My response to the public consultation on proposed future arrangements for hospital and community health services in Huddersfield.
The announcement by Clinical Commissioning Groups of Calderdale and Greater Huddersfield of plans to reconfigure hospital and community health will significantly impact and reduce services currently available in Huddersfield and will change how my constituents access services in the future. The plans essentially amount to the closure of the Huddersfield Royal Infirmary (HRI).
Ensuring the people of Huddersfield and neighbouring towns receive the highest quality of health, social and community-based care now and in the future is my primary concern. I recognise that all stakeholders across our community share this objective, even if views differ on the means of achieving it.
The current proposal tabled by the Clinical Commissioning Groups provide one way forward that they believe will ensure health and community health services remain sustainable and provide high quality care. It is in the best interests of my constituents that I give these proposals fair consideration and make an informed and rational assessment based on the evidence available. To inform my response I have taken counsel from current and former health professionals working in the NHS and I have listened to the informed opinions of patients, patient groups and other stakeholders in my constituency.
It is my current opinion that while the proposed reconfiguration might help address some of the underlying challenges facing the NHS locally, such as staffing levels and the dire financial situation of the Foundation Trust, many questions remain unanswered about the broader impact it will have on patients, carers and the public generally. Little evidence has been provided to reassure me that services (such as the Emergency Centre, Urgent Care Centres, Community Pharmacy, NHS111, Care Closer to Home and care homes) intended to replace the capacity and range of those lost at HRI will be sufficient to meet current and future needs of my constituents and those of neighbouring constituencies. In fact without a full impact analysis and assessment of the investment required in these other services it is impossible to ascertain whether the reconfiguration will deliver value without eroding overall provision or simply create pressures elsewhere in public services.
Like many of my constituents I have deep concerns about the ability to access acute care services located at Calderdale Royal Hospital (CRH) quickly and efficiently. I am particularly troubled for constituents living in outlying rural areas or those dependent on public transport and it is unacceptable that this reconfiguration is being considered without fully assessing their needs and requirements. There remain unanswered questions about the capacity of an already severely congested road network between Huddersfield and Halifax to cope with significantly increased traffic. I would also like to understand the projected impact this would have on the ambulance service which I expect would face significantly increased demand.
It appears to me that the financial challenge facing the Calderdale and Huddersfield NHS Foundation Trust, as a consequence of the CRH private finance initiative, has unduly influenced the decision to close HRI in favour of CRH and is not based on an impartial assessment of what is best for the local population. In fact I have listened carefully to the concerns of well-informed stakeholders who have raised questions whether CRH is fit for purpose and as such whether the estimated required investment is sufficient. One senior healthcare professional informed me that the site “simply wasn’t big enough” and that “heroic assumptions” have been made about patient numbers and the ability of other services (GPs, pharmacies etc.) to provide services where the hospital no longer can. I have a major concern about the long term investment and commitment from the CCG in building and maintaining a Planned Care Hospital in Huddersfield. It is fanciful to believe that due to its size and dependence on CRH that it would not fall victim to a future ‘efficiency’ drive, as another senior healthcare professional warned me.
On this basis, I would urge the CCGs to delay any decision on the future arrangements for hospital and community health services until a full and independent assessment of the proposals and their impact has been undertaken.
I also believe that a pause in this consultation would provide an opportunity for a full review of current and future health, community and social care needs of the local population. This is essential to provide a clear context and defined role for all services – including the future of emergency and acute care – and where available investment should be targeted. I do share a belief with the CCGs that primary care services supporting people to live healthier lives for longer at home and in their community is preferable to acute intervention and hospitalisation. However, without a coherent and costed strategic plan that weaves together the interests of health and social care providers, reflects the needs and requirements of patients, carers and communities and secures the commitment of all stakeholders, it is difficult to imagine our reliance on secondary care diminishing over the coming years. This is a once in a generation opportunity to develop a truly integrated health, community and social care strategy that will provide for our community now and in the future.
I have set out below a number of concerns about the current proposal. This is not an exhaustive assessment but in my opinion provides sufficient justification to delay any decision on reconfiguration pending further investigation.
Accessibility for emergency and acute care services
Delivering high quality care and meeting exacting national standards in areas such as mortality and children and young people in emergency care settings is not in question, neither is the need to attract and retain qualified and experienced staff. However I am concerned that insufficient work has been done to understand how access would be impacted by this reconfiguration and what investment would be required to improve local infrastructure.
- Increased distance and travel times for people seeking emergency and acute care at CRH. This should not be a secondary consideration as it appears to be in the consultation (page 39). I dislike the lack of certainty and commitment to prioritise this issue and using language such as ‘we need to think’, ‘we will be thinking’ or ‘we will be talking’ is simply not good enough when considering these proposed changes and their ramifications to patients. Setting up a Travel Group to ‘explore what more we could do’ needs to be given independence and authority or it risks becoming a token gesture. I would like to understand more about how the Journey Time Assessment Study arrived at an estimated 15 to 20 minute extended journey time. On reading the study methodology it is unclear to me whether a projected increase in traffic volume has informed this estimated extended journey time, or whether the figures are based solely on current traffic data. If there is an assessment on increased traffic volume (both related to this hospital reconfiguration and other housing and commercial developments occurring en-route) which I suspect would be significant I would welcome publication of the data and also a view on required infrastructure investment and public health and environmental impact. I have a deep concern regarding how these changes would impact the elderly, socially disadvantaged and those living in rural locations in my constituency and while these groups have been recognised by the CCG as facing particular challenges there is no identifiable plan for supporting them. The roads approaching CRH are already very congested and I have been informed by staff at the hospital that it can take ten minutes just to get out of the car park. Such concerns about accessibility are barely mentioned in the 2014 Journey Time assessment. How much worse will these problems be after reconfiguration? There are currently bottlenecks at the bottom of Salterhebble and at Ainley Top, and there appears to be very little potential for road improvements and modifications to increase access.
- The impact on the ambulance service is not clear. In particular how projected increased demand would be managed, the effect on emergency response times, and the capital and operational investment required to maintain national service standards. I presume extended travel times for ambulances to and from CRH, together with an increased public demand on ambulances because of the extended travel time, will reduce availability of ambulances and could negatively impact on their response times to emergencies. I would welcome a full impact assessment by the Yorkshire Ambulance Service as a matter of priority and also a projection of capital and operational investment required to meet increased demand.
- The capacity of CRH to support increased emergency, outpatient and visitor demand. It is essential that a full independent assessment is made of the required capital expenditure and planning requirements that would be needed for expanding acute care services at CRH, or alternatively what it would cost to expand these services at HRI. One justification for the reconfiguration is recruitment, retention and training of NHS staff, however I have seen no independent assessment on how current staff views these plans. They, like their patients, will face increased journey times and an impact on their quality of life and morale. There are many unknowns on how successful the CCG plans will be on reducing demand on the Emergency Centre at CRH, in my experience much talk and investment has been made to encourage the public use of other services but demand on A&E continues to rise. NHS111 is referenced as a means to triage or sign-post the public away from the Emergency Centre however NHS111 continues to face serious criticism over its performance which questions its reliability as a key partner in this reconfiguration.
- The CCGs’ proposals would mean that the whole of Kirklees, a metropolitan area with a population of over 420,000, would be without a single A&E and Huddersfield would be one of the largest towns or cities in the country without an A&E. Furthermore, as one senior consultant commented, one can imagine that years down the line the new Acre Mills site will be closed in a further centralisation drive leaving the Town with no hospital care whatsoever. This would severely compromise Huddersfield’s position as a strategic town in Yorkshire as it would make it a less desirable place to live. The knock on effects to local businesses and major employers such as the university could be catastrophic.
Primary and community care
I am in no doubt that primary and community care should provide the bedrock for future healthcare needs in my constituency. Keeping people healthier for longer, living independently and remaining active is better for them and is a more efficient use of finite resources. However I am concerned that while the consultation document makes reference to these services, there are few concrete plans or evidence to show that they are delivering a fundamental change in how health and community care is organised and or how the public is engaged.
- General Practice is identified as an alternative to A&E and yet I hear constantly about the challenges they themselves are under due to increase demand. I would like to understand more fully how the CCG plans to alleviate this pressure, for example there is reference in the consultation to GP hubs but no further consideration of what this means. Without credible plans I am not assured that general practice can play its part in reducing demand on A&E while managing its own capacity challenges and leading the way in the development of an integrated primary care service.
- Community Pharmacy is referenced as an alternative provider of healthcare services and support in the community. I wholeheartedly agree with this assessment and believe that pharmacy is an underused resource that provides accessible and convenient services in the heart of many of our communities. However current government plans to cut pharmacy funding by £170 million a year could result in upwards of 3,000 pharmacies closing across England. Undoubtedly many of these will be independent pharmacies in small or disadvantaged areas that provide the kind of support required as part of this reconfiguration. Senior representatives from community pharmacies in West Yorkshire have expressed deep concerns to me about the CCGs’ plans, ranging from the lack of details in the plans to the persistent underinvestment by CCGs into community pharmacy based services, but most significantly they are concerned about “the future ability of the pharmacy network to take on the additional workload without parallel investment”. I would welcome further details from the CCG on how it sees community pharmacy evolving as part of a broad primary service and how it can help alleviate the burden on general practice and A&E
- Care Close to Home is a valuable initiative that hopefully will demonstrate its value in providing care services in our community and avoid the need for hospitalisation. However, as the programme has only been running for six months there is insufficient qualitative and quantitative data to successfully demonstrate it can deliver over a sustained period and successfully scale its services to meet the increased demand. While patient testimonies are encouraging to read, I would welcome further information from the CCG on the performance of Care Close to Home and the required capital and operational investment to ensure sufficient capacity can be built to meet current and future needs.
- The proposals also rely on the future ability of NHS 111 to deliver healthcare advice and support to people who would otherwise attend a hospital. As one senior consultant told me this service has “been found wanting”. It is a relatively new service and there is a paucity of data on how effective it has been, particularly with regard to reducing the strain on other services, and in the absence of such evidence it is reckless of the CCG to use it as a reason for reducing hospital services.
- In Greater Manchester NHS England has agreed to provide a £450m “transformation fund” to cope with the changing health needs of the local population and reduce pressure on hospitals. In the absence of such a fund being identified for Huddersfield and Calderdale, I do not see how the CCG’s assumption that healthcare services will be provided elsewhere add up clinically or financially. The ‘pre-consultation business case’ produced by the CCG estimates that the having CRH as the site for unplanned care will save a significant amount of money each year compared to doing nothing or using HRI as the unplanned site, but do these figures account for the additional costs incurred by other health service providers who will inevitably have to pick up the slack as hospital services are reduced? If this additional cost is greater than the supposed saving of using CRH as the unplanned site, then the CCG is simply shifting the costs elsewhere in a way that is inefficient for the overall local health economy. The CCG must address this point and provide a detailed explanation of what extra resources will be available to other healthcare providers to reduce the burden on hospitals.
Capacity planning and long term sustainability
It is claimed that these proposed changes would “secure the future of health services in both areas for the next 20 years” and that the CCGs can progress “the future shape of hospital services ensuring these are high quality, safe, sustainable and affordable and result in the best possible outcome and experience for patients.” Based on the evidence I have seen I am not convinced that these plans offer a sustainable and affordable future vision of care or one that offers the best outcome and experience for patients.
- I am unclear in reading the consultation how the CCGs have arrived at the need for 732 hospital beds with 612 beds at CRH (with the potential to increase it to 700) and 120 at the new proposed hospital in Huddersfield. Despite recognition of an increasing demand on services due to an ageing population 732 beds is 69 less than the 811 we currently have spread across HRI and CRH. The strong consensus among the clinical experts I spoke to was that the estimates for bed numbers was too low. Even now the two hospitals struggle with bed numbers but after reconfiguration and with an increasingly elderly population, demand is very likely to increase. As I have already stated, I am concerned that without a robust and fully costed plan on how primary and community health care will stem the flow of patients into hospital or aid early discharge, then demand on acute care beds could outstrip supply. I would welcome the publication of the CCGs modelling (referenced on page 28) that has informed their assessment.
- I have been informed by senior healthcare managers at the highest level that the CRH site is “simply not big enough” to absorb all the services currently provided at HRI without making “heroic assumptions” about the ability of other services (such as GPs, pharmacies etc.) to deliver additional care. One senior consultant warned me that the CCGs’ entire plan “is predicated on the need to keep the PFI building [CRH] full”, but that this “cuts across all the plans the Trust has made over the last 10 years”. “The CRH building is not fit for purpose”, this consultant went on, “the wards are cramped and they lack facilities such as clean utility rooms, storage for drug trolleys and areas for patients to sit away from their beds for private conversations … There will not be enough office space if most consultants and teams are based [in CRH]. ” While I agree with the CCG’s view that in the future fewer people should be treated in hospitals, until proven alternative strategies are developed, hospitals must have sufficient capacity to meet the healthcare needs of the local population. Moreover, as the CRH site is “landlocked”, as another senior NHS manager informed told me, there is very little room to increase its capacity. HRI is a massive site to close, and is the one hospital that is actually owned by the Trust, and senior managers have told me that while the building is not as new as CRH and would benefit from some renovation, it is a perfectly serviceable hospital building going forward. It had long been assumed by senior management and senior clinical staff that if services were to be consolidated on a single site, HRI was the pragmatic choice. The CCG must explain how CRH could be expanded if demand rose, and it will not do to say that demand will never rise because of the ability of other services to reduce pressures on hospitals, which itself is a dubious claim as I have outlined.
- The forthcoming downgrading of Dewsbury A & E will put even more pressure on existing hospitals in Huddersfield and Calderdale, yet this receives almost no attention in the consultation document. What extra demands will the diminution of services in Dewsbury place on hospitals in Huddersfield and Calderdale, as well as the other healthcare providers on which the CCGs plans are so heavily reliant?
- I have a major concern about the long term investment and commitment from the CCG in building and maintaining a Planned Care Hospital in Huddersfield. It is fanciful to believe that a Huddersfield hospital as a satellite of the CRH and with a fraction of its capacity would not fall victim to a future ‘efficiency’ drive, the Acre Mills site sold to pay for the development of CRH or traded as part of a deal to secure the required investment from central Government. It is not unimaginable that the people of Huddersfield will be left without any easy access to emergency and acute care services.
- I have deep concerns about the impact the CCGs’ plans will have on other health service providers and about the lack of consideration given to these other providers. While it is clear that the proposals are at least partly motivated by a desire to save money, I fear that the CCGs are simply shifting the cost elsewhere and are counting on other health services to pick up the slack. There is very little detail on what the increased costs will be to GPs, pharmacies, the ambulance service, local authorities and NHS 111, and no assessment of these other services’ ability to meet this additional demand. I therefore feel it is necessary to have a full impact assessment which takes into consideration all health service providers to ensure that this is not just an exercise in shifting costs onto other organisations’ balance sheets.
- Without clarity on the broader investment costs required to support this reconfiguration, such as infrastructure and investment in primary and community care and the ambulance service, I find it difficult to know whether this offers an overall cost effective and sustainable solution or not to the healthcare needs of my constituents. Before any decision is made these unknowns need to be accounted for or hidden costs could undermine the financial robustness of this case. I therefore reiterate my call for the CCG to delay any decision on the future arrangements for hospital and community health services until a full and independent assessment of the proposals and their impact has been undertaken.