Councillors’ Democratic Scrutiny 1, NHS Chiefs’ Smoke and Mirrors 3

Calderdale Council Adult Health and Social Care Scrutiny Panel meeting on 28th July failed to effectively question hospitals Trust chiefs about their “Balanced Plan” for meeting a £20m funding shortfall this financial year, and a £19m shortfall in 2015-16.

By failing to provide clear straightforward information, equally the NHS chiefs failed in their duty of candour as public servants.

Chatting after the meeting, a group of Save Our Hospitals campaigners expressed deep scepticism about the conduct of the meeting as well as confusion about what had been said.

They agreed that it would be good to have an idiots’ guide to the meeting.

This is an attempt to provide that idiots’ guide.

It looks at:

  • background – effect on Calderdale of NHS changes and cuts brought about by the Health and Social Care Act, best skip this section if this is familiar stuff
  • what new information came out of the meeting
  • what key issues are at stake and why they matter
  • what the job of the Scrutiny Panel was
  • what the job of the NHS Chiefs was
  • whether they succeeded in these tasks (basically, no)
  • how they need to up their game so they can do their jobs properly

At the end, it also links to a more detailed account of key aspects of the meeting.

Background

The basic story here is that the Coalition government is slowly, year on year, starving the NHS of adequate funding – with predictable results.

The hospital Trust’s Balanced Plan is their response to this government-imposed funding shortfall. The Trust’s funding shortfall has nearly doubled from around £11m-£12m/year over the past couple of years to the current £20m this financial year and £19m next.

The NHS chiefs’ loyalty is to the Trust, which has an absolute duty to break even. They have breached this duty April-June this year and gone into the red.

This is a national problem. Across the country, unprecedented numbers of hospital Trusts are now in the red – including Hinchingbroke, the first NHS hospital to be run by a private health care company.

NHS Foundation Trusts, like our hospitals Trust, are run as businesses (‘independent Public Benefit Corporations’). Their boards are free to meet in secret, can choose not to publish their board papers and can take big decisions without reference to anyone except Monitor, the national healthcare market regulator, and the Commissioning Groups that decide whether to buy their services.

The hospitals Trust have cited commercial confidentiality as the reason why the public will not be able to see the Outline Business Case for the “Right Care” service change proposals, to cut acute and emergency hospital services and replace them with care in the community.

Not only is the NHS facing a chronic, government-imposed funding shortfall, its funding is increasingly being diverted to fill gaps in social care funding which have opened up because of government funding cuts and welfare reforms.

For instance Calderdale Clinical Commissioning Group (CCG), the body responsible for commissioning NHS hospital and community care services in the area, has just funded a £150K 2 year programme for Calderdale Citizens Advice Bureau to help unwell people to prepare their appeals against their loss of benefits as a result of Work Capability Assessments.

The Better Care Fund is also to slice a substantial amount of NHS funding and divert it to social care.

The CCG’s are responsible for paying the hospitals Trust for services they choose to buy from them. But increasingly, under pressure from Monitor and under financial pressure because of the government-imposed NHS funding shortfall, they put services that they want to procure out to open tender. For instance they just put CHFT’s wheelchair services contract out to tender and CHFT have lost the contract to Opcare Ltd, who put in a much lower bid than the CHFT’s.

The Council too now has a role in commissioning public health care. CHFT says that the Councils now intend to put public health services which they currently buy from the Trust, out to competitive tender.

The Trust is therefore in quite a precarious position. Its commissioners are looking to put many of its services out to competitive tender on the one hand, and on the other hand, the government is increasingly shrinking the tariffs it pays for its services.

Two key pieces of new information came out in the meeting

One was that the Clinical Commissioning Groups have not yet bothered to look at the Trust’s Outline Business Case for cutting acute and emergency hospital services and replacing them with care in the community. As a result they have not yet decided whether to take it to public consultation.

This is because the Clinical Commissioning Groups have been working on their own models for care in the community and the kinds of hospital services that would be needed alongside this.

They are to present their models to the August 14th Calderdale Clinical Commissioning Group Governing Body meeting. This will decide whether these models provide an adequate basis for judging the Trusts Outline Business Case.

The other new information was that the £13.45 cuts/efficiency savings predicted in the April version of the Balanced Plan – the document that Scrutiny Panel members had received – had shrunk to £7.7m as of July, because the Trust had realised that the rest of the savings were not “deliverable.”

The Trust is now working up other ways of cutting its spending and think that they will be able to cover £17.7m of this financial year’s funding shortfall – taking into account the predicted extra new income of £6.55m from private and overseas patients and increased commissions of orthopedic services.

So the document Scrutiny Panel members had received is now outdated.

Surely this has to raise questions about the Clinical Commissioning Group’s assurances throughout the meeting that it had “quality assured” all the cuts and guaranteed that they are all efficiency savings that do not change the amount or quality of the services the hospital provides.

Because which cuts are they talking about? The ones the Trust thought in April that it was going make but in July discovered they couldn’t? Or the ones that they are working up now and think will allow them to cover most of the funding shortfall?

What key issues are at stake and why they matter

The hospitals Trust’s Balanced Plan 2014-2016 only came to public knowledge through a leak to local media.

It identifies cuts to staff and services – including cutting 66 hospital beds from October and another 44 in 2015/16 – as well as plans for new sources of income from private and overseas patients, and from more orthopaedic treatments that the Trust hopes that the Commissioners will pay for.

Taken together, the cuts and extra income should mean the Trust can make government-imposed efficiency savings of £20m this financial year and £19m next financial year. These  amount to around 4% of the Trust’s annual budget and are needed because the Trust’s income isn’t enough to cover its spending.

However, in April the Trust thought it had identified ways to make £13.55m cuts and balance the £6.45m gap by generating new income, but in July it found that it would only be able to safely make £7.7m cuts. It has since looked at new ways of making cuts and thinks that with the new income sources (including from more private patients and  overseas visitors) it should be able to meet over £17m of the £20m shortfall this financial year.

The shortfall is mostly the result of reduced government payments for the services the Trust gives its patients, and the failure of government payments to keep pace with the increased costs of drugs and population growth.

At the start of the meeting, the Scrutiny Panel Chair Cllr Malcolm James identified that the business of the meeting was to identify:

  • whether the Balanced Plan proposals amounted to a substantial variation in service that would cause other services to be changed and would require a joint scrutiny with Kirklees Council
  • where the Balanced Plan sits with the Strategic Review/Strategic Outline Case for cutting acute hospital services and replacing them with care in the community

These issues matter because if the Balanced Plan proposals amount to a substantial change in service, the hospitals Trust and the CCG would need to go to public consultation, before its cuts and its plans for increased private and overseas patients’ income could go ahead.

We also need to know if the Balanced Plan cuts and its plans for increased new income from private and overseas patients are in fact the thin end of the wedge for the much bigger Right Care changes. This could mean that the Trust is trying to carry them out by stealth, without public consultation.

In particular, there is considerable suspicion that the Trust plans to install private patients in the hundreds of surplus beds that would be created when one hospital is turned into an 85 bed planned care clinic plus a Minor Injuries Unit.

These two issues are plenty to be going along with, but Save Our Hospitals campaigners had also asked Scrutiny Panel members to get NHS chiefs’ answers to these questions:

  • Whether the Trust had carried out equality impact assessments for the proposed Balanced Plan cuts and service changes – it is a legal requirement for NHS providers to assess the impact of proposed changes on vulnerable groups
  • How much additional income does the Balanced Plan propose to raise from private and overseas patients – this matters for reasons already identified and also because increasing the amount of income raised from private and overseas patients could damage the quality and availability of care for NHS patients (see bullet point below)
  • whether and how the Trust management has consulted staff about the Balanced Plan cuts and service changes – this matters because frontline staff are best placed by virtue of their experience to know if and how efficiency savings can be made without compromising patient safety and their own wellbeing as staff. It is also common decency.
  • whether the proposed cuts and service changes will damage the principle of universal, equitable access to health care that is free at the point of need, and will require rationing of NHS services – this needs no explanation
  • what the £4.8m savings are from Workstream 9, the Efficiency Programme Board. The Balanced Plan does not provide any information, about them beyond the amount of savings

The Job of the Scrutiny Panel

The job of Scrutiny Panel members is to be well enough informed about the current state and operational processes of the NHS in general, and the Trust’s Balanced Plan and Strategic Outline Case in particular, to be able to hold the NHS chiefs to account and make them explain in clear laypeople’s terms the questions that the Chair identified at the start of the meeting – as well as at least some the questions that members of the public asked them to put to the NHS chiefs.

Or, lacking this information (as they acknowledged at their first meeting at the start of July) to get training to bring them up to speed, and to get funding from Cabinet to allow them to employ an external adviser who will help them hold the NHS chiefs to account.

The job of the Scrutiny Panel chair is to make sure that:

  • the meeting follows the agenda and covers all its items in the allotted time
  • everyone gets a fair chance to speak freely
  • NHS chiefs answer the questions they are asked in a clear and straightforward way
  • he provides a clear and impartial summing up of points at the end of each agenda item and at the end of the meeting

The NHS chiefs’ job

As already noted, the NHS chiefs are public servants. They have a duty of candour towards the public, the politicians that represent them, the staff they employ and the patients they provide care for.

In the context of the Scrutiny Panel, their job is provide full, straightforward answers to all the questions they are asked.

Self-described “NHS bean counter” Jonathan Allsop, says that NHS managers and finance officers need to speak out against NHS cuts and the changes brought in by the Health and Social Care Act which are designed to allow the NHS to be chopped up and sold off. He says they should speak out against the damage done by these financially-driven reforms.

Did they succeed in their Scrutiny Panel jobs?

The Chair failed to make sure the meeting followed the agenda. Instead, the Trust’s Chief Executive Owen Williams and his posse of NHS chiefs ran rings around the Scrutiny Panel and took control of the agenda.

As a result the meeting was inconclusive and did not nail key questions.

It failed to do its job of getting Owen Williams to identify whether the Balanced Plan amounts to a significant variation in service – in which case it would need to go to public consultation before its cuts and its plans for increased private and overseas patients’ income could go ahead.

NHS chiefs made repeated assertions that the cuts were efficiency savings that would not affect the quality or level of service, so they would not vary the service at all. But their assertions were not convincing, imo. Particularly since front line staff are saying they can’t take any more cuts and preserve patient safety and comfort and their own wellbeing, now that the services have been pared to the bone following five years of effficiency savings.

 

And particularly since it wasn’t clear which efficiency saving cuts the CCG had quality-assured: the ones that in April the Trust thought they would be able to make but have now realised they can’t? Or the ones that in July they were still in the process of working out?

The Scrutiny Panel also failed to conclusively show what the relationship is between the Balanced Plan and the Right Care proposals for cutting acute hospital services and replacing them with care in the community – despite the NHS chiefs’ claims that the Balanced Plan was nothing to do with the Right care proposals.

So we are no closer to knowing if the Balanced Plan cuts and plans for increased new income from private and overseas patients are in fact the thin end of the wedge for the much bigger Right Care changes, which the Trust is trying to carry out by stealth without public consultation.

At the end of the meeting the Chair had to settle for a weak statement that the session had been “useful” in clarifying that the Balanced Plan was about making the 4% efficiency savings, and in explaining the Trust’s relationship with the Clinical Commissioning Group and the fact that the CCG was clarifying the model of care in the community before looking at the Trust’s Outline Business Case.

The Chair said the Scrutiny Panel would call in the NHS chiefs again.

It is vital that they get their act together next time.

Cllr Adam Wilkinson persistently asked questions that aimed to uncover answers to the two agenda items set by the Chair, but the NHS chiefs, clearly well schooled in evasiveness and playing off each other to wrongfoot their questioners, failed to fulfil their duty of candour as public servants.

Relevant and focussed questions from Scrutiny Panel members were in fairly short supply, as quite a few SP members seemed often to be grabbing at straws rather than following a clear line of inquiry.

The Chair didn’t exactly help SP members to follow clear lines of enquiry, since he failed to check the NHS chiefs’ evasiveness and hold them to straightforward answers to the questions that Scrutiny Panel members asked them.

He took a lot of his cues from the NHS chiefs and, whether or not he meant to, at times redirected the Scrutiny Panel’s line of questioning to fit in with NHS chiefs’ evasions and buck passing.

Perhaps he is just a naturally conciliatory person, but a Scrutiny Panel is not about conciliation, it’s about nailing the facts even or especially when people don’t want to state them, for whatever reason.

The Chair’s timekeeping wasn’t brilliant. He let Scrutiny Panel members’ often unfocussed questions about cuts fill up the entire two hours, without initiating or prompting any switch to vital questions about Trust chiefs’ proposals for raising extra income from private and overseas patients.

It was left to Plain Speaker to question the Trust Chief Executive about this after the meeting.

How the Scrutiny Panel needs to up its game before its next meeting

At its first meeting at the start of July, when it planned its work programme for the year, the Scrutiny Panel acknowledged that it needed to learn how the NHS operates. Otherwise it would not be able to do its job of holding the NHS chiefs to account.

The SP also agreed at that meeting that they would ask Cabinet for funding to pay an External Adviser to help them hold NHS chiefs to account, given their own lack of appropriate knowledge and skills.

Calderdale Council Chief Executive Merran McRae disputed that this was necessary. She said the advice the SP needed is available in-house, from officers like the Public Health Officer Paul Butcher. The Chair overrode her objection and committed to asking Cabinet for this funding.

The SP has not asked Cabinet for this funding. When Plain Speaker asked the SP Chair Cllr Malcolm James why, Cllr James replied that the SP would ask for the funding when they needed an External Adviser.

The 28th July Scrutiny Panel meeting showed that they needed an external adviser then.

They were no match for Owen Williams, the Trust’s Chief Executive, and his expensive posse of:

  • management consultant Mags Barnaby (whom the Trust has brought in to prepare the Balanced Plan),
  • the new Medical Director Dr Birkenhead (Dr Barbara Crosse having recently vanished without trace),
  • the Trust’s Finance Director Keith Griffiths, and
  • Calderdale and Greater Huddersfield Clinical Commissioning Groups’ Chief Finance Officer Julie Lawreniuk.

The Scrutiny Panel even allowed itself to be wrong footed by Owen Williams’ cheeky opening gambit, when he protested innocence of the fact that the Scrutiny Panel only found out about the Balanced Plan because it was leaked to local media. He asserted:

“The notion of things being leaked doesn’t fit with the fact that CHFT’s ideas for meeting the challenge that don’t come from us – but from our 6,000 staff.”

He said the Trust had given the Balanced Plan to all the Trades Unions in the hospitals.

That version of events may be true – although the Scrutiny Panel should know that it is roundly disputed by CHFT staff and the Unison regional health rep Gary Cleaver.

But it doesn’t begin to account for the fact that the Trust withheld the Balanced Plan from the Scrutiny Panel, who have a duty of oversight of the Trust in order to hold it to democratic account.

But no-one said so.

How the NHS Chiefs need to up their game right now

They are clearly so practiced at the dark arts of smoke and mirrors that probably this is hardwired into them and only a miracle – or focussed, relevant, persistent questions from the Scrutiny Panel, the public and politicians – will compel them to part with the real facts, however unwillingly.

But they need to accept and fulfill their duty of candour.

Links to more detailed accounts of Councillors’ lines of enquiry at the meeting

There is a report here that gives more detail about:

  • Balanced Plan bed cuts and whether they amount to a significant service change; Strategic Outline Case/Outline Business Case bed cuts; and whether there is any relationship between the two sets of cuts – ie if the Balanced Plan cuts are a way of sneaking in the SOC cuts before the public has been consulted
  • the reality of the Trust’s engagement or lack of engagement of its staff
  • Balanced Plan proposals to raise extra income from private patients and overseas visitors

Updated 30th July with the addition of the Background section

Posted from Hebden Bridge, England, United Kingdom.