The Unkindest Cut - Article in Public Health News (June 5)

The unkindest cut
Supporting people with mental health problems and helping people to resume as complete a life as possible is not just a matter of NHS finance but about how well the different parts of a complex network work together. Chris Reynolds reports on how funding cuts are threatening services in Hertfordshire

On 17 May, the Hertfordshire County Council health scrutiny committee decided that the mental health cuts proposed by the local primary care trusts were not in the interests of the people of Hertfordshire. A week earlier objections that the cuts were inappropriate, ineffective or put patients and carers at risk had been ignored by the joint commissioning partnership board which acts for the eight PCTs and the county council which funds the Hertfordshire Partnership Trust (PHN, 15 May, page 7). The scrutiny committee took a different view and the matter has been referred to the secretary of state for health.

So should those of us who opposed the cuts be celebrating? Of course we are very pleased that the scrutiny committee agreed the cuts were badly flawed. But celebrate? No. Not yet.

In 2005, the strategic health authority organised a major consultation, Investing in your mental health, in part to rationalise in-patient services and in part to speed up implementation of the national service framework across the county. By providing improved early diagnosis and strengthening the network of community support services, the plan was to maximise recovery and minimise the need for more expensive acute hospital beds. It was clear there were serious gaps in primary care services between the community mental health teams (provided by HPT) and GPs. It was also obvious that more voluntary sector services were needed, on a more reliable funding basis, particularly in some parts of the county.

The consultation was approved in December 2005. It was also agreed that new facilities should be available before old ones were withdrawn. Unfortunately the financial 'cancer' affecting the Hertfordshire acute hospitals spread to the PCTs and, in January, the secretary of state said the rot must be eliminated. The brakes were slammed on throughout Hertfordshire. The SHA responded by top slicing all trusts, including HPT. What has happened since is an example of 'more haste, less speed' with mentally ill patients being the losers all down the line.

The PCTs wanted £5m worth of cuts in place for April - about 10 weeks away - and asked HPT for suggestions. It was immediately clear that most of the money would have to come from cutting real services. Within days, HPT reluctantly came up with a provisional list of possible cuts for discussion, with an indication of the implications and estimated savings.

A hurried meeting of the JCPB froze this discussion list as if it was written in stone. It agreed consultation was needed on £3.2m significant service changes, but with no proper assessment of how one cut affected another if both were made. The effect on patients, carers and other parts of the mental health support network were not seriously considered. As a non-voting member of the board, I pointed out the danger of not properly evaluating the risks associated with the cuts.

At the JCPB's request, the scrutiny committee approved a truncated consultation period ending on 3 May. The consultation document contained no risk assessment table but asked separately about the possible risks associated with each cut. There was a very good response - nearly 400 questionnaires or written submissions were received. Many identified significant risks and more than 60 came from organisations with specialist knowledge of the areas being cut, ranging from patient groups through to clinicians in both primary and secondary care.

Eight days later, the JCPB considered the response document and, by a majority, approved all but one of the cuts. While the consultation document specifically asked for risks, this was skated over - with no analysis of those submitted. There had been some minor variations and some expansion in detail, and all the cuts would be expected to return the exact sum promised in the initial 'for discussion' list.

To most people this appears to be a whitewash. Detailed written submissions from knowledgeable organisations pointing out significant risks relating to specific cuts were summarised in a table - maximum circa 60 words per submission - but otherwise ignored. While the wording is obtuse, it gives the impression that risks to patients are not a matter for the planners but something to be sorted out after the cuts are made by clinicians. I could go on. A few days later the scrutiny committee was asked to accept a response document which failed to properly address patient safety and inadequately covered the consequences of the cuts on other organisations in the mental health support network. It also seemed at that at least some cuts will prove a false economy.

So what happens next? The cuts, coming so soon after the Investing in your mental health consultation, have been a public relations disaster. Mentally ill patients, their carers and support staff are left in limbo until a decision is made. If the NHS insists on extracting its pound of flesh from underprivileged people, the cuts and the associated betrayal will be devastating. Some of Hertfordshire's mentally ill will no longer go on long waiting lists for treatment - the service they need will have been withdrawn.

Chris Reynolds is vice chair of the "Herts Parts' PPI forum, a non-voting member of the JCPB, official PPI forum observer on Herts County Council health scrutiny committee and official PPI forum rep on the HPT board.He is writing in a personal capacity

Scrutiny Committee June 8th - My Report (also covers Foundation Status, the PCT budgets and Hospital plans)

Notes and Observations on the
Hertfordshire County Council
Health Scrutiny Committee Meeting
held at County Hall
8th June 2006

Agenda Papers – on line at
http://www.hertsdirect.org/portal/eDemocracy/Civic%20Calendar/HCC/archive/Health%20Scrutiny%20Committee_5

HPT – Letter to the Secretary of State.

Letter to Secretary of State: (and related documents) http://www.hertsdirect.org/havesay/scrutiny/scrutinycomm/scrutcomm/healthscrutiny/

This relates to the decision at the last meeting of the committee to refer a number of proposed cuts in the mental health services provided by the Hertfordshire Partnership Trust to the Secretary of State.

It was the first time such a letter had been sent by the County and because of the need to check the text with the county's legal advisers, etc. there was some delay in sending it off. Confirmation of its receipt has been received. The service changes objected to in the letter cannot (in theory at least, see below) be made.

It is far from clear how long it will take to resolve the issue – and it is worth noting that a similar objection to changes affecting mental health services in Cambridgeshire was referred to the Secretary of State in March and has still not been resolved.

HPT – Application for Foundation Status
Links: See Agenda Papers

Because the change is purely a management change that does not directly affect services the Scrutiny Committee is not directly involved – but is kept informed – and was asked for its opinion relating to the Governance arrangements. The aim is to have a membership of some 5-10,000 who will elect a Board of Governors who would influence stratecy and appoint the Chair and non-executive directors, The Board of Governors would consist of 19 public, 5 staff, and 13 representative of relevant organisations.

Because of the arrangements with adult care services some of the later positions would need to represent the County Council.

Timetable: Consultation starts for full period starting 5 July – result to Secretary of State on 3 November

All trusts are required to move to Foundation status so the key question is “When” rather than “whether”. The following seem to be the key issues:

➢ One of the problems is the definition of the boundary between the primary and secondary care trusts.
➢ Would it not be better to leave this matter until the new PCT arrangements had had a chance to settle in.
➢ While funding would be on three year contracts, giving more stability – it might be disadvantageous to sign up the contracts at a time of significant financial problems.

HPT – Closure of St Julian's Ward

Bill Macintyre, CEO of HPT, informed the Scrutiny Committee that St Julian's Ward had been closed on safety grounds, although it could be re-opened if money became available. He reported that even with St Julian's being closed there were currently 10 empty acute beds in Hertfordshire. This was anticipating the cuts which were technically “on hold” and he was given a stiff questioning about it.

The Scrutiny Committee missed the real significance of this. The nature on mental illness id that it is inadvisable to start a treatment and then, perhaps only a week or two later, withdraw it on financial grounds. Change has to be phased in gradually and if the Scrutiny Committee had not taken the action they did on 17th May most of the changes would have been completed in June. The decision was taken some time back to stop new admissions so that patients' treatments would not be disrupted by the closure – and in addition staff had been transferring elsewhere. The greatly reduced numbers of both patients and staff raised important safety issues ...

By concentrating on “the building” issue, the key question was not asked. This would have asked about the possible run-down in the other services in anticipation of the cuts. For instance are GPs referring less patients to the CMHT, and are the 10 empty beds (plus those from St Julian's) empty because new tougher acute bed admission standards are already being applied.

SHA – Financial Recovery
Links: See Agenda Papers

The SHA was asked if the 2006/7 figures were any more reliable than those which were so disastrously wrong in their predictions for 2005/6. I thin it would be fair to say the Scrutiny Committee was not convinced.

I suspect that there are many people in the SHA and the PCTs who are also not convinced that the changes will actually succeed in balancing the books and the much of the exercise is to make the budgets look “acceptable” to the Secretary of State – and the SHA and the PCTs will not longer be here when the silliness of some of the predictions, and increased levels of ill-health in the community, becomes apparent.

PCTs – Arrangements from October

While it has been agreed that there will be two PCTs for Hertfordshire the plan is for them to share a management team under Anne Walker who is currently heading up the “new” management team in Bedfordshire Heartlands PCT which had major financial problems.

PCTs – Recovery Plans
Links: See Agenda Papers

Eight recovery plans were presented in four groups of two. In general each plan (but see next section) was a long list of “efficiency savings” worded in such a way that it was impossible to really know how the changes might affect patient services. Several councillors queried whether they were really efficiency savings, in a way that implied that if they really where there must serious management shortcomings. (One councillor referred to “launching the lifeboat after the ship had sunk.”) In some cases there were large “savings” which had not yet been identified.
Adult Care Services made it clear that the proposals said nothing about the implicalions of the changes. It was far from clear that there were enough resources to cope with the existing demand – even before the proposed cuts begin to bite.

I was very disappointed that the Scrutiny Committee was not more questioning on these plans – although it would be impossible to have gone through them in details – especially as the documents were late in being made available – so it was not really possible to make comparisons between PCTs. From the point of view of mental health this could be an advantage. If all the PCTs need to do is make “efficiency savings” and the cuts on mental health cut hard into real services one can reasonable claim that the cuts on mental health are unduly savage.

When there are 8 PCTs, each with a separate deficit, working in pairs, and which will, in October be working as two boards but one management team it seems rather silly to have eight different plans when the first thing the new PCT(s) will want to do is to get some kind of unified policy in their area.

PCTs – Consultations

Two particular items were separated out for consultation. These relate to the closure of the Intermediate Care Beds at Harpenden Memorial Hospital and changes at the Elms Clinic, Potters Bar. It was agreed that 30 day consultations would be adequate.

West Herts Hospital – Consultation
Links: See Agenda Papers

The document presented to the Scrutiny Committee had three options, two of which appeared comparable, and the other much weaker. The Scrutiny Committee pointed out that there was little point in including a non-viable option and suggested that the only option which would have kept Hemel Hempstead Hospital open should be dropped.

There will be a pre-consultation event on 22nd June, the consultation will start on 10th July for three months . There will be an overall loss of 120 beds. It was stated that the medical staff committee fully supported the proposals.

David Law (CEO) admitted if financial balance was not achieved this could put at risk a new hospital on the Watford site. We could end up with no Hospital at Hemel, an overcrowded hospital in ageing and temporary buildings at Watford (with more patients and less parking?). My own view is that we can thank those who campaigned to stop us having a new hospital at Langleybury some 10 years ago for the current mess.

Could this help the Dacorum Mental Health mess – if the plans go ahead the Watford Hospital will want to get rid of the mental health wards A.S.A.P. And there could be space available on the Hemel Hospital site. ....

North & East Herts Hospital – Consultation
Links: See Agenda Papers

This was keeping the Scrutiny Committee advised on progress to a consultation to be held later.

Chris Reynolds
14 June 2006

Parlimentary Health Committee Hearings start today - My written submission

Inquiry into NHS Deficits

Submission to the Health Committee

By Christopher F Reynolds

B.Sc. (London), Ph.D. (Exeter),
F.B.C.S. (retired), C.Eng. (retired)

This submission gives details of the NHS Deficit on
the funding of mental health budgets in Hertfordshire and the potential impact of
up to £12 million reduction in funding on services.

1. Following a family suicide in 1985 I have been actively involved in the mental health provision in Hertfordshire as a trustee for Mind in Dacorum, on the North West Herts Community Health Council, as the lay member on the board of the Dacorum Primary Care Group, and on many other committees.

2. I am currently vice-chair of the Hertfordshire Partnership Patient and Public Involvement Forum. In this role I represent the Forum on the Board of the Hertfordshire Partnership NHS Trust (which provides mental health and learning disabilities services), the Joint Commissioning Partnership Board (which commissions mental health and adult care in Hertfordshire and involves 8 PCTs and the Hertfordshire County Council), and the Hertfordshire County Council Health Scrutiny Committee.

3. I was actively involved in the Investing in Your Mental Health consultation, the findings of which were agreed in December 2005. This looked at how better primary care and community services could improve recovery rates and reduce the number of long-term disability patients and the demand for expensive in-patient beds.

4. In making a submission to this committee I am concentrating on the relevance to mental health issues in Hertfordshire and when I criticise local management decisions I am aware that national decisions and policies may have ruled out more rational local actions.

5. A significant problem relates to the acute hospitals – and the rejection of a consultation in the late 1990s to centralise on a new site due to public pressure from those who lived close to the hospitals. Multiple site working on less than ideal locations is at least part of the financial “cancer” which has infected the acute hospital budgets, and spread to the PCTs. The result has been a comparative squeeze on the mental health budgets, with the end of year expenditure being a smaller percentage of the actual spend compared with the start of year budget.

6. When the 8 Hertfordshire PCTs were set up in 2001 the Joint Commissioning Partnership Board allowed them to delegate responsibility for mental health. While things have improved with the SHA led Investing in Your Mental Health consultation, the delegation arrangements meant that the subject was comparatively ignored at the primary care level. Some PCT Boards seem to have initially considered it as little more than a black hole in the financial spread sheet. It seems that the comparatively low profile of the medical aspects of mental health at the PCT board level have made it “easier” to put pressure on its finances.

7. Since it was formed in 2001 the Hertfordshire Partnership Trust has balanced its books in every year. It income has increased during this period (but at a slower rate than some other areas of health in Hertfordshire) and it has been increasingly under pressure to subsidize the overspend elsewhere. For 2006/7 the SHA advised the PCTs to apply a 5% top slice to all trusts – with no medical risk assessment being made to see if this could be done without significantly disadvantaging patients. HPT assess that this brings the total “efficiency” and other cuts it has been asked to make to £12 million over two years. For those working in the voluntary sector there is good evidence that some of the efficiency savings made in 2005/6 have proved to be real cuts in the level of service to patients.

8. Because the decision to make a 5% top slice came only a couple of months after the major Investing in Your Mental Health consultation had been approved it was clear that there would need to be a consultation. This was rushed through on a shortened timescale, received overwhelming opposition and £3.2 million of the cuts have been referred to the Secretary of State by the County Council Scrutiny Committee. The cuts are now in a state of limbo – which is no good for patients or staff.

9. If cuts have to be made it is important that one is honest about them. To present them as if viewed through rose-coloured spectacles misleads both the public and also the Secretary of State as to the real risks to patients and carers. The following examples come from the consultation (I could give many more) – but I am sure they are commonly used to misrepresent the effect of cuts across the NHS.

9.1. Mental health support
is provided by many agencies and not just the NHS. It was assumed that other agencies would have the spare capacity to provide services to replace those which were being cut. However the PCTs knew full well that voluntary sector services were already inadequate in many parts of the county – and their funding was being reduced. Nowhere were there any mentions of the quality of any replacement service of patient support.

9.2. The consultation ignored what would happen to patients between the time the cuts were made (immediately) and the time other agencies could fund (where from???) and establish replacement support services. This would be a period of significantly enhanced risks.

9.3. The consultation specifically asked for risks associated with each cut. Over sixty organisations from user and care groups, through to clinicians in primary and secondary care provided written submissions indicating significant risks – ranging from increased suicide rates to cuts which would prove to be false economies. These were all ignored – in some cases without the area of perceived risk even being identified.

9.4. 1984 newspeak type arguments, often robbing Peter to pay Paul, were used to justify cuts. For example continuing care services were transferred to Hertfordshire Partnership Trust – but under-funded. This represented a cut of circa £1 million p.a. in core mental health funding and a saving of £3 million p.a. by the PCTs. The fact that the PCTs had previously overspent was used as an argument for further cuts on core mental health services.

10. The problem with this consultation, and I suspect many others, is that the consultation was carried out by managers with little first-hand understanding of mental health (see para 6) and who were under orders to make the cuts regardless. I would like the committee to consider the following recommendation, to ensure that cuts in medical services which could adversely affect patients are seen to be approved by suitably qualified expert committees, and not just by managers.

10.1. When any consultation involves cutting services for financial reasons the consultation document, and the final response document, should contain signed reports by the clinical governance committee of all relevant trusts (and the equivalent from any relevant support agencies) relating to patient safety and welfare issues.

11. The national weighting of per capita payments protects the more needy geographical areas of the UK. The committee might consider proposing a mechanism to protect the interests of the more vulnerable members of society, so that money is not taken from mental health and learning difficulties to bail out
overspending acute hospitals.

I will be very happy to provide further evidence if requested.

Chris Reynolds

chris.ppif@codil.co.uk

Herts Mental Health makes BBC TV News

I write this shortly after seeing the 1.30 pm London news on BBC 1 on 22nd June. There was good coverage with an interview with a service user at Mind in Dacorum, a shot of the outside of the now closed St Julian's ward, an interview with Simon (Viewpoint) and a shot of the protest banners being unloaded from a car. All very good apart form the announcer's opening brief remark which suggested that the mentally ill doulb be a danger to others.

Iunderstand it will be repeated on the 6.30pm London news this evening - and may get a longer shot.

Apologies for my absence ....

During the consultatio period many other activities got put to one side to do later - and I got myself into the position that if I started to tackle the backlog I started to get depressed - so I would retreat into my "depression avoidance mode" which actually meant the the backlog continued to get bigger (and the dog gets more walks) ...

Blow it. I don't care about the ***** backlog - and will post some of the more interesting "missing" documents directly to this blog without any additional explanation, to at least make sure that they are available.

Friday May 26 - What comes next - Link to report summarising the situation.

There is still much to be done - and much depends on Patricia Hewitts's response to the Scrutiny Committee letter (which I have not yet seen).

I have attended to meetings. I reported on the current situation to the "Herts Parts" PPI Forum meeting on Monday, and the PPI Forum Chair's meeting on Tuesday. For the later meeting I prepared Report on the Background and Current Sate of the Hertfordshire Mental Health Consultation. This looks at how we got where we are now, and contains some background information to make it more meaningful for people from other areas who face similar difficulties.

I am also trying to keep track of media coverage (see following entry) and have written one article for the technical press. There have been various discussions, phione calls and emails about strategy which I feel is best kept until the NHS shows its hand.

I have also spent several days "getting away" from mental health issues. Not as easy as you might think. This afternoon I walked the dog at Ashridge, and was just sitting down to a piece of cake and a cup of coffee when I was hailed by a former Community Health Council colleague, who congratulated me on my blog and expressed pleasure at the Scrutiny Committee decision. Mark you - I quite enjoy being reminded ot the crisis in such terms.

Yesterday we took my 20 month old granddaughter to Whipsnade Zoo where she really enjoyed herself as the picture shows. I almost relaxed!

I imagined the nearest tiger was called Patricia, and the two in the background were called SHAh and PeeCeeTeese. They looked very hungry and determined to get their pound of mental health flesh. Nearby an elephant called DougH was busy trampling on public opinion.

Media Coverage of the Scrutiny Committee Decision and similar matters elsewhere in the South and East

PLEASE LET ME KNOW OF ANY COVERAGE [email] SO I CAN ADD IT BELOW together with a brief extract.

Health cuts referred to the minister. This in Hertfordshire (online) May 18. - The cutbacks include the closure of St Julian's acute psychiatric ward at St Albans City Hospital, which serves people of south west Hertfordshire, reductions to day services, the closure of the Direct Access Psychology Service and the closure of the Early Intervention in Psychosis Service.

MP Brands patients the victims of slash and burn plan. icBerkshire (online) May 18 - Mr Wilson said: "It's a national disgrace that this government is slashing and burning services to one of our most vulnerable groups. Mental health services are already under pressure and in Berkshire they have turned around a financial crisis in the last few years so that we have a service based on solid foundations. I cannot believe they are now being penalised for being well run."

Mental Health Protest Victory. Welwyn & Hatfield Times (online) May 24 - Committee chairman Michael Downing said: "We don't see any reason why the people of Hertfordshire should be punished when mental health and learning disability services in Herts and elsewhere have always been grossly underfunded." [see picture]

Plea from the Heart: Dad's call to prevent mental health cuts. Berkhamstead & Tring Gazette. May 24. [Front page headlines and lengthy interview with Glyn Trollope with other quotes, etc. ] Protesters against the closures and cut-backs, including members of mental health charity Mind in Dacorum and Hemel Hempstead MP Mike Penning have raised concerns that proposed cuts could see more suicides. Dacorum Borough COuncil are also concerned that more mental health patients will be made homeless. [Paper also contains articles "Top doctors lead attack on 'factory unit' surgicentre" and "Meet the Health Boss" [Public meeting, David Law, CEO, West Herts Hospitals, at Tonman House, St Albans, 7 pm, June 5 - online as "Open Up, Mr Law"]

[Not seen] - Herts Mercury.

New plea for help to health secretary. Cambridge Evening News (online) May 24 [Similar problems in an adjacent county.] "GPs and other local health professionals do not believe there is a sustainable community support structure." [Further information on the health economy in Cambridgeshire in Health chiefs in race against time., May 25]

Mental health Cuts Attacked. This is Hertfordshire [Borehamwood] (online) May 25 - David Grayson, chair of the Hertfordshire Partnership Patient and Public Involvement Forum, said: "We are very pleased the scrutiny committee have realised there are serious issues regarding the level of risk and the impact on patients. It is fairly unusual for the committee to make a referral of this kind." Mr Grayson expressed concern that a final decision could be dragged out for months but added: "The ball is in the secretary of state's court."

County Refuse Health Cuts, The Herts Advertiser 24 (online) May 25 - Sally Newton, executive member for adult care services, added: "We feel it would be a retrograde step to make cuts in mental health spending at a time when the number of people suffering mental health problems is increasing. We are really concerned about the domino effect these planned changes could have on our services. They are really big issues which need to be taken up at the highest possible level." [Also includes lengthy article Voluntary Service Fear Big Cuts in Funding.]

Anger as PCT cuts counselling service. Hounslow Guardian (online) May 25 - Criticism of the PCT's lack of consultation has also been voiced by John Hunt, co-chairman of the Patient and Public (PPI) Forum for West Middlesex Hospital and Brentford councillor Andrew Dakers. The closure of the Bics is outside the PPI Forum's remit but Mr Hunt has brought the matter to the attention of the overview and scrutiny panel.

We may have won the Battle - but we must not forget the War.

OK. So the Scrutiny Committee has referred the proposed cuts to the Secretary of State.

So we can all relax and put our feet up? .... NO

The matter will go to the Secretary of State who will refer it back to local resolution and this could go on for some time. Meanwhile Hertfordshire Partnership Trust is in the middle of preparing for the cuts – and is left in a kind of limbo – it cannot go one making them, but it cannot go back either, until the issue is finally resolved. This is extremely unsatisfactory for both patients, carers and staff. It may not be practical in some cases to simply reverse changes where, for example, key staff have already found employment elsewhere.

This means that the top priority must be to ensure that things are resolved in a satisfactory manner as soon as possible to minimise further damage. The matter is confused by the fact that the Strategic Health Authority ceases to exist at the end of June, and the Primary Care Trusts cease to exist at the end of September. My suggestion is that the Alliance writes to all PCT (and SHA) chief executives, chairmen and non-executive directors (copies to MPs, Scrutiny Committee, media, etc.?) saying

• The Alliance is dedicated to promoting the welfare of the mentally ill in Hertfordshire and looks forward to working with the new Primary Care Trusts to ensuing the best possible cost-effective user-oriented service in Hertfordshire
• Unfortunately damage has already been done to the mental health economy because inadequate and unsafe proposals were sent out for consultation. For this reason the sooner the matter is resolved the better. It would add to the distress to patients and staff for time to be wasted in further futile attempts to show that the current proposals were both safe and cost effective, when they clearly are not. We suggest that the proposals are withdrawn in time for the final Strategic Health Authority Meeting on 26th June, and that discussion on any other changes in the mental health services in the County are deferred until the new Primary Care Trusts are appointed in October.

It is also important that the Alliance strengthens its ties, and increases its memberships and a meeting of interested parties in June (definitely before the Summer Holidays) would seem to be essential with the aim of exploring better ways of working together in the future.

We must not forget that others can benefit by what has happened – because “false economy” cuts (in terms of both patient safety and consequential damage) are happening (and in some cases have already happened) elsewhere. Information exchange is to be encouraged, and I am happy to keep this blog open – but on a topic based rather than a daily update based arrangement – with people being encouraged to add comments (currently possible but few have made comments).

There is one area which needs quick action, and this is to make a submission of evidence to the House of Commons Health Committee on the NHS Deficit before June 6th. If the cuts were going ahead ours would have been just another sob story about “how we woz robbed.” The fact that we succeeded in getting the Scrutiny Committee to accept that the cuts were inappropriate, ill-planned and unsafe makes it a far more relevant exercise. Because of my very close involvement with the key committees I think it important that I make a submission, and I am happy to make the draft available for comment and suggestions before I sent it.

Wednesday 17 May - Scrutiny Committee - We've done it !!! ### !!!

Woke early - had left computer on overnight (not the first time) and it was "broke". After half an hour of abortive attempts to start it wondered if it had overheated. Switched it off for 15 minutes and I have now got on long enough to type this message and am hoping it will be working this evening when I get back from Hertford. However if this blog (and email contacts) goes silent this message may provide an explanation.

See many of you at County Hall today - and make it a good demonstration.

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The advance guard arrive for the Demonstration

(Photo by Glyn)
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I'm feeling exhausted - but it was well worth it.

The Scrutiny Committee decided to refer the £3.2 million pounds worth of cuts to the Secretary of State on the grounds that the decision to impose 5% cuts was arbitary, there was inadequate assessment of risk, the cuts were not proven to be clinically valid and the impact on users, carers and other service providers had not been properly evaluated. (I will post the formal wording when I get a copy.)

Tuesday 16 May - Strategic Health Authority Meeting - Scrutiny Committee Papers - 2 PCTs for Hertfordshire

I attended the SHA meeting in St Albans this morning. Nothing exciting to report.

Total Beds & Herts overspend £107 million (after 19 million from reserves) compared with the target of £75 million. West Herts year end total comes to £51,864,000 over-spend compared with a target of £22,370,000. HPT in balance but could not hand back £1 million the SHA had hoped it would.

HPT is the only Hertfordshire Trust which is not getting an overdraft - and has to find £10 million over two years.

The Department of Health has sanctioned the failure to provide the target number of Early Intervention Teams in light of current financial restraints.

In response to a direct question John de Braux, Chief Executive of the SHA, agreed that in making cuts "Patient safety was paramount".

New PCT arrangements, including Hertfordshire, to be announced in the House of Commons at 3.30 pm today.

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Scrutiny Committee Papers are now online at http://www.hertsdirect.org/portal/eDemocracy/Civic%20Calendar/HCC/archive/Health%20Scrutiny%20Committee_13

Key document - which explains how the meeting is to be organised - with speaking times, etc., - and the key issues the Scrutiny Committee may want to raise are at

http://www.hertsdirect.org/portal/eDemocracy/Civic%20Calendar/HCC/archive/Health%20Scrutiny%20Committee_13/Item%202%20(1).doc

The papers include the JCPB paper - I think unchanged apart from an additional appendix 12 which attempts to answer some of the points raised at JCPB and includes the commissioners own assessment of rick drawn up before the submissions were received. There are also a number of written submissions.

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The Government has announced that there will be two PCT's for Hertfordshire

Monday 15 May - Notes on last Thursday's JCPB Meeting - and Speculation about the Strategic Health Authority meeting tomorrow

I have now produced my notes and observations arising from the JCPB Meeting [see copy for full details]. It includes the following paragraph:

In conclusion: Because of the way the consultation arose there was a very high risk that at least the savings that could be achieved from some of the proposed cuts would proved to be over-optimistic and the risks under-estimated. It was therefore very reasonable for the Consultation Document to explicitly ask about risks and it was most improper that, a large number of responses which highlighted risks to the viability or safety of individual cuts have been ignored. The failure of the Response Document to come up with any risk assessments for the recommended cuts makes it almost impossible to monitor the effects of the cuts, or to make safe adjustments if the level of funding changes. In fact, because of the amateur approach taken there is a very real possibility that at least some of the proposed cuts are unsafe, and this has been missed because of the inadequacy of the analysis.

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Tomorrow there is a Special Meeting of the Strategic Health Authority [Agenda] which will look at the financial crisis in Bedfordshire and Hertfordshire. At first sight it is of little direct interest as the online paperwork does no more than show that the HPT is the only Trust Hertfordshire which has a financially clean bill of Health. However financial adjustments could mean that HPT is now being treated in a less favourable way to trusts which ran up large deficits. In this context a little bird has told me that the mental health cuts may be raised.

Let us look at the position from the viewpoint of the Secretary of State, Patricia Hewitt. Government action to recover the debts run up by many acute hospitals has generated bad publicity. In addition some mental health trusts such as HPT have had their budgets cut despite being in balance, even though, at least according to Louis Appleby, this was not meant to happen.

So why is the Hertfordshire position special?

Scrutiny Committees are meant to look at significant changes in NHS services and have the power to formally object - unless the changes are purely financial - and in many counties I gather the Scrutiny Committees feel pretty powerless. In Hertfordshire, because the proposed mental health cuts came immediately after the Investing in Your Mental Health proposals it was impossible to avoid a formal consultation. The consultation put a great emphasis on risks - and then the commissioners do a whitewash job by failing to consider the risks submitted by people and organizations with first hand knowledge of the areas being cut.

So on Wednesday the Hertfordshire Health Scrutiny Committee, which has already made its disquiet with the Secretary of State well-known, will be deciding whether the consultation has reached proper conclusions. Because the Response Document had demonstrably ignored risks to the inhabitants of Hertfordshire the Committee could have excellent grounds for blocking the cuts for reasons of safety which have nothing to do with finance.

If the Herts Scrutiny Committee wins this battle it will send out a message to campaigners and Scrutiny committees all over the country that they should take a good look at the risks associated with all cuts - and maybe they can win their local battles as well.

For this reason the Secretary of State and the Department of Health might be grateful if, in considering its recovery plan on Tuesday, the Beds & Herts SHA just happened to reallocate a trivial few million pounds in such a way which means that on Wednesday the Scrutiny Committee finds the mental health cuts have been cancelled and it has nothing to discuss.

OK. This is speculation - but not impossible - one must remember the devious way in which politicians think.

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Now to send out a few emails - then relax for the rest of the day, apart from attending an Alliance Strategy Meeting this evening. To the SHA meeting tomorrow and my next planned report will be tomorrow afternoon - with any news from the SHA.

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Planting a Candle

We are not sure whether it was "Plant a Tree in 73" or "Plant Some More in 74". Whichever it was Lucy put a conker in a plastic cup with some earth and it grew, and got planted in the garden. Lucy killed herself in 1985 and now, every May, we get a display of white candles to remind us of her.

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Alliance Strategy Meeting very helpful - and got some more information on QOF.

An email brings news of the new PCTs - in the form of an advert for Non-Executive Directors.

The Weekend

8 am: Awake after a solid 8 hours sleep - first that long since I started this blog - helped by Temazapam which I now only use after a string of sleepless nights to help me catch up.

Overnight Craig moved my web site to a new and faster server. The email account has gone smoothly - and the new password works. The web site www.hertfordshire-genealogy.co.uk is up and running. It includes a folder which holds the mental health documents associated with this blog, so you can still access them. Only problem is that I currently cannot upload any new files. It's wonderfully helpful when your software remembers the username and passwords automatically - until things change and you have forgotten what they were!

Now for breakfast - and back to my notes on the JCPB meeting.

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10:30 - In reply to an email from Heather I highlight some of the lines of attack for the Scrutiny Meeting on Wednesday.

I think the points that will need to be covered will include.

(1) Failure to adequately consider the "risks" highlighted in the organisational submissions - particularly where these could affect the safety of users - or the ability to make the savings listed. Failure to include problems raised by HPT specialist group submissions as well as your own are important - If users, voluntary orgs and HPT staff all raise the same "serious risk" issue for a particular cut the failure of the response document to deal with this - and say what the implications are is damning.

(2) The gaps between the withdrawal of services and the establishment of any replacement.

(3) The failure to include a risk analysis associated with each cut - despite asking explicitly for details of risks. (Thank god I made a great fuss about including risks in the consultation document at the time it was being drafted. Without those questions it would be a lot harder to attack the current response.)

(4) No clear statement about how risks to users, carers, and other support organisations have been evaluated.

(5) Absolutely nothing to indicate how the changes will be monitored - or to how the standards of care expected compare with the levels of care currently provided by HPT. If the change is a disaster there is nothing in the document by which success can be judged.

(6) Of course the "Is it fair argument" needs to be made - but one sharp well informed attack would be better than everyone spending 30 seconds on this. How this is done will depend on what happens at the SHA meeting.

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Not a good afternoon and evening - took a break from drafting the notes and fell asleep - and the computer crashed at least six times - so I decided to call it a day.

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Sunday - Partly relaxation and walking the dog in the woods - and partly work on the JCPB Meeting report. Needs some editing but should be ready Monday morning.