Jane Rendles Deputation Statement at Calderdale and Kirklees Joint Health

Scrutiny Committee Meeting, 29.1.16

My name is Jane Rendle and I am Chair of Calderdale 38 Degrees NHS Group. However
I'm speaking as an individual as I haven't had time to agree what I'm saying with the
group.
The plans being considered are not fit for purpose and consultation should be delayed
until they are.
We have been engaging with Calderdale residents on the streets for more than two years
and people have been eager, even crossing the road, to sign our petition against the
closure of either A+E.
As well as this, people have talked to us of the difficulties of travelling to Huddersfield for
appointments or to visit patients, particularly for those who don't drive and are coming from
Todmorden.
The Clinical Senate has made it clear that the Right Care Right Place Right Time plans are
based on nationally generated models with no significant local input.1
They found no evidence that local clinical staff had been asked about either the 2 hospital
model or the model of 3 community care.
4They

could not certify that the proposed models would generate the required quality of

care.
This is another reason why we believe that until that engagement with staff in the area has
been completed, the consultation should be delayed.
Those are things I would like you to consider.
The key messages on your proposal here say:
Our proposals will improve quality and safety for the whole population of Calderdale
and Greater Huddersfield.
Its easy to make statements like that, but what is necessary here is a backing for those
statements which show that it is the case. And that is not anywhere we can find, in the
papers that have so far been presented.
Thank you.
Notes:
1) Sources of information for Janes statements in Para 4
1 The

Clinical Senate review of the hospital services model (Pages 159 and 163) states:
...the standards proposed in the documentation ... are taken from a variety of
national documents... The standards are very generic, however, and could largely

apply to any Trust, which left the Senate with questions about their deliverability.
Commissioners are recommended to include more detail about the level of local
clinical engagement in agreeing how deliverable these standards are...
2

The Clinical Senate review of the hospital services model (Page163)

The documentation does not give a sense... of what local clinical discussions there
have been in agreeing how achievable these standards are locally. From the
information provided, we could not have confidence that the model would guarantee
performance in the absence of clarity on the other key factors including staffing
levels, which the Senate agreed are crucial to the delivery of these standards.

The Clinical Senate Review of Community Services Specifications for Calderdale,

Greater Huddersfield and North Kirklees CCGs (PCBC p 137) says that these
Specifications contain no evidence to support commissioners claims of extensive
engagement with staff over the last two years.
It considers it likely that there would be workforce issues during such a large scale
transformation and recommends further work on how risks to patient care can be
mitigated during the transition period, that would result from current CHFT workforce
issues getting worse as the morale and motivation of clinicians continues to deteriorate.
This is identified as a Principal risk.
It also says that there will be resistance and refusal to change in primary care.
4.The

Clinical Senate Review says (p164) that it cant tell how achievable the hospital
services clinical models aspirations are, because there isnt enough clarity about the
more centralised model of care, and there is a lack of operational detail - particularly the
workforce model, including recruitment and retention.
The Clinical Senate review of the hospital services model says (p159) that:
The lack of detail at this stage left the Senate with questions regarding the ability of
this model to deliver the standards proposed.
As for the community services/Care Closer to Home model, the Clinical Senate Review of
Community Services Specifications for Calderdale, Greater Huddersfield and North
Kirklees CCGs says:
...the visionary style of the documents...has compromised our ability to assess if the
risks have been addressed.
2. Information about the Clinical Senate and its reviews of the Right Care Right Place
Right Time clinical proposals
The Clinical Senate is one of the organisations set up by the Health & Social Care Act
2012. It is made up of doctors.

The Clinical Senate Review of Community Services Specifications for Calderdale,

Greater Huddersfield and North Kirklees CCGs, is on p 129, Appendix B of the Pre
Consultation Business Case.
2.1 The CCGs had asked the Clinical Senate to Review to assess a large number of
specific risks associated with moving services out of the hospitals into the community.
The Clinical Senate review concluded that it:
did find it very challenging to assess the risks due to the visionary style of the
documents...This has compromised our ability to assess if the risks have been
addressed.
2.2. The Clinical Senate notes that the CCGs are assuming that the vision will translate
into practical proposals through the use of a competitive dialogue process.
This is the process GH CCG used to award its 238m Phase 1 Care Closer to Home
contract. It took way longer than planned, led to a formal complaint by CHFT to Monitor
and was described to Upper Calder Valley Plain Speaker as:a nightmare - the CCG didnt
know what it wanted, by a board member of the South & West Yorkshire mental health
trust.
2.3 The Clinical Senate Review gives many examples of where the documents visionary
style means that key information is missing.
2.3.1 On p 136 it says that that the Community Services Specifications for Calderdale,
Greater Huddersfield and North Kirklees CCGs lack information about:
The primary care strategy, the services and activity that are currently delivered including
demographics, referral rates and demands in the current system, discussions with staff
and their willingness to work in the ways proposed
Whether the care closer to home vision is achievable financially
This hampered the Clinical Senates efforts to review the proposed functions and capacity
of the new system and the risks associated with the service transformation.
2.3.2 On p 137 it says that the Community Services Specifications for Calderdale, Greater
Huddersfield and North Kirklees CCGs contain no evidence to support commissioners
claims of extensive engagement with staff over the last two years.
It considers it likely that there would be workforce issues during such a large scale
transformation and recommends further work on how risks to patient care can be
mitigated during the transition period, that would result from current CHFT workforce
issues getting worse as the morale and motivation of clinicians continues to deteriorate.
This is identified as a Principal risk
2.3.3 On pages 137/138, it says that because the Community Services Specifications for
Calderdale, Greater Huddersfield and North Kirklees CCGs do not include the primary
care strategy, it has been difficult to judge whether insufficient capacity and capability to
complete and deliver the primary care strategy will scupper the community services
programme.

It says that from what they can gather, the link between primary care and community
services hasnt been thought through.
They say that there will be resistance and refusal to change in primary care (wonder why
that could possibly be the case?
Could such resistance and refusal to change possibly be justified by the Care Closer to
Home plan to degrade GP practices even further than government funding cuts and
senseless tick boxing exercises already have, and turn them into a primary care lite care
model based on American private health insurance company models, like United Healths,
on which these Commnity Services Specifications are based?
The Clinical Senate Review doesnt consider this likelihood. Instead, it says
Commissioners need to think about how they will assist in the development of a new
culture and avoid the interservice conflict which result in demoralised workforce and add
to workforce recruitment and retention problems.
2.3.4 On p 138 the Clinical Senate Review is trying to address the risk of lack of clinical
workforce and skills to deliver the services due to inadequate resource, identified in the
Community Services Specifications for Calderdale, Greater Huddersfield and North
Kirklees CCGs.
The Specifications said this would cause delays and/or issues with implementation of the
programme.
Commendably, this sorry euphemism seems to have set off the Clinical Senates bullshit
detector.
At this point, the Clinical Senate Review comments fairly tartly that the consequences of
lack of clinical workforce and skills will result in a poorer service to patients.
The Review proceeds to identify the following lack of workforce information in the
Community Services Specifications:
how many extra staff would need to be recruited or whether current primary and
secondary staff are adequate for the service
whether staff are available regionally or nationally if it proves necessary to attract new
skills
who would triage the whole system - which is likely to be beyond the remit of one
speciality - and how staff would be trained to do that
how specialist staff would be moved round to provide 24 hour care
a workforce plan
how to provide a consistent service for patients, given lack of assurances about staff
quality and staff turnover
how statutory organisations will train staff from non-statutory organisations http://
www.nhsidentity.nhs.uk/all-guidelines/guidelines/non-statutory-organisations/introduction
and how much this will cost
plans to manage the risks of a deterioration in service to patients during the
implementation of the new services
2.3.5 On p 139 the Clinical Senate review says that Community Services Specifications for
Calderdale, Greater Huddersfield and North Kirklees CCGs dont say how data are to be

integrated across the services, including social services and mental health services although all the Care Closer to Home stuff over the last 2 years has made much of the vital
importance of data sharing, particularly patient records.
2.3.6 Skipping over a few more bits of missing information that made it impossible for the
Clinical Senate to work out if the new community services would do what theyre meant to
do, the next particularly glaring omission is noted on p 139.
Here the Clinical Senate notes that the CCGs have not worked out how to avoid fractured
delivery of care to patients, given the complex integrated system, and that the CCGs are
planning to commission a lead provider for their Care Closer to Home schemes. This
means that one provider would get the contract and then subcontract it out to multiple
other agencies.
2.3.7 On p 140 it says that further missing information from the Community Services
Specifications includes:
how local authority and secondary care providers have actively shaped this model -which
depends on social care involvement and funding at the patient level
the role and responsibility of the end of life care coordinator and the processes for
delivering end of life care in the community
there is no mention of consultant geriatric provision but the difficulties in recruiting
consultants will potentially pose a risk to the service
2.3.8 It says (p141) that Greater Huddersfield CCGs CC2H document omits information
about:
the level of health knowledge available in the triage process - this is where patient calls
go to a Single Point of Access and are then transferred to an Access and Coordination
Hub within each locality. Sounds like a rerun of NHS 111 problems
what is meant by therapist in the rapid response function and how commissioners are
going to deal with shortages of specific therapy skills
how mental health teams will work with Care Closer to Home services and make use of
the access and co-ordination hubs
how hubs link with mental health single point of access
lack of information about the numbers of specialist staff that will be available to support
patient care closer to home and how this relates to staff who currently work in the
system
I am now too exhausted to continue listing any more reasons why the Clinical Senate
found it couldnt figure out how risky of the Care Closer to Home care model would be for:
staff morale and motivation,
worsening workforce issues,
the quality and consistency of patient services,
patient safety,
the survival of GP practices and their valuable, trusted and much appreciated working
culture,
end of life care and geriatric services
etc....

3. Appendix C Clinical Senate Review of the Future Model of Hospital Services for
Calderdale and Greater Huddersfield CCGs, is on p 156 of the Pre Consultation
Business Case.
Like the CCGs Community Services Specifications, the Future Hospital Services clinical
model doesnt seem to be in the public domain, so there is no way of assessing the
fairness and accuracy of the Clinical Senates reviews of the clinical models.
3.1 The Clinical Senate review of the hospital services model says (p159) that:
The lack of detail at this stage left the Senate with questions regarding the ability of
this model to deliver the standards proposed.
3.2 It also says (Pages 159 and 163)
...the standards proposed in the documentation ... are taken from a variety of
national documents... The standards are very generic, however, and could largely
apply to any Trust, which left the Senate with questions about their deliverability.
Commissioners are recommended to include more detail about the level of local
clinical engagement in agreeing how deliverable these standards are...The
documentation does not give a sense... of what local clinical discussions there have
been in agreeing how achievable these standards are locally. From the information
provided, we could not have confidence that the model would guarantee performance
in the absence of clarity on the other key factors including staffing levels, which the
Senate agreed are crucial to the delivery of these standards.
3.3 On page 161, the Clinical Senate Review says that the National Institute for Health
Research Report acknowledges that whole-hospital- and - system change is an area in
which there is little robust evidence. Which is hardly reassuring.
3.4 On p164, The Clinical Senate Review says that it cant tell how achievable the
hospital services clinical models aspirations are, because there isnt enough clarity about
the more centralised model of care, and there is a lack of operational detail - particularly
the workforce model, including recruitment and retention.
3.5 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 individuals care. We
expect this is likely to be GPs 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 theyre waiting
for an ambulance to come. Somehow this doesnt inspire confidence.
The Clinical Senate didnt think so either, they say:
an inexperienced staff member seeking advice from colleagues via Skype does
not offer a rounded solution.
And that (p167):
Secure telemedicine links are required to provide the ability to transfer Digital
Imaging and Communications in Medicine files (DICOM) easily together with other
imaging and pathology data. Skype is not appropriate for this purpose.
They 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 centresWe 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.