Letter sent today to CCG Board Members in advance of their meeting tomorrow, Wednesday, August 10 at 11:00 in Shirehall, Shrewsbury
Dear Governing Body Member
Apologies for an unsolicited email. I am contacting GP members of the Governing Body, and members with a responsibility for public engagement (including David Evans as Accountable Officer). I am also copying in Jane Randall-Smith from Healthwatch, and local MP Philip Dunne who now has Ministerial responsibility for NHS finance. I will also be forwarding this email to Gerald Dakin, Chair of the Health and Adult Social Care Scrutiny Committee, with some additional comments on the possible impact of these cuts on Shropshire Council.
I am concerned about the implications of agenda item 8.4 on CCG decommissioning and disinvestment plans. The impact of these cuts on some very vulnerable people will obviously be detrimental to them, as I’m sure you are aware. The patients most affected are people with mental health problems, frail elderly people, and people with complex disabilities (adults and children).
Could I flag up a few areas that I am particularly worried about?
- I know that communication with providers of affected services has been minimal or non-existent. I have personally been in touch with two service providers who were completely unaware that the CCG was considering disinvestment. I also know that the manager of one service regards your summary report as extremely inaccurate. My own clinical background leads me to believe that another summary report is misleading. Is it safe to disinvest from services on this basis, without a full understanding of what services do, and what the impact of ending them might be? This is crisis management – but not an approach that is in the interests of Shropshire’s NHS users.
- The decommissioning of ICS will have a huge impact on the Community Trust. I’m not in a position to quantify this, but this is a flagship service in which they have invested heavily. The sudden loss of this service (and its income) is really quite likely to destabilise the Community Trust, and therefore jeopardise the provision of a very wide range of community services. I was in a meeting two weeks ago where a Community Trust Non-Executive Director commented that any further cuts could cause the Community Trust to ‘fall over’. You may have noticed the letter from Michael Sommers, former Vice Chair of the Community Trust, appended to the minutes of your 29th June meeting (Appendix C). The letter is worth reading. Mr Sommers is sharply critical of Future Fit modelling and assumptions, but of relevance here, he comments on the Community Trust’s financial position. He says the only way ShropCom was able to break even last year was by taking £900,000 of proposed capital expenditure and putting it through as revenue, and describes the Community Trust as ‘effectively bust’.
Are you confident that the Community Trust can withstand the cuts you are proposing tomorrow? Surely cuts that will impact significantly on the Community Trust should be a matter for the STP, and an integrated approach, not bounced through because of the pressure on the CCG to reach its control total? The approach cannot be in the long term interests of the health economy as a whole.
- Mental health services feature quite prominently in your list of services from which you will disinvest. I’m thinking here of Enable, the specialist employment service; Path House, the crisis centre in Ludlow; and GP counselling services. Commissioning of mental health employment support services is in line with NICE guidance, and Enable is a well-regarded ‘best practice’ service. It is obviously a national priority for the NHS to achieve parity of esteem for mental health and physical health. Are you confident that the emphasis on cuts to mental health provision satisfies that requirement?
- Carol McInnes, who wrote this paper, seems to have a very poor understanding of equalities legislation (and the principles behind this). Her comment on the proposed disinvestment from The Movement Centre, the centre of excellence for children with cerebral palsy, is ‘There is evidence to support the fact that The Movement Centre delivers a high standard of treatment however it is high cost and benefits a small number of patients, so arguably does not deliver value for money’. Her comment on the proposed disinvestment in Oak House, offering specialist health assessment and intervention for adults with complex disabilities and sensory impairments, is similar. Here, she argues ‘The service is accessed by a small cohort of the population therefore it will not address inequalities’.
This is genuinely not good enough. NHS England notes ‘The laws mean that all NHS organisations will be required to make sure health and social care services are fair and meet the needs of everyone, whatever their background or circumstances’ (my emphasis). Equality in healthcare provision cannot be about treating everyone just the same. It has to include the concept of need, and a recognition that the needs of a child with cerebral palsy are different to those of a child with a sprained ankle; a recognition that the needs of an adult with profound and multiple learning disabilities are necessarily different to those of a healthy adult. The CCG could potentially find itself open to legal challenge if it were to interpret the Equality Act on the basis of ‘There aren’t many of them, so their needs can be disregarded’.
- I am aware from Agenda Item 7.1 of the CC’s escalating deficit, and that you are now implementing additional savings of £3.6m as well as your planned QIPP savings of £12.6m. From the paper before you, the cause of the deficit is primarily ‘over-performance’ at SaTH, and to a lesser extent at Robert Jones and Agnes Hunt. The CCG is spending more money than it planned to on acute services. The emphasis within Future Fit is on keeping people out of acute services by offering community-based alternatives. Consider what you are planning to cut tomorrow, though. Proposed cuts to ICS could lead to even more problems with delayed transfers of care. You are cutting rehab beds in the Much Wenlock area, created to offer care close to home for patients post-hospital discharge and for admission avoidance. You are cutting CHAS, the service that offers targeted pro-active management of the health needs of the care home residents most at risk of hospital admission. You are closing the Home from Hospital service, that supports the safe discharge of patients (primarily frail elderly people) from hospital. You are likely to disinvest in the Moving and Handling Service, leaving less support for people with dementia and older people with mobility loss (and less support for their carers). This will leave people more vulnerable to injury, a decline in their health, and hospital admission. Reduced services for disabled children, profoundly disabled adults, and people with mental health problems will be immensely likely to create additional expenditure for health and social care services, quite apart from the distress caused to those individuals and their families.
This is firefighting – but doing so in a way that actively undermines the strategic objectives of the CCG. Is this what you should be doing? The alternative is to go back to NHS England/NHS Improvement and argue a case for the control total being wrong. Your constitution places a specific responsibility on Governing Body members to ‘Ensure quality of care is always prioritised’. Are you confident that approval of paper 8.4 is consistent with this requirement?
Chair, Shropshire, Telford and Wrekin Defend Our NHS