On 13th March, Calderdale Clinical Commissioning Group Governing Body gave the nod to proceed to the next stage of Calderdale and Huddersfield NHS Foundation Trust’s Strategic Outline Case (SOC). This is about Transforming Calderdale and Greater Huddersfield’s NHS and social care services.

The SOC describes in outline what the future of the NHS and social care might look like in Calderdale and Huddersfield. It’s based on the Strategic Review’s proposals that came out towards the end of February.

The next stage for the Strategic Outline Case is public and staff “engagement.”

The SOC doesn’t say so, and no one at the Governing Body meeting mentioned it, but the SOC’s proposed new combined NHS and social care system appears to be a copy of NHS England’s “right place” model, which in turn closely resembles a newish American commercial health care model, called Accountable Care Organisations (ACOs). ACOs are supposed to cut costs while improving care.

But the 2012 Nuffield Trust’s Health Policy Summit, which is a big event in the UK health politics world, heard an American senior policy analyst say that the ACO system is relatively new and untested. Results of one of the largest ACO demonstration projects have been mixed at best.

So the biggest reorganisation ever of the NHS and social care, right across the country – because this isn’t just happening in Calderdale and Greater Huddersfield – seems to be based on an American commercial health care system, that hasn’t even shown it works.

More of this in a later article.

Rubber stamping

Since the Strategic Review stated weeks ago that Calderdale CCG were recommending that its proposals progress to the next stage of Business Case Development, the meeting seemed little more than a rubber stamping exercise.

The Strategic Review put forward 5 options for change, and CHFT’s preferred option (number 2) calls for:

• A loss of 100 hospital beds overall
• Making CRH solely an unplanned care hospitel – ie where all the routine, non-emergency operations etc happen
• Moving CRH A&E and all its unplanned care beds/servicesto HRI, which would provide all acute/unplanned care, including A&E.
• Reducing hospital admissions, including to A&E, by introducing a new system of community and primary health care combined with social care.

“Engagement”

After a presentation and discussion of the SOC, the Governing Body agreed that the Strategic Outline Case should move on to “engagement”.

I understand that this is a marketing term that means getting closer to your customers in order to find more effective ways of selling them stuff.

Caldedale CCG’s definition, in its Patient and Public Engagement and Experience Strategy 2013 – 2016, is:

“…the active participation of public, patients – including children and young people, carers and community representatives in the development of health services… Engagement gives local people a say in how services are planned, commissioned, delivered and reviewed.”

NHS staff “engagement” was the subject of a  written question that Calderdale 38 Degrees Chair Ken Cheslett had sent in earlier and was expecting an answer to in the meeting.

He didn’t get one.

He wanted Calderdale CCG to publish evidence for the claim in the National Clinical Advisory Team’s Report, that staff at both Calderdale and Huddersfield hospitals support the Report’s proposals for closing one or other of the A&Es and centralising all the acute services, including A&E, in one hospital.

After the meeting, Ken Cheslett said,

“I felt massively disadvantaged when they read out and answered another question we’d asked, but omitted to mention this one. So I had to speak up and ask why they’d omitted this question, and then read it out to them.

To do this I had to break the “rule” that the Chair tells the public at the start of each meeting, that we are not allowed to speak at the meeting.

They didn’t answer this question, but fobbed me off by saying they couldn’t understand what had happened to it but that we will get a written response.

I think it was all part of their stalling tactics.”

After Mr Cheslett had read out his question to the meeting, Dr Walsh said,

“One of the purposes of engagement is to work with staff to see if there is understanding of and support for the proposed changes.

We will take account of the question because it’s a totally important question.”

The SOC Presentation

The CCG Governing Body Chair Dr Alan Brook, read a few of the first slides which seemed the same as ones already presented in the Strategic Review slideshow.

Public “engagement” and “consultation”

The Chief Officer, Dr Matt Walsh, presented this topic. He said,

“We’re getting into tricky territory and tricky decision making.

We have a duty to engage service users and the population at a stage when our plans are forming.

We have a statutory duty to lead a formal consultation.

As we move through engagement, if we reach a point at which major service changes is the course of direction we have a statutory duty to carry out a formal public consultation.

Decision making rests with Greater Huddersfield CCG and Calderdale CCG.

We have a duty to deliver our statutory responsibilities.”

Dr Walsh also said:

“No decisions have been made about which hospital will be the planned care site and which unplanned. If we decide to accept this scenario, the decision will be made here.

If that scenario goes ahead, there will be an urgent care offer at both sites.”

(This would be Minor injuries units)

Dr Walsh went on,

“We’re starting an engagement process, we’re not in public consultation.

Some media coverage hasn’t been helpful (although it’s been understandable), because it doesn’t help us tell our story.

This strategic change is about everything, not just A&E.

We are willing to listen, we’ve done a lot of work reaching out to the population.”

Locala and CHFT

Jim Barwick, Transformation Manager at Locala, the social enterprise community that took over Kirkless Primary Care Trust community health services when PCTs were dissolved in the 2012 Health and Social Care Act, said that the design of the new NHS and social care system outlined in the Strategic Outline Case would involve social care, primary and GP care and 3rd sector providers (ie voluntary organisations, charities and social enterprises).

He said,

“There will be an important and vital role for the 3rd sector, including housing, welfare and leisure.”

He also went on about the importance of enhancing and supporting patient choice.

Martin De Bono, speaking for Calderdale and Huddersfield NHS Foundation Trust (CHFT), described himself as a CHFT consultant gynecologist and also as holding a senior management role at CHFT. (When I did an online search to check how to spell his name, I found he also practices privately at Spire Hospital in Elland.)

He said that the SOC was about “whole system transformation” and it was important to keep that in focus when discussing scenarios and models. He said CHFT would need “an enormous amount of building” for the options that involve creating two specialist hospitals – one with acute care and A&E and the other with routine/planned care; and that there is room for that building work at HRI.

Also, although he didn’t mention it, CHFT has set up a property development company with developers Henry Boot Developments. This joint venture is called Pennine Property Partnership and it is redeveloping the Acre Mill site in Huddersfield.

Dr De Bono also said that the existing set up is already similar to CHFT’s preferred option, in that HRI has most acute services. He claimed that this model allows better protection for community services. But I don’t think he explained how this is so, or else I failed to make a note.

What the CCCG doesn’t yet know about the SOC

Dr Walsh said there were loads of questions about the SOC that the CCCG needed to answer, and went through a list of them. He said the CCCG would publish the answers as they come through.

The main unanswered questions about the SOC are:

• money
• clinical evidence to underpin various SOC scenarios
• the impact of SOC scenarios on ambulance care, which Dr Walsh admitted

 “is fundamentally important for urgent care. And the impact of journey time more generally on carers and families.”

• locality-based primary care and social care – this seems to mean grouping GPs, community health services and social care together across Calderdale
• how to phase in changes to keep them safe and effective
• risks and potential benefits of each of the SOC scenarios

Dr Walsh said that if, following “engagement”, the CCCG gets into a significant change programme, it needs to follow procurement regulations

Procurement regulations  and the £1.2bn question about NHS privatisation

At the start of the meeting UCV Plain Speaker asked a question about whether the SOC system would lead to the privatisation of Calderdale NHS. The question was:

“Last week, NHS Greater East Midlands Commissioning Support Unit offered up £1,222,000,000.00 of our NHS to Private Health, in two Supply2Health advertisements that said:
Commissioners are seeking genuine, transformational and sustainable service change that recognises the primacy of the patient in the service model…

These terms are identical to proposals in the CHFT Strategic Review of Health and Social Care. Will WSYBCSU be selling off similar amount of our NHS if the CHFT Strategic Review gets put into action?”

This is Dr Walsh’s reply:

“ We were aware that things were going on in other parts of the world. We don’t understand the details, but it’s not quite as straightforward as selling off everything in the new service model.

We’ve no intention of asking our Commissioning Support Unit to take that sort of approach in relation to our services in Calderdale.

There are competition requirements that the Clinical Commissioning Group has to take account of and follow the law.

But our intent is to work with our strategic partners.

Any approaches to the market would need to be part of the public consultation.”

Presenting the Procurement Considerations slide, Martin Pursey said that Monitor will require evidence about CCCG’s procurement process.

Martin Pursey didn’t say this, but Monitor was set up by the Health and Social Care Act 2012 to regulate the new NHS “market”. It is run by an executive team drawn almost entirely from private sector management consultancies – KPMG and McKinsey in particular.

(KPMG was also closely involved in setting up the West and South Yorkshire and Bassetlaw Commissioning Support Unit.)

Martin Pursey went on to say that CCCG will be

“treating providers equally and not discriminating”.

This seems to contradict Dr Walsh’s answer to my question, when he said,

“our intent is to work with our strategic partners. Any approaches to the market would need to be part of the public consultation.”

Martin Pursey added,

“A lot of work needs to be done on that to show we’re doing that effectively” (ie treating providers equally)

He also spoke about the competition question in relation to integrated care proposals in the Strategic Outline Case.

I missed what he said because I was still registering the apparent contradiction between his statement about “treating providers equally and not discriminating”, and Dr Walsh’s assertion that CCCG’s “intent is to work with our strategic partners”.

However, it was clear that procurement regulations and privatisation are a biggie in relation to the SOC.

Other CCGs that have already gone down their own version of the SOC route have put vast contracts out to tender. Opinion in Health Investor, the trade magazine for private health companies looking for investment opportunities, is that they are on the verge of an entirely new ballgame.

Timetable

• “Engagement” – spring 2014
• Clarify options on which to consult people – June 2014
• 13 week consultation summer 2014 (July, August, September – how convenient, when everyone’s away on holiday)
• Review consultation feedback – 6 weeks
• Potential Secretary of State review – 3 months

Existing engagement

By this point, information overload had kicked in, so my notes on this section are incomplete. This is all there is:

• There has been “engagement” with Councillors and MPs about the general overview of Strategic Review and the SOC
• There are 90 organisations identified as reference groups that need to be consulted
• Healthwatch was mentioned but I can’t remember what was said about its role in “existing engagement.”
• My handwritten notes say: engagement- 9 drop in sessions,10 locations for road show activities, comment cards and boxes, media and comms, existing networks. But I can’t remember if Healthwatch has done this, or what.

Discussion

Following the presentation, Dr Walsh said the CCCG needed decisions on a number of points:

1. Whether to progress  through to “engagement” about the SOC. He said,“The public is quite rightly asking, will things be as good as they are now?”
2. Will CCCG feed the outcomes of “engagement” into the development of proposals for consultation?
3. Will the CCCG agree to delegate authority to sign off on the “engagement” strategy to Penny Woodhouse (CCCG Head of Quality), Kate Smyth (CCCG Governing Body Lay Member) and Dr Steven Cleasby (Assistant Clinical Chair, CCCG).

The Case for Change – last summer NHS England told CCGs to cut an extra £30bn from their spending by 2020

A GP whose name tag I couldn’t see said,

“We need to clarify the case for change and bring it to the fore. The public can’t understand what it is without explanation.”

Dr Walsh replied,

“The case for change has been used so far in engagement events. The national Call to Action informs the Strategic Review and we need to publish the case for change.”

Dr Walsh didn’t say this, but the national Call to Action identified the need to cut NHS spending by an additional £30bn by 2020, on top of the £5bn/year efficiency savings that CCGs already have to make over 4 years. These efficiency savings represent 4% of the CCGs’ annual budget.

The Foundation Trust Network Chief Executive, Chris Hopson, recently blogged that the Call to Action creates a massive “financial challenge” for Foundation Trusts and other NHS “providers” – eg GPs’ primary care, community and mental health services.

NHS England’s Call To Action, published last summer (2013) tells CCGs to come up with new 3-5 year commissioning plans that will find ‘local solutions’ to cutting their share of the £30bn NHS funding shortfall. CCGs are supposed to consult with charities and patient groups about ‘local solutions’ to cutting their share of the £30bn.

Calderdale Council Leader Tim Swift calculated on his blog that this means Calderdale CCG will lose £80m out of its budget over the period to 2020/21.

Keighley GP cheerleads for the SOC

Apparently ignoring the sobering implications of Dr Walsh’s comment, Dr Peter Davies spoke in favour of Option 2 as part of:

“a modern trend of moving to specialisation as part of modern medicine.”

Dr Peter Davies, a Keighley GP, has published a book advocating that the NHS should use Coca Cola marketing and management methods to improve patient care. The book was published by the pro-market thinktank, Civitas.

Dr Davies’ trendy enthusiasm for modern medicine opened the floodgates for Martin De Bono, who exclaimed,

“There’s absolutely no doubt that we believe the worst decision we could take is to do nothing! The whole system is unsustainable as it is at the moment! Change needs to happen!”

Although this assertion has more holes than a sieve, and in a BMJ Data Briefing the Kings Fund Chief Economist John Appleby described it as a “politician’s syllogism”, the meeting let it pass.

Not surprising, since this is the Coalition government mantra on the NHS and probably the CCG isn’t allowed to criticise government policy. Healthwatch certainly isn’t.

(More below, in section Never Let A Good Crisis Go To Waste.)

How to be sure the SOC proposals will improve things and do no harm

Penny Woodhead, CCCG Head of Quality, said,

“From a governance perspective, one of the main things is to be sure we’re improving things and doing no harm.

We need to identify and track clinical outcomes that we want to see, so we can be sure we’re delivering what patients need and delivering improved outcomes.”

Dr De Bono exclaimed,

“Doing no harm isn’t good enough! We need to reduce harm! Centralisation of acute services has been associated with reduced mortality. We want to continue saving lives from major trauma! So we must centralise!”

(Another editorial aside here:

Leeds General Infirmary is the West Yorkshire major trauma centre, so won’t people with major trauma go there, regardless of whether or not Calderdale and Huddersfield A&E is centralised?

And centralisation of acute services appears to be associated with higher mortality not reduced mortality, according to research as well as data obtained through Freedom of Information requests.

Research led by Professor Jon Nicholl of Sheffield University has found that overall, mortality will increase with longer ambulance journeys. In his study, 5.8 per cent of patients who travelled less than 6.2 miles to A&E died before being discharged from hospital. Among patients who travelled more than 13 miles, almost nine per cent died.

Mortality statistics obtained by the Mail on Sunday through a Freedom of Information request show that, following the closure of Newark A&E, in 2013 4.85% of Newark patients who were admitted for emergency treatment died within 30 days of admission. In 2009, before Newark A&E closed, the figure was 3.53%.

The Mail on Sunday article quotes MP Andrew Percy, a member of the Commons health
committee, as saying:

‘Shutting local A&E centres does not improve patients’ survival changes, it dramatically worsens them. There should be no more such closures until we have a thorough review of this policy.’)

Questions about capacity and evidence

Jackie Bird, Registered Nurse, asked whether the CCCG had the capacity to deliver this, and also asked about the clarity and transparency of evidence. She said

“We need assurance that the Governing Body has the capacity to do this.”

Dr Matt Walsh replied, as he did on the other (two) occasions when anyone asked a focussed, critical question, that this was a good question, and then neatly sidestepped it.

“The question of capacity is a really good one. The partnership organisations across the system are committed to providing resources to underpin the engagement and consultation exercise.

As the CCG are more challenged than Primary Care Trusts because of the size of the management resource, we need to think really carefully how the Commissioning Support Unit can support some of that and we need to continue to work as a partnership to do engagement and consultation.

Thinking about how to quality assure the consultation, I have been in touch with the Consultation Institute which has a lot of experience in supporting high quality engagement and consultation. They also quality assure the outcomes of engagement and consultation.”

Outline business case

Lay member John Mallalieu asked how the timetable for engagement feeds into the outline business case.

Dr Walsh said the process was to use all the products of “engagement” to generate the consultation document and the “providers” would generate the Outline Business Case.

Dr Walsh said,

“The consultation wraps around the Outline Business Case. This describes in detail what will be consulted on.”

Media

Dr Sanjay Sun asked,

“How will we demonstrate to people that we will deliver what we’re promising?”

Dr Walsh said,

“We need to work on this.”

The Locala guy said something about a balanced scorecard.

Dr Walsh spoke of needing to get the message out to the media.

The CCG leader on urgent care, Dr Majid Azer, said,

“This is the biggest transformation of Health and Social Care in Calderdale. It’s not just the headlines of A&E. A&E is a tiny part of this.”

Money

Dr Steven Cleasby said, what about finance?

The CCCG Chief Finance Officer Julie Lawreniuk said,

“It’ll be our job to decide whether to commission this and that will depend on whether we can afford it for the next 10 years. Will it be sustainable? Can we pay for it?”

The Locala Transformation Director Jim Barwick said,

“There will be investment in the community and it’s really important that there is the capacity in the community.”

I wondered momentarily about conflict of interest rules for meetings, since Locala clearly has an interest in investment in the community.

Decisions

The meeting agreed that CCCG would:

1. progress  through to “engagement” about the SOC.
2. feed the outcomes of “engagement” into the development of proposals for consultation
3. delegate authority to sign off on the “engagement” strategy to Penny Woodhouse (CCCG Head of Quality), Kate Smyth (CCCG Governing Body Lay Member) and Dr Steven Cleasby (Assistant Clinical Chair, CCCG).

Spin

A member of the public said afterwards,

“That was a load of spin.”

I agree, there is far more to say about the SOC.

Because the decision to go ahead had already effectively been made and announced at Strategic Review presentations weeks before, with a couple of exceptions the meeting was just a about asking  a few “how” questions – not questions about “if”, “why”, “is this really such a good idea” and “will we still have an NHS at the end of it or will it all be privatised”.

There will shortly be some Plain Speaker articles about these questions. Including the whole Accountable Care Organisations issue mentioned at the start of this article.

But enough for now. Just a couple of points and then we’re done.

Never let a good crisis go to waste

Andrew Landsley’s claim when he was Secretary of State for Health, that the current NHS system is unsustainable and therefore has to change, is an example of a “political syllogism”, according to a BMJ Data Briefing by economist John Appleby.

Unsustainable is code for “not bringing in enough money to cover costs”.

If NHS England’s Call to Action means Calderdale CCG has to cut an extra £80m from its spending by 2020, it could well be true that there won’t be enough money in the system to cover its costs.

But this is the result of a political decision, not an economic necessity. So it is entirely open to question.

The UK is the 6th or 7th richest country in the world. Among countries of similar levels of wealth, it has one of the lowest per person spends on healthcare.

Contrary to much pro-austerity propaganda, UK government debt is not very high in historical terms. Britain was far more heavily indebted after WW2 when it found the political will to set up and fund the NHS.

The idea that a national economy works in the same way as a household economy is misguided. So applying household economics to a country doesn’t work. The best thing to do when a national economy is in recession and the government deficit is rising is not to cut public spending, but to increase it.
This is because of the multiplier effect – increasing public spending means more people are employed, earn money, pay more taxes and spend more money. So other sectors of the economy benefit and more people become better off. And pay more taxes.

The deficit goes down as more taxes come in.

The fact that the UK government deficit has increased massively as a result of Coalition government public spending cuts demonstrates this fact.

The decision to cut public spending, including spending on the NHS, is nothing to do with sustainability or unsustainability and everything to do with ideology and a greedy desire to make the rich richer and the rest of us poorer.

We could easily fund the NHS properly. The decision not to do this is purely political.

The austerity lie is about never letting a good crisis go to waste. Big companies, with the help of government politicians whom they have bought, use the austerity lie as an excuse to acquire public assets at cheap prices. They also use the “too big to fail argument” to get the public to bail them out and pay off their debts, in a grand demonstration of socialism for the rich and dispossession for the rest of us. Naomi Klein wrote about this in Shock Doctrine. More recently, Philip Mirosski has written Never Let a Serious Crisis Go To Waste: How Neoliberalism Survived the Financial Meltdown. Unlike the SOC, it’s very readable.

If you haven’t got time to read a book, here’s John Appleby’s BMJ Data Briefing Can We Afford the NHS in Future. This is about the Coalition government’s NHS unsustainability myth, or what John Appleby calls a  political syllogism.