Rhubarb rhubarb for two hours as Calderdale NHS commissioners outwit Councillors’ scrutiny of shake-up plans

A dismayed member of the public who attended the 17th September Scrutiny Panel meeting, where Councillors allowed themselves to be outwitted over Calderdale NHS commissioners’ plans to delay public consultation on the NHS shake-up, said,

“They might as well have been saying rhubarb rhubarb for two hours, for all the use that meeting was.”

There is an overview report of the meeting here.

For anyone who has the stomach for rhubarb, here is a more verbatim account. It covers

    • The CCG’s evasiveness about whether it will dump the hospitals Trust as the provider of existing community health services, and switch to buying them from private companies or 3rd sector/voluntary organisations.
    • The Scrutiny Panel’s failure to use its power to decide whether the CCG’s plan to re-specify and re-purchase existing community health services by the end of this year would significantly change existing NHS services in Calderdale and so require public consultation.
    • The timeframe for costing Phase 2 community health services, which will happen over the next 3 months. Phase 2 would involve taking services for frail elderly people with multiple illnesses out of hospital and into the community or people’s homes.

Phase 1: “There will be a bidding process and the best tender will win”

The CCG told the Scrutiny Panel that in Phase 1, which will be complete by the end of this year, they are coming up with new specifications for 15 existing community health care services that the hospitals Trust currently provides.

The CCG will then take this “shopping list” of community health care service specifications to the hospitals Trust. According to Dr Brook, the Chair of the CCG Governing Body, if the Trust can’t offer the re-specified services, the CCG will put the services out to competitive tender.

This information only came out late in the meeting, well after Cllr James had asked if the CCG was looking to improve the service that the hospitals Trust provides by getting them to do a better or different job. Or whether this would involve re-tendering the service to other providers.

Debbie Graham, Calderdale CCG’s Head of Service Improvement, avoided his question by replying,

“The new specification for existing community health services has lots of opportunity for improvement, for example making the community services work better together.”

Cllr James returned to the same question much later in the meeting. Asking the CCG to present their new specifications to the Scrutiny Panel, which they agreed to do once they have a work-in-progress draft, he inquired,

“Will you enact that specification with the present providers”

Again Ms Graham didn’t answer the question.

Dr Walsh covered up for her evasion by asking the Scrutiny Panel a totally irrelevant question, about the relationship between the People’s Commission and the Scrutiny Panel.

The Scrutiny Panel happily chased this red herring for some minutes.

Expert at avoiding whatever they don’t want to reveal, the CCG didn’t tell the Scrutiny Panel about their “Approach to Market”, which they had explained to their own Governing Body meeting last month.

This is about how they are going to decide whether to continue to buy services from NHS organisations like the hospitals Trust, or whether they are going to put them out to competitive tender and buy them from private and/or third sector companies.

Cllr Shoukat seemed to be familiar with this though, and asked whether the services which the CCG are taking out of the hospital at the moment will make the hospital unviable.

Dr Brook replied,

“I find it hard to see why we would do anything other than design services with the best intention of patients at heart.”

Cllr Shoukat said he feared that the reconfiguration might cause consultants to up and go elsewhere. And he had a concern about private providers coming in that put profit above all else. He said,

“Phase 1 may go to private consortia. But there’s faith in local GPs. But large corporate organisations don’t get the best pr.”

Dr Walsh gushed,

“This is a real question, it relates to the question of the voluntary and third sector.

At our recent stakeholder event they told us they want to do more. We have to tap into that and do more. We want to tap into the 3rd and voluntary sector.

The new specifications will find ways to build on making links to the voluntary and market sector – that is our market approach.”

Cllr Shoukat went on,

“Will local expertise play a part in the new specifications?”

Dr Brook said,

“We are creating a shopping list of services that are required. If the current provider can’t offer them we will look elsewhere but the service will stay the same to patients. We shouldn’t get too tied up on who the provider is.”

Cllr Shoukat persisted,

“But will local expertise play a part in the specifications?”

Dr Brook said:

“There will be a bidding process and the best tender will win.”

Round 1: Cllr Shoukat 1, Dr Walsh 1

Does Phase 1 of the community health system amount to a significant service change that requires public consultation?

If the CCG puts Right Care services out to tender, according to Dr Walsh’s statement at the March 2014 meeting of the CCG Governing Body, this would require public consultation.

This is what Dr Walsh told the March Governing Body meeting:

“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.”

But Councillors appeared to be unaware of this.

Cllr Bob Metcalfe asked when the CCG was going to consult the public.

Dr Walsh said,

“We’ve been engaging with the public for the last four years.”

Cllr Metcalfe:

“But there’s been no public consultation on Phase 1.”

Dr Walsh:

“We need to continue to engage with the public on Phase 1.”

Cllr Metcalfe:

“You’ve gone back to engaging.”

Dr Walsh:

“Formal consultation brings a set of processes and checks, for example with NHS England. So we won’t consult until we’ve done that process. Meanwhile we’ll develop our plans and consult the Scrutiny Panel.”

Cllr Metcalfe asked about the time frame and Dr Walsh said the CCG would implement Phase 1 this year.

Cllr Metcalfe asked if that meant that the CCG would consult on Phase 1 before December.

Dr Walsh spluttered and then said,

“We’re not going to consult unless you tell us we are making a significant change.”

Cllr Metcalfe said,

“So there won’t be any consultation this year.”

Dr Walsh:

“We don’t believe Phase 1 represents significant service change.”

Dr Brook piped up:

“It’s about iterative small changes.”

Cllr Metcalfe persisted;

“Phase 1 community services are to be built around GP practices. That’s a significant change, to introduce integrated working compared to how GPs already operate.”

Dr Brook piped up again,

“That’s not so. GPs are already drawing up care plans. We have multidisciplinary teams in Care Homes through  Quest for Quality in Care Homes. But GPs can’t do that alone and we need a much wider team to work with GP practices.

Quest for Quality in Care Homes has increased record sharing and the use of technology.

Phase 1 is putting right the shortfall in the existing system.”

Dr Brook didn’t mention that the CCG Finance and Performance Committee had heard on June 14th that the Quest for Quality in Care Homes project is currently RAG rated at red. Which is not good. This was because:

  • GPs had been unable to access patient records in care homes – an issue which should have been sorted in summer 2013 but was only recently resolved
  • The Information Governance process had not been completed to allow the Quest team access to the shared records. This requires a description of what information different team members in different organisations can access, and clear patient consent policies. Dr Brook raised concerns that this IG process may be “inhibiting” matrons’ “capacity to deliver”.

Nor did Dr Brook mention that at the CCG Finance and Performance Committee on May 29th he had raised concerns about staff recruitment to the Quest for Quality in Care Homes project, because some nurses recruited to the project had already been working in the community or for the hospital Trust and there was anxiety that this had created gaps in the community.

The Minutes of that meeting also record that the Local Medical Committee had said that every project had taken experienced nurses out of the community. And that it was disappointed that “there was no metric on GP contact in homes which had been flagged up as one of the aspirations of the project.”

The Scrutiny Panel did not seem aware of these inconvenient facts, that suggest that instead of fixing problems with existing community health care services, Phase 1 could introduce a whole new set of problems.

Cllr Shoukat returned to his earlier question about what services would be left with the hospitals and what would be brought into the community.

He asked how this would sit with GP practices that haven’t got the resources to take on new patients. For instance the GP practice that recently announced that it isn’t safe for either doctors or patients.

Dr Brook said it would be about enhancing team working alongside GPs, not about increasing GPs’ work.

Cllr Shoukat asked what services the CCG was looking at taking out of hospital.

Dr Brook said that they were looking at taking out specialist care for the frail elderly with multiple illnesses and replacing this with care from “physician extenders” or nurse practitioners at home or in the community.

Averting further talk of “physician extenders”, Dr Walsh chipped in with information about phase 2 and phase 3.

Phase 2 is about taking services for frail elderly people with multiple illnesses out of the hospital and putting them in the community. Phase 3 is when this causes cuts to acute and emergency hospital services.

Cllr Draycott asked if GPs were on board with the proposal to build Phase 1 around GP practices.

Dr Brook, who as we have seen can be economical with the truth and is also inclined to veer off the point like a wind-up toy when it hits an obstacle, said

“The plan has been developed with the enthusiasm of GP practices. It’s something generally very welcomed by GPs.

We don’t want to consult on the hospital services model until we’re ready. The Strategic Outline Case is only one possible model.”

Dr Walsh said that the CHFT have found CCG plans for phasing community care very hard to take.

Round 2: CCG 7 – Scrutiny Panel 1

Money, and lack of

The BMA has said that setting up integrated community health and social care services cannot be done on the cheap.

But Dr Walsh, the CCG Chief Officer, told the Scrutiny Panel that the Better Care Fund project is doing economic modelling of different kinds of care for Phase 2 of the community care system and that,

“If it’s going to cost us more to do this work we just can’t do it anyway.”

The link between Phase 2 of Care Closer to Home and the Better Care Fund economic modelling will be clarified over the next 3 months and the CCG will come back to talk to the Scrutiny Panel about this.

Cllr James ended the meeting by wishing the CCG good luck with developing Phase 2 and said he looked forward to more Scrutiny Panel meetings with the CCG.

What next for Save Calderdale Royal Hospital campaigners? Not being too keen on more hours of “rhubarb rhubarb”.

Personally I think a pantomime would be good. Ideas please.

Round 3: Dr Walsh 1, Cllr James 0

Final Score: CCG 9, Scrutiny Panel 2, Public 0.

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