This is the second Plain Speaker report on the proposed hospital cuts that are scheduled for public consultation, starting at the end of February. If you’d like to find links to several other reports on different aspects of the proposals, they’re at the end of this report.

Here you can find out about:

• Lack of evidence that these proposed changes will deliver the required standard of care
• The danger of mixing up aspirational goals with political goals
• An outline of proposed cuts and changes to hospital services
• The loss of around 77 hospital beds
• More detail about the proposal to knock down Huddersfield Royal Infirmary , sell the land and build a new 119 bed planned care clinic
• The Equality Impact Assessment conclusion that making all Calderdale & Kirklees people go to Huddersfield for planned care could “cause a negative impact”
• What planned care services everyone would have to travel to Huddersfield for
• Services that would be available at both hospitals
• Kirklees patients needing A&E would be sent to other “emergency care centres” – not necessarily Calderdale Royal Infirmary
  
• The Huddersfield urgent care centre (and other urgent care centres at Halifax and Todmorden) may not even be staffed by a doctor
• The Huddersfield planned care clinic/hospital would cut costs, through more day case and outpatients’ planned care, and shorter stay for inpatients
• Moving whole swathes of planned care services out of hospital
• Lack of information about the “financial case” for the hospital cuts and changes

Independent clinicians “in the dark” about standard of care if these cuts and changes happen

Lack of clarity in Calderdale and Greater Huddersfield NHS Commissioners’ Pre Consultation Business Case proposals for cutting and changing hospital services has left Clinical Senate doctors in the dark about the standard of care that would be available if these changes were to go ahead.

NHS Commissioners asked the Clinical Senate to review their proposals, specifically to

“answer questions regarding the ability of this model to deliver the standards proposed.”

But the doctors’ review says it can’t answer these questions, because

“The standards are…drawn from national documents but they are therefore very generic.”

and they would like to know more about:

“…the level of local clinical engagement there has been in agreeing how achievable these standards are locally.”

In other words – do local doctors, nurses, therapists, paramedics etc think these plans will work? Have they even been asked?

Danger where aspirational goals overlap with political goals

Speaking in general about the relationship between cases for change and quality standards documents, a consultant said:

“These standards are said to be evidenced-based, and certainly had a lot of clinician involvement. And much of what is included is good, though some of it is aspirational.

The danger is where aspirational goals overlap with political goals, and the only way to achieve an aspiration is claimed to be the merger of units from two hospitals into one, in order to have enough staff.

Then you have a clash of what is aspirational and what may be unintended or neglected consequences….

It evades the issues of WHY there are insufficient staff.”

So, what are these unclear proposals with dangerously overlapping aspirational and political goals?

Cutting and changing hospital services

Ernst and Young’s “preferred option” for the so-called Right Care Right Time Right Place scheme involves:

• knocking down Huddersfield Royal Infirmary
• selling off the site for development
• building a 119 bed planned care clinic plus outpatients and and urgent care centre on Acre Mill (which they are calling a hospital – but not as we know it)
• expanding CRH from 400-ish beds to 615 and make it the unplanned care hospital and emergency care centre for both Kirklees and Calderdale – except Kirklees patients will be sent to the nearest A&E, not necessarily to Halifax
• taking services out of the hospital and put them in the “community” (so-called Care Closer to Home)
• introducing the “modern workforce” required by NHS England’s 5 Year Forward View
  cutting costs in order to prevent a £281m funding shortfall in
• protecting the banksters’ PFI equity & profits
• introducing new “models of care”, based on American private health insurance company models, particularly Kaiser Permanente and United Health (although the PCBC doesn’t acknowledge the source of these care models)

Loss of hospital beds

The plan would mean the loss of 77 hospital beds- instead of the current 811 beds in both hospitals, there would be 734 beds. This is while the population of both Kirklees and Calderdale is growing.

Huddersfield would lose around 280 beds, Calderdale would gain around 215 beds.

125 beds would be cut through Quality Innovation Productivity and Prevention (QIPP) – ie so-called “efficiency” cuts.

Huddersfield would end up with one 119-bed planned care clinic (plus outpatients, medical day case, midwife-led maternity, therapies and an urgent care centre for minor injuries and illnesses).

Calderdale would end up with one 615 bed unplanned care hospital, with A&E services in an emergency care centre, plus a Paediatric Emergency Department and an urgent care centre.

This reverses the current situation, which is that most acute care takes place at HRI and most elective care happens at CRH (PCBC p72).

Huddersfield: Knock down HRI , sell the land and build a new 119 bed planned care clinic

They are calling it a hospital, but it would only do routine elective care, ie non-risky planned operations, plus outpatients and treatment for minor injuries & minor illnesses at an urgent care centre.

When the hospital Trust’s previous preferred option was to turn Calderdale Royal Hospital into an 87 bed planned care hospital, Calderdale Cllr and GP Jennie Lynn called it:

“A small planned care clinic”.

And I reckon as a GP she should know. The proposed 119-bed Huddersfield version would have 32 more beds that were proposed for CRH, but would still be only around 1/3 the size of Huddersfield Royal Infirmary (HRI)

This planned care clinic with 10 operating theatres would  be built on the Acre Mill site across the road from HRI.  Of its 119 beds, 113 would be surgical, 4 medical and 2 maternity.

A full day case theatre suite would also be needed, including recovery beds/trolleys.

Making all Calderdale & Kirklees people go to Huddersfield for planned care could “cause a negative impact”

Instead of going to CRH – which is where most planned care services for both Calderdale and Huddersfield are currently provided – Calderdale and Huddersfield people would all go to the Huddersfield planned care clinic.

The Equality Impact Assessment (Pre Consultation Business Case p 259) says that putting all the planned care services on one site could:

“cause a negative impact”

on users of planned care – in particular

“those aged 26-64 [who] are the highest users of planned care.”

These are the planned care services everyone would have to travel to Huddersfield for

These are the planned care services that all Calderdale and Kirklees people would have to go to Huddersfield for:

• medical day case (when you come in for treatments that are done in one day and you don’t have to stay – the Pre Consultation Business Case p56 mentions specialist services such as specific cancer or chemotherapy treatments)
• endoscopy – when they put a tiny camera down your intestine to see what’s going on (although acute endoscopy would be available at Calderdale Royal Hospital)
• planned inpatient surgery
• all ophthamology & maxillo facial surgery
• rheumatology and dermatology
• specialist psychiatric liaison services
• elective orthopoedics (except hip revisions and complex patients who would go to Calderdale Royal Hospital)
• 90% of hand trauma
• ear nose and throat
• rehabilitation of older people

Services available at both hospitals

The Pre-Consultatoin Business Case says these services would be available at both the Huddersfield planned care clinic/hospital and the acute/emergency Calderdale Royal Hospital:

• outpatients
• therapies
• day case surgery
• midwife led maternity
• diagnostics

Ambulances to be diverted from Huddersfield to other “emergency care centres”

As the Huddersfield planned care clinic would not have an A&E (only an urgent care centre for minor ailments  and accidents), the Pre Consultation Business Case says:

“All ambulances will be diverted from HRI to other Emergency Care Centres.”

Kirklees patients would not necessarily be sent to Calderdale Royal Hospital.

The Pre Consultation Business Case says that if this proposal goes ahead, an extra 1,089 patients a year would go to the already horribly overcrowded Pinderfields hospital, 330 to Oldham, and small numbers to a range of other hospitals.

Urgent care centre may not even be staffed by a doctor

The urgent care centre would treat minor injuries and illnesses. It would not carry the emergency red sign and would not be the place to go in a medical emergency, when 999 should be used. (p59).

But in case some hapless soul pitched up there by mistake while having a potentially life- threatening medical emergency, it:

“would have protocols in place with the ambulance service’

The Clinical Senate was particularly scathing about the CCGs’ proposals for staffing urgent care centres. Its review starts out by saying:

“There is a lack of detail within the evidence supplied about the urgent care centre model.”

To find out more, they had to talk with the Commissioners, who told them that each of the 3 urgent care centres would be:

“medically-led by a clinician with the knowledge and skills to undertake triage and autonomous decision making regarding the next steps in an individual’s care. We expect this is likely to be GP’s but have to recognise current and future workforce issues.”

So there might not even be a GP present to see patients who come to Urgent Care Centres (UCCs).

The Clinical Senate review then says:

“patients in the remote UCC(s) [ie Huddersfield and Todmorden] who have serious illness will be triaged, stabilised often with technology assistance (Skype) from the specialists at the Emergency Care Centre, and then transferred.”

So someone who may not have the diagnostic and treatment skills of a GP will skype the Emergency Care Centre to ask what to do with a seriously ill patient while they’re waiting for an ambulance to come. Somehow this doesn’t inspire confidence.

The Clinical Senate didn’t think so either, they say:

“…an inexperienced staff member seeking advice from colleagues via Skype does not offer a rounded solution.”

And they have told the CCG to:

“consider the skills of the workforce. The triage skills and staff clinical portfolios need to be sufficient to enable them to make timely and informed decisions. There is always the possibility that a very ill patient will attend the Urgent Care Centre and commissioners need to ensure that staff have the medical and nursing skills, experience and capabilities to safely stabilise that patient. Currently, the Senate has no information on the staffing of these centres…We are also not clear on the paediatric expertise at each centre.”

However, there is nothing in the Pre Consultation Business Case (PCBC) to suggest that the CCGs have taken any notice of the Clinical Senate.

Cutting costs: more day case and outpatients’ planned care and shorter stay for inpatients

The planned care clinic would be getting patients in and out faster than currently happens at HRI and CRH. It would aim to deliver most planned care as day cases; and what would previously have been day cases, as outpatient care.

This is one way they’re going to cut costs – which is the key driver of all these cuts and changes, as the PCBC makes clear, given the projected NHS funding shortfall of £22bn by 2020.

Another way they plan to cut costs is by reducing the length of stay for inpatients, eg the average length of stay for non-complex hips and knees would be 4 days.

Complex elective patients (hip revisions) would go to CRH where there would be a high dependency unit.

Moving whole swathes of planned care services out of hospital

The planned care hospital would have some of its services moved into the community in Phase 2 Care Closer to Home.

It seems this is supposed to happen before the new planned care clinic opens, while the existing HRI and CRH are still operating as they are now.

These are the services that the PCBC is considering moving out of the hospital into the “community” – on the basis of “assumptions” the CCGs have “created” with their “providers” (p 46):

• Respiratory (children and adults)
• Frailty – falls, UTI and Care Homes
• CVD
• Diabetes
• MSK
• Opthamology
• Dermatology
• Diagnostics (Vanguard)
• ENT
• End of Life Care
• Rehab Bed Days

This looks like most of the planned care services – so how many of the planned care services will actually end up in the planned care clinic?

And where in the “community” will the rest of them end up?

The PCBC is a bit vague about this, but the section on Calderdale CCG’s Care Closer to Home plans (4.3) mentions

“developing plans to maximise our use of community estate” (p46) and upgraded premises”

and (p42)

“making better use of community facilities”,

so that:

“primary and community care staff will also work closely with secondary care and social services through some of the models outlined in the NHS Five Year Forward View”

For more info, please see Taking services out of the hospital and put them into the community  [link coming soon]

New Public Management

In its project of cutting hospital services and moving them into the “community”, the Pre-Consultation Business Case says (p6)

“The Right Care Right Time Right Place programme is one element of wider public service system reform being implemented nationally…”

Dr Bob Gill identifies this “public service system reform” as New Public Management, which blurs the distinction between public and private sector and has allowed NHS money to be  siphoned away from patient care.

Money money money, it’s a rich man’s world

Getting back to the question of: why reverse the current siting of most planned and unplanned care?

The CCGs say the “preferred option”, of switching to CRH as the acute and emergency hospital, is down to money, and that the income/expenditure position is better with CRH as the unplanned care hospital.

But there is no publicly available evidence to support this assertion.

When the public asked for evidence at the 20th Jan CCGs’ meeting, this request was ignored.

The Pre Consultation Business Case also says (p95) that the reason for CRH to be the unplanned ( Acute and Emergency) site is cost saving is because of its

“lower capital requirement than for HRI”.

But the fact is, there’s a  sadly familiar pattern of sacrificing a publicly owned hospital in order to protect bankers’ equity and profiteering in a PFI hospital.

Just down the road, the publicly-owned Dewsbury hospital has been sacrificed to keep the debt-burdened Pinderfields PFI hospital afloat.

And that was what the battle to Save Lewisham Hospital (SLH) was all about – to keep the hospital intact, when the government wanted to cut its services and use the money to protect bankers’ profits by bailing out the finances of a nearby PFI hospital that had gone to the wall.

Like the campaign groups listed in the Two Towns, One Fight report, SLH also campaigned for both hospitals to survive intact.

What needs sorting is the PFI debts – PFI shouldn’t be used to drive a wedge between people whose hospital is publicly owned, and people whose hospital is privately owned and shlurping huge sums of NHS money in profiteers’ pockets and tax havens.

There are plenty of clues that Ernst and Young has imposed the sacrifice of HRI to save the PFI banksters’ bacon, at Monitor‘s behest.

On p111 the PCBC says the “preferred option” was the Trust’s decision – but it wasn’t the Trust’s preferred option until Monitor landed Ernst and Young on them

And quite apart from sacrificing HRI for banksters’ profits, it’s possible that Huddersfield is the chosen site for planned care so that it can sooner or later be sold off to a private health company. This would be in line with NHS England’s stealth privatising agenda, which seems to be resurrecting New Labour’s privatised Independent Sector Treatment Centres – also known as Darzi clinics – despite their dismal failure.

It would not be possible to sell off a planned care clinic if it were based at CRH – no private health care company would take over CRH with its PFI debt. Only a publicly owned building would do.

These hospital cuts and changes can only go ahead if the hospitals Trust can get its hands on an extra £490.4m to cover their capital costs. (Pre Consultation Business Case, p96.)

This means applying for funding from the government. Monitor told the Calderdale and Kirklees Joint Health Scrutiny Committee last October that:

“Some factors are beyond our control… We’ve started conversations with the Department of Health and the Treasury but can’t say when they will decide. If funding isn’t forthcoming, we can’t consult.”

The fact that the CCGs have now decided to consult suggests that some kind of positive message about the funding has come from central government. But who knows?

Links to other Plain Speaker reports on the so-called “Right Care Right Time Right Place” hospital cuts proposals

• “Care Closer to Home” – Patients Will Suffer
• Care Closer to Home – Too bad there’s little or no evidence it will work
• Two Towns, One Fight: Why We Have To Keep Both A&Es Open
• Wakefield and Dewsbury Hospitals Groaning Under “Clinical Model” Now Proposed for Calderdale & Kirklees
• A single “Emergency Care Centre” for both Calderdale and Kirklees – Not Safe, Not Fair