OCCG Written Responses to KONP Questions put to Special Board Meeting on 20 June 2017

Questions for OCCG Board extraordinary meeting 20 June 2017 from Oxfordshire KONP with response from OCCG

Q1-6: Our previous questions (to be answered in the meeting 20 June)
Please see link to previous board questions here

Q7: Given that OCCG has reiterated its intention during its decision-making process to put patient safety factors and clinical best practice ahead of consultation findings (unless they endorse its proposals presumably), how will the Board refute the criticism that their intention has been less about genuine public engagement than compliance with official edicts to consult?

OCCG needs to balance its duty of commissioning safe and effective services with its duty to consult and engage with the public.
Our board paper said: “The public consultation is a very important part of the decision-making process; however it is not a referendum. Its purpose is to seek views from the public, answer questions and allow other suggestions to come forward that may not have been considered. This feedback will be considered alongside other relevant information such as patient-safety factors and clinical best practice; OCCG Board will use this to help them make decisions about the proposed changes.

Q8: Given that the Board has to ‘agree it is assured about the process for the consultation’, how will it respond to the widespread criticism of the process found in the report, including: the split into two phases, revealing a failure to recognise/willingness to overlook clinical interdependencies; the disconnect between the themes of the Big Conversation and the proposals; the low numbers engaged by the Big Conversation; the leading questions of the survey; the lack of options; timing and venues of meetings; the confusing and unhelpful management-speak consultation document; the late uploading of the PCBC appendices; and the absence of risk and impact assessments?

OCCG recognise the public have strong views and have raised their concerns throughout the consultation as might be expected. However the Board of OCCG is assured that the consultation gave many opportunities and ways for the public to respond. The Board felt that the consultation was far reaching in Oxfordshire and across the northern borders. More than 10,000 individual responses were received by OCCG:
 646 surveys were completed, 509 online and 137 self-completion;
 1,407 people attended the 15 public meetings held;
 9,248 letters from the public were received;
 43 submissions from stakeholders;
 Other engagement activity took place including outreach to seldom heard individuals and communities

The Board has received the consultation report and interrogated it thoroughly in private and in public. They have heard the views and strength of feeling from the public. Given this, a number of areas will be explored further before final recommendations will be brought in August.

Q9: In noting the findings of the consultation report, will the Board not find it hard to avoid being deeply concerned about the extent and range of concerns expressed by the public and other key stakeholders about OCCG’s proposals?

As above in Q8.

 

CCG refused to answer KONP questions at its June meeting

The Clinical Commissioning Group had promised that, at its Board Meeting on 20 June, which would receive the Report of the consultation results on the NHS transformation plan for Oxfordshire, it would answer questions about the consultation. This is what it put on its website:

‘Members of the public can submit questions to the Board by 9.30am on 19 June. Board members will do their best to answer these questions during the meeting.’

What happened? KONP had submitted questions before the deadline. The Board ended early with no mention of any questions from KONP or from anyone else. The questions were too embarrassing for them. KONP had earlier sent questions to the OCCG’s May meeting. Shortly after the June meeting,  answers to these questions were posted online.

You can view the questions and answers here.

General Election Hustings about the NHS

IS THE NHS THE BIGGEST ISSUE

IN THIS ELECTION ?

Come and hold local Parliamentary candidates to account!

Your chance to question their intentions on:

  • Accident & Emergency closures
  • Health and Social Care
  • Mental Health
  • Maternity Services
  • Staff Shortages and waiting times
  • The Sustainability and Transformation Plans” which mean cuts in funding and services of £30billion
  • Fragmentation and privatisation
  • NHS reinstatement Bill

And any other concerns

General election hustings about the National Health Service

7.30pm – 9.30 pm in Oxford Town Hall, St Aldate’s, Thursday 25th May

We are inviting the Conservative, Green, Labour and Liberal Democrat parties to nominate one representative each and the Independent – vote for the Horton candidate from Banbury, Roseanne Edwards, to make short presentations and answer questions from the floor about the NHS locally and nationally.

Oxon KONP chair, Dr Ken Williamson, a retired GP, will facilitate/chair the meeting. Organisations and individuals may submit questions to him in advance at knbw@mac.com or on the day. Further questions from members of the public will be taken on the day, time permitting.

https://keepournhspublicoxfordshire.org.uk/

Joan Stewart, Oxfordshire KONP, Speaks to Health Overview and Scrutiny Committee about CCG Response to HOSC Concerns, 6 April 2017

Address to HOSC 6 April 2017 – on item 10

Phase 1 consultation: Oxfordshire Clinical Commissioning Group’s (OCCG) response to the Health Overview and Scrutiny Committee (HOSC’s) concerns

  • Thank you Chair. Your report (item 10) includes OCCG’s response to the serious and justifiable concerns the committee has about the lack of clarity, detail and vison in the phase 1 proposals. OCCG’s failure to clear up the ambiguities and to clearly make the case for change has led to confusion, uncertainty and even greater suspicion about the erosion of services, especially in the north of the county.
  • OCCG’s response, disappointingly, again falls short of expectations – evidenced by the evasive, derelict and high-handed way OCCG have dealt with your challenge.
  • You would have thought that OCCG would have used their formal response to allay genuine fears. But their case for splitting the consultation in the way they did, is flawed. Their arguments for the proposals are weak and don’t hold up to scrutiny, even after a second attempt to convince you and us that they have dealt with our concerns.
  • They have hoped to silence you by implicating you in the decision to split the consultation, saying you agreed with them, despite the lack of critical detail available to you and the public – then and now;
  • They have ignored your genuine concerns about the knock-on effects of phase 1 decisions on phase 2 – with their obvious interdependencies, especially in the north of the county – and with 146 acute bed losses all too real but with proposals for the shift to the community unavailable until phase 2;
  • Their response to your concern about how inequalities will be tackled was one of the feeblest in their whole letter: in essence – wait and see!

The list goes on:

  • They have attempted to shift responsibility to OUHT for access and car park issues, and have ducked accountability for the elephant in the room – investment in the Horton – which they’ve dumped on OUHT too (the buck doesn’t appear to stop with them!);
  • They have sidestepped the whole question of whether the proposals are workable and sustainable, given the available financial resources and limited workforce capacity. And so on and so on…[more detail can be found in the paper we circulated to members]
  • Of course, you can draw your own conclusion about OCCG’s intentions in responding to you in the way they have, and why they would want another meeting. But if once again you are left with more doubts about these proposals than reassurance, then OCCG has clearly failed to make their case, and your way forward is clear: REFER to Secretary of State for Health!

Joan Stewart, Oxfordshire Keep Our NHS Public, 6 April 2017

Oxfordshire KONP Responds to Commissioning Group’s Consultation

Response to the Oxfordshire Clinical Commissioning Group’s ‘Big Consultation’ on Phase 1 of the Oxfordshire Transformation Programme
From Oxfordshire Keep Our NHS Public

Introduction

This split consultation, itself only one third of the BOB STP, is flawed from the outset.

The current consultation (Phase 1) is based on a ‘Pre-consultation Business Case’ which we discuss below and find unconvincing. We expose its assumptions, lack of clarity, lack of sound evidence, and absence of financial detail. Although it is entirely based on an interdependency of Health and Social Care, it does not include any evidence or future planning for Social Care, in the contents of either Phase 1 or Phase 2.

The glossy ‘Big Health and Care Consultation’ and the Business Case fails to pass the test of public accessibility through the use of plain language and simple evidence-based argument.. Terms such as ‘ambulatory care’, ‘emergency multidisciplinary unit, or ‘acute hospital at home’ are not adequately explained in the consultation in our view, and nor is the difference between urgent and emergency treatment. These choices are hard in the consultation, but would be even more difficult for a family to grapple with in the heat of an emergency situation.

There is a telling phrase at 12.2 p. 217 in the Business Case: the consultation is to ‘create understanding of the need for change and the case for developing new models of care’.

In other words – nothing more than a charm offensive.

The basis of our response: Examination of the Pre-consultation Business Case

We think that this Phase I document can only be properly understood and debated in the context of the ‘whole system’ STP footprint plan. We observe that it is one sixth of the plan for the full BOB footprint. We also note that though it is headed ‘Health and Care’, it does not contain the Care element, despite the proposals’ high dependency on the success of the Care element.

The Consultation Document is based on a 235-page ‘Pre-Consultation Business Case’ agreed by NHS England prior to the launch of the consultation itself on January 16th 20171. We have therefore responded to that document which underlies the widely available document the public have been sent, the ‘Big Health and Care Consultation: Phase 1’.2 All page numbers in this text refer to the Business Case document unless otherwise stated.

We note that the business case had to satisfy four tests before NHS England would accept it, and that the final draft and addenda had been to and from NHSE more than once. The four tests are:

Test One: Strong public and patient engagement

Test Two: Consistency with current and prospective need for patient choice

Test Three: A clear clinical evidence base; and

Test Four: Support for proposals from clinical commissioners.

We are not convinced that the OTP passes any of these.

We also note that the appendices are not in the online document. We have responded to this as the most complete description of the OTP available to us.

A phased approach falls at the first hurdle

Your chart on pp. 30-2 of the Business Case shows that a phased approach is not feasible. It shows the interdependency of every part of the patient’s care and treatment , including self-care and social care, primary care and hospital care.

We agree that the patient needs to be at the centre of a whole picture including self care, decent housing and nutrition, social and primary care in the community, and appropriate access to the right level of specialist intervention.

Therefore, to agree to proposals of one element of this picture without knowing the rest of the picture is ludicrous – like agreeing to the roof of a building without knowing anything about the walls (or indeed if there was to be any money for walls)

Weaknesses in the argument for the need to change

The detailed discussion about the need to change the services at the Horton (stroke, maternity, diagnostics, elective work) is predicated on:

  1. Travel time evidence. The source of most of the adduced evidence is the Oxford university Hospitals Trust and the Clinical Commissioning group (CCG) (pp. 92-3, 134-7). We would have expected evidence that had been tested to destruction before the public could trust it. The ambulance service, the volunteer drivers who take villagers to hospital, or the Automobile Association might have been better places to begin if the purpose was to convince the public of the accuracy of the 40-minute ‘blue light’ travel time . (p. 93)

  2. The desirability of separating elective from trauma work. This is taken as a given in the proposals for rebranding the Horton as a diagnostic and elective care centre. There is no discussion by clinicians about the effectiveness or desirability of this separation for best practice. Yet specialists in the early days of Independent Sector Treatment Centre work argued coherently for the importance of i) giving surgeons a mix of every day and emergency work for better patient outcomes and ii) keeping them together so any quick escalation of treatment which might emerge could be done in the same setting – elective surgery which turns into an emergency, for instance. (pp. 76-90)

  3. Declining need for services in the Horton. Yet much of the evidence for stroke, heart, and maternity change comes from the fact that the OUHT has already been diverting patients by ambulance to Oxford over the past months, as is noted in the document. (pp. 57-8)

  4. The lack of any negative impact on the John Radcliffe and Churchill hospital facilities. In fact, the document suggests dropping the number of available beds by 194 through the closure of the Horton and other facilities. With bed occupancy climbing again, when the existing measures for ‘safety’ suggest hospital bed occupancy should be no more than 85%3, we would assert that all the evidence points to growing waiting times, deaths, and disasters in trauma care if these proposals are implemented.

Lack of adequate clinical evidence

  • Over the different sections, the interdependency of services is identified as a key issue; it is said that hospital beds cannot be closed without adequate care in the community. Simon Stevens himself has called for three tests to be met – “Demonstrate sufficient alternative provision, such as increased GP or community services, is being put in place alongside or ahead of bed closures, and that the new workforce will be there to deliver”, and/or

Show that specific new treatments or therapies, such as new anti-coagulation drugs used to treat strokes, will reduce specific categories of admissions” and/or “Where a hospital has been using beds less efficiently than the national average, that it has a credible plan to improve performance without affecting patient care (for example in line with the Getting it Right First Time programme before accepting any more bed closures)4;

Yet there are 800 vacancies in domiciliary care with no concrete plans as to how these will be filled. (p.157) Since Phase 1 appeared, several more care agencies in Oxfordshire have folded – to the point where even councilors are beginning to call for bringing the service back in house.5

  • The chart at fig. 9.2 on p.158 should be full of information on community posts but much of the community post information is ‘not available’ (N/A).

  • There is an arguably highly speculative chart of levers to encourage displaced staff to change their jobs at fig. 9.4 p.160 and, although staff housing is identified as a problem (pp. 53-4), no concrete solution is offered.

  • Some of the evidence is extremely thin.  In fig. 10.4 p.176, where did the need for less than 800 beds come from? In the whole OUH?

  • Figure 1.1, p.10 shows Social Care is a key component but Social Care is not included in the documents.

  • The growing contribution expected from carers in this ‘pared to the bone’ service is not mentioned. 

Problems of geography

Where does the calculation come from which claims that it is safe to have 30,000-50,000 population per GP practice? It cannot possibly have included problems of a scattered rural population. Looking at the map of Oxfordshire, and hearing stories of rural isolation, would lead one to conclude that primary care facilities in the county are already inadequate..

Over reliance on self help

There are many assumptions about the population improving its own health with timely support from community staff. Nothing about the increased numbers of staff necessary to make this work, and the costs and supervision needed.

Staff recruitment and retention key problems

There are suggestions for new levels of staff in primary care – physicians assistants, nurse practitioners. However, the evidence is that these can increase costs and reduce timely accessibility – also that there are additional costs attached to recruitment, training, housing, and developing new systems. In fact, a report published on 1st of March 2017 by the Nuffield Trust, (Shifting the Balance of Care) points to the mixed evidence for overall cost reduction where the following services are used :Intermediate care: rapid response services Intermediate care: bed-based services Hospital at Home – and yet all of these are in the CCGs overall plan to cut costs ) (p14 of the report) 6

A 2016 study published by the BMJ and mentioned by HSJ shows that diluting the nursing skill mix increases the risk of patient death. The study found that for every 25 patients, substituting one registered nurse with a non-nurse increased the possibility of the patient dying by 21 per cent on an average ward. The research was published in the BMJ Quality and Safety Journal. 7

The impact of imminent changes to the historical doctor-patient relationship which is at the heart of the NHS

The impact on all parts of the NHS system, including those in Phase 1 of the consultation, of the imminent and inevitable changes to primary care, brought on by the extraordinary blindness of the government to the need for workforce planning and training in this area which is likely to lead to

total loss of the historical doctor-patient relationship, the corner stone of the whole NHS: it looks set to lead to ‘GP Federations’ (no evidence for this working), as well as ensuring that the only front door left to the unsuspecting public will be through ‘physicians assistants’ and the revamped ‘111’ service.

Other issues

The proposals seem unimaginative.  No thought seems to have been given to sharing estate with schools, or bold housing solutions.

The suggestion that volunteers and pharmacists could play a crucial part in implementing the proposals (fig.1.4, p.12) would only work if the CCG could provide funds for support. Support has recently been withdrawn from a number of pharmacists, so evidence suggests that many will struggle to survive in the next few years.  

In view of the cuts to public transport and the withdrawal of subsidies to bus services, and the as yet unknown distribution of car ownership (unknown but strongly suspected to be patchy, disproportionately hitting the poor, the elderly, and the isolated) the access to specialist care under these proposal seem unlikely to be adequate

Where is the evidence that the proposed technologies will work (no evaluation given p.14)? Yet they are presented as a crucial part of the success of the proposals.

Funding is inadequate for these proposals

It is acknowledged that some of the problems identified with the current system are about inadequate equipment and unsuitable buildings. Much of the argument about proposals for the Horton is based on this. Yet the documents are reticent about how the necessary changes would be funded.

One concrete figure produced on pp. 162-5 concerns changes to the Horton Hospital. The figure of £14.5million is produced with no indication of where this money will come from. On p. 196 the CCG says it will put £3.5 million aside: hardly enough to cover the costs of these changes. 

On February 21st this year, the House of Commons Committee of Public Accounts published their damning report on ‘the financial sustainability of the NHS’ which has thrown even more doubt on the possibility of any of the 44 footprints developing a viable transformation plan at this time . The report shows that capital budgets earmarked for long-term capital funding have already been raided, severely compromising any major capital changes such as that envisaged for the Horton.

The report goes on to develop the point that all the changes are predicated on well-funded social care and it challenges the government as follows: ‘The Department and NHS England should assess the impact that financial pressure in social care is having on the NHS, so that it can better understand the nature of the problem and how it can be managed. It should publish the findings of its analysis by July 2017.’

We offer the same challenge to the Oxfordshire CCG. The CCG should assess the impact of financial pressures on Social Care in Oxfordshire. Meanwhile, the Phase 1 consultation should be halted until such time as an assessment has been carried out and published and the holes in the programme referred to above have been filled in.

Phase 1 of the Oxfordshire Transformation Programme fails on all four counts demanded by NHS England and will deliver only cuts and confusion for the people of Oxfordshire. We deserve better.

Dr Ken Williamson

Chair, Oxfordshire Keep Our NHS Public

12 March 2017

1See the arguments behind the CCG Phase1 proposals at http://www.oxonhealthcaretransformation.nhs.uk
3Dr Foster, the healthcare intelligence firm formerly part-owned by the government, has said that when occupancy rates rise above 85% “it can start to affect the quality of care provided to patients and the orderly running of the hospital”. A 1999 paper published in the BMJ argued that any occupancy rate over 85% risked bed shortages and periodic bed crises. (Guardian, 27 March 2015)
5 tbc Oxfordshire County Council meeting March 21 2017
6 nuffieldtrust.org.uk ‘Shifting the balance of care: Great expectations.’
7 HSJ 16 Nov 2016 The research mentioned was first was published in the BMJ Quality and Safety Journal.

Halt the Consultation on NHS Cuts

 

Oxfordshire Keep Our NHS Public, Press Release, 7 February

Oxfordshire Keep Our NHS Public demands that the current phase 1 Consultation on the Oxfordshire Transformation Plan, part of the first two years of the Buckinghamshire, Oxfordshire and West Berkshire Sustainablity and Transformation Plan, is halted.

The Oxfordshire Clinical Commissioning Group’s (CCG) decision to effectively permanently downgrade the Horton maternity unit has been referred to the secretary of state by the Oxfordshire Joint Health Overview and Scrutiny Committee (HOSC).

The consultation has become meaningless as the public does not know what it is being consulted on. The secretary of state may still decide that the Horton maternity unit should retain full obstetric cover. This would have a fundamental affect on the whole Transformation Plan including the Oxford hospitals.

There is considerable opposition to a two-phase consultation because it artificially separates interdependent parts of health and social care.

A new single-phase open consultation should start after a new plan emerges when the Horton situation has been resolved.

Oxfordshire Keep Our NHS Public is seeking legal advice to clarify the effect that the HOSC decision may have on the Transformation Plan – a plan developed by the CCG, Oxford University Hospitals Trust, Oxford Health Trust, and clinical and scientific opinion to conform with NHS England’s requirement that a further £22 billion is cut from the already overstretched NHS budget by the imposition of the STPs.

Contacts: Dr Ken Williamson, chair of Oxfordshire Keep Our NHS Public, Mobile: 07831 570936

Mark Ladbrooke, secretary 07501 071 526

Bill MacKeith, press officer 01865 558145

keepournhspublicoxfordshire.org.uk;   https://www.facebook.com/konpoxon;   @keepNHS_oxon