Category Archives: Accountability

This article was first published at HIV i-Base on 25 April 2018.

The revised BHIVA Standards of Care for people living with HIV are primarily produced as a reference for commissioning HIV services. It also describes a minimum standard of care that HIV positive people can use as a reference.

These 90-page guidelines were last updated in 2013 and this third edition was launched at the 4th Joint BHIVA/BASHH Conference in Edinburgh.

The Standards was produced by a writing group of more than 90 individual doctors, health workers and people living with HIV. It was a collaboration with numerous professional associations, commissioners and community groups.

The main changes to this edition include:

  • Reducing the number of standards from 12 to 8, but with each one covering broader themes.
  • A new section is included on person-centred care. This includes wider aspects of social circumstances, including stigma and discrimination, self-management, peer support and general well-being. The importance of these issues are emphasised by this being an early chapter.
  • Recognising the new U=U consensus: an undetectable viral load means HIV cannot be sexually transmitted – with or without a condom (although some sections of the document have inconsistent information on U=U that will hopefully be quickly updated).
  • The section on complex care has been broadened with more detail about access to specialist non-HIV treatment.
  • Another new section covers HIV across the life course covers HIV treatment and care from adolescence to end of life. This includes palliative care in the context that ART might continue to work well to the very end of life.

There are now eight chapters covering major themes. Each chapter and subsection includes quality statements and auditable targets.

Standard 1 covers testing, diagnosis and prevention and the 90:90:90 goals to eradicate HIV. All three areas are ways to maintain and develop combination prevention. This includes increased testing, early treatment, viral suppression and PrEP. Combination prevention helped bring about the dramatic reduction in HIV transmission seen recently in the UK. HIV positive people are important partners in combination prevention.

Standard 2 is about person-centred care. This has been described as “the fourth 90” and focusses on the whole person, not just HIV. BHIVA say it considers, “desires, values, family situations, social circumstances, and lifestyles. And in so doing, the needs and preferences of HIV positive people can be responded to in humane and holistic ways.” It challenges HIV stigma and discrimination and works towards equality in health and social care. Social inclusion and well-being – crucially aided by peer support – are key to person-centred care.

Standard 3 covers HIV outpatient care and treatment. Anyone newly diagnosed must be seen by a specialist HIV doctor within two weeks and given access to psychological and peer support. In some cases this referral needs to be within 24 hours. There is no gold standard for measuring engagement in care, but transfer of care should be seamless whether a person moves home, is incarcerated or simply moves to another clinic. Increasing numbers of children living with HIV from birth are now becoming adolescents. Management by interdisciplinary teams must ensure successful transition to adult HIV services. A qualified doctor must prescribe ARVs and monitoring according to current national guidelines.

Standard 4 is about complex HIV care. Inpatient care must ensure that an HIV specialist is included in the hospital multidisciplinary team. HIV positive people are living longer and often go into hospital for non-HIV related problems. They may be cared for safely and appropriately in a local ward or clinic. But they must also be supported by immediate and continued HIV expertise and advice. HIV positive people must have access to specialist services for other conditions such as cancer. But clear protocols and agreed pathways are essential for safe delivery of services. This section also includes supporting people with higher levels of need. It includes successful management of multiple long-term conditions, poor mental health, poor sexual health, and problems with alcohol or substance use.

Standard 5 is on sexual and reproductive health. It is important that HIV positive people are supported in maintaining healthy sexual lives for themselves and their partners. In addition, anyone at risk of other STIs and infectious hepatitis, perhaps through drug use, should be supported and given advice. Care should be given for contraception, fertility services, pregnancy planning, and access to abortion services. Care must ensure that babies are born healthy and HIV negative. Care for the mother’s health is key to giving birth to a healthy baby.

Standard 6 is on psychological care. HIV positive people should receive care and support that assesses, manages and promotes their emotional, mental and cognitive wellbeing and health. This should be sensitive to the unique aspects of living with HIV. HIV positive people have higher rates of depression, anxiety, addictions, self harm, and other mental health issues than the general population. Mental health needs must be screened on an annual basis. This includes screening for poor cognitive function that can cause memory problems and reduce ability to perform simple tasks.

Standard 7 covers HIV across the life course. This section looks at standards of care for everyone who is HIV positive. Management of ART should be individualised at every age. It starts with adolescents (aged 10 to 19 years) and young adults (aged 20 to 24 years). Education and personal development – as well as achieving healthy sex lives and relationships – should be supported by experienced sexual health advisers and specialist nurses.

The years from 25 to 65 are described as early to middle adulthood. Most people in this age group are diagnosed as adults. Care for early diagnosis and treatment should include peer support as well as psychological support. HIV positive people should be supported in having healthy and fulfilling sex lives and engaged in treatment as prevention (U=U).

The over 65s – whether newly diagnosed or long-time positive – should be given access to treatment for complex comorbidities. This is an area of significant emerging knowledge and will likely develop over the course of these standards. Successful care may be achieved through co-speciality clinics, mentoring schemes, or by identified experts in advice and guidance. Palliative care is now included here. Palliative care ensures that the individual and their family are supported, receive appropriate care that meets their needs and preferences, and do not experience unnecessary suffering

Standard 8 covers developing and maintaining excellent care. This standard covers knowledge and training to ensure specialist services are provided. It sets standards for monitoring, auditing, research and commissioning. It also sets standards for public health surveillance, confidentiality and information governance.

Roy Trevelion was a community representative on the Standards writing group.

COMMENT

These comprehensive Standards are very welcome.

The community was involved at every stage from planning to the final draft, with at least one community representative on each chapter and more than 15 UK-CAB members collaborating overall.

The result is a comprehensive benchmark for health and wellbeing for HIV positive people.

All sections provide bullet points for measurable and auditable outcomes and must be promoted in primary and secondary care, health & social care, public health, and local authority healthcare provision.

As bureaucratic and structural changes affect the structure of HIV services, these Standards should be a reference for ensuring that high-quality care for HIV positive people is maintained.

The inconsistent messaging over undetectable viral load and HIV transmission will hopefully be corrected. As the publication is only available in PDF format, this should be relatively easy. Several formatting problems, including difficult legibility (light font, justified text) would benefit from being revised. 

It is good to see the inclusion of HIV positive people in the photographs throughout the report, supported by the UK-CAB and Positively UK.

Reference

BHIVA. British HIV Association Standards of care for people living with HIV 2018. April 2018.
http://www.bhiva.org/standards-of-care-2018.aspx

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In 2009 the internal market was abolished in the Welsh NHS. Seven unified Health Boards (and three trusts – Ambulance, Public Health and Velindre cancer services) took over the responsibility of the former 22 Local Health Boards and most of functions of the seven Trusts to both plan and deliver health care for the population resident in their geographical areas.

In the initial phase following the internal market abolition the acute hospital sector seemed to have “captured” the planning process. But as things have matured the Welsh Government has sought to re-balance matters with the introduction of Integrated Medium Term Plans (IMTP).

All NHS organisations are now expected to operate to three yearly IMTPs as part of their planning cycle. The latest framework covers the period 2018-2021 with yearly iterations providing firm plans for the initial year, indicative plans for Year 2 and outline plans for Year 3. At the heart of the process is the creation of a collaborative approach which will be sufficiently robust not only to withstand the continuing pressures of austerity but to deliver real improvement for patients, service users, carers and wider public health.

The planning framework ( http://gov.wales/docs/dhss/publications/171013nhswales-planning-frameworken.PDF ) and the IMTPs continue to be informed by the principles of “Prudential Healthcare” ( http://www.prudenthealthcare.org.uk/ ) and an emerging distinctive Welsh legislative backdrop including the Mental Health Measure (2010), Social Services and Well-being Act (2014), The Well-being of Future Generations Act (2015),  Nurse Staffing Levels Act (2016) and Public Health Act (2017).

The planning and delivery process needs to achieve the “Triple Aim” of improving outcomes, improving the user experience and achieving best value to money supplemented by the Parliamentary Review’s ( http://gov.wales/docs/dhss/publications/180116reviewen.pdf ) recommendation of enriching the well-being, capability and engagement of the health and social care workforce.

There are five priority delivery priorities outlined which represent a real effort to re-balance the Welsh NHS away from its initial over-focus on acute secondary care covering such areas as:-
Prevention
Tackling health inequalities
Primary & community care
Timely access to care
Mental health.

Each of these priorities are important in their own right. The prevention and tackling inequalities agendas acknowledge the social determinants of health but they also re-emphasise the importance of addressing “the inverse care law” which is about how the health service responds to the unequal health experience of people. Access to care is recognised as being both clinically important and a key quality measure of the patient’s experience. And as well as timely access to services the quality agenda requires that patients receive safe, effective, personal and efficient care in an equitable way.

Health boards and trust IMTPs must be the product of collective working that extends from the clinical experience of patients and NHS staff to engaging with a wider range of bodies outside the NHS family. Particular attention must be paid to the plans being developed by the primary care clusters ( http://www.primarycareone.wales.nhs.uk/primary-care-clusters ) as well input from traditional sources such as Public Health Wales. In addition participation in regional and local service boards, as well as bilateral discussions, must be used to co-ordinate planning and delivery with other public bodies such as local government, social care, education and housing.

The governance within the Health Boards and the wider NHS must improve if the planning process is to effectively identify and respond to local need. To date the record is not great. Health boards are not always adept at either identifying service failures or responding effectively to them. The Welsh Government has a clear pathway of escalating intervention when health organisations are struggling but even then improving performance has proven elusive ( http://gov.wales/topics/health/nhswales/escalation/?lang=en ).

The final report of the Parliamentary Review recommended that the Welsh Government itself needed to more pro-active in promoting innovation, evaluation and implementation of best practice across NHS Wales. The planning framework preceded the publication of the final report and its silence on the Welsh Government’s role in being a catalyst for service transformation is therefore missing. This needs to be rectified.

The abolition of the NHS internal market was widely welcomed in Wales. This in itself it does not provide automatic answers to all of the problems the NHS faces. But it allows for new ways of addressing them based on the principles of partnership, collaboration and public service values which are more clearly reflected in the latest planning framework guidance.

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We like to think that we own our NHS.  It’s a public service.  If we do own it, then the joke is on us.  The NHS is now an unaccountable secretive mess and our interests are not being protected.  The people tasked with looking after our interests are bullied or manipulated into amnesia.

We are supposed to have the most open and transparent health service in the world, pause here for prolonged laughter.  What we have is a howling mess with providers behaving like autonomous private companies and claiming commercial confidentiality over everything; meeting in private to keep things secret.

We have CCGs that commission £billions of services but have no accountability to the public they serve and who keep their business as private as they can.  They are even trying in some places, Staffordshire and Cambridge as examples, to evade all responsibility by transferring their responsibilities by contracting them out.  The next wheeze might now be Accountable Care Organisations (that could be private companies) and which have no accountability yet hold long term contracts to plan commission and deliver NHS services.  This is wrong.

We had the whole NHS being divided into 44 planning areas with Sustainability and Transformation Plans, making a brave attempt to overcome the chaos in the NHS caused by the dreadful Lansley Health and Social Care Act.  Most of these STPs came out without any semblance of consultation with the public, patients or staff or even with the local authorities they were supposed to have included.  Hardly a day goes by without some new idea for some new body yet none of them look like something we would be able to hold to account.

We have NHS bodies which are supposed to be public and which are paid through public funds behaving like the worst in the private sector.  There was the legendary Strategic Projects Team spending years advising on half baked schemes to privatise services, all of which failed.  The award winning SPT, set up initially to manage the Circle deal in Hinchingbrooke went from failure to failure but was never held to account.  A proper record of what they did and on what authority will never be made public, good luck with any FoI request.

QE Facilities

Now we have the new SPT – QE Facilities.  Again, an NHS body, again with insider status, going around the country charging Trusts for advising them about how to evade VAT by setting up a wholly owned company.  This publicly owned company has just refused an FoI request to list those Trusts it has spoken to.  This is commercially confidential – we are not allowed to know if one part of the public sector has spoken to another part.

The saga of forming wholly owned companies to avoid VAT has been the latest stain on the NHS.  Boards have gone down this route in secret, refusing to engage with the hundreds of staff involved – who will move out of the NHS.  They make public claims about improving services which are wholly untrue – their own figures show all the savings come from tax changes and service improvement does not feature.  They refuse to provide documents, meet in secret and refuse even to consult with their alleged partners in their local STP.

This behaviour by Foundation Trusts who do not even bother to involve their own Governors ( as they are not trusted) probably signals the end of the experiment with trying to get public bodies to behave like private companies.

These are the same Trusts that sign up to Sustainability (all the Transformation plan money has been nicked) Plans that are not sustainable and to control totals they know they have no chance of achieving.  We live in the fantasy world where Boards are too weak to say no, they just play the game.  Since almost every other Trust is in some kind of trouble retribution is unlikely.

Of course all this is in part a reaction to the absurdity that the legislative background is totally incoherent and is being largely ignored.  Yes, there are examples of people coming together and trying to do their best for patients by trying new ways of working.  All good.  But none of this gets us anywhere unless we make the funding available to make sustainable changes possible.  We get nowhere without decent workforce planning.  We fail if we don’t address the yawning gap in accountability.

We will fail unless we get better Boards that tell the trust not just to power but to their own staff!

As waiting lists grow and cancellations increase satisfaction with the NHS is beginning to fall; more people are opting to spot purchase private care, the clear signs of a system in deep trouble.

So if we are the owners how do we get our say?

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Instead of Accountable Care Organisations

The NHS in England is being reorganised, yet again. Jeremy Hunt and his advisors have decided to turn upside down their own previous reforms. Now commissioning organisations (CCGs) and service providers (NHS Trusts) will be brought together into large Accountable Care Organisations (ACOs). How this will work in practice is not clear and rightly there have been calls in Parliament to scrutinise the changes. A coalition of health campaigners, including Stephen Hawking, are also trying to take the Government to court to stop these plans.

In one minimal respect these changes are positive, for they could mark the end of the era of the internal market and commissioning. The Government’s austerity programme and the cuts, not just to the NHS, but in particular to social care, have further undermined the ‘purchaser-provider split’ and the complex tariff arrangements that are used to fund NHS service provision. Now, as demand rises, and real funding falls, it makes no sense to continue with this pseudo-market model, one that has dominated the NHS since 1992.

However the threat of continuing privatisation to the NHS continues. In fact the term ACO is an American term which is used to describe an insurance-based model for funding healthcare, one which is generally associated with low quality and highly rationed care. It is entirely feasible that the NHS is being parcelled up into large chunks which can then be taken-over by US companies for profit. Even if this does not happen immediately there is every sign that these new arrangements will worsen the quality of the NHS:

  • Even more privatisation, for larger contracts, won by larger profit-making corporations
  • Even more rationing according to bureaucratic tick-box systems
  • Even less connection to local communities and people
  • Even more centralisation of money and jobs in fewer places

Even if ACOs are not privatised they are certainly likely to adopt the kind of heartless rationing and contracting systems adopted by US companies to control costs. They will be so out of touch with real communities that anything more human or positive is not available to them.

Inevitably central government will try to reassure the public that they do not intend to do any of these things. They will likely talk about ‘working in partnership with local communities’, increased ‘personalisation’, ‘asset-based approaches’ and addressing the ‘social determinants’ of health. But, after seven years of austerity and regressive social policies none of these reassurances are remotely credible. Taking money, power and authority away from local communities and away from local government will only reduce local influence on the NHS. Austerity is a policy of central government and further centralising the NHS further will only make things worse.

Despite the lack of any clear democratic mandate, any clear policy and any legislation, there remains considerable momentum behind the drive from Whitehall to reorganise existing NHS organisations into ACOs.

So this short paper tries to offer some provisional answers to just two questions:

  1. What should we do in the short-run to resist these changes?
  2. What kind of new arrangements should we seek in the medium and long-term?

Urgent next steps

The first urgent priority must be for all those who care about the NHS and its future to make clear, at every opportunity, that they are opposed in principle to the development of ACOs, for the following reasons:

  • No case has been made for the use of the ACO model. There is no research to support taking a model developed in the worst-performing country for health care in the developed world (the USA) and using it to replace the system used in the best health care system in the developed world (the NHS).
  • In fact these changes are just a smoke-screen for cuts. The Government should be pressed to properly fund the NHS and social care, not to make radical organisational changes that will waste more money on new salaries, redundancies and consultancy fees. We should not be wasting our time on planning organisational change but overturning austerity.
  • There is no democratic mandate for the reforms. There is no legislation to support them and there has been no Parliamentary scrutiny of them.
  • ACOs are not statutory bodies and so, as the functions of local statutory bodies are moved into new regional entities, that work can be bundled together and privatised.
  • ACOs themselves are not democratic. They are not accountable to local people, neither directly by election, nor indirectly by the involvement of elected local councillors on their board.
  • ACOs do not respect local democracy and are disconnected from local identities. Their boundaries frequently make no sense to citizens nor to existing institutions. For example, the proposed South Yorkshire & Bassetlaw ACO effectively annexes part of Nottinghamshire into Yorkshire.

In particular, it is surely the duty of local government to reject this shift in policy and to refuse to cooperate with plans to establish ACOs (or similar non-statutory regional bodies).

Principles for change

Most of us who want to defend the NHS are united in wanting to see an end to the era of internal markets, privatisation and commissioning. However this does not answer the question of how we would like the NHS to be organised instead.

Even prior to 1992, when the era of commissioning began, the NHS has had a history of being constantly and pointlessly reorganised by Whitehall and London-based politicians. We all want a National Health Service – but not every decision can or should be made in London by a bureaucrat or politician. The NHS is one of the largest and most complex organisations in the world. Decisions need to be made at many different levels and in many different contexts, by citizens, professionals and democratic bodies.

To begin with we need to reflect more deeply on the principles that should underpin the long-term organisation of the NHS, and so I am going to propose 5 broad principles:

  1. Justice – The organisation of the NHS must be designed to promote social justice, not just by providing free high quality healthcare to everyone, but also by promoting income equality within its own salary structures and social justice in wider social structures (e.g. housing, social care, social security and education).
  2. Democracy – The NHS belongs to the people and it must be accountable to the people through established democratic structures and appropriate statutory bodies.
  3. Subsidiarity – The NHS is a large and complex system and decisions need to be made by the right people, at the right point. Some decisions should be left to citizens or to professionals; others must be made at the level of the local community or at appropriate regional levels. Only those decisions which really must be made nationally should be made in Whitehall (or Edinburgh, Cardiff or Belfast).
  4. Citizenship – The NHS must encourage a culture of trust, openness and citizen responsibility at every level of society. It is a public good, part of our common and shared inheritance and we all have a shared responsibility to develop and improve it for future generations.
  5. Stability – Constantly changing managerial structures undermines effectiveness, innovation and trust. The NHS needs to work within a framework which is much more stable over time. The costs of constant reorganisation far outweigh the putative and contradictory benefits of any proposed reform.

Democracy and the NHS

If these are the right principles then our goal over the long-run must be to push for significant positive reforms to apply these principles and to protect the NHS and strengthen its status as part of our common inheritance.

In outline the following steps for positive reform can be envisioned:

1. Constitutional reform – The right to free healthcare for all should be a constitutional right, protected not just by law but by further constitutional measures that would limit the ability of politicians to interfere unduly in the principles of the NHS or in the structures of local government. Such rights could be established alongside other economic and social rights – rights which the UK has signed up to internationally – but which it currently does not respect at home. Under the current administration the prospects of fundamental and positive change may well be very poor, but looking to the future it is quite possible to imagine changes in the constitution of the UK that would better safeguard the NHS and our social and economic rights more generally for the future.

2. Democratic control – Central government must guide overall policy and help define the general rules within which local people work. However there is no reason why people in different areas cannot make their own decisions about how they want to organise health care in their own communities. Developing a strong and sustainable welfare state means working through and with citizens and ensuring democratic accountability.

3. No ACOs – The idea of Accountable Care Organisation must be abandoned. It refers to US system which we do not want and which offers no value. It suggests additional accountability, but it in fact it is about reducing accountability. The idea is worse than useless and must be abandoned.

4. Stable local structures – Ideally the NHS would be organised around a stable configuration of local government boundaries and one that allowed for regional, local and neighbourhood levels of discretion, with suitable democratic structures at every level. However, currently local democracy in the UK is very weak and needs to be improved. Until better systems are developed the NHS must be organised around existing local authority boundaries. Any plan to make decisions at a level larger than the local authority – let’s call this an Area level – should only be possible with the explicit agreement of all local authorities within that area. It is totally unacceptable that NHS structures can be gerrymandered by Whitehall. Local authorities must agree to the creation of any area or regional structures that includes them.

5. Governance – If we accept the need for a larger decision making body beyond the boundaries of the local authority then let us call these Area Health Authorities. If there are no direct democratic elections to such Area Health Authorities then only existing local councillors from local authorities within that area have the necessary mandate to speak up for local people. Hence the board of the Area Health Authority must, as a minimum, be made up by a majority of locally elected councillors.

6. Management – Taking on the role of overseeing local health services is complex work and so a proportion of the significant existing resources currently spent on management within the NHS should be shifted into the direct control of local authorities.

7. Legality – Until any new statutory body, like an Area Health Authority, is created then the primary responsibility for delivering NHS responsibilities must lie with either an existing statutory NHS body or a local government body. There should be no risk that the management and over-sight functions are delegated to some non-statutory body which can be privatised or can avoid direct democratic scrutiny.

Although many of these potential reforms would certainly not be supported by the current Conservative Government it is not clear that other political parties would not support these principles. In fact several Conservative MPs are showing signs that the creation of ACOs is one crazy reform too far.

Nor is there any reason why local councils could not adopt some of these ideas a goals as part of their negotiations with the NHS, whatever the pressures from Whitehall. Currently Health & Wellbeing Boards are supposed to act as the guarantors of locally defined plans and appropriate shared accountability between the NHS and local government. In the short-run it should be these bodies who decide how local services are organised.

Shifting power away from local authorities and towards bureaucratically defined and unaccountable areas will do nothing to improve the NHS or to resolve its funding problems.

A short note on social care

There is a tendency to run together health and social care as if they are, or should be, one service. In fact the idea that health and social care can or should be integrated is a very dubious nostrum. There are good reasons why social care has remained stubbornly distinct from health care, not just in the UK, but around the world:

  1. Social care is predominantly focused on helping people live their lives as citizens, by respecting and supporting person autonomy – it is not a form of health care where the professional is largely the expert.
  2. Social care, because it is about the whole of life, must also be sensitive to issues of housing and education – not just health care – in fact for children education is a much more significant partner than the NHS.
  3. Social care is best organised in partnership with citizens, families and local communities, with support by systems of funding controlled by individuals.
  4. In practice social care can be organised by people and families, with support from national or local funding, and underpinned by local services. There are good reasons why local government will continue to play an important role in shaping social care and other local community services.

Clearly the current crisis in funding, which particularly targets social care and local government, is caused by the ideological commitment of the Government to drive down the level of public spending. This is putting the current system under tremendous strain. However this is not a reason to shift adult social care into the hands of the NHS. Instead local government must insist on their right to play its part in ensuring that local healthcare systems are designed to respect the rights and needs of local people.

Local government must not become a bystander, watching on as the NHS is pushed through another wave of chaotic organisational changes, instead it should be the champion of the interests of local people.

Conclusion

The idea that the NHS should be democratic and more accountable at a local level has been around along time. In fact it is, as I understand it, the policy position of the Socialist Health Association. However the debate about a more local NHS was derailed by the 1992 market reforms and since then the drift of policy has been to increased bureaucratisation and to central control.

Personally I think the Labour Party’s new stance, committing itself to the full renationalisation of the NHS, is entirely correct. I am hopeful that the era of mindless neoliberalism and meritocratic top-down management is finally tottering (if far too slowly) to a close.

So now is an excellent time to start thinking about the kind of NHS we really want.

We certainly want end to the crazy market systems; but surely we do not want to go back to an era of centralisation and to constant reorganisation. Perhaps it is time to consider entrusting the NHS to us – the people.

Further reading

These ideas reflect a long tradition of human rights developments around the world. These publications may be of interest:

Duffy S (2017) Heading Upstream: Barnsley’s Innovations for Social Justice. Sheffield: Centre for Welfare Reform.

Hunt P (2017) Social Rights Are Human Rights: but the UK system is rigged. Sheffield: Centre for Welfare Reform.

Potts H (2008) Participation and the Right to the Highest Attainable Standard of Health. Colchester: Human Rights Centre, University of Essex.

Potts H (2008) Accountability and the Right to the Highest Attainable Standard of Health. Colchester: Human Rights Centre, University of Essex.

First published by the Centre for Welfare Reform.

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The decision to accelerate the development of Accountable Care Organisations (ACOs) in England is unwise, unnecessary and should be challenged.  It is hoped the SHA will support the Judicial Review and the Early Day Motion from Labour.

Sadly ploughing ahead with the contracting model for ACOs without any proper explanation, consultation or engagement is typical of what the NHS has been doing, with the secrecy around Sustainability and Transformation Plans as a textbook example of how not to do things.  You cannot make changes on this scale without taking staff patients and public with you – and you should not try.

It’s time to stop, consult and think again.  In earlier communications NHS England were saying that it would be some years before the first ACOs could emerge – what is the hurry?

Moving to ACOs is a major change.  An ACO has its own legal form with a legally binding contract “for the majority of health {primary, communication and secondary including GPs} and care {social care} services and population health {mostly now with local authorities} for a defined area”. As NHS England has made clear the contract for an ACO will have to go through a proper procurement process.

An ACO need not be a public body but it will get income from public funds in £hundreds of millions and will plan and provide vital services for populations of hundreds of thousands.

ACOs are described in the limited documents so far as the next step along the path that started with the Sustainability and Transformation Plans, which are becoming Accountable Care Systems and only then ACOs.  In a few places like Northumberland some good progress has already been made but most Sustainability and Transformation Plans are still in cloud cookoo land.

The implications of moving to an ACO will be felt across both NHS commissioners and providers but also local authorities and many third sector and a few private sector organisations.  It has major implications and yet so far there has been little or no attempt to explain and consult about this with staff, patients and the public – it’s mostly the NHS talking to itself.  It will be yet another bail out of hospitals plan. Few local authorities accept they have been adequately engaged anywhere along this path yet they should be leading the process if it is about population health and wellbeing.

Concerns are obvious.  It is entirely possible, some would say inevitable, that an ACO will be led by or include a private sector organisation; as we have seen in earlier skirmishes around service integration in Cambridgeshire and Staffordshire, which failed spectacularly after early enthusiasm.

So how will these new bodies be held to account?  They are getting lots of public money so who decides how much and what outcomes are set for the contract?  How do local authorities and NHS control the money and the performance?  Are some staff still in NHS and others not?

The issues are many and complex and solutions have consequences.

In a public system, as in Wales and Scotland, the merits of ACOs might outweigh the disadvantages and we can already observe what is happening in our neighbouring countries as they progress in a more measured way to better integrate services; something known worldwide to be far from easy.  And even in market ridden England it is possible to use ACOs as part of a move to proper population based planning of services, to removing the commissioner provider split and to joining up better disparate services for the benefit of service users.

But a change on this scale will only have a reasonable chance of success if it builds on public understanding and support.  Nothing has been learned from the ludicrous antics of some Sustainability and Transformation Plans.

And to be clear the huge strain on the NHS and social care is due to inadequate funding with serious workforce issues as a consequence.  Forming a few ACOs will make little or no difference and could just be a distraction from making care as good as possible under almost impossible circumstances.

Stop now.  Explain.  Consult.  Think again.  What is the hurry?

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We hear that NHS England faces a tough dialogue with the Treasury post-Budget and will, most likely get the go-ahead for its latest plan – to set up Accountable Care Organisations (ACOs). For some, it is a rational response to the failure of the Lansley structural reorganisation – a logical extension to the 44 STPs created in 2016. For others, it is the clearest yet pointer to a privatised NHS, USA-style.

We need not enter the controversy. Ours is a simple question. Where does this leave the statutory obligations to engage, involve and consult patients and public?

The term ‘accountable’ should be a promising sign. But accountable to whom? And for what?

Early signs are that these new bodies will be consortia of providers cutting across traditional NHS and social care services, so the primary route of accountability is clearly contractual. Until primary legislation is changed, that means that CCGs remain responsible for commissioning services and as part of that, have an extensive requirement to involve and consult, covering their plans, service performance and proposals for change. Few Parliamentarians would support the removal of these rights. The prospects of key decisions being taken by obscure arms-length bodies beyond the reach of public accountability would be anathema to MPs whose constituents fully expect to have their voices heard.

We hear that ACOs will face a barrage of legal challenges across a wide range of disputed issues. But as far as public and patient involvement is concerned, this is unnecessary. All that is needed is for Ministers to clarify that ACOs will be bound by the well-established requirements to engage and consult that apply to single providers. We already have the confusing position that major service changes see CCGs bound by the statutory provisions in the 2012 Act, NHS Hospital Trusts still operating under the 2006 Act and local authorities wrestling with the 2014 Care Act and the ‘legitimate expectations’ of consultation on social care and other services.

In practice, common sense applies. Our experience as an Institute is that Managers are, in general, eager to consult local people as effectively as possible. Legal and political challenges only delay and frustrate their plans to implement change – many of which are needed to improve patient care.

The danger is that a BREXIT-battered Treasury may seize upon the ACOs as a means to accelerate its cost-reduction agenda by sidestepping the expensive and time-consuming processes of dialogue with local communities. Such an approach is a recipe for political turmoil, and the Parliamentary arithmetic suggests they would be foolish to try. All one needs is a handful of Conservative MPs in marginal seats with threatened hospital services to mount a rebellion.

On the subject of which, watch for the coming judicial review about Horton Hospital (re Oxfordshire CCG) in the coming days. For local people, their elected representatives, the media and for the staff who work in the NHS and at Councils, having such recourse to the Courts matters. For it is their ultimate assurance that Managers cannot by-pass the duty to involve and consult that Parliament has decreed. If the Government confirms that all these rights will apply fully to ACOs, it will do much to retain public confidence, avoid uncertainty and dodge the bullet of political turbulence.

This was first published by the Consultation Institute

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The issue of citizen accountability in the NHS has been troublesome from the outset. Aneurin Bevan’s preference for centralised control ushered in fifty years of citizen accountability channelled through Parliament and successive health ministers and secretaries of state. As long as patients and the public were satisfied with the way their health services were functioning, there may have been little interest in greater citizen involvement. But the combination of the global recession and the austerity programmes pursued by UK governments since 2010 has changed the situation.

Under intense financial pressure, the agency responsible for the day-to-day functioning of the NHS – NHS England – has required local areas to plan for radical reconfiguration of their services through Sustainability and Transformation Plans (STPs), in the hope of securing more cost-effective provision. The genesis of STPs lies in the seminal Five Year Forward View published in 2014 which set out a vision of how healthcare services needed to change to meet the needs of the population. Since the vision underpinning these models was around ‘systems’ rather than separate organisations spanning secondary, primary, and community care, there was also a need to develop some planning mechanism.

Although not even mentioned in the Forward View, STPs are intended to fill this planning gap. Guidance issued in 2016 indicated that STPs were destined to be the main vehicle for planning services across areas in England – 44 areas were identified as the geographical ‘footprints’ on which the plans would be based, and these had to be submitted to NHS England by October that year. This tight timescale took hold without any consideration of how these new entities were to be led, structured, and held accountable.

These changes are significant and many will find them attractive. They could provide the vehicle for planning that was lost to the system when strategic health authorities were abolished under the Health and Social Care Act 2012, and might serve as the catalyst for the holy grail of integrated health and social care services. Indeed the new care models could presage a landmark shift in the NHS machinery that will challenge the purchaser-provider split that has dominated the policy landscape for a quarter of a century.

Patients and the public, however, have been more concerned about the prospect of loss of access to valued services, especially accident and emergency facilities, maternity units, and smaller cottage hospitals in rural communities. These concerns have only been heightened by their exclusion from the STP decision-forming process. The Commons Public Accounts Committee has found that the rapid turnaround time demanded by NHS England between production of an STP and consultation on the contents has left little time for meaningful engagement. In addition, STPs are not accessible documents, consisting of ‘a mixture of jargon and technical language’ with few concessions to lay readers and those unfamiliar with the ways of the NHS.

Even where those working in STP footprints might have wanted to engage more effectively with their populations, the attitude of NHS England has hampered their efforts. Local areas were left uncertain as to when they were allowed to publish their plans, whether this should be the full plan or a summary version, and how they could control ‘unauthorised’ disclosure by their less constrained local government partners. By mid-October 2016, footprint leaders were being told to publish only summary plans – and only after they had been discussed with NHS England. Some local authorities broke ranks and published full plans, though the crucial financial summaries were not made available.

In addition to weak engagement channels with patients and the public, STPs inhabit an ambiguous legal status. They are non-statutory bodies with no formal powers yet needing to reach agreement with a raft of statutory agencies, each of which is pursuing separate agendas. What’s more, the STP footprint is often bigger than existing health and local government structures, leading to complex and unchartered multi-agency relationships.

Some clarity (and no little ambition) has now emerged with the publication of the ‘Next Steps’ review of the FYFV. This declares that STPs are to be ‘more than just the wiring behind the scenes’; rather they are to have their own ‘basic governance and implementation support chassis’. This, it is said, will consist of:

  • an STP Board drawn from the constituent organisations and including ‘appropriate non-executive participation’;
  • an appointed STP chair or leader subject to ratification by NHS England;
  • and programme management support created by pooling expertise across local commissioners, providers and other partners.

All of this would amount to a fundamental rewiring of the previous major restructuring brought in as recently as the 2012 Health and Social Care Act, but there is still no indication that patients or the public would have any formal role in these new arrangements.

This situation is now further complicated by the rapidly shifting nature of commissioning and provision in the NHS and local government – changes that challenge the role and purpose of existing mechanisms for citizen engagement. On the commissioning side, the trend is towards a bigger scale of activity with clinical commissioning groups coming together to share senior leadership, decision-making, contracting and other management functions, or even formally merge.

Local government is also undergoing major change. Public scrutiny and accountability was already opaque with the creation of health and wellbeing boards but now separate local councils are changing in nature by coming together to form ‘combined authorities’. More recently there have been major devolution settlements in some conurbations – Greater Manchester, for example, is bringing together 37 local authority and NHS organisations under a joint commissioning board. Channels of accountability to local people are becoming increasingly incomprehensible in these larger, more remote, configurations.

Similar issues arise on the provision side. Foundation trusts are coming together in a number of ways ranging from ‘buddying’ relationships, hospital ‘chains’, other forms of ‘group’ status and merger. Indeed some areas are being encouraged to develop an ‘accountable care organisation’ model that seeks to combine both the commissioning and providing functions. General practice – traditionally small-scale – is not immune from this trend with practice mergers, the creation of GP hubs and locality-wide GP ‘federations’. Meanwhile the scale of private sector delivery of publically funded contracts is growing. Half of the spending on community health services now goes to private companies while adult social care provision is now effectively entirely privatised. This raises important and unresolved issues of accountability to service users and local citizens.

Current NHS mechanisms for engaging patients and the public are weak and fragmented. Responsibilities are spread across Local HealthWatch, foundation trust governors, lay members of clinical commissioning group boards, and patient reference groups based in GP practices. All are characterised by weak powers and limited engagement: foundation trust governors are relatively powerless in relation to their boards and are invisible to their small electorates; most clinical commissioning groups are stuck on a failed engagement model centred on public meetings; patient reference groups are optional and focus on micro issues like patient appointment arrangements and opening hours; and Local Healthwatch has yet to prove itself as a ‘consumer champion’.

Further tweaking of existing approaches would not be adequate. The bigger task is to rethink the whole notion of accountability and put in place a raft of options and opportunities that, in aggregate, bring people’s views and preferences squarely into the equation. Moreover this remit should not be confined to healthcare. As Polly Toynbee and David Walker observe, almost all public services are now characterised by the blurred lines of responsibility that accompany the outsourcing of delivery.

Accountability matters because in its absence those in power with the capacity to act might do so without regard for those whose lives are affected by the actions. The ways in which STPs and other changes are affecting local services and support is exposing the weaknesses in how public officials are acting to fulfil public trust. Policy networks, invisible to outsiders, are constituted in such a way that it is hard to identify those who are responsible for decisions. Both elected representatives and the wider citizenry can too easily come to be regarded as intrusive and potentially troublesome. Opening up this ‘black box’ and engaging with citizens will need to move from rhetoric to reality if the healthcare debate – or indeed our wider democracy – is to have legitimacy.

First published on the British Politics and Policy blog

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Do you want to start your own healthcare or medical blog? If so, something you better be doing right now is following the most popular healthcare blogs online.

If you’ve done any research on starting a healthcare blog so far, you’ve no doubt come across tips on creating engaging content or using an SEO website analysis checker to make your blog stand out. Both of those tips are great, but there will still be no better way to see what’s resonating with readers than to follow the most popular healthcare blogs yourself.

Here are the top 8 healthcare blogs you should be following:

Better Health

Better Health is simply a community of doctors and nurses who write commentary and opinion pieces about the health and medical industry. For this reason, it will be one of the best resources for keeping up-to-date on the most recent developments on healthcare.

Everything Health

Everything Health is run by Tony Brayer, a medicine physician with more than twenty years of experience. Her posts tend to focus on recent developments in medicine and medical science.

Global Health Blog

The Global Health Blog initially began as a small website run by medical students at Northwestern University in Illinois, but has now expanded into becoming one of world’s most popular health blogs with daily posts now regularly made by doctors and medical professionals.

Healthline

Operated out of San Francisco, Healthline is currently one of the biggest health websites on the web. All posts are read and approved by licensed medical professionals before publishing. Examples of information you will find on Healthline include symptoms and recommended treatments on practically any medical condition you can think of, and recent innovations made in the health industry.

The Population Health Blog

The Population Health Blog has a collection of professional opinion articles and peer-reviewed links on the medical industry. But the best aspect of this blog is how it is largely free of medical jargon, so it will be easy to understand for non-medical professionals.

The Public’s Health

The Public’s Health focuses on the work that health practitioners are doing across the globe, in addition to posts on health insurance, medication, and addiction. Since most of the contributors has a doctorate for their education, this is a quality resource you can use.

Public Health Matters Blog

Run by the Centers for Disease Control (CDC), the Public Health Matters Blog provides information and expert opinions on recent developments in the medical industry, disease prevention, vaccinations, and even natural disasters.

The Pump Handle

In operation for ten years now, the Pump Handle is a blog that focuses mostly on what’s going on behind the scenes behind the healthcare industry itself, as well as the effect that recently passed laws have on public health and safety.

The Best Healthcare Blogs Online

Are there other great healthcare blogs out there? Absolutely, but the eight we have outlined and discussed in this article are simply the most popular ones, and therefore the blogs you will want to check out first.

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Please note that the following is just rough notes, and should be supplemented by viewing the video of the event;

26/9/2016 Democratic Accountability in the NHS
Chair Chris Bain

Speakers:
Dr Brian Fisher: Vice President of the Socialist Health Association: Brian firmly believes that patients should have full access to data about them and that this will enhance safety and care.

Andrew Gwynn MP: was appointed to the Shadow Health team by Ed Miliband, and was reappointed in September 2015.

Dr Ivan Bennett: sits on the GM Clinical Senate and is a Non-Executive Director at the Central Manchester University NHS Foundation Trust with an interest in Patient Experience and is ‘Freedom to speak out” guardian

Estephanie Dunn: regional director for the Royal College of Nursing’s North West region.

Chris Hopson: Chief Executive NHS Providers

Brian Fisher: ACCOUNTABILITY IN THE NHS – THE LEFT’S BLIND SPOT

The streetfighting in the LP about democracy has no echoes on the left in the NHS. The left appears to have almost no interest in enabling patients and communities to shape their care and their NHS.
Communities have huge commitment and love for the NHS. In Lewisham we had 25000 people on the streets to save our A+E. And the same is happening up and down the country in face of the govt’s austerity and dismantling of the NHS.
But policy discussions on the left rarely consider how that energy and intelligence can be hard-wired into our plans for the NHS. We talk endlessly about privatisation and restructuring and the powers of the SoS. If we want a thoughtful, responsive and personal health and care service, we need to pay as much attention to how individual patients and communities can become part of the decision-making in the heart of the NHS.
I am shocked and angry that the debate remains at the level of “Let’s bring back CHCs”. Yes, we need such formal structures, but this remains a totally inadequate policy programme for accountability and transparency.
We need to offer a vision of health and involvement that enhances care, improves health and makes sure that NHS and LA organisations are responsive to the communities they serve.

We now have good evidence that health improves when people can:

  • CONNECT with others
  • CONTROL more of their lives
  • Gain CONFIDENCE

So, to integrate accountability and transparency throughout the NHS we need to ensure that these relationships and support for them are built and sustained by every NHS worker and every NHS structure. Here are 2 ways that illustrate what I mean and about which I have personal experience.

E-HEALTH AND RECORD ACCESS

IT offers huge scope for improving the responsiveness of the NHS to individuals and communities. I am co-director of a company that makes all this possible, as part of the NHS now.

  • Feedback
  • Links with community groups through social prescribing
  • Record access +
    • All integrated
    • PHR
    • Understanding and control

COMMUNITY DEVELOPMENT

Experience from across the world, backed by good evidence, shows that by building face to face social networks between people through processes such as community development, huge changes can happen – to people’s lives, to professionals’ lives and to the lives of communities. By supporting communities and their own assets to develop their own agenda for change and then working with statutory agencies to meet the issues that matter to them, we can:

  • Improve health
  • Improve the responsiveness of the statutory sector
  • Help tackle Health Inequalities
  • Improve individual health behaviours

AND it appears to be a good investment. 1:4

We need Community Development Workerss throughout communities linked to the NHS and Local Authorities, and probably housing as well.

WHY ARE THESE ISSUES NOT ROUTINE ON THE LEFT?

They are being implemented now. The LP and the left has a huge legacy of community action and social movements. The right wing is hijacking these right now. This should be our agenda. We can offer real and powerful ways that push the boundaries of accountability and transparency – let’s do that together.

Andrew Gwynn MP:

Parliamentary accountability for healthcare was though the Secretary of State for Health, and it is a disaster this link has been broken. Jeremy Hunt can now say it has nothing to do with him as its NHS business, but by the same token he can’t claim at the same time to be the voice for patients. When patients want to complain they should be able to take it up with the Secretary of State for Health.

The agenda for the devolution of health in Manchester was developed from spring 2016. We must be careful. there may be some positives, but there are also some risks. Manchester’s’ 6-billion-pound health budget can help forge new relationships and plan better, more patient centred services, but there is still a funding gap. By 2021 that gap is projected to be £1.7 billion, and there are endemic health inequalities in the region. Is devo being set up to fail? Manchester is one of the first care and health integrated regions. Thameside local hospital and clinical Commissioning group work with a single aim and budget. So is national accountability reclaimed at a local level? We need more MPs aware of what is going on and Local authorities to hold the integrated care organisations to account. Too many councillors just nod through decisions therefore we must upscale the capabilities of councillors and hold them to account. Local Authorities are well placed to meet the challenge, but they must invest in training and their capabilities to hold the NHS bodies to account.

Empowering the patient: The NHS does things to you. With new technology we can genuinely empower patients to be far more involved locally. STPs have planned health and care to meet budgetary needs, but now there is an opportunity to meet health and care needs. Health cuts backs have been to the detriment of tackling health inequalities, Life expectancy in Denton South is 10 years less than Denton North, therefore we need to empower patients to ensure we determine the social needs of an individual – inoculations, housing, environment and wellbeing. We need to develop a wellbeing strategy to narrow inequalities. However we devise accountability we must retain the N in NHS. We can deliver locally, for local needs but the N is crucial. There must be no postcode lotteries. Best practice should be picked on and developed nationally. Accountability must be strengthened to restore the powers of the Secretary of State for Health. We need accountability in Parliament, Councillors, neighbourhoods and local communities.

Chris Bain: We should also emphasise the S for Service in the NHS – not a privatised S for system.

Estephanie Dunn:

I put patients at the heart of whatever I do. We came early to the idea of devolution, but there was no conversation with nurses around concerns with service quality and sustainability. Details about how funding will work were not laid down. We now have the added challenge of economic uncertainty. A lot of the investment was going to come from the EU. It is crucial that the people on the ground change their behaviours, but the numbers of nurses, doctors and other health professionals is reduced, the numbers and role of school nurses is reduced at a time when safeguarding is needed more than ever, due to bullying, suicide, deprivation and people are disengaging. There is an increasing number of women in single parent households who are disadvantaged. Activated patients take more responsibility for their health and we need to re-educate society how this will work. People need to take more control, but there must be a safety net. When people feel disadvantaged and dis-empowered they don’t take care of themselves. They use social tranquillisers like drink, smoking illegal drugs, overeating and poor diets. The change will not happen overnight after generations of disadvantage. There is a lack of awareness as to how the body works. A massive education programme is needed. 80% of the local population in Manchester didn’t understand how devolution works. There should be “nothing about us without us”. We need to be held to account not by the Local authority, but by the people. They should know we now have a system with insufficient resources – we lack the numbers needed of doctors, nurses, and other healthcare staff.

Ivan Benett:

I have an interest in the patient experience. What say do patients have in the service they receive? There is some demonstration of accountability in the NHS, but not a lot. The Health and Wellbeing Board in Manchester works well, and is a positive force for change. The Health and Wellbeing Board has a say in strategy for the city. The Health Scrutiny Committee reviews and scrutinises health services and acts as a consultative body to local health providers when they have a duty to consult. It is not responsive to patient’s needs.

The Clinical Commissioning Group is thought to have more power than it does. It is made up of GPs, and is accountable to group practices. If they don’t want to do something, then they don’t. Patient Participation Groups. PPGs can speak, but they are not really listened to – they are a kind of add on. CCGs hold the secondary care budget as well as the prescribing budget.

We need better input from people. Group practices are not a part of the health service and have no more accountability than a greengrocer. Most just pay lip service and they should be doing much more. Acute Trusts are more reasonable. The public can have a role and can influence. By becoming a Governor, you can hold the board to account. Governors can appoint and dismiss the chair and non-executive directors. To sum up there are a number of gaps in accountability.

Chris Hopson:

The NHS budget is £120 Billion, around 1/6th or 1/7th of GDP. It provides a vital national service. The NHS is the one thing that stands out making us proud to be British. Since the NHS has so much of public funding then the Secretary of State for Health should be capable of scrutiny by Parliament. The NHS has 1.3 million staff, so we are dealing with a complex structure. However there is the implication that the Secretary of State should make all the decisions. Too many roads lead to the Secretary of State’s office, and he has been meddling. Initially Alan Milburn thought he should be solely accountable but later he felt it was too complex and there should be local accountability. A key role of local government is as commissioners of care. There is a need to support local people better. Clinical Commissioning Groups have an important role to play, along with Foundation Trusts.

It is an important model. The system is under huge amounts of pressure and clear governance is needed. Who do we hold to account if things go wrong? A single unitary board, acting as a whole seems the most practical model.

Questions:

Corrie Lowrie: I felt that as a governor I was just there for window dressing. Too much money was wasted on booklets to tell people “how good they were”. Nobody has mentioned the elephant in the room – privatisation, or the people who don’t want to share their medical notes. Nobody asked me if I wanted to be devolved. The amount of money going into private companies is not mentioned at all in the Socialist Health Association, nor are the numbers of private health organisations hiding behind the NHS banner. A sugar tax would be more effective in supporting people to live healthy lives than these private companies with their interest in profit, and Milburn owns a private health company. If we had true democracy then we should let the public know how the NHS is being sold off, and the government is Americanising it. I hate to see all this “manage your own health” rhetoric. It is an empty slogan.

Mike Hobbs: consultant psychiatrist; Public and patient engagement forums are not engaging and are not well heard. How do we engage with the community and at the level of the people who use the services? Healthwatch is still very patchy and the budget is stripped out. Local authorities are increasingly taking on the role of commissioning in health and social care, but they are not very accountable.

Responses:

The NHS needs to go back to basic principles. An integrated health and care system would strip out the waste of tendering and break down the commissioning split. I don’t agree with the free market approach, it is inadequately challenged through democracy. Andy Burnham has been looking at how to bring the care system back into the public sector. Local authorities cannot put sufficient packages into place as numbers and quality are not adequate. The NHS is looking at how to bring care provision in house. Care is integral to the NHS. Some decisions Parliament has made are detrimental to the public NHS, and the Shadow Health team are working on how to put “Public” back in the NHS. But it is not just the public who are in the dark. I sometimes only get to hear things via my opposite numbers. Shadow Health Ministers are cut out of any discussions. Devo is an opportunity, but also a risk. Not only does the government cut our grant, but then Hunt ignores the good stuff and concentrates on the bad bits cause by his governments funding gap…he puts the blame on Labour, Manchester.

There is a difference between organisations which must put profits and shareholders first and for example, hospices. The hospice movement has made a fundamental contribution. It is not profit making, and there is an appropriate role for non-profit making organisations.

Taking responsibility and looking after yourself; People should get support to do that, but they must also get the support they need if more specialist healthcare is needed.

There is an opportunity to make it better with formal democratic involvement. The NHS is undemocratic. Parliament under the Health and Social Care Act is becoming less and less accountable, due to among other things the STPs. There are informal ways in which communities can make a difference in shaping care locally. Become a member of a Trust, and PPGs can be really active.

Katy Gardner: Already councillors are too overworked and underfunded. They must be really on the ball or they will be run by council officials. The SHA has a role to play in upskilling councillors – you don’t know what you don’t know.

Derek Timmins: Talking about elephants in the room, think of Kaiser Permanente. It is a nightmare. We are five minutes to midnight to the breakup of the NHS. It has the second lowest funding in Europe. This is a political choice and political ideology. As for public accountability. Look at the case of Cheshire sexual health. The contract was awarded to Crewe. The councillors raised objections, the chair of the clinical commissioning groups raised objections. Everyone thought the weight of opposition was such that the day had been won, but the chairman pushed it through on a nod (his nod). To fight such huge injustices is beyond most peoples’ capabilities.

Patient Participation groups. The patient voice has been disenfranchised to be replaced with that of transactional costs, lawyers, management consultants and accountants. Locally we see increasingly the phenomenon of revolving doors, for which I blame the influence of MPs. There is a huge democratic deficit. One last point on conflicts of interest. Conflicts of interest are all too often simply not declared. MPs are supposed to represent us. They need to get their act together, and we need to get ours together and make sure they do. It’s down to our representatives doing their job better.

Jos Bell: There is a lot of consultation work around child and family services, but evaluating projects is now a token gesture. Shaping a Healthier Future;  Imperial College Healthcare NHS Trust closed two A&Es and there was a massive spike in the demand on A&E services in the one A&E department left. It became the worst in the country. They want to demolish Charing Cross hospital. Meetings are held in secret and doors guarded by security staff. They wouldn’t even let the MP in. There is a massive funding deficit. STP plans are barely known. We could swing a Tory majority to a Labour one by making these issues known about the NHS. Councils could start by refusing to sign off STPs or Shaping a Healthier Future. Councillors are told they won’t get public funding if they don’t sign up, but STPs are not a good thing. They might have potential, but not given the lack of funding and lack of staff. 90 minutes is the average length of time for a serious ambulance call out.

Brian Fisher:
STPs are another example of magical thinking. There are heroic assumptions but in practice the NHS will just experience cuts and privatisation as a result. The laws for tendering are still in place. Hunt is still in place as nobody else wanted to do it, and the press liked the Milburn version not the Burnham version. We are up against it. We have some fantastic MPs but there is a Tory majority. See ministerial appointments e.g. Phillip Dunne

Chris Bain:
Thank you for a fantastic discussion. We must work on ideas on how to engage the wider community, and hold up a mirror to where things need to be done differently. There are huge challenges, especially around private sector involvement, a world where they would rather have an empty bed than be commissioned at a loss. We also need to deal with the poor quality of care and somehow make things work again. I had hoped there would be more positivity. We must find a simple and easy to operate system which does not come at the expense of the running of a complex system like the NHS.

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Videos of our meeting in Liverpool on 26th September

Dr Brian Fisher,

Andrew Gwynne MP

Dr Ivan Benett

Estephanie Dunn, Royal College of Nursing

Chris Hopson, Chief Executive NHS Providers

 

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If it was decided to move to an all public NHS in England with health boards then what would be the advantages and what would be the cost of making the transition?

So far this change has been argued for as an end in itself, stopping any private involvement in the NHS, but nothing has been said about how it could be brought about, what the benefits are for patients or the costs to be met.

The Welsh NHS has virtually no private provision of health care. It is structured through local health boards based on defined geographical areas and responsible for all healthcare services. This means that the NHS in Wales is an example of what some wish to see in England.

Despite appalling politically motivated attacks on the Welsh NHS by Tory politicians the actual evidence shows that on almost all important measures there is little difference between the performance of the two different systems. There is also relatively little difference in the funding levels and it is certainly not true that Wales has an advantage in having much lower management and administration costs. There is no evidence that either system is better in terms of efficiency; technical or allocative.

Perhaps the biggest difference is that political and administrative accountability in Wales is far clearer and Wales is better placed to be able to develop more integrated solutions and to reconfigure services should such changes be agreed. Although there is no thought of greater involvement of private providers or of moving to a market structure there are critics of the Welsh structure just as there are in England.

Both systems currently face similar major challenges especially the growing gap between expectations and the funding available. Although Wales is probably better placed in terms of its social care and further down the road of integration there is still a different system altogether for social care with some private provision.

In England private (for profit) providers of healthcare account for around £7bn (6%) of the NHS budget. The % is rising but in line with a well-established trend. The Health & Social Care Act did not accelerate the increase. And in England rather than health boards there is a hugely complex set up with hundreds of organisations, a split between commissioners and providers and multiple regulators.

There is little doubt that making the change in structure from English to Welsh would be complex, take time and managerial effort and would have significant costs. The last major reorganisation cost at least £3bn and the change to health boards would be far bigger and far harder to complete. Buying out private provision would also be costed in £billions.

So the transition would be costly and disruptive but, if we compare with Wales, the immediate gains to patients and to the exchequer would be minimal. Many would agree the Welsh structure is better in many ways but in itself changing structures solves none of the current problems both countries face.

So why would we do it?

One original claim – that taking out the market would save £billions – has been disputed and anyway the Welsh experience (and in Scotland) says it can’t be true.

That leaves only the claim that this is the only (or the best) way to stop privatisation. This claim too has been disputed with alternatives not requiring major reorganisation put forward instead. It is also obvious that the only way to stop privatisation is to elect a government that does not do it.

It would be very helpful to our debates if someone could set out the answer with some explanation of how change would be brought about, how long it would take, some evidence to support the claims made, and a few numbers – instead of just making assertions.

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The Health and Social Care Act is a zombie – a dead concept that NHS England is obliged to work around

NHS England’s Sustainability and Transformation Plan (STP) project is an attempt to answer two major problems. One is to find ways to do without the £22 billion a year that the NHS, as it presently   operates, will need to cut by 2020-21 (and post-Brexit the gap may of course be much larger). Britain already spends 1% less of its Gross Domestic Product (equivalent to about £20 billion a year) on health than France, Germany and other comparable European neighbours, leaving very little fat to trim. So the primary aim of STPs is to make both Clinical Commissioning Groups and NHS providers adapt to falling per-capita budgets, using a mixture of carrot (a piece of the £2.1 billion STP fund) and stick (no money from the fund if NHS England’s requirements are not met).(The 2016/17 Sustainability and Transformation Fund by CHPI Research Team)

Both carrot and stick also aim to force CCGs and providers to implement the new organisational models for healthcare outlined by NHS England chief executive Simon Stevens in the Five-Year Forward View (FYFV) – multispecialty community providers, primary and acute care systems -transformations that the FYFV sees as being better for patients as well as saving money.

Competition

The second problem STPs are intended to overcome is the failure of the 2012 Health and Social Care Act to make providers more efficient by having to compete for patients. By 2013, NHS clinical work had been opened up to private providers for almost 10 years. But the private sector had secured footholds in only a limited range of NHS services. For example, in 2014 it provided 31% of out-of-hours GP services in England, and in 2012-13, 20% of community health services. In 2013 Monitor allowed CCGs to renegotiate contracts with existing NHS providers, without serious private sector protest. It seemed that with the post-crash state paying for healthcare out of constrained revenues, ‘More extreme’ means two things, first the STP process places extraordinary power in the hands of the chief executive of NHS England, since under the 2012 Act the NHS is independent of the secretary of state who  is now only responsible for promoting the NHS not providing it. Second, in exercising power through the STP process, the chief executive is acting outside the law. That is not the same as acting illegally. Schedule 4 of the Act authorises the secretary of state or a CCG to do ‘anything which is calculated to facilitate or is conducive or incidental to, the discharge of any function conferred [on them] by the Act’. Yet when asked about the legal status of the changes to health and social care proposed in STPs, health minister George Freeman replied for the Government that “The STP has no legal basis” and “any plans submitted will be proposals that will form the basis for discussion [which] may form the basis for further plans and actions…” and keeping a close eye on costs, there were no big profits to be made from care. So the FYFV made no mention of competition; improved efficiency was now to be achieved by command and control, arguably more extreme than any the NHS has ever known. Implementation of the new models of care, and meeting numerous other requirements laid down in the STP planning guidance, is to be enforced by tough financial incentives and disincentives mentioned above.

This could hardly be more vague. Yet all over England CCGs, NHS trusts and social care providers and others were scrambling to come up with what the planning guidance says are plans, and to do so by the end of June this year if they didn’t want to lose their footprint’s share of the STP fund ‘footprint’ as defined in the guidance as ‘geographic areas in which people and organisations will work together’. That could hardly be more definite: because as Freeman went on to say, once real plans have been made informally CCGs must adopt them formally into their legal planning processes. He said: “The local, statutory architecture for health and care remains, as do the existing accountabilities for chief executives of provider organisations and accountable officers of CCGs. Organisations are still accountable for their individual organisational plans, which should form part of the first year of their footprint’s STP.”

Recipe for chaos

The changes that ‘local health systems’ are thus being required to make in their ‘footprints’ are substantial, involving serious sums of public money, with serious implications for patients. Yet how agreement is to be reached between the multiple players in each footprint, and how decisions are to be made if there disagreement, is not specified in law. When Dr Marlowe, a CCG board member in Hackney, London, asked whether in case of disagreement any two of the seven CCG chairs in the north-east London footprint could outvote his own chair, he was told that legally they couldn’t, but one CCG withholding consent could mean that the whole footprint got no STP money.

This kind of informal policy-making process, with the law saying one thing but practice being driven by quite different incentives, is familiar in the developing world. Being untransparent and unaccountable, it risks producing bad policy and falling prey to conflicts of interest, special deals, nepotism, cronyism and corruption, at the expense of the public interest. It is hard to think of any other major field of public policy in England where policy is made in this way. Why is it now being accepted for the NHS?

The obvious reason is the desire for urgent action to cope with the intensifying squeeze on resources, combined with the Government’s unwillingness to admit that the 2012 Act is an expensive failure, even though many Conservative MPs are believed to say so in private. Leaving the Act in place also has a political advantage. The cuts in services that are likely to be made in order to stay within shrinking budgets, plus any problems from implementing the new care models of the FYFV, will be blamed on those in the CCG who signed the plans, as many GPs warned would happen when the Health and Social Care Bill was put before Parliament in 2011.

Lack of evidence

But why might implementing the FYFV give rise to problems? The FYFV cites examples of the new models of care that it wants to see adopted, and which are said to be working well, but that is not evidence. How many of them have saved money? How well will they work in widely different socio-economic local settings? Most innovative models of care are time and place dependent, and often turn out to cost more than the model they replace. People impatient for reform are tempted to gamble on success, but it is a gamble with resources that are critical for patients’ health. Past reorganisations of the NHS have been the subject of extensive public discussion and parliamentary debate. What justification is there for the unaccountable process being followed this time round?

And the 2012 Act has become a zombie: it is dead, but has to be ‘worked around’, as insiders say. It fragmented the NHS into multiple self-financing structures so that they would compete, not collaborate. It was with this in mind that in October 2013, when two hospital trusts in Dorset wanted to merge in order to rationalise services, the Competition Commission vetoed the merger. Yet ‘urgent and emergency care networks’ (rationalising emergency care services between hospitals) are now one of the ‘innovative’ care models STPs must encourage. The ‘purchaser-provider split’ is central to the idea of competition, but a merely awkward formality under the STP regime: what is commissioned must reflect the aims of a plan made under duress and finalised at a higher level. Some CCGs also now seem likely to be allowed to merge with each other – for example, to form a single CCG for Birmingham and Solihull. In such cases the original justification for CCGs, that they would be groupings of GPs who ‘know what is best for their patients’, is abandoned in favour of the advantages of scale. The Health Service Journal puts it bluntly: “The bodies created at great expense and even greater opportunity cost four years ago [CCGs] are not fit for purpose in the eyes of those responsible for their stewardship [ie NHS England].” And it is true: they were not designed for the purpose – integration – which NHS England is now pursuing.

Accountable care organisations, embracing both commissioning and providing services, are increasingly viewed as the logical outcome.

How acceptable is all this? How far should voters and taxpayers accept the surrender of the independent authority that the Act appears to give to CCGs to shadowy decision-making structures under direction from the regional teams of NHS England? And how content should commissioners be with being obliged to use their formal powers as, in effect, directed by NHS England, and not as they themselves judge best?

As noted, the changes CCGs are being required to sign off on are not minor. For example, NHS England’s ‘new care models’ team wants primary and acute care systems and multispecialty community providers to cover 50% of the GP-listed population in England by 2020, and intends to achieve this via the STP process. Although no evidence has been publicly provided that these models will be good for patients, or save money, CCGs must adopt them or be financially penalised. We must hope that the overall effect will be positive. Endorsing the plans means officially committing to whatever the changes turn out to mean for patients – and the cuts in funding they are premised on. It will be interesting to see how CCG members feel about them in five years’ time.

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