Thursday 15 February 2018

Curtains for Community Cardiology in Brent

Guest post by Peter Latham of Brent Patient Voice
Brent Clinical Commissioning Group (CCG) has announced that its Community Cardiology Service is to close on 28 February 2018.  So far there is no replacement. Existing patients are to be transferred to the cardiology out-patient service at the Royal Free Hospital (RFL) in Hampstead unless they opt out. 

I presume that new patients with heart conditions who need to be referred to a consultant will be offered appointments at existing acute hospitals, such as Northwick Park and Hammersmith. It is far from clear if those hospitals are set up to absorb the extra caseload in the short term – or if Brent CCG has contracted with them to take these patients.

Brent Patient Voice (BPV) members have been closely monitoring this community cardiology service since it was first thought of – before BPV began.  It was part of a scheme to create 13 ‘Out of Hospital’ NHS specialist community out-patient clinics taken over from the previous Primary Care Trust at the start of Brent CCG in April 2013 under the policy “Better Care, Closer to Home”.  

In the event, after huge effort and expenditure, only 2 of these 13 community services were set up. The others were shelved. The original thinking was that community clinics would save money via lower tariffs as well as delivering the policy slogan. Now 5 years later the strategy lies in ruins.
NHS England policy is currently to increase transferring hospital specialist out patient services to new community clinics.  The problems with the Brent Community Cardiology service provide a valuable lesson for the NHS and its patients and public on the difficulties with this that led to the abandonment of the project.

This community cardiology service started in March 2015 at the Willesden and Wembley Community Healthcare Centres provided by the Royal Free Hospital after a closely contested – some would say flawed - tendering competition and various start-up postponements. The service was originally contracted for 3 years, but it was seen as a permanent new feature of the Brent healthcare scene.

We were first alerted to serious problems with this service when the BPV chair was offered a first and supposedly urgent appointment with the community cardiology service for a date 10 weeks later than required by the contract specification.  This led to my on-site investigation, which revealed that the service was only being operated with about half the opening times required by the contract specification and various other shortcomings such as a manually operated appointments system.  We notified the CCG who thanked us for the feed-back.  It appeared that they had not been monitoring this service on-site to discover these breaches of contract by the Royal Free Hospital.

In August 2015 the CCG invited me to take part in monitoring meetings with RFL over the continuing numerous breaches of contract by them in failing to deliver the community cardiology up to contract specification.  It was not until Spring 2016 that the CCG was satisfied that the service was being provided substantially up to specification. In essence the RFL had discovered that it was much harder to recruit and retain fully qualified consultants and certain specialist technicians than they had anticipated in their bid.

There was a period of around one year during which the service was delivered more or less as required. Then in March 2017 RFL notified Brent CCG that it was no longer willing to provide the weekday evening and Saturday working that the contract specification required them to deliver, and stated that this was ‘non-negotiable’.   The CCG rejected this ultimatum and further NHS ‘contract query notice’ discussions took place, but in summer 2017 it decided it would not try to force RFL to restore the out of hours working. 

Faced with my threat of Judicial Review proceedings  further NHS ‘contract query notice’ discussions took place between the CCG and RFL. As a result in November 2017 the RFL conceded that it would restore part of the weekday evening and some Saturday out of hours working on a temporary basis.  

The RFL then notified the CCG that they were not willing to continue providing the Brent Community Cardiology Service after the end of the first contract on 28 February 2018, and would stop accepting new patients after 9 December 2017.  This apparently took the CCG by surprise. They have admitted that they understood that RFL had agreed that they would continue to provide the service during the process of procuring a new provider. It would not be surprising if RFL thought that this process might be drawn out over many months since the CCG had begun to suggest that they were looking into a community cardiology procurement across all 8 NW London Borough CCGs (the “Collaboration” arrangement).

The outcome is that the Brent CCG Community Cardiology service has collapsed contrary to the long-term plans of the CCG.  Its ‘Out of Hospital’ community service ‘Better Care Closer to Home’ policy has been all but abandoned with the transfer of the service for existing patients to the RFL out-patient cardiology department in the hospital at the more expensive hospital procedures charging tariff. Never mind the deep inconvenience for most Brent patients of travelling to the RFL Hospital close to Hampstead Heath. 

It is now less than a month before the end of the Brent Community Cardiology service.  No clear long-term proposals have been published by Brent CCG for commissioning its out-patient cardiology services.  Nor have any future patient and public consultation and involvement arrangements been published to comply with the statutory duty on the CCG under section 14Z2 of the National Health Service Act 2006 as amended.  I am currently involved in High Court Judicial Review pre-action protocol correspondence with Brent CCG solicitors on these issues.

The CCG has discovered that it is not as easy as originally thought to cut the costs of hospital out-patient services by setting up a new replacement community service.   This unhappy episode has revealed the weakness of a CCG when faced with the ruthless intransigence of the Royal Free London NHS Foundation Trust as a major NHS provider organisation willing to repeatedly dishonour its contract specification obligations to NHS Brent patients when the CCG prove unwilling to take effective action to compel it to comply with its contract.

BPV would like to see the CCG produce a serious assessment of this sorry chain of events to establish clearly what lessons have been learned, but we doubt if it will happen. We suggest that the major mistake made by the previous Primary Care Trust was to make cost-cutting its principal objective, instead of starting with an analysis by clinicians and patients of the existing services and new ones which could be provided “closer to home” safely and in a context which would appeal to both patients and professional staff.

I have no financial or party political interest in these issues. I am a retired Circuit Judge.  I remain open minded about the merits of the NHS community specialist service model as compared with the traditional secondary hospital model.

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