation on the proposed hospital cuts and closures and the split into a planned hospital and an acute/emergency hospital, until after the community care system was set up.

I believe this is probably unlawful and recently wrote to Calderdale CCG asking them for their view of the matter. They have replied without answering my question. As is their habit.

It’s no kind of victory for the Save Calderdale Royal Hospital campaign, that the NHS Commissioners have decided to go ahead without any public consultation and set up the new community health & social care system as proposed in the “Right Care Right Place Right Time” shake-up of our NHS.

This makes it inevitable that they will also go ahead with cuts to existing hospital services, because the Clinical Commissioning Group can’t afford to retain services in the hospitals when they are also funding them in the community.

In my view, this just sidesteps the public consultation on the proposed hospital cuts and closures.

I can’t see how Calderdale Clinical Commissioning Group (CCG) will be able to keep an open mind regarding what services should remain in hospital if it has already decided about what services should be moved from the hospital to the community.

I’m concerned that by deciding upon what services should be moved from a hospital setting to a community setting at this stage, the CCG will predetermine their proposed subsequent consultation on what services should remain in hospital. It is not possible to separate out these two issues.

The law on public consultation is that the CCG has to consult the public on all available options.

But clearly if the new community health care system has been set up before consultation takes place, that has foreclosed Option 1 in the OBC – which is to do nothing. Because once the new community care system is set up, that will make it necessary to cut and close existing hospital services, as there isn’t the money to run both the new community care system and existing hospital services.  Also, the new community care system is itself a significant change to the NHS – so that should also be included in the public consultation.

It’s vital that decisions about the NHS shake up are taken democratically, on the basis of clear, full and honest information, with Calderdale Councillors fulfilling their duties to the public.

Calderdale & Kirklees Joint Health Scrutiny Committee, and Calderdale Adults Health and Social Care Scrutiny Panel have the power – and the duty to use this power – to ask the Secretary of State to stop the implementation of the Right Care/Care Closer to Home proposals, if they think that the plans will damage the NHS in Calderdale and Greater Huddersfield.

The “RIght Care Right Place Right Time” shake up is driven by an NHS cuts and privatisation agenda that will do just this – damage our local NHS.

The Council Scrutiny Committees also have the power – and the duty – to tell the Clinical Commissioning Groups to consult the public now – in order to avoid predetermining the outcome of the postponed consultation on hospital services.

Save Calderdale Royal Hospital campaigners are demanding that our Councillors use their powers effectively on behalf of the public, as it is their duty and responsibility to do so.

Why was the OBC commercially confidential?

The OBC was deemed to be commercially  sensitive or commercially confidential because it was written by the Hospitals Trust, the mental health Trust (SWYPFT) and the community health care company Locala. And they recently bid for the Greater Huddersfield and North Kirklees £284m, 5year Care Closer to Home contract to provide some of the community care elements outlined in the OBC.

The OBC authors didn’t want any rival bidders for that contract to see information in the OBC.

When the deadline for submitting bids for that contract passed, the OBC ceased to be commercially confidential and it was made public. CHFT explained this in an email to me on 29th October.

There were 2 separate bids for the contract by the OBC authors.

Calderdale and Huddersfield NHS Foundation Trust (CHFT) has bid for the contract as part of a consortium with  Mid Yorkshire Hospitals NHS Trust, Forget Me Not Children’s Hospice and two private provider GP organisations in Kirklees (Prime Health Huddersfield and Rowan Healthcare Ltd).

The presence of Kirklees GP Federations as bidders raises the question of conflicts of interest. How will GP commissioners on the CCG decide whether to award contracts to themselves as GP Federations?

Dr Ollerton of Greater Huddersfield CCG said at a Healthwatch meeting that it would be absolutely wrong & unethical for CCGs to commission GP services. So what happened between last spring, when he said that, and now?  .

In a separate bid, Locala has also bid for the Care Closer to Home contract.

Greater Huddersfield and North Kirklees CCGs were to announce the outcome of the bids on 12th December, but there seems to have been a delay and the CCGs have not yet announced who’s won the contracts.

What clinical evidence is there to support centralised acute specialist hospitals?

Clinical evidence to support centralised acute specialist hospitals is contested.

a) Local NHS bosses say that this avowedly cost-cutting exercise will improve patient safety, through centralising acute and emergency care in one hospital with 24/7 consultant presence.  The ‘clinical’ reasons for closing CRH A&E and sending all A&E patients to Huddersfield were given in the 2013 National Clinical Advisory Team Report, and were based on the recommendations of the Keogh Review that proposed cutting the number of  A&E departments across the country from around 140 to between 40-70 “major emergency centres”.

But in August 2014, NHS England’s Update on Keogh’s Urgent and Emergency Care Review has dropped these proposals. It acknowledges the pressures on A&E that Keogh identified need dealing with, but says “the challenging issue” is how to deal with them – not that the original proposals need to be implemented.

By rowing back from proposals to cut the number of A&E departments, the Keogh Update has to raise questions about the validity of the OBC proposals to close Calderdale A&E.

Because when the NCAT team came and did their report  that was the basis for proposals to close Calderdale A&E, they were basically saying what Keogh said they should say.

If NHS England is no longer saying this is the way to solve A&E pressures, then surely that justification for closing Calderdale A&E crumbles?

b) More generally, claims that clinical evidence supports the reconfiguration of hospitals to create centralised specialist hospitals are questionable.

The first big drive for centralised specialist hospitals came from the Blair New Labour government. In Dec 2007 Blair made a widely-reported speech claiming that hundreds of lives could be saved through service specialisation in the NHS.

But the Future Hospital report from the Institute for Public Policy Report that he got his figures from did not provide convincing evidence for this claim. Keep Our NHS Public campaigners judged this to be a “dodgy dossier”. An assessment by health policy academics  said the Report’s evidence was selective and often used misleadingly. And the evidence wasn’t even published until more than a month after Blair’s speech, so there was no way of checking it at the time.

In addition, the IPPR has a record of close collaboration with organisations that stand to benefit from NHS privatisation; and their Future Hospital report was sponsored in part by a commercial organisation, Prime PLC, with a vested interest in hospital reconfiguration.

On top of that, the IPPR had strong ties with the New Labour government, as its director Matthew Taylor had been director of policy for the Labour Party during the 1997 Election and was later seconded to work in the No 10 Policy Directorate.

A need to overcome opposition to the closure of local services was the political context for the IPPR’s report, claiming that clinical evidence supported the push towards reconfiguring hospitals into centralised specialist hospitals was

In turn, New Labour’s drive to reconfigure hospital services in this way was the outcome of an NHS budgetary crisis, that resulted from various Department of Health messes including the costs of introducing a competitive market in the NHS and payment by results, and privatisation through PFI, Independent Sector Treatment Centres and other public private partnerships.

c) Other academic health policy assessments of NHS reconfigurations that involve the centralisation of services from two or more hospitals, and the sale or downgrading of the other sites, have also found no evidence that the reconfigurations are underpinned by clinical evidence.

In a BMJ article about planning the “new” NHS for PFI hospitals, Prof Pollock and others point out that planning is based on financial, not clinical, needs, although the New Labour government of the day argued that the crucial planning decisions were all made by clinicians. But Prof Pollock points out that healthcare planning has never been a core clinical competence and making decisions is very different from agreeing to decisions taken by others. The pattern has been that total capacity has been decided on financial grounds and then clinical decisions have been confined within the financial limits.

The 1990 NHS and Community Care Act that required Trusts to balance their budgets has driven the process of reducing capital charges, through selling or mothballing assets and through hospital mergers and so-called rationalisations.

In addition, Prof Pollock points out that the case for change is not stringently tested in the new NHS planning processes, which have the core function of justifying cost restructuring.  Clinical activity has to be brought into line with this.

d) The claim that patient deaths are reduced by closing general A&E departments and sending patients to specialist centres has been challenged by the British Medical Association, which says that centralising acute and emergency services doesn’t always improve things for patients and there are risks associated with cutting existing A&E provision.

In London, some patients who would’ve been expected to die of their injuries have survived as a result of the introduction of four major trauma centres with 24/7 consultant presence. But in London, most patients are within a short travel time from home to major trauma centre.  The BMA are concerned about increased deaths that have been linked to the closure of Newark A&E, which led to longer patient journeys to A&E.

There is also evidence from a recent big study in USA showing the negative impact of A&E closures not only on the places where they had closed, but also on the neighbouring A&Es which became very overcrowded, and it led to a rise in mortality rates there.

Is the NHS privatisation agenda driving the proposals?

It’s clear is that the NHS cuts and privatisation agenda, set into law in the 2012 Health & Social Care Act, is driving the proposals. It’s also clear that the NHS is under pressure, at least in part as the result of austerity politics in the shape of cuts to social care funding since the recession.

Research carried out by the LSE found that social care funding cuts have left half a million older and disabled people, who would have received social care five years ago, without support. The number of people receiving social care has plummeted for five years in a row – by a total of 347,000 since 2008. This has put huge pressure on the NHS.

Management consultants and think tanks thrive on organisational upheaval – it’s their raison d’etre – and NHS spending on management consultants has more than doubled since 2010.

In 2014, management consultants cost the NHS £640m, compared with £313m in 2010.

£640m would pay for 20,000 nurses.

PA Consulting’s involvement in the Calderdale and Greater Huddersfield NHS reconfiguration is typical of the outsourcing of NHS policy making, both locally and nationally.

Calderdale and Greater Huddersfield Clinical Commissioning Groups paid the management consultancy company PA Consulting nearly £1m for support with Strategic Review Development during 2012.

PA Consulting’s Future of Healthcare Report trumpets the need for “innovation in business models” and “entirely new commercial arrangements”, saying,

“The infrastructure, institutions and culture in healthcare can exert powerful forces to maintain the status quo and,
unlike almost any other industry, healthcare professionals – and the institutions in which they serve – hold a special place in the general public’s heart. All this is set to change; all of this has to change.”

PA Consulting has a direct interest in the kind of “innovation” its reports for Calderdale NHS promote. It is working on the kind of centralised digital patient data systems which will underpin such plans.

This is the same company whose misuse of pseudonymised patient data, bought from the Health and Social Care Information Service, sparked the still-unresolved furore over the Government’s care.data plans.

Turning pseudonymised patient data into identifiable patient data would allow drug companies and private healthcare providers to target patients directly. This is the basis for Big Pharma’s new business model.

Meanwhile,  NHS England boss Simon Stevens’ announcement earlier in 2014 that the NHS must stop closing cottage-style hospitals and return to treating more patients in their local communities was billed in the Daily Telegraph as a “reversal of policy”.

But in fact this seems to endorse “Right Care” policies for redesigning care in the community, with the aim of reducing acute and emergency hospital admissions.

These Right Care proposals for  “redesigned” care in the community are based on a system imported from the American private healthcare company Kaiser Permanente.

In an interview with the Health Service Journal, Simon Stevens advocated that hospitals should adopt a more recent American version of this system, called the accountable care organisation.

An accountable care organisation is a single “provider” eg a hospital, or a group of providers, that is given a single budget to serve a specified population.According to Stevens,

“In some cases it’s going to mean we’re going to have to completely reinvent what we mean by a hospital, by a local hospital.
“We’re going to have to say that the division between what consultants do in hospitals [and] what GPs do in community settings, that is going to be dissolved.”

Lining up hospitals or a group of providers to deliver pretty much all health and social care in and out of hospitals, along the American Kaiser Permanente/accountable care organisation system, would open up the NHS nicely to US healthcare companies to take over.

Replacing acute hospital services for the elderly with community health care is not endorsed by experienced geriatricians and GPs.

A&E closure is very much part of the Outline Business Case

The proposed Minor Injuries Units at Calderdale Royal Hospital (CRH) and Tod and Holme Valley “hubs” are not replacements for A&E, they do what they say on the tin and only deal with Minor Injuries. In addition the Tod hub won’t treat children at all. The People’s Inquiry into London’s NHS found that where the reduced service of urgent care centres (like minor injuries units) replaced A&E, sadly most parents and patients were not always able to tell whether they or their child needed the A&E or the urgent care centre.

The acute services still offered at Calderdale Royal Hospital would have to go if its A&E closes – these include complex maternity and acute paediatric services, which would have to go to Huddesfield Royal Infirmary if Halifax A&E closes.

Where hospital services are cut and centralised, there is evidence that this particularly affects low income patients and their families who may not be able to afford the extra travel costs and travel time to attend centralised hospital services.

The fact that Calderdale CCG has postponed consultation on the Right Care Right Place Right Time/Outline Business Case proposals doesn’t mean they have rejected these proposals – including the proposals to cut existing hospital services, turn Calderdale Royal Hospital into a small planned care hospital with a Minor Injuries Unit, and centralise A&E in Huddersfield Royal Infirmary with the aim of turning it into the specialist acute care hospital for both areas.

Setting up the so-called Care Closer To Home system without any public consultation is a way for NHS bosses to sneak in hospital cuts, changes and the closure of Halifax A&E, without asking the public and risking hearing a big fat NO as their answer.

For politicians to claim otherwise is just electioneering.

Links to more info

Information about the bids for Greater Huddersfield and North Kirklees CCGs’ Care Closer to Home contract is here

You can find more info about the two private provider GP organisations (Prime Health Huddersfield and Rowan Healthcare Ltd) in Greater Huddersfield here

Info here about the Institute for Public Policy Research “dodgy dossier” on case for hospital closures

Info here about increased NHS spending on Management consultants


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