Critical dementia care: who’s deciding Wiltshire’s health policy? Is it you? Or is it local politicians?

Written by Tony Millett.

A consultation is expected to be begin soon on how to provide specialist hospital care for Wiltshire’s severe dementia patients who suffer serious crises as their condition develops.

The number of patients needing this level of care each year in Wiltshire is about 120.  But a hospital stay to stabilise their condition averages 84 days.

The provider of Wiltshire’s mental health care is the Avon and Wiltshire Partnership (AWP.)  Last February they had to close the 24 dementia beds at Charter House in Trowbridge.  As a temporary replacement similar beds were established at Amblescroft South in Salisbury.

The consultation (from December 1 to February 28) will put forward three options for a permanent solution:

1. To renovate and improve Charter House – and close Amblescroft South.
2.  To move all specialist dementia care to an upgraded Avebury Ward at Green Lane Hospital, Devizes.
3. Make Amblescroft South into Wiltshire’s sole facility for this level of dementia care.  (There will still be the opportunity to send some patients from the north and west of the county to AWP beds in either Bath or Swindon.)

The first two options have ‘significant financial implications’ – in capital costs and in consequent annual interest charges for the private finance needed.  Only the Salisbury option is capital and annual cost free – indeed it would give the Wiltshire Clinical Commissioning Group (CCG) a £440,000 a year saving.  And you get the chance to advise the CCG how they should spend that saved £440,000.

The Charter House/Trowbridge option involves extensive works, but it is not stated how these will overcome “the stand alone nature of the site” which was one of the main reasons for its ‘temporary’ closure.

For many people in Wiltshire deciding on their favoured solution will probably be about geography more than money.  And if Salisbury is chosen, there will be a renewed feeling north of the Plain that ‘everything goes to the south of the county’.

However, much of the significance of this consultation is basically about politics.

The first public acknowledgement of this plan and its consultation comes in papers – now published – for Wiltshire Council’s Cabinet meeting on Tuesday (November 11.)  The draft of the consultation document had been agreed at a private meeting of the CCG in September.

And the CCG’s senior accountable officers can only sign the consultation papers off once the Cabinet has agreed them – it is the CCG that will bear all the costs and most of the risks.

There appears to be something of a turf war developing between Wiltshire Council and the CCG over the county’s health provision.  Several sections of the paper for Cabinet discussion explain (some might say ‘justify’) the Council’s involvement.

The basic argument is spelled out in this lengthy paragraph:  “Whilst the commissioning and provision of specialist dementia hospital care is health-led, it is acknowledged locally that these services make up only a small element of the whole dementia pathway that people living with dementia may pass through. In addition, it is recognised that any changes to a service within the pathway will impact upon other care and support services, including those commissioned and delivered by Wiltshire Council.”

The paragraph continues:  “For this reason and in its role as a community leader, Wiltshire Council is supporting Wiltshire CCG in developing and delivering specialist dementia hospital care, including them proceeding to consultation on these options, pending approval from the Cabinet.”

You do not have to read between many of those lines to see the gist of the Council’s real position.

Council and CCG have worked together on the county’s “Dementia Strategy 2014-2021” and on the Better Care Plan (BCP.)  However, the latter was negotiated through the Health and Wellbeing Board.  There is no mention of the Board in this Council document.

The BCP involves passing millions of pounds from the CCG’s budget to Wiltshire Council.  The savings for the CCG that the BCP aims to make from reduced hospital admissions costs will be very small compared to the sums the Council get.

[It has just been revealed by the Health Service Journal that of the £5.3bn pooled by councils and CCGs, £2.07bn will be spent on councils’ social care services, and £1.66bn on community healthcare provided by the NHS via the CCGs.]

Consultations, tender processes for contracts and lawyers fees are all lines of the CCG’s budget that are ballooning.  This consultation exercise involved paying for cost estimates for the building work.

The government has frequently told us that sort of ‘bureaucracy’ was being cut – instead it is increasing.  It is not yet clear how much this consultation will cost – but it is a cost that will be borne by the CCG and not by Wiltshire Council.

This consultation on critical dementia care is not a simple box-ticking exercise.  It requires complex balancing of financial and many other factors and shows again the complexity of the CCG’s role.  

The Lansley reorganisation of the NHS in England – now described by Nos. 10 and 11 Downing Street to The Times as the coalition government’s ‘greatest mistake’ – was supposed to put patients in charge of choosing their treatment and clinicians in charge of commissioning how those treatments are provided.

In fact only 25 per cent of CCG’s accountable roles are held by GPs. Now we have more and more involvement at the edges of commissioning by unelected council staff and politicians.  And the government is now talking about encouraging more ‘joint commissioning’ between local authorities and CCGs.

Is this what was meant to happen or are we drifting into the choppy waters of unintended consequences?  Or is this the way the government is planning to try and make good its ‘greatest mistake’?