Trust Chairman Roger HillRoger Hill has been chairman of the Great Western Hospital Foundation Trust (GWH) for just two months. But he has been a non-executive director there since 2008 so he knows the hospital and its staff well.
He could not have taken up his important new post at a more testing time for major NHS hospitals. As he told MNO: “The era we are moving into is the most complex, most difficult and most high risk. If we get it wrong…what’s next?”
The challenges increase by the week. GWH has had a pretty fraught winter with staff stretched and target watchers circling. This year sees the start of the government’s Better Care Plan which will scoop money from hospital budgets. And there are vital contracts to be tendered for.
Roger Hill retired some years ago after an international and successful career in the computer business – he was chairman and managing director of the UK subsidiary of the American computer giant Intergraph. And he has also set up companies himself.
He lives in Aldbourne and has been chairman of Marlborough Golf club for four years.
GWH seen from the southMany people see GWH as Swindon’s hospital – even Swindon’s ‘community hospital’. But one third of its patients for acute treatment and of its income comes from Wiltshire. It also attracts patients from Gloucestershire, West Berkshire and Oxfordshire.
One of its problems is Swindon’s ever growing population. Another is the ageing of the population: “There is a material increase in the older population and a growing need for us to provide care for the frail elderly.”
GWH has just recruited three more consultants to their geriatrics team. Their successful drive to recruit more nurses continues and they have already increased nursing staff in the last year by 130 - over and above nurses retiring and leaving the area.
This has been a very tough winter for the GWH. Having put into action a whole list of ways to cope with extra pressures – those pressures kept on coming. They did not meet the target for 95 per cent of A&E patients to be seen with four hours – and for one week were in the bottom ten of hospitals in England.
Having analysed the statistics for the whole hospital rather than just their emergency department, Roger Hill knows that their ambulatory care unit (for walk in rather than ambulance delivered patients) and their surgical assessment unit certainly helped filter patients through the system.
Now with winter over some of the extra beds are being mothballed again and planning has already started for next winter.
However, GWH is facing a year-round and steep rise in the number of patients it sees. In January and February this year they saw a ten per cent increase in patients who have not chosen to have operations – the majority following referrals by GPs.
Recently GWH, with about 500 beds, has been accepting 350 admissions every week. To handle that level of demand needs some very astute planning and a tight control over ‘blocked beds’ so people can leave hospital quickly when they are ready to.
How will a hospital under such pressures cope when the Better Care Fund not only takes away some of its budget, but with the integration of health and social care for the frail elderly also tries to keep them away from hospital?
Hospitals will have to change their ways. Roger Hill tells MNO that GWH has saved £500,000 in the last year by holding thousands of ‘virtual clinics’: if a patient needs no further treatment, they can be signed off over the ‘phone by their consultant rather than having to make time to travel to GWH.
As it costs £1 million a year to run a ward, that £500,000 is a very worthwhile saving.
Roger Hill believes the NHS in Wiltshire is “ahead of the game” when it comes to integration of health and social care services. He is full of praise for the Council’s Health and Wellbeing Board and the way the Wiltshire Clinical Commissioning Group is working. And GWH is fully on board: “All the time we are actively involved in the integration of care – we want to participate in the way care is delivered.”
They have employed the new Care Coordinators that are the advance guard of the Better Care Fund’s aim to treat people at home for as long as possible. Some are clinically trained, but in the Marlborough Area they are trained in social care.
As Roger Hill sees these developments, it helps both provider and patient when instead of sending three services to look after a frail and elderly person, you can send just one.
As someone who has first-hand experience of computers, he wants to get GWH staff in the field fully set up with appropriate IT systems. That is a challenge when Wiltshire’s open spaces have gaps in mobile ‘phone coverage.
A distinct change in the life of a hospital administrator is the constant round of tendering. The bid to continue GWH’s contract for community maternity services was not successful – the service went to the Royal United Hospital in Bath.
Now they are starting their bid for children’s community health services in Wiltshire. This is complex because while at present GWH runs the main part of the service, there are several other providers, some of them working across county borders.
Wiltshire CCG wants either to give the whole service to one provider, or to find an organisation that would have overall responsibility for a group of providers.
GWH has found, Roger Hill tells MNO, it needs a small team looking after all the Trust’s bids for service contracts: “We have to be able to manage bids professionally.”
Not exactly a boost to the front line of the NHS and another unintended consequence of the Health and Social Care Act’s policy to favour non-NHS providers.
Roger Hill is bullish about the role for Savernake Hospital – which GWH now owns. He says the hospital’s space is full at the moment and he is pleased consultant clinics are being held there, extra beds are in place and the mobile chemo truck visits.
GWH is now looking to see how they and the Prospect Hospice (which serves the Marlborough area) can accommodate an end of life ward at Savernake. This would support the work Prospect does with its home care service.
As always there is an element of uncertainty about Savernake’s future – something GWH’s new chairman is very aware of. Next year GWH will be tendering for the contract to provide adult community health care across Wiltshire.
The results of that competition could mean Savernake Hospital – and its hefty annual PFI payments – might be sold.
How does Roger Hill sum up the coming years? “Significant strides have been made as to how we are going to achieve integrated care – it’s got to be done as a system – and there is no evidence that the acute [hospital] element of the NHS is under threat. I am fairly confident we will make it happen.”
First year report on the coalition government’s major NHS shake-up – part two
The NHS is about to begin yet another major change in direction. April 2014 sees the inauguration of the coalition government’s Better Care Fund (BCF) which will put NHS money into social care in a bid to reduce the NHS’ fast rising costs – largely fuelled by the ever increasing age of the population and the complexity of long-term illnesses.
The size of the problem is best seen in numbers: in Wiltshire the over 65s make up 21.8 per cent of the population. But, Wiltshire Clinical Commissioning Group (CCG) reckon they use 47.4 per cent of the health services the CCG commissions.
Or, to put it another way, the CCG’s annual spend per head of Wiltshire’s 479,992 population is £1,023. This increases to £1,600 for those between 65 and 74, to £2,917 for those between 75 and 84, and to £4,913 for those over 85 years old.
Wiltshire's Better Care Fund planThe BCF aims to reduce these costs by providing better social care for the ‘frail elderly’ in their own homes, treating them locally and avoiding inappropriate admissions to hospital. And if they do have to be admitted it wants to make their length of stay shorter.
The basic means to those ends is the close integration of social care (the responsibility of the Council) and health care (the responsibility of the CCG.)
The Fund was originally given the descriptive title of ‘Integration Transformation Fund’, then political spinners re-christened it with an aspirational title: ‘Better Care Fund’ – more like an election manifesto headline. Will it deliver what it aspires to deliver?
In 2014-2015 the BCF will start with modest pots of money – Wiltshire’s will be £22.37 million some of which will come from the CCG’s budget. In the first year, this money will be used “as a catalyst for stimulating integration of health and social services.”
For 2015-2016 Wiltshire’s BCF pot will rise to £29.51 million. The money will only be available once each local authority-and-CCG has a jointly agreed plan that is approved (by ministers) detailing how the fund will be used.
The BCF will rely on projects and commissioned services agreed, planned and run jointly by the CCG and the Council acting under the Wiltshire Health and Wellbeing Board (HWB) which was set-up under the Lansley reorganisation.
There is one somewhat grey area: some of the fund will be allowed to fund mandatory changes brought in soon by the Care Bill (now before Parliament.) And at least one CCG has agreed that it should fund existing social services on the grounds that they come under ‘preventative health measures’.
The BCF’s budget will not be new money. So where is it coming from? The BCF will largely be funded by ‘top-slicing the CCG’s annual budget’.
In Wiltshire it will mean the CCG surrendering – or ‘top-slicing’ – £15.52 million from its budget for 2015-2016. This will go into the pooled budget together with existing council social care funds.
While this sounds eminently sensible and laudable, there are four main risks around the BCF.
The first is that the CCG top-slicing will in fact come totally from the budgets of the foundation trust hospitals like the Great Western Hospital which would further destabilise this vital part of the NHS’ cradle to grave treatment regime.
When a Wiltshire Council committee examined the Council’s budget for 2014-2015, they delivered this analysis of the BCF: “The funding …will be drawn from the acute hospitals in the form of top slicing three per cent from their budgets to streamline services and form a centralised system aimed at providing more community care.”
If that becomes the norm England’s already struggling hospitals could become endangered species. And when frail elderly people – not to mention other patients – are too ill or their condition too complex to be treated ‘close to home’, will there be beds and expertise left in the acute hospitals to treat them?
De-stabilising the acute hospitals is something that Wiltshire CCG’s finance director, Simon Truelove, has been warning against during the past year. All the BCF money is going to social care and community health care – there is no money in the fund to bring about the necessary changes in our hospitals.
At the March board meeting of NHS England (NHSE), its chairman, Sir Malcolm Grant, gave a stark warning about the BCF: “I think this is one of the most challenging and daunting things that lies ahead of us…I think it carries very high risks.”
NHS England's Jane CummingsNHSE’s Chief Nursing Officer, Jane Cummings explained the BCF’s inherent risks: “We anticipate that emergency activity [in hospitals] will need to reduce by about 15 per cent. There will be a massive risk if we continue to have the same system of patients in hospital and try and create this fund…there is quite a lot of risk associated with this.”
Where the BCF will show bright red on NHS risk registers is over the inevitable time lag between the steady build-up of relevant social services resulting in the promised “better care”, and the withdrawal of funds from acute hospitals leading to a swift reduction in their capacity.
The Wiltshire BCF plan lists seven areas of risk and they are all rated as ‘high’. The risk of destabilising hospitals is not among those risks – that is somebody else’s risk.
Outgoing NHS chief Sir David Nicholson warned the board meeting about the consequences of missing that 15 per cent reduction target: “We’ve never quite done it in that way. If we can’t do that we have to get hospitals to provide not [the existing] four per cent efficiency, but eight per cent – which I think is simply impossible.”
Or as one commentator put it: “Top slicing CCGs is fine, but there is the risk that the benefits of community oriented integrated care conforms to a longer timetable than that of the loss of funding created locally.”
Julie Jordan of the law firm Mills and Reeve, who specialises in health matters both NHS and independent, calls the BCF an “effective cut in the acute care budget” and she identifies another hurdle in the process of setting up the BCF.
This second risk stems from the change in CCG’s spending which will have to take place: “The mechanics of extracting such a large amount from acute service contracts must demand a degree of service reconfiguration, so we should expect to see a raft of public consultations on proposed service changes in the months leading up to April 2015.”
“Won’t that be jolly when it coincides with the final months of the current parliament, as we head for a general election on 7 May 2015?” (The Secretary of State’s new powers in Clause 119 of the Care Bill [see the third article in this series] may pre-empt any consultation.)
The third risk is that the money transferred from the CCG and from other NHS budgets will not be ring-fenced when it reaches the new pooled pot and may not be used only for its agreed purposes.
Ms Jordan, writing in the Health Service Journal, believes new legislation will be necessary to ensure ring-fencing is robust. And NHS England’s deputy chairman, Ed Smith, warned against “the diversion of money into other activities.”
And this brings us to the BCF’s final risk factor: it is being overseen locally by the HWBs which are committees of local authorities and very new, untried institutions.
Wiltshire’s HWB is chaired by the Council’s leader, Jane Scott, with the Chair of the CCG, Dr Steve Rowlands, as her deputy. It now meets in public and is responsible for the broad strategy for health and social care provision within the county.
But the CCG retains legal responsibility for the services it commissions. If it sees money from its allocated budget going into social care services it does not rate or which are non-health social care services, sparks may fly.
Julie Jordan again: “Some CCGs have already expressed concerns that the pooling of budgets will in effect result in the NHS subsidising non-health social care services. Not exactly the health and social care ‘happy families’ the government intended.”
MPs have called for HWBs to have a greater role in the move to integrated care. The Commons health committee’s chairman, Stephen Dorrell, said HWBs should become “commissioners of joined up health and care services.”
But the committee also said that without ring fencing of social care funds, “…there is a serious risk to both the quality and availability of care services to vulnerable people in years ahead.”
Ed Smith again: “We are reliant on the HWBs. I think the jury is out at the moment on whether they are sufficiently robust to be able to provide the assurances we need.”
It should be noted that at the March meeting of the Wiltshire HWB Jane Scott said: “I don’t think it’s going to be easy – it’s going to be quite challenging for all of us.” And she added that she was disappointed the BCF was restricted to the frail elderly. She wanted to include disabled adults and children and mental health patients.
The outline plan for Wiltshire’s BCF had to be drawn up in a great hurry to meet government deadlines. It already carries a list of seven risks rated ‘High’ with an outline of measures needed to mitigate those risks.
According to an NHSE executive the Wiltshire BCF plan has been “very well received – as being people centred.”
In its section on ‘Integration Aims and Objectives’ the glossy covered plan includes 17 principles for the integrated plan. They include principles of very great interest to everyone in the county:
• “Our principle: we will shift our services from being paternalistic to ensuring that services are designed for and with the people who use them.
• Our objectives for integration: People will be involved in the redesign of integrated services.
• Our measures: patients and service users will be involved in pathway reviews, service specifications and tendering.”
Whether it is ‘people’ or ‘patients’ or ‘service users’, Wiltshire Council and Wiltshire CCG are now committed to listen to and consult a very large proportion of the county’s population. We will see over the coming year how they intend to do that.
Marlborough News Online will be reporting on the specific projects the BCF is providing for Wiltshire.