Jeremy Hunt insists the NHS should be more open when things go wrong. Laudable - but why does the same openness not apply to decisions to close A&Es and outsource ambulances, being made in the shadows?
Government health ministers Jeremy Hunt and Norman Lamb are splashed over the news with the message that NHS staff have a duty of candour to patients and their families. If a patient’s treatment or care goes wrong, staff must be honest about what’s happened and how this is going to affect the patient, we are told.
This is clearly right. Patients and their families must receive a full, honest, compassionate account from NHS health care staff if anything goes wrong.
Jeremy Hunt should practice what he preaches. It’s equally important that politicians and NHS managers practice a duty of candour to the public whose health service they are responsible for planning and running.
But this doesn’t seem to have occurred to them.
Government has been hollowed out by the incursion of corporate interests, providing huge opportunities for corruption. It’s now commonplace for corporations to second staff to government ministries where they work on drawing up government policies. Shady public-business deals have become endemic.
“There is nothing in the [Health & Social Care] Bill that promotes or permits the transfer of NHS activities to the private sector”, then Health Secretary Andrew Lansley told Parliament.
The total absence of candour that characterised the Health and Social Care Act’s passage into law has spread throughout the institutions that it created: NHS England, Monitor, the Clinical Comissioning Groups, the Commissioning Support Units and Healthwatch.
To take some examples from my own neck of the woods, West Yorkshire.
A shady NHS-private business deal for ambulances across the country?
West and South Yorkshire and Bassetlaw Commissioning Support Unit (WSYBCSU) is part of the NHS and has the job of supporting the local Clinical Commissioning Groups to buy health services for their area.
It entered into what it called an “innovation pact” with its then-chief operating officer, Sarah Fatchett, who was (and remains) a director of a private company, 365 Response Ltd. The aim of the “innovation pact” was to jointly bring to market an urgent care planned transport service, with the intention that this service would then be commissioned by local health bosses.
Once the service was on the “market” - a telling word in itself - this CSU would oversee 365 Response Limited’s “Managed Transport Bureau”. This would network urgent care ambulance providers with NHS organisations across the country that want to commission their services.
Last year, both organisations jointly advertised their intention of setting up this service - valued at half a billion pounds - in three advertisements on the Supply2Health website. The ads named Calderdale Clinical Commissioning Group and many other NHS groups across the country as an “involved commissioner”.
But when I asked them, Calderdale Clinical Commissioning Group said the ad was nothing to do with them and they knew nothing about it. They later checked in with WSYBCSU and reassured me that on the basis of a verbal assurance from the CSU, they were confident that the CSU had properly respected standards of integrity in public life.
The CSU has declined to provide with evidence that it has properly observed conflict of interest rules, such as would be available in emails, minutes and notes of meetings.
There are at least two potential conflicts of interest around the CSU’s plan to both commission an urgent care ambulance service on behalf of NHS organisations whose commissioning activities it is meant to support, and to provide an essential part of that service itself, in partnership with 365 Response Limited.
If the WSYBCSU advocates that CCGS and other NHS organisations commission urgent care ambulance services that the CSU is itself involved in providing, this is hardly likely to be disinterested advice in the best interests of the commissioning organisations.
The other potential conflict of interest is whether Ms Fatchett used her position as a Chief Operating Officer in part of the NHS, the WSYBCSU, to advance the commercial interests of a private company, 365 Response Limited, of which which she is a director.
The employee, Ms Fatchett, has now left WSYBCSU to run 356 Response Limited fulltime.
Going through the motions on consultation
Last month Calderdale and Huddersfield health bosses fiinally revealed their “Right Care Right Place Right Time” proposals for the future of health and social care in the area.
Proposals include closing Calderdale’s A&E, reducing the hospital’s services to planned care only, and reducing its beds by 75%, whilst transferring all acute services to Huddersfield Royal Infirmary. The wide ranging plans have raised fears that much of Calderdale hospital might be sold off to a private healthcare company. Across both sites, hospital beds would be reduced by 100.
A new, low-cost system of integrated health and social care in the community is mooted - explicitly copying the American Kaiser Permanente company’s private health insurance/private health care system. This, we are told, will supposedly keep patients out of hospital, so justifying the cuts to hospital services.
Because they have a legal duty to consult the public on such changes, the Clinical Commissioning Groups are saying at every opportunity that they have not made a decision and it will only do so after a public consultation, scheduled for summer 2014 (when people will be on holiday).
Local people did not get sight of the Right Care Right Time Right Place proposals - produced by the two local Clinical Commissioning Groups and three NHS Trusts - til last month.
But now that a whole slew of interlocking proposals for the future of Calderdale and Greater Huddersfield NHS are on the table, it’s clear that key decisions have already been made.
Calderdale CCG’s 5 year Strategic Plan and its Better Care Fund Plan (the latter produced jointly with Calderdale Council) are explicitly aligned with the Right Care Right Time Right Place and are due to start implementation in 2014.
These local health bosses had sat on a National Clinical Advisory Team Report on the future of Calderdale and Huddersfield A&E since June 2013 - without even informing local MPs of its contents, though rumours swirled.
Now we’ve finally had sight of it, the NCAT Report is more notable for what it doesn’t say than what it does say.
It says that the fit with future funding has been a consideration.
It doesn’t say that its recommendations align closely with outgoing NHS England Chief Sir David Nicholson’s remedy for the £30bn NHS “funding gap” that will open up by 2020/21.
According to Sir David:
“This gap cannot be solved from the public purse but by freeing up NHS services and staff from old style practices and buildings.”
There are contradictions - the report does warn that increasing care in the community will in fact cost a lot in terms of extra staff and/or capital investment.
It acknowledges that its recommendations for reduced cover at one site - probably Calderdale Royal Hospital - “present significant challenges over opening hours, workforce, clinical dependencies, handovers and public perceptions.”
But in public pronouncements, CCG Governing Body members are claiming that the replacement A&E services will be just fine for everyone.
Weirdly, in a set of proposals that aim to put the patient first, the National Advisory Panel did not hear from any patient representatives.
Although their Report recommends huge changes to GP and community care health and social care services, only one Calderdale GP - Dr Maji Azeb, urgent care lead on the CCG - took part in the presentation by GPs and CCGs on urgent care in primary care.
No patient representatives or political representatives of local people had a voice in the discussions and presentations to the NCAT Panel. A Calderdale Councillor made a Freedom of Information request to see the Report last summer and was refused. Calderdale 38 Degrees asked Calderdale CCG what was going on. Linda Riordan MP asked the Under Secretary of State for Health what was going on.
The Under Secretary of State said that the Department of Health had no say in the discussions and that this was a matter for local clinical judgements.
The Clinical Commissioning Groups when say they will only decide whether to close Calderdale A&E department, and make all the other related changes, after the public consultation. Few locals believe them.
The evidence of key planning documents undermines such statements.
Jeremy Hunt rightly expects NHS health care staff to observe their duty of candour.
He should extend that duty to himself, all politicians and all NHS managers and CCG members.