Category Archives: NHS

Integrated Care is the most recent re-naming of Accountable Care: the system currently being implemented in the NHS in England and which is derived from the US. This blog addresses issues arising from this implementation and whether or not Integrated Care is fit for public purpose.

The narrative that comes from Westminster, echoed by parts of the media and even some campaigners, is that whilst cuts and closures, underfunding, understaffing and poor NHS management at the highest levels are all contributory factors to the problems the NHS faces, there is no overarching concern with Integrated Care itself.

On the contrary, the bringing together of commissioners (purchases of services) and providers of services is viewed as getting rid of the hated ‘purchaser-provider split’ which is isolated in this narrative from all other structural components and becomes a proxy for the market system. On this point alone the move to Integrated Care is seen as a stepping stone to a return to public service. There is even some movement to reclaim ‘integrated’ as a term of public service.

There are very good reasons why tackling this issue head on may be politically sensitive. Labour is keen to claim for itself not only the creation of the NHS (which it historically deserves) but a current role as the best defence against Trump. The Secretary of State for Health also claims that he will not allow the NHS to be in US-UK trade talks ‘on his watch’. That is understandable, but the love affair of the major UK political parties with United Health and Kaiser Permanente, amongst others, goes more than skin deep. US Integrated Care has been introduced into the NHS piecemeal over the last 30 years and we are now into the full adoption of an NHS ‘version’ being rolled out at speed. It’s here where the argument lies for politicians, think tanks and amongst campaigners . A question mark is raised over its origins and over whether it is irredeemably bad for the NHS or not.

Our counter argument is threefold:
1. The Integrated Care System does not in fact remove the ‘purchaser-provider split’, but merely changes it to a different type.
2. The constraints put upon the NHS to meet the requirements of Integrated Care are set out in terms of restructuring the service in such a way that it will no longer meet the key tenets embedded in it from its creation: delivering all services for everyone within (mostly) easy reach.
3. “One thing the community cannot do is insure against itself. What it can and must do is to set aside an agreed proportion of the national revenues for the creation and maintenance of the service it has pledged itself to provide.” Bevan’s statement worked on a national level while the ICS model creates a risk and reward system in which profit and loss are to be shared locally between the constituent players of 44 ‘local health economies’. This is entirely upending the basis for financing the NHS.

Integrated Care
The concept of Integrated Care is a longstanding method in the United States which was created to try and reduce the healthcare costs which are spiralling out of control. The most expensive part of any healthcare system anywhere in the world is acute care. It needs higher concentrations of staff per patient, more infrastructure – both buildings and equipment – and changes more rapidly than other parts of the service in its response to technological advances.
It follows from an accounting point of view that any measures which can be taken to ‘reduce demand’ on the acute sector will reduce costs. Part of the cost reduction exercise in the US involves forming collaborative bodies (Accountable Care Organisations aka Integrated Care) which share profit or loss across the different constituent bodies – that is to say the insurance groups who provide the funding from their clients (state or private) plus various hospitals, GP practices and other health services. The profit and loss sharing is designed to provide incentives for keeping people out of hospital and in theory to keep them more healthy in the community.
From the above, it is clear that purchasing and providing still exist within US Accountable Care and that it in no sense represents a return to the kind of planning required to run a public service NHS. The same is true of the system being implemented in England.

Restructuring the NHS
In order to attempt to meet the accounting criteria behind Integrated Care, the NHS’ historical provision of local GP family practices, local District General Hospitals that include full Accident and Emergency and other local services must be dismantled. Acute and emergency provision is calculated to be more cost effective if it is concentrated in hospitals that service a much larger population. Local hospitals then become satellites to the centralised major trauma hospital no longer offering the full service we are used to.
GPs are being corralled into much larger units which may run the satellite hospital or work from large centralised clinics. Property made ‘surplus’ from these restructurings can be sold as a result.
These changes are an intrinsic part of the development of Integrated Care. They are not optional, nor do they come about only as a result of the last nine years of below inflation funding.
None of the descriptions above are based on assumptions. They all come from official NHS England and Sustainability and Transformation Partnership policy documents. The reality is evident on the ground.

Risk and Rewards
“Risk and reward sharing is underpinned by a theory of change that expects a provider to adjust its behaviour in response to financial incentives”
Early adopters of the ACO model in 2012 in the US, known as Pioneers (see our report on ACOs for more details), were allowed to move to a full capitated budget. This represents the full transfer of risks from the commissioner to the ACO and it means the ACO has the incentive to cut costs in order to maximise its profit share from the budget. As in those early pioneer ACOs, NHS England has made it clear that it wishes to pass all financial risks to the Integrated Care Systems. But unlike the US model, an NHS ICS does not necessarily have to include acute hospital services in its provider collaboratives. As the greatest losses fall on acute hospital services this creates the possibility of a collaborative being formed only from those providers who can best make profits.
Our report into ACOs explains how many of the participants in the early US pioneer programme failed to see many of the implications of a shared savings programme, seeing only its potential benefits. They later discovered that they had serious financial difficulties.
This question of risk and reward sharing is one of the most important issues for an NHS provider and illustrates how they have moved from being government provided services to government commissioned services. Under this scheme an NHS provider could potentially suffer significant losses risking its financial viability to the point where it may collapse as a business.

The failures of private sector providers, as we have seen in recent years, causes inconvenience for commissioners and loss of services for patients but the potential collapse of an NHS body would have far more serious ramifications. There is also the case where a majority of an ICS’ services are provided by private sector organisations which opens the door to profits flowing out of NHS funds. Furthermore the arrangements for how both risks and rewards will be shared between providers adds another layer of complexity to the transaction costs of the NHS. This, of course, provides yet more work for management consultancies, big accountancy firms and lawyers.

What’s to be done?
We fully appreciate the desire of campaigners to achieve victories in the face of what feels to be overwhelming odds. Each local victory does throw a welcome spanner in the works. However, to ignore the structural changes being brought in and not to recognise the part that each individual closure or downgrade plays in the overall pattern of change is to ignore the elephant in the room.
That is why we think the slogan ‘Act Local, Think National’ should always be embedded in every campaign. It is important to understand that the national picture gives the corporate sector a major role in the future of the NHS as it has done increasingly over the last thirty years and that the model currently being adapted is specifically based on US Integrated Care.
This is a system built fundamentally on business principles with competition and the profit motive in its DNA. This is not a system that lends itself to public ownership and provision serving the public interest.
President Trump’s statement about the NHS being on the table in future trade talks set off a raft of responses including Jeremy Corbyn tweeting, ‘Labour will [..] ensure US private companies cannot lay a hand on our NHS. The NHS is not for sale’ and Matt Hancock saying, ‘not on my watch’. It has understandably provoked a lot of comments on social media and discussions in the press about the importance of keeping the US out of the NHS in the future. But the challenge is to change the conversation so that we openly oppose US corporate interests influencing our NHS now.

Deborah Harrington

Who We Are

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This article was first published in the Camden New Journal under the title, Brexit, and spectre of NHS US sell-off, on 16 May 2019.

There is much talk at the moment about the prospect of Brexit resulting in a trade deal with the US which will sell off our NHS to American private healthcare providers.

This fear has also been expressed by Shadow Health Secretary Jonathan Ashworth. [1] But it is critical to understand this “sell-off deal” has been under way for a long time and is fast gaining momentum, argue Susanna Mitchell and Roy Trevelion.

 

The driver of the “sell-off deal” is Simon Stevens, who in 2014 was appointed head of NHS England, the body that controls all NHS spending. Before this, Stevens had been vice-president and CEO of the mammoth American healthcare corporation the UnitedHealth Group.

Stevens has proceeded to “Americanise” the service through his subsequent NHS policy, based on a privatisation strategy he had outlined at the World Economic Forum at Davos in 2012. [2]

From first to last, his NHS policy – the Five Year Forward View, the Sustainability and Transformation Plans and Accountable Care Organisations (renamed Integrated Care Programmes) that back it up, and now the 10-year Long Term Plan – have worked to import the US model into the UK.

Unsurprisingly, the UnitedHealth Group will make major gains from this transformation. It is now the largest healthcare company in the world, with a 2018 revenue of $226.2 billion. It has many secondary companies that serve more than a hundred-million people globally. [3]

Over the years it has been prosecuted for fraud and bad faith practices. This included limiting insurance payments to doctors, and not stating its true financial results in reports to shareholders. [4] [5]

One of its fastest growing subsidiaries is Optum (formerly UnitedHealth UK). This is a leading information technology- enabled health services business. In February 2015, it was one of the commercial organisations approved by NHS England as “Lead Providers” to carry out the financial work of GPs.

It is now firmly positioned in the system and ready to take away more public money. [6]

The healthcare system in the United States is hugely more costly, and outstandingly less effective than that in the UK. In terms of funding and wellbeing, there is no rational argument for imposing it on our NHS. The only benefit it brings is increased profits for shareholders in the commercial healthcare sector.

To take three examples, first comparing cost:

On average, other wealthy developed countries spend about half as much per person on health as the US – in the US $10,224 compared to $4,246 in the UK. In 2017 the US federal government spent 7.9 per cent of GDP directly or indirectly on healthcare; however in total, taking into account private expenditure, the US spent a vast $3.5trillion or 18 per cent of GDP. This private sector spending is triple that of comparable countries. [7] [8]  This structure excludes many citizens from affordable health­care. Appallingly, one in four adults skipped a medical treatment in 2017 due to an inability to pay. [9]

Secondly, from the point of view of efficacy and wellbeing, statistics are also devastating. The US has the lowest life expectancy at birth among comparable countries (US 78.6, UK 81.2). Statistics show that life expectancy for both men and women has increased more slowly in the US. It comes 12th in the global life expectancy table. [10]

Thirdly, the US maternal mortality rate is truly shocking. It stands at 26.4 per 100,000 live births, the worst among all developed countries. [11]

In the UK the rate stands at 9.2 per 100,000. [12] [13]

Deaths for African-American women are three to four times higher than for white women. [14]

The infant mortality rate is also worse. The US rate is 5.79 deaths per 1,000 live births. [15]  The UK rate is 3.8 deaths per 1,000 live births. [16]

It is clear that if we follow the American model of healthcare it can only reduce wellbeing in the UK. Simon Stevens’ “sell-off deal” simply increases the wealth of global corporations (such as the Mayo Clinic, which has recently opened in London [17]).

It is time that this fact was “called out” loudly and clearly. All possible measures must be taken to prevent the continuing imposition of this ineffec­tive and costly system.

Susanna Mitchell and Roy Trevelion are members of the Socialist Health Association.
References, some links, live at the time of writing, may not have been maintained:
[1] BBC Question Time 25.04.2019  at 47.21 ff  https://www.bbc.co.uk/iplayer/episode/m0004hkk/question-time-2019-25042019 .
[2] https://www.sochealth.co.uk/2017/05/25/truth-stps-simon-stevens-imposed-reorganisation-designed-transnational-capitalism-englands-nhs-stewart-player/
[3] http://selloff.org.uk/nhs/CVforSimonStevens260516.pdf
[4] https://www.sec.gov/news/press/2008/2008-302.htm
[5] https://law.freeadvice.com/insurance_law/insurers_bad_faith/unitedhealth-pays-400-million-in-bad-faith-claim.htm
[6] http://selloff.org.uk/nhs/CVforSimonStevens260516.pdf
[7] https://www.crfb.org/papers/american-health-care-health-spending-and-federal-budget
[8] https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-average-wealthy-countries-spend-half-much-per-person-health-u-s-spends
[9] https://www.federalreserve.gov/publications/files/2017-report-economic-well-being-us-households-201805.pdf
[10] https://www.healthsystemtracker.org/chart-collection/u-s-life-expectancy-compare-countries/#item-le_the-u-s-has-the-lowest-life-expectancy-at-birth-among-comparable-countries_2019
[11] https://www.npr.org/2017/05/12/528098789/u-s-has-the-worst-rate-of-maternal-deaths-in-the-developed-world?t=1560004210914
[12] https://vizhub.healthdata.org/sdg/
[13] http://digg.com/2017/uk-birth-us-safety-comparison
[14] https://www.huffingtonpost.co.uk/entry/elizabeth-warren-black-maternal-mortality_n_5cc0e93fe4b0ad77ff7f717b?guce_referrer=aHR0cHM6Ly93d3cuZ29vZ2xlLmNvbS8&guce_referrer_sig=AQAAACQmWXh6QTnSJI5sjLN1KEdQCuSnVb__LEQLJAyEiK2PZwqnVABYxo500JrU24NHWCooflTZAia50H4OJ-YzSPMUqXyGODWHMGcBXUxhfVY-fau-ViM-Ly9n32SQ1vXD-SGhWXohZRVo2givDSEbM1D3TVs38R5MjmfY_5rGZXuP&guccounter=2
[15] https://www.cdc.gov/nchs/nvss/deaths.htm
[16]https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/childhoodinfantandperinatalmortalityinenglandandwales/2016
[17] https://www.medcitybeat.com/news-blog/2019/mayo-clinic-oxford-university-clinic-partnershiphttps://www.medcitybeat.com/news-blog/2019/mayo-clinic-oxford-university-clinic-partnership.

 

 

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All the Tory contenders to be prime minister should categorially rule out the NHS being part of any future US/UK trade deal, Unite, Britain and Ireland’s largest union, said today (Wednesday 5 June).
Unite, which has 100,000 members in the health service, said the new prime minister ‘should not offer up the NHS as a sacrificial lamb to US president Donald Trump’.
Unite national officer for health Colenzo Jarrett-Thorpe said: “The Tory prime ministerial contenders need to put the national interest – in this case, the safeguarding the NHS from US privateers – before the personal ambition of getting their hands on the keys to 10 Downing Street.” 
Concern about what a US/UK trade deal could mean for the NHS has heightened this week following remarks by Donald Trump and his ambassador in London, Woody Johnson about the NHS being included in a future US trade deal
Colenzo Jarrett-Thorpe added: “The NHS is the UK’s greatest achievement – but for Trump and his ilk, who despise the very idea of universal healthcare free at the point of delivery, all they can see is the money to be made from the sick, frail and vulnerable. 
“This was made obvious by the US ambassador’s very frank comments about his country’s intentions towards the NHS in any future US/UK trade deal, a point that was again made by Trump himself. The president’s comments today are not reassuring in any way. Unless the government categorically says that the NHS is not for sale, then patients and staff will face increasing uncertainty and worry.
“The Tory leadership hopefuls need to state categorially to the British public that the NHS is not up for sale to profit hungry US private healthcare companies as part of a future trade deal.
‘Leading Tories and their cheerleaders in the media may think that the US offers a blueprint for how a post-Brexit Britain should be – however, it should not be forgotten that millions of Americans don’t have any health insurance which does not inspire confidence.
“We strongly believe that the NHS should not be offered up as a free trade sacrificial lamb to the mercurial whims of Donald Trump – our sick, frail and vulnerable deserve so much better.”

 

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We are the regulator for pharmacists, pharmacy technicians and registered pharmacies in Great Britain. We set standards for pharmacy professionals.

We are consulting on guidance for pharmacist prescribers which sets out the key areas they should consider when prescribing to ensure they provide safe and effective care. Pharmacist prescribers can diagnose conditions and prescribe medicines to patients. They often work in GP practices as well as in other healthcare settings, and can also work as part of an online prescribing service.

 

Read our proposals and tell us your views now

 

We want to understand the impact of these proposals on patients and the public. Help us spread the word by encouraging your members to take part. To help, we have a toolkit of materials which you can download from our website.

We look forward to hearing your feedback.

Best wishes

Mark Voce
Director of Education and Standards

 

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Patients still make enquiries at busiest hours, despite 24/7 online access

· University of Warwick publishes first independent evaluation of one of the main providers of online consultation platforms

· Targeting services at younger patients and those with general administrative enquiries could be most effective

· “In reality, patients were seeking access to health care at the same times and for the same sort of problems than they did using traditional routes.” Says supervising author.

Patients are using online consultations in the same way they would arrange a consultation via traditional means, a new independent evaluation by the University of Warwick reveals.

Despite this, the study identifies several opportunities to tailor online platforms to specific patient requirements and improve their experience.

Primary care researchers from Warwick Medical School have today (26 March) published the first independent evaluation of one of the main providers of online consultation platforms in NHS general practice. Published in the British Journal of General Practice, it provides independently analysed information on the types of patients that are using online triage systems, how and when patients are using this platform, and what they think of it.

Online triage is a system in which patients describe their problems via an online form and subsequently are telephoned by a GP to conduct a telephone consultation or arrange a face-to-face consultation. Practices aim to respond within one hour of receiving the request.

The researchers examined routine information from 5140 patients at nine general practices using the askmyGP platform over a 10 week period. Highest levels of use were between 8 am and 10 am on weekdays (at their highest on Mondays and Tuesdays) and 8 pm and 10 pm at weekends, mirroring the busiest time for patients contacting their practice via telephone.

Supervising author Dr Helen Atherton, from Warwick Medical School, said: “With online platforms there is an assumption that having a 24/7 ability to make contact with a general practice will cater to those who wish to deal with their health problem at a convenient time, often when the practice is shut, and that being online means they will perhaps share different problems than they would over the telephone or face-to-face.

“In reality, patients were seeking access to health care at the same times and for the same sort of problems than they did using traditional routes. This suggests that patients’ consulting behaviour will not be easily changed by introducing online platforms. Therefore practices should be clear as to exactly why they are introducing these online platforms, and what they want to achieve for themselves and their patients in doing so – the expectation may well not meet reality.”

The NHS Long term plan sets out that over the next five years all patients will have the right to online ‘digital’ GP consultations. The main way these are being delivered is via online consultation platforms. The online platforms claim to offer patients greater convenience and better access and to save time and workload for GPs, however there is currently a lack of independent evidence about their impact on patient care and care delivery.

Patient feedback analysed as part of the study showed that many found the askmyGP system convenient and said that it gave them the opportunity to describe their symptoms fully, whilst others were less satisfied, with their views often depending on how easily they can normally get access to their practice, and on the specific problem they are reporting.

The study found that two thirds of users were female and almost a quarter were aged between 25 and 34, corroborating existing evidence. The commonest reason for using the service was to enquire about medication, followed by administrative requests and reporting specific symptoms, with skin conditions, ear nose and throat queries and musculoskeletal problems leading the list.

The researchers argue that practices should avoid a ‘one size fits all’ approach to implementing online consultations and should tailor them to suit their practice populations and model of access, considering whether it is likely to add value for their patient population.

Dr Atherton adds: “Individual online consultation platforms are uniform in their approach, patients are not. We found that patient satisfaction is context specific – online consultation is not going to be suitable for all patients and with all conditions and that one approach is unlikely to work for everyone.

“Practices could focus on encouraging people to deal with administrative issues using the platform to free up phone lines for other patients. It could be promoted specifically to younger patients, or those who prefer to write about their problems and not to use the telephone. Clear information for patients and a better understanding of their needs is required to capture the potential benefits of this technology.”

· ‘Patient use of an online triage platform; a mixed-methods retrospective exploration in UK primary care’ published in the British Journal of General Practice, DOI: 10.3399/bjgp19X702197

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Peter Beresford, Professor of Citizen Participation at Essex University and Co-Chair of Shaping Our Lives, the user led organisation.

Nothing less than a root and branch reform of English social care is now needed. Its funding and principles must be radically reviewed. Only this will end its permanent state of crisis. Nothing else will make anything like a reasonable life possible for the millions of older and disabled people and family carers now suffering-  sometimes in extreme – from its gross failure and ever declining reach. Some commentators still wait hopefully for the promised government green paper that never comes, but given this administration is still committed to its same old neoliberal goals, it is difficult to see why. What’s needed is a fresh start.

According to the NHS’s own figures, since 2009 the number of people receiving adult social care in England has fallen, despite significantly growing levels of need. In 2009 1.8 million people received some adult care services in a 12 months period. Today the figure is estimated just over 1 million, a cut of 44%. People are also receiving less support and in the many cases where they have to pay, paying more. This year Age UK estimated that 1.2 million people don’t receive the care support they need with essential living activities.

Most people assume that social care is provided on the same basis as the NHS, paid for out of general taxation and free at the point of delivery. In fact the absolute opposite is the case. It is a relic of the old much hated Victorian Poor law. It is both means and needs tested. This coupled with years of arbitrary welfare benefits cuts in the name of ‘austerity’ and combatting ‘fraud’, means that the lives of many older and disabled people have never been so insecure, impoverished or undermined since the creation of the post war welfare state.

So that’s the first thing that must change. It’s not just that social care needs to be ‘integrated’ with the NHS – a favourite word of current policymakers – in principle and practice – in values and funding base as a universalist service, free for those who need it. It also need to be based on the philosophy of independent living developed by the disabled people’s movement. This means that instead of framing service users in deficit terms – what they can’t do – it is rebuilt on the fundamental principle of making it possible for them to live their lives on as equal terms as non-disabled people, non-service users. And this demands similarly based income maintenance, housing, education, employment, planning, transport and other policies.

We are not going to see this from right wing governments committed to ‘the small state’, the individualising values of the market, regressive taxation and cutting state spend on supporting people. But this must be the basis for any political party committed for the future to securing the rights and needs of all its citizens (as well as challenging hostility and discrimination against non-citizens).

To achieve this, advocates of truly radical reform of social care, are calling for an ‘independent living service’, which has the financial backing and overview of the treasury and which brings together the roles and responsibilities of all departments to make possible equal lives for the rapidly growing minority of disabled and older people who can expect to need support. Thus, like the NHS it would be harmonised from the centre, to avoid the problems of the present post-code lottery arrangements linked with the current locally led system.

The present loss and impoverishment of many user led organisations; that is to say those directly controlled by disabled people and other service users, needs urgently to be reversed and such a national network supported to be a key provider of support and services on a human and local scale for service users, offering a key source of accessible high quality training and employment to service users for whom employment is a positive and realistic choice.

Finally in an aged of AI – artificial intelligence – social care needs to be reconceived as a major generator of positive relationship-based employment and a net social and economic contributor that can be part of a new sustainable economics and social policy. Here we can see the vanguard of a new planet friendly approach to social policy, that offers the promise of high quality support, high quality employment and truly participatory policy and practice.

Professor Peter Beresford is author of All our Welfare: Towards Participatory Social Policy, Policy Press. He is emeritus professor of social policy at Brunel University London, professor of citizen participation at Essex University and co-chair of Shaping Our Lives.

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Background

The NHS Executive outlined eight groups of suggested legislative changes in the NHS Long Term Plan and, as promised in the Plan, these have now been set out in further detail in Implementing the NHS Long Term Plan: Proposals for possible changes to legislation [1]. The intention is to make it easier for NHS organisations to work together. Ostensibly these proposals are supposed to help the NHS improve its delivery of services but we see real problems here.

Principal objection

The Health and Social Care Act 2012 was a package promoting a range of checks and balances on the operation of the NHS, designed to support local commissioning; patient choice and competition at the provider level; governed by arm’s length regulators safeguarding quality and the NHS market; and local authority and consumer scrutiny, consent and supervision.

It is not easy to change one part of this without unravelling the whole but this is what is now proposed. There are good arguments for the complete revocation of this Act with its muddled thinking, naive faith in competition and GP-led commissioning, and the notion that politicians could shirk their own responsibility for taking difficult decisions by passing the buck to NHS managers and regulators.

But such a major change should only be done after full discussion, white papers, consultation and time to debate primary legislation in Parliament. These proposals are nothing more than a way of avoiding full Parliamentary discussion. The danger is that ad hoc tinkering rather than fully thought through reform will do more harm than good.

Lack of evidence

The supposedly new ethos promoted in these changes is ‘integration’ of service provision under one body. This may appear a plausible way forward but it is unproven as an operational principle or as a means of delivering improvements in efficiency or quality. The House of Commons Select Committee[2], the National Audit Office[3] and more recently the Nuffield Trust[4] have all produced highly critical reports of the new fashion for so-called integration. As yet these criticisms have not been answered.

A recent perplexed quote relating to the Greater Manchester (GM) experience sums matters up, “Everyone I’ve spoken to is at a loss to explain why GM’s performance has been so poor, given the progress that’s been made on integration and the transformation investment that’s gone in”, HSJ 25th February. The true lesson here is that integration does not guarantee success. But this is a lesson that NHS bosses do not want to hear.

We have closely monitored projects in various parts of the country that have been forced to pursue this transformation and integration agenda and, in for example Manchester where massive investment has taken place, there is precious little to show for it. The latest reports from the Nuffield Trust show that integration is a more costly model[5]. These proposals therefore lack evidence that the new policy response will succeed.

The downside of the proposals

All new proposals must demonstrate that they will do no harm. But, by making it easier to force mergers and close down acute hospitals in the name of ‘integrating’ services, the NHS is seeking to institutionalise a model that seeks to cut local services for patients without adequate consultation, and push back onto the patient the costs and delays of the failures of care that will result. At least checks and balances were built into the Health and Social Care Act 2012 requiring proper presentation of detailed plans, independent regulator support, widespread local stakeholder support and the right to challenge decisions; these would now be scrapped in favour of a centrally-led structure with NHS England at its heart, leading a purge of NHS capacity as it strives to meet government-imposed arbitrary financial targets.

These proposals are nothing more than a power grab by NHS England to enable its own transformation and integration policies to be imposed on unwilling communities. This is to be achieved by reducing the role of the independent regulators to mere ‘yes men’ as NHS England becomes the only source of power; by elevating the achievement of financial results to the overriding objective (best value); by being unaccountable to local people by removing the link to local accountability which however faulty was the basis for major decisions; and, by promoting a vague and meaningless slogan (integration) as the main principle justifying its activities.

Concluding remarks

This is a power grab by NHS England under cover of the distraction of Brexit to achieve for itself untrammelled power over the future of the NHS. It will then act quickly: a wave of mergers, closures and sub-contracting of new models of care would be unleashed. These changes would be enacted quickly and with very limited means for local people to challenge decisions.

MPs will find themselves and their constituents faced by a fait accompli with little that can be done. Voters in upcoming general and local elections will express their feelings for local hospitals in the traditional way (by voting against politicians who allowed this to happen). But it will be too late. Hospitals and A&E departments once closed rarely re-open. Services sub-contracted for 10-15 years or more will be difficult to restore. Huge integrated care organisations will be monopolistic in attitude and operation, and impossible to be held accountable effectively.

Local authorities will be either incorporated into this mess in return for crumbs off the NHS table, or left out in the cold while decisions take place around them that will push the costs and implications of changes onto patients and communities.

Oppose these changes to legislation. Integration is a smokescreen for NHS England to overrule local objections to service closures.

 

Roger Steer

14.3.2019

[1]

Implementing the NHS Long Term Plan: Proposals for possible changes to legislation

Engagement Document  February 2019 Prepared by: NHS England Strategy & Innovation Directorate and NHS Improvement Strategy Directorate

https://www.engage.england.nhs.uk/survey/nhs-long-term-plan-legislation/consult_view/

[2]

https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/650/650.pdf

[3]

Health and social care integration NAO February 2017

[4]

Shifting the balance of care Great expectations Nuffield Trust March 2017; and

Doomed to repeat? Lessons from the history of NHS reform  Nuffield Trust October 2018

[5]

https://www.nuffieldtrust.org.uk/research/age-uk-s-personalised-integrated-care-programme-evaluation-of-impact-on-hospital-activity

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We welcome comments on this article which has come out of the Reclaim Social Care Campaign. It is not SHA policy, but it raises important questions relevant to both social care and the NHS.

This is a wide field in which a variety of species flourish, some of which are dangerous invasives. We need to cultivate systematically to ensure that what grows in this field is healthy, productive, and not a threat to other growth. We need to be able to classify, in order to isolate rogues, and then eradicate them. We need to be able clearly to identify some of the more rampant plant life, in order. maybe, to consider techniques of pruning.
I come to this view of the wider challenge from an interest in cultivating a little patch in this field – one area that I think is growing some special and healthy new life. My patch is occupied by a Community Interest Company. This organisation safeguarded one local piece of our National Health Service, by propagating it and preserving it from being hybridised – merged– a with a completely different plant that would have taken us over. We have created an organisation that is of our community, for our community, and owned by our community.
I am a fervent supporter of the NHS, especially having, for 15 years, suffered under the US excuse for a health system. I have been a member of the Labour Party since 1972. The principles of the NHS, as promoted by the Labour Party from 1948, are not negotiable, but there are different ways to organise to support those principles. I believe that there are freedoms in a CIC organisation that make it easier to maintain some aspects of health and social care in conformity with those principles – not everything in the way the NHS organises itself and runs its staff and services is perfect. My purpose in writing this paper is to try to distinguish the different types of possible organisation, to identify the healthy growth points, and also rogue growth.

I start with a straightforward definition:
“A simple definition of “public sector provider” in this context is: one that is constitutionally owned by the community or the State and operates not for profit.”

If one were to operationalise that definition, one would be able to draw a line across one large sector of our field – often called “The Third Sector”. If I understand that term correctly, it contains both charitable bodies and the range of different social enterprises. My simple definition, once operationalised, would separate those two parts of that Third Sector: charitable bodies are accountable through Boards and the Charity Commission – they are not “constitutionally owned by the community or the State”.
The largest part of our health field – diminishing and under threat, but the revered sector whence proliferate (or struggle) the heirloom crops – is defined by the phrase “constitutionally owned by the State”. It should not be hugely difficult to operationalise this definition, in which “State” could be national or local.
That leaves, I think, the cultivators of two sections of field to be pinned down: commercial cultivators and the social enterprises. The word “enterprise” – a word sullied with muck in some horticultural circles – creates a confusion for some, but I think my first definition, with its reference to “constitutionally owned by the community”, serves to draw a line between private enterprise and “mutual enterprise”. I think that an operational definition of private enterprise is achievable.
That leaves the mutuals, or social enterprises. That is a field with subdivisions. Those dividing lines have been traced by Geraint Day and Mo Girach, among others -The semantics of the ‘Big society’: Social enterprises, mutuals and co-operatives, NHS Alliance, August 2010. One subdivision contains CICs, like the one I am associated, whose constitutions place ownership in the hands of not just the workers in the mutual, but the whole community.
There is a programme in this for a whole load of research, I guess:


I would like to ask readers of this paper:

a) If they find the subdivision of the field proposed above useful
b) If they know of any work that pushes forward on defining some of the boundaries in a way that generates precise facts
c) If they know any facts that would give a more accurate version of the numbers guessed in the left-hand part of the diagram above

Once we have divided up the field in a manner that commands some agreement, we can then consider different ways of dealing with different plant species. Even the more aggressive plants might have their uses, if we can refine our horticultural techniques. I believe that there is a lot of mileage in looking at this horticulture from the point of view of risk management. If one can be clear about the risks involved in handling each type of plant, one can be more confident of training each plant to grow to maximise its useful productive capacity. Leaving this (rather seductive) metaphor behind – what one needs to aim at is to understand the types of contract each type of organisation can sustain in a way that optimises their capacity for good, and minimises the risk of bad.
I believe that we can get a long way by distinguishing between contracts in which the best way forward is to share risk between commissioner and provider – those are not safely handled outside public sector partners. But there are also opportunities for what I would call “segregated risk” contracts, where we might watch private enterprise do what it is best at, without massive risk.
But that is another discussion.

And there is a third related discussion we could have: in addition to an operational – i.e. useful – definition of the concepts discussed above, it would be advantageous to come up with legal definitions of some of these concepts. Here are some of the challenges encountered in searching for legal definitions with reference to a CIC:
• The CIC may be “owned” by the citizens of the community/Borough/town, but …
• What are the implications of “ownership”?
• How is the CIC accountable to the owners?
• Our CIC has a Membership Council – community and staff, but …
• Are the members of the Council representatives?
• … of whom?
• What is the “membership”?
We tried launching a membership drive, but foundered on the fact that there was nothing we could offer “members” that we didn’t want to give them simply as one of our population of potential or actual service users. We eschewed the practice of our Acute NHS Foundation (and many other Foundations) – of simply “signing up” everyone who comes through the door, in order to create an artificial “membership” number.

• What if some services are also offered in other communities? What if the organisation is willing to expand into other places it the circumstances are propitious?
• How does one characterise membership in locations where the organisation plays a minor role in the range of care?
• and on and on
The efforts of the CIC to represent the needs of its community may be completely genuine. The CIC may know that the core, at least, of its community is the citizenship of the community/Borough/town that it serves, and that may be enough for pragmatic purposes. It is better to have a practical rationale for pressing forward with doing good, rather than getting too caught up in definitions.
But, if there are readers out there who can help with legal definitions, or examples, or processes for enacting representative monitoring, then please share.

The risk for some social enterprises is that they can be captured by the profit motive or by the private sector. This is a risk that increases as money gets tighter. There are ways to have insurance against that threat, and not necessarily in terms of formal accountability and representativeness. One approach is to mount a diligent programme to embody the principles of organisation in the whole organisation – all members of the staff – and to ensure that principled continuity is not dependent on a small group of founders.
The CIC of which I am a Community Governor has some very creative approaches to ensuring continuity, principle and direction in this way. But that is yet another story.

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It is over 40 years since the Alma-Ata Declaration asserted the crucial role of primary care in the promotion of the health of people world wide. Since then global health policy has attempted to give effect to the Declaration with varying levels of success. The situation has been no different in Wales.

The Wanless Review in 2003 re-emphasised this message. It stated “ …(t)he current configuration of health services places an insupportable burden on the acute sector and its workforce. This is the most expensive part of the system … (t)he primary care sector in turn is not sufficiently resourced or incentivised to keep patients out of hospital though it is hoped that the new General Medical Services Contract (under discussion at the time of this report) will create such incentives.”

The publication of the final report by the Welsh Parliamentary Review on health and social care ( January 2018) shows that this still remains the main challenge. In response the Welsh Government has published A Healthier Wales and a Strategic Programme for Primary Care. Both these policy statements will have to be matched by a determined political will if they are to prove successful.

In 2018 the Wales Audit office stated that “ (b)etween 2010-11 and 2016-17, total health board spending in Wales …. increased from £5.39 billion to £6.32 billion. However, over the same period, recorded spending on primary care as a percentage of total health board spending in Wales ….. reduced from 25% to 22%.This would suggest that the shift in resources towards primary care that has been at the centre of much of the NHS policy in recent years is not being achieved.” No amount of smart or new types of working will be able to make up for this basic deficit. If primary care is to thrive it needs resources and investment.

This has been highlighted in the number of GPs working in Wales. Between 2004-05 to 2010-11 the number of GPs rose from 1,800 to 2,000. However since then things have been more or less been static until there was a 4% decline between 2016 and 2017. By way of contrast the numbers of hospital consultants has increased by 40% between 2009 and 2017.

However these headline figures do not tell the full picture. While there are now just under 2,000 GPs listed in Wales. Approximately 1,500 of the listed GPs were contractors with the remaining 400+ being salaried. However there is a concern that the official statistics do not present a fully accurate picture particularly in relation to the number of salaried doctors. And there are, in addition, a further 750 doctors working in system who are classified as locums or sessional GPs . This represents a 10% increase since 2016 when figures were first collected.

Vocational training is central to securing a future workforce. The RCGP estimates that Wales needs to have 184 positions to be on a par with the rest of the UK. There has been an increase of 15% in posts over recent years with to 90% being filled but the overall numbers have still to reach UK levels.

The Welsh Government therefore faces a major challenge to increase capacity in its primary care and general practice service. There is abundant evidence that GP workload is increasing both quantitatively and in its complexity. In response there must be an a substantial increase in the workforce as the Welsh Government itself acknowledges the service is not sustainable if it can only survive by the “heroic” efforts of its staff.

Non-medical practice staffing levels has increased by over 7% in the last half decade with approximately 2,500 clinical and 5,000 administrative staff now being employed. Despite these increases the RCGP reports that there are still 20% of GPs do not have access to a practice nurse, 35% to a practice pharmacist and 50% to a physiotherapist. This is clearly not good enough.

The challenge in recruiting and retaining GPs also looms large. Both the GPC and RCGP in Wales still insist that “.. (i)t is a fact that the independent contractor model is best for the patients of Wales and is the most cost-effective option for those who hold the purse strings in both Welsh Government and Health Boards. “ But with 20% of GPs already salaried and with almost twice as many more working as locums and sessional doctors there must an urgent need to review the way they work for and with the NHS.

The Welsh Government acknowledges that the contractor partnerships will continue to be the cornerstone of general practice in Wales. But it also accepts that this model it is no longer a preferred option for many new doctors. They are not attracted to the business ethos, financial risks, administrative demands, inflexibility and investment costs which go with being an independent contractor. So while the concerns of independent contractors must be addressed there is also a need for a more diverse range of career options for future general practitioners.

There are some interesting innovations taking place seeks to address this need. The Primary Care Support Unit in the Cwm Taf Health Board has been in existence since 2002. Social enterprise models for care delivery have been adopted in Bridgend and south Powys. But overall they are still too few to achieve the critical mass that is needed to achieve transformational change.

Somewhat strangely the “GP establishment” seems to fear that health boards and the Welsh Government are rubbing their hands in glee at the prospect of becoming direct providers of primary care services. The reality is almost totally the opposite. There are now over 30 directly managed GP practices in Wales but in virtually every case local health boards have found themselves reluctantly obliged to get involved. This lack of enthusiasm for a public service general practice option must be urgently addressed.

The Strategic Programme for Primary Care confirms the Welsh Government’s commitment to delivering primary care services through 64 primary care or clinical networks based on populations of 50-100,000. These networks are tasked with bringing primary and social care services together along with the third sector to cater for the needs of their populations. There is a widespread support for this model both politically and across the professions. The Welsh Government has channelled much of its recent primary care investment through the networks to stimulate local innovation and service improvement. Their success to date is a bit mixed and in some cases they have an uneasy relationship with their local health boards.

Innovation in primary care is also being actively promoted though the £4m Pacesetter / Pathfinder programme which began in 2015 with 24 distinct projects. The objective was to either develop new ways of working or to promote the wider dissemination of new ways of working. The programme received support from Public Health Wales and it is hoped that health boards would mainstream the practice of the successful projects. As these projects come towards the end of their initial phase this is recognised as being critically important. But it has also been appreciated that those areas where services are under the greatest stress are least likely to engage with the exercise.

The Welsh Government has prioritised tacking health inequalities and asserts “..the fundamental Bevan principle that it is clinical need which matters when it comes to deciding treatment by NHS Wales.” In his annual report 2015-16 the Welsh Chief Medical Officer, Dr Frank Atherton, recognised this in stating “ … we make the case that one-size-fits-all health and care services in the traditional sense may not always be the best approach, as they can maintain, and sometimes increase, health inequalities. Instead we argue for an approach which is proportionate to the level of disadvantage which is often referred to as proportionate universalism.” But Welsh Government policy  is at its weakest it comes to outlining how this is to be achieved.

Public Health Wales (PHW) has done a lot of work in identifying health inequalities across Wales and profiling populations to clinical network level. It shows that the difference in prevalence of good health between people living in the least and most deprived areas is already apparent at age 0-15. This gap then grows as age increases, peaking in males at age 65-74 (79% in least deprived vs 52% in most deprived) and in females at age 55-64 (84% vs 56%). And it is in these disadvantaged areas where we also find the greatest prevalence of patients with complex multi-morbidity.

This work by PHW provides an excellent stepping stone for planning the promotion of health and well-being and the delivery of primary care services. But there is little evidence that this is happening on any scale. The Strategic Programme for Primary Care provides a lot of important one-size-fits-all advice for primary care but it only makes the most cursory of references as to how the new, transformed Welsh NHS will address health inequalities on the front line where 90% of health service contacts take place. This is its fundamental weakness.

Welsh health and social care policy strongly argues for a new approach that will put a focus on prevention, which promotes a social model of health and well-being, seeks to address the social determinants of poor health and which will tackle the stubborn continuation of health inequalities. In many policy areas concrete proposals have been put forward to address this agenda. But there in health and social care the details still need to be outlined and put in place.

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Security staff at Southampton General Hospital being attacked in the A&E department is key to an industrial dispute over pay and sickness pay.

Unite, Britain and Ireland’s largest union, said its 21 security staff members were being attacked on a regular basis by members of the public either under the influence of drink or drugs, or with mental health problems.

Unite is currently holding a ballot for strike action or industrial action short of a strike of its members, employed by Mitie Security Ltd, at Southampton General Hospital over pay and conditions. The ballot closes on Wednesday 15 March.

Unite said that Mitie Security was refusing to provide adequate personal protection equipment (PPE), such as stab vests and  safety restraints, even though knife-related incidents are increasing.

Unite lead officer for health in the south east Scott Kemp said: “With cuts to the police force and mental health services, there is a tendency for those suffering from various conditions to be dropped off at the hospital and left to the security guards. 

“The statistics are not easily available as to the number of our members who have been injured. There has been a lack of proper investigation into the incidents over a considerable period.

“The guards report incidents that have occurred on every shift, but the bosses at the University Hospital Southampton NHS Foundation Trust and Mitie Security will only investigate when someone is injured.

“Our members are very concerned over incidents occurring right across the Tremona Road site when there has been little or no support from the police who are under pressure because of government cuts.

“Our argument is that we should not have to wait for someone to get injured before a full investigation is instigated.

“That is why the sick pay arrangements are really important. At present, if the security staff are injured at work, and if the resulting investigation finds in their favour, they get two weeks’ full pay and then two weeks’ half-pay. After that, it is the statutory minimum.

“We have members getting beaten up and then having to return to work after two weeks, when they are clearly not fit to, as to drop down to half-pay would mean missing mortgage or rent  payments and significant financial hardship.

“What we want is enhanced sickness payments for those off work due to being injured protecting patients and hospital staff; proper and transparent investigations into all attacks; and our members having the necessary personal protection equipment.

“Our members are seeking six months’ full-pay, followed by six months’ half-pay for all sickness absences. We don’t think those are unreasonable requests, given the level of violence in today’s society generally.”

Unite said that the demand for an increase in pay from the current £8.64 an hour reflected the stress of the job. The security staff are seeking £10.50 for security officers and £12.16 for supervisors, with additional payments of 50p per hour on night rates; £1 an hour on Saturday and double time on Sunday.

Scott Kemp added: “Our members are at the forefront of providing security and a safe environment for staff, patients and visitors – that’s why Mitie’s management needs to get around the table and negotiate constructively.

“There is now a good window of opportunity for such talks before the ballot for strike action closes on 15 March.”

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The Pharmaceutical Journal reports that the Good Law Project threaten DHSC with legal challenge over “failure to consult properly”

From The Pharmaceutical Journal 21 FEB 2019 By Carolyn Wickware:

The Good Law Project has warned the Department of Health and Social Care that it will start judicial review proceedings if serious shortage protocol powers are not revoked on the grounds that the consultation was “insufficient and unlawful”.

A non-profit group has threatened the government with legal action unless it revokes new powers designed to allow pharmacists to switch patients’ medicines if there is a shortage.

The Good Law Project has said it will start judicial review proceedings over newly implemented “serious shortage protocol” powers if the Department of Health and Social Care (DHSC) fails to remove the amendments in legislation by 25 February 2019.

Amendments to the Human Medicines Regulation 2012, which came into force on 9 February 2019, mean the government can now issue protocols asking pharmacists to respond to a medicines shortage in one of four ways: to dispense a reduced quantity, a therapeutic equivalent, a generic equivalent or an alternative dosage form of the drug.

Under the protocol, the pharmacist would not have to consult the patient’s GP before making the switch.

The Good Law Project is now seeking to launch a judicial review of the amendments, partially on the grounds that the government’s initial consultation – which lasted one week on 5–12 December 2018 – was “insufficient and unlawful”.

In a legal document sent on 19 February 2019 from the group’s lawyers to the DHSC to inform them of their intent to start the review proceedings, the Good Law Project said it was “unclear exactly who the Secretary of State consulted with and how/on what basis”.

It added: “The failure to consult properly with organisations representing specific patient interests was unlawful.”

Ekklesia reports:

Jolyon Maugham QC, Director of the Good Law Project, said: “Both doctors and patients have proper concerns about their safety in the event of medicine shortages. We want the Government to withdraw the prospect of SSPs [Serious Shortage Protocols] until it has complied with its legal duties and consulted properly on their use. If the Government does not take this step, the Good Law Project will launch judicial review proceedings in the High Court.”

Professor Tamara Hervey, Specialist Adviser to Parliament’s Health and Social Care Committee, said: “In the event of a no-deal Brexit, there would be likely to be shortages of medicines. The absence of a legal framework for imports and exports drastically affects supply chains. Stockpiling plans cannot cope for more than a few weeks. This is a serious issue for people needing a regular supply of a particular type, strength and quality of medicine.”

Jane Hanna, Chief Executive of SUDEP Action, who is supporting the judicial review said “Patients, doctors and pharmacists are used to prescriptions and the processes surrounding them. For people with long-term conditions, like epilepsy, what is on the prescription may represent months and years of trying out the best medication schedule. Changes made to this delicate balance can for some, undo this in an instant. For epilepsy this could lead to less seizure control, impacting on quality of life (ie: losing a driving licence, affecting home and work) and significantly for some this can prove fatal.  At present if a supply of medication is made in error, lessons can be learnt because of the clarity of who signed and who supplied the prescription.

Deborah Gold, Chief Executive of NAT (National AIDS Trust) said: “We are deeply concerned that these changes were made without proper consultation. Prescribing HIV medication is a complex process which must take account of a multitude of factors. The only person qualified to safely alter the medication prescribed to a person living with HIV is that person’s HIV consultant.”

• The Pre Action Protocol Letter can be seen here

 

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Responding to the Health Secretary’s pledge to overhaul mental health and wellbeing services for NHS staff following the launch of a Health Education England review, BMA mental health policy lead, Dr Andrew Molodynski, said:

“Staff are fundamental to the delivery of patient care in the NHS and without a healthy workforce our health service can barely function, let alone thrive.

“Given the current pressures that the NHS workforce is under, the Secretary of State for Health and Social Care’s commitment to improving mental health and wellbeing support for staff is both timely and necessary.

“We know that doctors’ mental health and wellbeing has been adversely affected by the increasing demands of their work and this is true also for medical students who are dealing with stress, fatigue and exposure to traumatic clinical situations, very often without adequate support on hand.

“The BMA recently for greater provision of mental health support for NHS staff as their report¹ found that only about half of doctors were aware of any services that help them with physical and mental health problems at their workplace – while one in five respondents said that no support services are provided.

“While these measures will go a long way to providing much-needed support for NHS workers who are struggling with their mental health and overall wellbeing, more must be done to address the wider pressures on the system, such as underfunding, workforce shortages and rising patient demand, so we can reduce the number needing to seek help in the first place.”

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