Devastating Cuts: Letters

Following the Shropshire CCG’s announcement that they are planning devastating cuts to community and mental health services, Shropshire, Telford & Wrekin Defend Our NHS has written to both the County’s MPs and the Chair of Shropshire’s Health Scrutiny Committee to call for action to prevent them. The letters are below (or click on the links above).

Letter to MPs

Dear [MP Name]

We are writing to ask for your help regarding the planned cuts to NHS provision in Shropshire.

You will know by now of the financial difficulties faced by Shropshire CCG, and its plans to make in-year spending cuts of £3.6m (in addition to the £12.6m QIPP savings already planned). The first tranche of these cost savings was agreed in principle at the CCG Governing Board meeting of 10th August, along with the policy under which the cuts proposals had been developed. The service cuts proposed to date will, if they are all implemented very speedily, realise cost savings of only £690,000. This is less than 20% of the cost savings that are being sought; it is therefore very likely that further substantial cuts lie ahead within the next few months. The cuts proposed so far will be devastating to some of the most vulnerable people in our community.

CCG Accountable Officer David Evans has commented on the 2.6% uplift in CCG finances this year, explaining ‘The difficulty was this would not meet NHS inflation as this always ran above the CPI index and so it could be questioned whether this was real growth’[1]. He has said ‘We are going to be making difficult decisions over the next few years’[2]. His comment a week later was, ‘In the current financial situation, while of course we would prefer to improve the quality of care our patients receive, that’s very difficult to do’[3]. You will of course know that NHS financial settlements over the next three years are set to be a good deal tighter than this year. We trust there is no expectation from you as a local MP that the NHS financial crisis and cuts that we are now seeing in Shropshire will somehow blow over. The CCG’s financial position reflects a funding allocations formula that makes life exceptionally difficult for rural areas and areas with an older population.

The people who will be most affected by the current round of proposed cuts will be people with mental health problems, frail elderly people, and people with disabilities (adults and children). The cuts are to community-based services, and include the closure of many services that reduce hospital admissions or support early discharge from hospital. The cuts were not agreed in partnership with other NHS organisations in Shropshire, and provider organisations (including Shropshire Community Trust) were not advised by the CCG that their services were at risk. Indeed, several organisations learned from Shropshire Defend Our NHS that their services were at high risk of disinvestment or decommissioning. At least five provider organisations and voluntary organisations wrote to the CCG with their concerns once they learned of the threats. Unfortunately the CCG Chair did not share this correspondence with the Board. There are strong concerns too over the CCG’s inability to commit to public consultation on the cuts, and over the unusual interpretation of equalities duties that is being applied.

The strategic direction for the local health economy is meant to be one of transferring hospital care to community settings, investing in the provision of community alternatives to hospital care, and providing care closer to home. Many of the proposed cuts undermine that strategy. These are proposals that will create additional demand on acute services, and particularly on already stretched urgent and emergency care. The reality is that these are crisis-driven cuts.

The planned cuts for this year include axing a voluntary worker who worked on integrating services from health, social care and the voluntary sector; closing a crisis house in Ludlow for people with mental health problems; withdrawing funding from the handful of children with cerebral palsy who have intensive therapy at the Movement Centre in Oswestry (a recognised centre of excellence); closing Enable, a high quality specialist service helping people with mental health problems remain in employment; closing beds in a Much Wenlock care home that have been used to avoid hospital admissions; ending a service that provides proactive care to frail elderly people in care homes who are most at risk of hospital admission; ending a lifestyle physiotherapy service that has run for 8 years, is cost effective and well-used; stopping a Home from Hospital service that provides very practical help and personal care for patients following hospital discharge or requiring support to avoid hospital admission; ending a Moving and Handling service that provides support to the carers of older people with dementia or mobility problems; probably ending most pain management services in Shropshire and hoping that GPs will absorb the work; and ending a specialist service at Oak House that provides health assessment and intervention for adults who have profound intellectual and physical disabilities and sensory impairments.

There are also plans to privatise START, a service that provides a short term period of intensive assessment and support to people who want to remain living in their own home. Several other services associated with the flagship Integrated Community Services (ICS) will end. Counselling services provided at GP surgeries is intended to end.

Likely targets for cuts or privatisation next year include community rehabilitation for people who have had a stroke or who have other neurological conditions; the RAID mental health crisis service; and the Bridgnorth and Oswestry provision of DAART, offering multidisciplinary assessment, diagnostic tests and clinical treatments to keep patients out of hospital where possible, with care provided in the community.

We hope that you will use your influence to ensure that these cuts are subject to proper public consultation, with the impact of the cuts as a whole being considered. This is not currently the CCG’s intention. We also hope that you will consider opposing cuts that will be directly harmful to your constituents.

There is a final issue that we ask you to consider. Shropshire CCG is underfunded by £8.7m in the current financial year[4]. This is the gap between the local ‘target’ allocation and the actual amount of money being given to the CCG by NHS England, a distance from target of 2.3%. NHS England’s view is that this is a small shortfall, and therefore does not need to be made up. However, Shropshire CCG is one of two CCGs placed under intensive intervention by NHS England because of its financial performance, it is under ‘legal directions’ from NHS England, and it is required to make the additional £3.6m cuts this year to adhere to a nationally imposed control total. It is these cuts that are now set to lead to the very damaging disinvestment and decommissioning of local services over the coming few months. Will you lobby NHS England for the early release of the £8.7m that has been withheld from Shropshire in this financial year?

In view of the importance of the issues we raise here, we may publicise this letter and your response in other forums, including the Shropshire Defend Our NHS webpage.

We look forward to your reply.

Regards

Gill George, Chair
Julia Evans, Secretary

[1] Minutes of North Locality meeting of 9th June 2016

[2] CCG Governing Board meeting of 10th August 2016

[3] Primary Care Commissioning Committee of 17th August 2016

[4] CCG Allocations 20016/17
https://www.england.nhs.uk/wp-content/uploads/2016/01/ccg-summary-statements.pdf

Letter to Cllr Dakin, Chair, Shropshire Health and Adult Social Care Scrutiny Committee

Dear Councillor Dakin

You will know by now of the financial difficulties faced by Shropshire CCG, and its plans to make in-year spending cuts of £3.6m (in addition to the £12.6m QIPP savings already planned). The first tranche of these cost savings was agreed in principle at the CCG Governing Board meeting of 10th August, along with the policy under which the cuts proposals had been developed. The service cuts proposed to date will, if they are all implemented very speedily, realise cost savings of only £690,000. This is less than 20% of the cost savings that are being sought; it is therefore very likely that further substantial cuts lie ahead within the next few months. The cuts proposed so far will be devastating to some of the most vulnerable people in our community.

Members of the public have had many concerns over the conduct of Shropshire CCG in its handling of these proposed cuts. Service providers (including Shropshire Community Trust) had not been informed by the CCG that their services were likely to face disinvestment or decommissioning. The providers and voluntary groups who were aware had found out in most cases from Shropshire Defend Our NHS. This alone is a serious breach of the partnership working and joint decision making that should be part and parcel of the CCG’s work. At least five service providers or voluntary organisations had written to the Chair and Accountable Officer of the CCG in advance of the meeting: Enable, the Movement Centre, Age UK, Shropshire Disability Network and Shropshire Cerebral Palsy Society. Unfortunately the Chair’s ruling was that these letters would not be shared with the Board before it took its decisions on progressing cuts to the next stage. We are aware that several provider organisations believe that the reports passed to the Board, and used as the basis for CCG decision making, were inaccurate.

The meeting itself reflected poorly on the CCG. There was no consideration of individual services, or the impact that service cuts might have on some extremely vulnerable people. There was no consideration of the clinical impact of cutting these services. The manager of a GP counselling service who attended the meeting was treated poorly, attacked for using ‘emotive language’ when she sought to advocate for a service that was under threat. Much of the meeting was inaudible to the public. Members of the public raised this repeatedly, but were ignored; three members of the public left the meeting early as they saw no point in remaining in a meeting they could not hear. At the end of the meeting, in a public question session, two members of the public were arbitrarily disallowed from asking questions. GP members of the Board barely spoke in the meeting, with decision making driven by Executive members and the NHS England representative present. It was not possible for members of the public to know who most of these people were or what their roles entail, as there is a new Executive team, the CCG website has not been updated to reflect this, and name plates are not used in meetings. Although Board members were sometimes called by name by the Chair, this did not help as the Chair was largely inaudible.

Overall, this was a model of how a public body should not conduct a meeting. One of us has contacted the CCG to remind them of the importance of the Nolan principles of public life, including accountability, openness and leadership.

The greatest concern, however, has to be over the proposed cuts themselves. If these cuts are implemented, they will probably impact most on people with mental health difficulties (despite the national requirement for parity of esteem between mental and physical health). Another group that will be sharply affected will be the frail elderly people who are most at risk of hospital admission. Cutting community based services for both these populations will almost inevitably create additional demands on acute healthcare provision (particularly urgent and emergency care). The third very vulnerable group to be affected will be people with disabilities, particularly adults and children with complex disabilities. To cut admissions avoidance services to these groups, and to increase pressures on our hospitals, actively undermines the strategic priorities agreed by health organisations and local authorities in Shropshire and Telford and Wrekin. The proposed cuts have not been developed under the auspices of the STP Partnership Board, and have not been agreed on a partnership basis. This is a firefighting crisis management approach by a single organisation.

The cuts include services that are recognised as centres of excellence and provided in line with best practice (e.g. The Movement Centre for children with cerebral palsy, and Enable, a high quality specialist service helping people with mental health problems remain in employment).  The Home from Hospital service supports safe discharge from hospital and avoids unnecessary hospital admission; it is in line with good practice, and is a cost-effective service delivered primarily by volunteers. The planned cuts for this year also include axing a voluntary worker who worked on integrating services from health, social care and the voluntary sector; closing a crisis house in Ludlow for people with mental health problems; closing beds in a Much Wenlock care home that have been used to avoid hospital admissions; ending a service that provides proactive care to the frail elderly people in care homes who are most at risk of hospital admission; ending a lifestyle physiotherapy service that has run for 8 years, is cost effective and well-used; stopping a Home from Hospital service that provides very practical help and personal care for patients following hospital discharge or requiring support to avoid hospital admission; ending a Moving and Handling service that provides support to the carers of older people with dementia or mobility problems; probably ending most pain management services in Shropshire and hoping that GPs will absorb the work; and ending a specialist service at Oak House that provides health assessment and intervention for adults who have profound cognitive and physical disabilities and sensory impairments. Counselling services based in GP surgeries are likely to end.

There are also plans to privatise START, a service that provides a short term period of intensive assessment and support to people who want to remain living in their own home. Several services associated with the flagship Integrated Community Services (ICS) are intended to end. The Sustainability and Transformation Plan for our area makes provision for Shropshire Community Trust to make £6m cost savings per annum and to implement 3.6% ‘efficiency savings’. Adding to these pressures by undermining ICS takes us towards a situation where the viability of the Community trust is threatened.

The CCG shows a very poor awareness of equalities in its proposals, advancing the argument that services for people with severe disabilities can be withdrawn because only a small number of patients depend on those services. Hence the justification for withdrawing funding for specialist treatment for a handful of 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’. Similarly, disinvestment from Oak House, a service offering specialist assessment and intervention for adults with profound disabilities, is supposedly warranted on the basis that ‘The service is accessed by a small cohort of the population therefore it will not address inequalities’. This approach is simply unacceptable. The NHS is required by law to promote equality of opportunity, and to offer a comprehensive service based on clinical need. The needs of a child with cerebral palsy are clearly greater than the needs of a typically developing child; the needs of an adult with profound and multiple disabilities are greater than those of a healthy adult. The CCG has to ensure that these needs are met, and cannot possibly absolve itself from this responsibility by arguing ‘There aren’t very many of them’.

Likely targets for decommissioning or disinvestment next year include community rehabilitation for people who have had a stroke or who have other neurological conditions; the RAID mental health crisis service; and the Bridgnorth and Oswestry provision of DAART, offering multidisciplinary assessment, diagnostic tests and clinical treatments to keep patients out of hospital where possible, with care provided in the community. Again, the strategic priorities of building community capacity, avoiding hospital admissions, and providing care closer to home are actively undermined.

The role of the Health and Adult Social Care Scrutiny Committee becomes a vitally important one in this situation.

Shropshire CCG is seeking to implement these cuts very quickly indeed, with a likelihood that some will be ratified at the CCG Governing Board meeting of 14th September. The CCG has made no commitments around public consultation (nor even the most rudimentary engagement). The interim policy agreed by the CCG Board states:

For any disinvestment proposal where the impact of the change could potentially be considered a substantial variation or development in service, the CCG will initiate informal discussions with the local Health Overview and Scrutiny Committee of the Local Authority via its Chair to establish if the proposed variation is “substantial” to warrant formal consultation. If, it is established that the proposed variation is “substantial” a formal presentation of the issue with a plan for formal consultation will be presented to the respective Health Overview and Scrutiny Committee for consideration and agreement. An appropriate period of consultation will then be undertaken before any decision to disinvest or decommission is made [our emphasis].

Individually, some of the cuts are superficially relatively minor; others are plainly substantial. However, what must be considered is the totality of cuts, the overall impact of cuts taken together on different groups of patients, and of course the overall impact on our community, on partner organisations and on the local strategy for healthcare provision. A service by service approach is plainly inadequate. For this fuller picture to be developed, it really is essential that the CCG publicise its plans for achieving the remainder of its £3.9m service cuts. It is easy to judge one service cut as ‘insubstantial’ when taken in isolation – but as part of a whole raft of cuts affecting frail elderly people, or people with mental health difficulties, or people with physical and learning disabilities, the impact may be very substantial indeed. The loss of community services may have a particularly damaging impact on our rural communities, or on a particular geographical area within Shropshire. Again, it is insufficient to judge whether or not an individual cut is ‘substantial’. What matters is the overall impact of the cuts considered in their totality. The impact on provider organisations and the Local Health Economy as a whole must be considered from the same standpoint.

You will of course know of the ‘key message’ from the Government that local authorities should ensure that regardless of any arrangements adopted for carrying out health scrutiny functions, the functions are discharged in a transparent manner that will boost the confidence of local people in health scrutiny[1]. This is entirely in line with the Nolan principles of public life, including accountability and openness. Informal discussions will not suffice. We therefore urge you as Chair of the Health and Adult Social Care Scrutiny committee to ensure that service cuts are considered in terms of their overall combined impact, not item by item; and that they are considered at a meeting of the full committee, to be held in public.

There are wider considerations. A part of the role of HOSCs is to be consulted by CCGs when substantial service changes are proposed – but this is only a part. You will know that HOSCs have an even more important role. You will be familiar with the most fundamental of the Government’s ‘key messages’ to HOSCs:

The primary aim of health scrutiny is to strengthen the voice of local people, ensuring that their needs and experiences are considered as an integral part of the commissioning and delivery of health services and that those services are effective and safe[2].

This mirrors the statutory duty placed on CCGs to ensure public involvement and consultation in commissioning processes and decisions[3]. This includes involvement of the public, patients and carers in planning of commissioning arrangements, which might include consideration of allocation of resources, needs assessment and service specification.  CCGs are required to make arrangements to involve individuals to whom services are being or may be provided; a requirement therefore to involve the wider community as well as current service users. The circumstances where this involvement must take place include the development and consideration or proposals by the group for changes in the commissioning arrangements where the implementation of the proposals would have an impact on the manner in which the services are delivered to the individuals or the range of health services available to them. The same requirements apply to CCG decisions as to proposals.

This is a separate and additional requirement to the CCG duty to consult with HOSCs over substantial change. It applies if implementation of the proposal would have an impact on the manner in which the services are delivered to users of those services, or the range of health services available to those users. Quite clearly this applies to all the cuts proposals that the CCG has currently decided to progress under its interim policy.

The CCG also has statutory duties[4] to reduce inequalities between patients with respect to their ability to access health services, and reduce inequalities between patients with respect to the   outcomes achieved for them by the provision of health services. This is the context in which cuts to services for older patients and for people with disabilities must be considered. The CCG has additional wider responsibilities around equalities under the Equality Act of 2010.

Is the CCG seeking to duck its responsibilities around public participation and involvement? Are its proposed cuts to services for older people and disabled people consistent with its statutory duties around equalities? Are the proposals from the CCG in line with the overall strategic direction of travel for health and social care? HOSCs of course have the power to review and scrutinise matters relating to the planning, provision and operation of the health service in the area. Government guidance on the regulations highlights that this may well include scrutinising the finances of local health services[5].

We ask you as Chair of the Health and Adult Social Care Scrutiny Committee to ensure that the HOSC is collectively mindful of its wider role in ensuring not just that local people have a powerful voice, but also in ensuring the safety and quality of healthcare going forward. Consultation is an important issue, but not the only one. Our belief is that these cuts are in and of themselves wrong, and will be particularly damaging to people who are not well-placed to articulate their needs.

There is a final issue that we ask you to consider. Shropshire CCG is underfunded by £8.7m in the current financial year[6]. This is the gap between the local ‘target’ allocation and the actual amount of money being given to the CCG by NHS England, a distance from target of 2.3%. NHS England’s view is that this is a small shortfall, and therefore does not need to be made up. However, Shropshire CCG is one of two CCGs placed under intensive intervention by NHS England because of its financial difficulties, it is under ‘legal directions’ from NHS England, and it is required to make the additional £3.6m cuts this year to adhere to a nationally imposed control total. It is these cuts that are set to lead to the very damaging disinvestment and decommissioning of local services over the coming few months. Will you join us in asking Shropshire’s MPs to lobby NHS England for the early release of the £8.7m that has been withheld from Shropshire in this financial year?

In view of the importance of the issues we raise here, we will be copying this letter to members of the Health and Adult Social Care Scrutiny Committee, and to the Leader and Deputy Leader of the Council; also to Councillor Calder as Portfolio Holder for Health and Wellbeing. We may also make this letter and your response public in other forums, including the Shropshire Defend Our NHS webpage.

We look forward to your reply.

Regards

Gill George, Chair
Julia Evans, Secretary

[1] Local Authority Health Scrutiny Guidance to support Local Authorities and their partners to deliver effective health scrutiny. Prepared by the People, Communities and Local Government Division of the Department of Health. June 2014. Page 6

[2] Local Authority Health Scrutiny Guidance Page 1. Op. cit.

[3] Section 14Z2, NHS Act 2006 (as amended)

[4] Section 14T NHS Act 2006 (as amended)

[5] Local Authority Health Scrutiny Guidance 2.1.1 Page 13. Op. cit.

[6] CCG Allocations 20016/17
https://www.england.nhs.uk/wp-content/uploads/2016/01/ccg-summary-statements.pdf

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