Category Archives: NHS Commissioning

The following article was first published in the Camden New Journal on 06 December, 2018

A private company being promoted
by government to recruit patients to its doctor service spells ruin for the whole-person integrated care we need from the NHS, argue
Susanna Mitchell and Roy Trevelion

The sneaking privatisation of our National Health Service now aggressively threatens our GPs. In Camden and across London, we all need to be aware of the long-term harms this development will cause GPs and primary care NHS services.

Last year, a global multinational corporation called Babylon Healthcare – owned by a former Goldman Sachs investment banker and Circle Health CEO – established a “digital- first” business called “GP at Hand”.

Disastrously for the NHS, Babylon Healthcare Services Ltd can be traced back to a holding company in Jersey, the offshore tax haven.

GP at Hand is contactable through a mobile app which uses standard calculations as a symptom checker. Unfortunately NHS England have not provided our existing practices with this software.

Instead any patient registering with this commercial enterprise will be deregistered from their normal GPs. And, although the GPs employed by the company can also be accessed by video or phone, this process delivers no continuity of care or whole-patient assessment.

Continuity of care is a cornerstone of general practices. However, Matt Hancock, the health secretary says, “If we need to change the rules to work with the new technology then change the rules we must.”

In addition GP at Hand’s own promotion material actively discourages older people from registering. Explicitly these are those who are frail or living with dementia, or in need of end-of-life care. Pregnant women and those it describes as having complex social physical and psychological needs are also discouraged from signing up.

In other words it is “cherry-picking” young and healthy patients who will be more profitable to its shareholders. Its use of standard practice via information technology, and the easy access it offers, is particularly attractive to the young.

Of the 31,519 new patients who have signed up with GP at Hand over the past 12 months, 87 per cent are aged between 20 and 39 years, while patients over 65 now make up just 1 per cent of the population registered with the service.

All this poses serious problems both for patients and general practices. In the first place, our present primary care system consists of GP practices committed to whole-person and integrated care for everyone in their local communities. Healthcare services are organised around geographic areas to enable better co-ordination with hospitals and social services.

In contrast to this, GP at Hand fractures this fair and impartial community-based model, registering patients who live or work anywhere within 35 to 40 minutes of one of the clinics. In addition, should any of their patients require more complex care, they will no longer have their own GP to turn to.

Secondly, by picking the most profitable patients, GP at Hand drains money away from ordinary GP surgeries. Normal GPs are funded according to the number of people on their patient list and this funding is combined into a single budget to provide the services they offer. This means that funding from the roughly 80 per cent of patients who remain reasonably well helps to pay for the 20 per cent who are elderly, who are chronically sick, or have multiple illnesses.

But if the “capitation fee” of the young and healthy is scooped up by a for-profit company like GP at Hand, it will critically undermine the funding available to surgeries. This will leave practices to deal with the sick, the frail and the old on a much reduced budget.

Shockingly this commercial entity is funded by NHS England. It can be commissioned through our clinical commissioning groups (CCGs).

It’s expanding fast, and already has over 35,000 patients. Currently the corporation operates out of five clinical locations in London including one in King’s Cross. Plans for rolling it out nationwide are under discussion. It is also advertised widely, with the health secretary Matt Hancock recently announcing that he has registered with the company.

Future developments in information technology and artificial intelligence that can be useful to our public health systems should be funded directly towards our existing GP surgeries.

It should not be used as a vehicle for profit-making by private corporations at the expense of our NHS.
We need to make the dangers of adopting this business model clear to the widest possible public. We must encourage those who care about our publicly-funded NHS to boycott Babylon’s GP at Hand.

We need to bring public pressure to bear and end this attack on a valued and trusted institution that serves us all.

The NHS has always been for the benefit of everybody. It must be kept that way.

• Susanna Mitchell and Roy Trevelion are members of the Holborn & St Pancras Labour Party and of the Socialist Health Association.

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Following the Judicial Review in London in July, NHS England quietly launched its promised public consultation on the Integrated Care Provider (ICP) Contracts on 4 August. The consultation closes on 26 October.  If the appeal granted at the other Judicial Review called for by 999 Call for the NHS in Leeds is successful, this ICP contract may yet be unlawful, but it is nonetheless essential that we respond to the feedback.

The ICP consultation document is a daunting read for most of the public. However, Health Campaigns Together (HCT) has provided expert answers to all 12 points in the public feedback document. 

HCT’s aim in providing these answers is to prevent flawed plans being adopted. They are seeking to prevent long-term contracts being signed that will undermine our NHS. This is in order to preserve any hopes of achieving a genuine integration of health and social care as public services, publicly provided free at point of use – and publicly accountable.

 

A reminder on what’s happened so far: There have been two judicial reviews on the Accountable Care Organisations and these Integrated Care Provider (ACO/ICP) contracts. And the courts found in favour of the NHS. But one of the campaign groups, 999 Call for the NHS, has now been granted permission to appeal. 

This is some very good news. But it also means NHS England is consulting on an ACO/ICP contract that may be unlawful. 

NHS England knew full well that an appeal was a possibility. Although fully aware of this, on Friday 3rd August – the day Parliament and the Courts went on holiday – NHS England started a public consultation on the ACO/ICP contract. The consultation says that the Judicial Reviews had ruled in their favour. This consultation runs until 26 Oct.

 

We all know that this ICP consultation needs to be combatted and stopped. But in the meantime, here’s all the information you need to fill in the consultation feedback.

As stated, the judge in the London NHS Judicial Review said that the ACOs (now ICPs) should not be enacted until a lawfully conducted consultation was held, and any eventual ICP contract would have to be lawfully entered into.

Since then, NHS England have moved swiftly and stealthily into gear, and you will find their monstrous ICP ‘consultation’ document at this link.

And here is Health Campaigns Together on the subject at this link.

As you see, the consultation document includes 12 points for feedback and Health Campaigns together has provided suggested responses to these points – very good responses too, I think. You’ll find them at this link.

When you’re ready here is the direct link for public feedback to the document, just copy and paste from the Health Campaigns Together link above.

As stated, there is a move afoot to get the consultation suspended until after the appeal granted to the 999 for the NHS has been concluded, but it’s very important to counter what will definitely be lots of responses from the allies of NHS England. Otherwise they will be able to hail the result as a democratic mandate.

Health Campaigns Together say that it is OK to copy and paste HCT’s responses into the feedback boxes on the questionnaire, although if possible, it would be good if respondents could add a few tweaks of their own.

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National Health Service (Co-Funding and Co-Payment) Bill

2017-19

Type of Bill:

         Private Members’ Bill (Presentation Bill)

Sponsor:

         Mr Christopher Chope

Progress of a Bill

House of Commons

First reading, Second reading, Committee stage, Report stage, Third reading

House of Lords

First reading, Second reading, Committee stage, Report stage, Third reading

Consideration of the Amendments

Royal Assent

This Bill is expected to have its second reading debate on Friday 26 October 2018.

This Bill was presented to Parliament on Tuesday 5 September 2017. This is known as the first reading and there was no debate on the Bill at this stage.

Details of the Bill

National Health Service (Co-Funding and Co-Payment) Bill (HC Bill 37)

A

BILL

TO

Make provision for co-funding and for the extension of co-payment for NHS services in England; and for connected purposes.

Be it enacted by the Queen’s most Excellent Majesty, by and with the advice and consent of the Lords Spiritual and Temporal, and Commons, in this present Parliament assembled, and by the authority of the same, as follows:—

1.    Amendment of section 1 of the National Health Service Act 2006

  (1)      The National Health Service Act 2006 is amended as follows.

  (2)     In section 1 (Secretary of State’s duty to promote comprehensive health  service), in subsection (4)—

           (a)   the words “the making and recovery of charges is expressly provided for by or under any enactment, whenever passed” become paragraph
                  (a), and

                 (b)   after paragraph (a), insert or

                 (b)   the charges form part of an agreement in England for co-funding or co-payment.

2.  Other amendments of the National Health Service          Act 2006

  (1)       The National Health Service Act 2006 is amended as follows.

  (2)      After section 12E (Secretary of State’s duty as respects variation in provision of  health services), insert—

                                       ““Co-Funding and Co-Payment

  12F                Co-Funding and Co-Payment: England

  (1)            For the purposes of this Act, co-funding of NHS care shall be permissible in England when NHS-commissioned care is proposed to be partly funded—

                     (a)         by a patient, or

                     (b)      on behalf of a patient

  (2)           Co-payments permitted by virtue of this Act shall, in England, include payments made through co-funding as provided for in subsection (1)

 3             Extent, commencement and short title

  (1)          This Act extends to England and Wales.

  (2)          This Act shall come into force at the end of the period of two months after the day on which it receives Royal Assent.

  (3)          This Act may be cited as the National Health Service (Co-Funding and Co-Payment) 2018.

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 Court of Appeal grants NHS campaign group permission to appeal against NHS England’s new Integrated Care Provider contract

Some very good news – which also means NHS England is consulting on an ACO contract that may be unlawful.

They knew full well that was a possibility, despite their protestations in the consultation document that both Judicial Reviews had ruled in their favour.

(They have rebranded the ACO contract the Integrated Care Provider contract and their consultation runs until 26 Oct.)

We shall be putting out more info shortly about this.

 

The Court of Appeal has issued an order granting campaign group 999 Call for the NHS permission to appeal the ruling against their Judicial Review of the proposed payment mechanism in NHS England’s Accountable Care Organisation contract.

The Accountable Care Organisation Contract (now rebranded by NHS England as the Integrated Care Provider contract) proposes that healthcare providers are not paid per treatment, but by a ‘Whole Population Annual Payment’, which is a set amount for the provision of named services during a defined period. This, 999 Call for the NHS argues, unlawfully shifts the risk of there being an underestimate of patient numbers from the commissioner to the provider, and endangers service standards.

In April, the High Court ruled against the campaign group’s legal challenge to NHS England’s Accountable Care Organisation contract – but the group and their solicitors at Leigh Day and barristers at Landmark Chambers found the ruling so flawed that they immediately applied for permission to appeal.

Although fully aware of this, on Friday 3rd August – the day Parliament and the Courts went on holiday – NHS England started a public consultation on the Accountable Care Organisation contract – now renamed the Integrated Provider Organisation contract.

The consultation document asserts that the payment mechanism in the ACO/ICP contract is lawful, because:

“The High Court has now decided the two judicial reviews in NHS England’s favour.”

Steve Carne, speaking for 999 Call for the NHS, said

“It beggars belief that NHS England is consulting on a contract that may not even be lawful.

And a lot of public funds is being spent on developing the ACO model – including on the public consultation.

We are very pleased that 3 judges from the Court of Appeal will have time to consider the issues properly.

We shall shortly issue our stage 5 Crowd Justice appeal for £18k to cover the costs of the Appeal.

We are so grateful to all the campaigners and members of the public who have made it possible for us to challenge the lawfulness of NHS England’s attempt to shoehorn the NHS into an imitation of the USA’s Medicare/Medicaid system.

We will not see our NHS reduced to limited state-funded health care for people who can’t afford private health insurance.”

Jo Land, one of the original Darlo Mums when 999 Call for the NHS led the People’s March for the NHS from Jarrow to London, added,

“All along we have been warning about the shrinkage of the NHS into a service that betrays the core principle of #NHS4All – a health service that provides the full range of appropriate health care to everyone with a clinical need for it, free at the point of use.

Since we first started work two years ago on bringing this judicial review, there have been more and more examples of restrictions and denials of NHS care, and the consequent growth of a two tier system – private for those who can afford it, and an increasingly limited NHS for the rest of us.”

Jenny Shepherd said

“NHS England’s rebranded Accountable Care Organisation contract consultation is a specious attempt to meet the requirement to consult on a significant change to NHS and social care services.

We don’t support the marketisation of the NHS that created the purchaser/provider split and requires contracts for the purchase and provision of services.

Integration of NHS and social care services, in order to provide a more straightforward process for patients with multiple ailments, is not aided by a system that essentially continues NHS fragmentation.

This new proposed contract is a complex lead provider contract that creates confusion over the respective roles of commissioner and provider. It requires multiple subcontracts that are likely to need constant wasteful renegotiation and change over the duration of the lead provider contract. This is just another form of fragmentation, waste and dysfunctionality.

The way to integrate the NHS and social care is through legislation to abolish the purchaser/provider split and contracting; put social care on the same footing as the NHS as a fully publicly funded and provided service that is free at the point of use; and remove the market and non-NHS bodies from the NHS.

Such legislation already exists in the shape of the NHS Reinstatement Bill.”

The campaign team say they are determined in renewing the fight to stop and reverse Accountable Care. Whether rebranded as Integrated Care or not, they see evidence that it is the same attempt to shoehorn the NHS into a limited role in a two tier healthcare system that feeds the interests of profiteering private companies.

Steven Carne emphasised,

“It is vital that we defend the core NHS principle of providing the full range of appropriate treatments to everyone with a clinical need for them.”

999 Call for the NHS hope the 2 day appeal in London will happen before the end of the year. The Appeal will consider all seven grounds laid out in the campaign group’s application – with capped costs.

Details on the first instance judgment can be found here, and the judgment itself here.
David Lock QC and Leon Glenister represent 999 Call for the NHS, instructed by Rowan Smith and Anna Dews at Leigh Day.

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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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STPs are loose coalitions of agencies without statutory powers, so they cannot implement change, only encourage it. With little money left in the Transformation Fund, they have to “work around” their local NHS and social care organisations. At the launch of the King’s Fund report ‘Delivering sustainability and transformation plans: from ambitious proposals to credible plans’ (on 21st February) we heard that “with the right leadership” STPs could stabilise the NHS, that STPs mean that “politicians must be brave” (and not impede changes in the NHS in their constituencies), that NHSE and NHSI need to work as one (because they don’t), and that “there is no Plan B”.

STPs

Much of what was said at the launch was familiar. Plans to shift care into the community and integrate health and social care have surfaced several times in the last decades, leaving little trace. There is little new in the STPs, except perhaps the higher profile of local government.  The NHS is famous for its lack of memory, a point made gently by Chris Ham of the Kings Fund at the end of the launch event. The language used was standard NHS speak – “challenges”, “conversations”, “journeys”, “taking plans forward”, “meaningful engagement” – and the speaker who described how the STPs were “moving fast” surprised those who thought progress was painfully slow.

It was not clear from the discussion that there really are many parts of the NHS or social care where practitioners are straining at the leash to change, are constrained by present structures and rules, and are ready to innovate given permission and leadership. Perhaps the Vanguard sites are such places.

The impression I left with is that transforming social care and health services that are struggling to survive is a David versus Goliath battle, in which STP advocates are hoping for a lucky shot. The Kings Fund launch did say that in a way, suggesting that STP footprints should prioritise two or three changes, in effect abandoning transformation as an objective. The NHS Confederation has since urged ‘patience’ in developing STPs, not the current unrealistic timetable. This may be an opening for Labour to gain some traction within the NHS, and avoid being marginalised into “Slash, Trash and Privatise” rejectionism. We need to look at provision over the whole health and social care system and sort out a governance framework for a single health and social care service. STPs are an attempt to bring together relevant players at a higher organisational level than Joint Planning Boards, so could offer the overview and design the governance. If the STPs were led by local government, with a topped-up Transformation Fund and a ten year remit to bring about change, we might just make haste slowly.

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Wales is the only part of the UK where “deemed consent” to organ donation applies. The means that any deceased who is over 18 years, is mentally competent and who had lived in Wales for  12 months is deemed to have given consent to organ donation unless they have formally registered their objection.

About a decade ago, the UK had a low organ donation rates (13 / million population) compared to countries such countries as Spain, USA and France. As well it had a much lower rate of next of kin refusal. In Wales around three people per month died while waiting for an organ donation with about 300 people on a transplantation list.

The issue was considered by the National Assembly for Wales Health and Well-being Committee in 2008. Though its report did not recommend  “presumed consent”, the Welsh Government felt there was sufficient public support for the proposal and indicated its intention to legislate on the matter. A commitment to do so was included in the Welsh Labour, Plaid Cymru and Liberal Democrat’s manifestos for the 2011 National Assembly election.

The Bill was introduced into the National Assembly in December 2012. Over the next year an extensive debate and consultation took place. There was broad support for its purposes though concern was expressed, by Christian and Islamic faith groups in particular, that “deemed consent” was not real consent and that it undermined the altruistic virtue of the gift of donation.

A key feature of the legislation was its “soft opt-out” option whereby close relatives are involved in the donation decision with particular attention being paid to any evidence that the deceased may not have wished to have their organs donated.

In the run up to the beginning of the legislation in December 2015 there was an major campaign to both explain the new legislation and to raise awareness on the wider organ donation need in Wales. The legislation will require the Welsh Government to maintain a programme of promoting public awareness and to report on progress.

At the end of the first year of the legislation the Welsh Government reported “… the latest figures show that 39 organs from patients whose consent was deemed have been transplanted into people who are in need of replacement organs.

In the two years prior to the introduction of the new system of deemed consent, .. (we) made significant efforts to inform the public of the exact nature of the upcoming changes in respect of transplantation activities. During this period the number of organs transplanted increased each year, from 120 between the 1 December 2013 and 31 October 2014, to 160 between 1 December 2015 and 2016.

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If something can’t go on for ever then eventually it will stop – so says Stein’s Law – attributed to the eponymous American economist.

Senior Health service managers are now openly admitting that the NHS cannot continue in its current state. Writing in the Observer recently, Chris Hopson, Chief Executive of NHS Providers commented: ‘It is surely now time for our national health and political leaders to publicly acknowledge that the NHS can no longer deliver what is being asked of it for the funding available. The evidence that there is now an unbridgeable gap between what the NHS is required to deliver and the money to pay for it is both widespread and compelling.’

The much vaunted plan to save £22 billion through ‘efficiency savings’ has been described as ‘virtually impossible’ by former Health Minister Norman Lamb and as being ‘substantially off target’ by the Health Foundation.

Despite the sombre inevitability of Stein’s Law, the NHS shows no sign of going down quietly. As former chancellor Nigel Lawson observed, the NHS is the closest thing the UK has to a national religion. Any politician brave or foolish enough even to suggest that the funding model for the NHS requires amendment or adjustment is instantly attacked by a variety of NHS zealots in a manner verging on the hysterical. Taking on the National idol is a recipe for political suicide, so Mr Hopson’s call for an ‘open, honest, realistic, national debate’ about the future shape of NHS services seems unlikely to be realised.
After 30 years working at the coal face in the NHS I have come to ignore what politicians and managers say and instead watch what they do. Few informed people dispute that the way the NHS does business needs to fundamentally change – the tricky part relates to who can make that case to the public and, more importantly, who is going to be responsible for forcing the change through in the face of personal and political abuse verging on the criminal – just take a look at the behaviour of junior doctors towards the current Health secretary for an example.

Redrawing the boundaries of what the NHS provides is one way by which the NHS reduces the volume of work it has to do. In my own specialty, the boundaries for varicose vein surgery have been changed substantially – it is no longer sufficient for patients to have aching and discomfort from varicose veins to get effective treatment. Instead the definitions have been changed, so that only the most severe cases with established skin damage leading to an ulcer can be put on the operating list. Elective surgery like varicose veins is an easy target for this type of manipulation – by redrawing the boundaries, health service managers simultaneously reduce the number of patients on waiting lists (thereby facilitating attainment of targets) and reduce the number of procedures carried out – thereby reducing cost to the commissioning groups. Similar schemes are in place across most of the country for a variety of other complaints such as hernias, cataract surgery and joint replacements. Initiatives to deny treatment to patients on the grounds of smoking habits or obesity have recently been reported.

Restriction of access to treatment on grounds of ‘insufficient severity’ preserves the ideological purity of the NHS ‘free at the point of use’ by sweeping the problem under the carpet. Unfortunately, pretending that the need has disappeared by a semantic redefinition does not make the problem disappear for the patient who cannot afford to pay for private treatment. This is not an open and honest way of dealing with real world clinical problems.

A serious examination of low cost social insurance systems or co-payment plans similar to those that exist in most developed Western economies is long overdue. Dogmatic adherence to a monopolistic model of centrally funded universal healthcare paid for exclusively via general taxation will not meet the health requirements of our population in the coming years and redefining the definition of severity of varicose veins isn’t going to solve the problem either.

Eddie Chaloner is a consultant vascular surgeon who operates at Lewisham and Greenwich NHS Trust and through his private practice Radiance Vein Clinic. Chaloner pioneered endovenous laser surgery treatment for varicose veins in the UK, which has revolutionised the treatment of this common condition worldwide.

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Last week the Governing Body of Bristol Clinical Commissioning Group agreed a plan to remove from its constitution the clause which prevents it from giving contracts to companies which practice tax avoidance.

We understand that it is likely that other CCGs with similar constitutional clauses will also move to remove them.

Bristol Protect our NHS was founded just over three years ago in response to a 38 Degrees campaign to amend the model constitutions of CCGs then in the process of being created. The inclusion of a clause preventing contracts going to tax-avoiders, and other clauses, was our first success. We know that groups in other parts of the country were also successful.

So this looks like the start of an initiative to counter those successes and make life more comfortable for the tax-avoiders.

This is astonishing timing given the almost daily reports about the immorality of tax-avoidance in the national media and the public distaste for it.

The paper agreed at yesterday’s Bristol CCG Governing Body is here:
https://www.bristolccg.nhs.uk/media/medialibrary/2016/01/govbody__26jan2016_item23.pdf

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Speech delivered in the House of Commons – 28/01/2016

Many Hon. Members have raised the seriousness of the financial challenge facing our health and care system. They are right to do so. Many Hon. Members have also been right to say that we need a big, honest national debate about what excellent care services look like and how we might pay for them.

I’ve been the Shadow Secretary of State for Health now for just over 4 months. In that time, it has become blindingly obvious to me – if it wasn’t at the outset – that the NHS and care system in our country is on the verge of collapse. Huge hospital deficits, care home providers on the brink of failure, older people in hospital because they can’t get the support they need at home, more critically ill people than ever before waiting too long for ambulances and large chunks of the workforce so demoralised that they want to up sticks and head for the Southern hemisphere.

For many people who use the NHS, this picture may sound unfamiliar. For the majority, it still provides excellent care – and it is important to recognise that and to thank the thousands of dedicated staff who ensure that happens. But for many others, the system fails them and the risk is that it starts to fail more and more people as time goes on.

When I was asked to do this job, I knew that the NHS and care system was under pressure. I knew that demographic change and the march of technology – both in and of themselves, good things – were placing demands on a system designed for a different century. As a constituency MP, I had visited isolated older people, many feeling like prisoners in their own homes, surviving with the help of a meagre care package or the support of family and friends if they were lucky. As a councillor before that, I had seen the soaring demand for adult social care and the woefully inadequate budget to deal with it. Demand which is growing because of our ageing population – but also because of advances in medicine which enable babies who may not previously have survived at all, to not only survive into childhood but adulthood too.

On a personal level, I knew that in my own family, my grandmother had spent the last few years of her life in and out of hospital on an almost weekly basis – driven as much by crises of loneliness as by a deterioration of her COPD.

And I knew that my other nan was forced to sell her own home to pay for her own care when she developed vascular dementia, meaning that all but £23,000 of her £140,000 estate disappeared.

All of these things I knew before I became the Shadow Secretary of State but it was only when I visited hospital after hospital, up and down the country, that my eyes were really opened. The image of frail, elderly people, perched alone on beds in emergency admissions units or in rehabilitation wards is THE abiding picture which stays with me following my first 4 months in this job. It made me feel uncomfortable. As a childless 40 year old woman, would that be me in 40 years’ time? Was it the best place to be? Was it the best we as a country could do? The image may have been uncomfortable, but the numbers say it all: 1 in 4 hospital beds occupied by people with dementia, half of all people admitted to hospital aged over 65, 300,000 people aged over 90 arriving at A&E by ambulance every year.

When we get older – and it will come to all of us, hopefully – hospital will sometimes be necessary but it shouldn’t become the norm. I know that we have to address this problem. The system needs to be redesigned so it gets the right sort of support to people at the right time and in the right place to prevent problems from escalating. But we have to be honest and say that there is a price tag attached to this.

Yes, there are still savings that can be made, ways to make the system more efficient and less wasteful but there are simple underlying pressure that can’t be wished away. Every day that goes by there are more and more, older people living with more and more complex, often multiple, conditions. Some say family members need to step up to care for elderly relatives. Others say that’s unrealistic. Every day that goes by, new drugs and treatments become available at not insignificant cost. It may be tempting to brush these uncomfortable truths under the carpet but we can’t and we would be failing generations to come were we to.

So, that brings us to the proposal we are discussing today to establish an independent, nonpartisan commission to establish what a long term financial settlement for the NHS and social care might look like. I understand the superficial attraction of this idea. I’ve been stopped on the street and in the gym by people I’ve never met before saying “why can’t the politics be put to one side when it comes to the NHS?” I understand that sentiment. Politicians aren’t the most popular bunch of people out there and too often we are seen to be advancing our own party’s interests and not those of the public. But for me, I think the question of how we fund elderly care going forward is THE most deeply political question our country faces over the next decade.

It’s political because it’s about who pays and who benefits.

Whilst the NHS is a universal, taxpayer funded system, free at the point of use, social care provision is a mixed bag – those with money, pay for it themselves, those without rely upon councils to provide what support they can. It’s been a make do and mend approach to social care in recent times but our changing population means that it no longer an option.

I spoke about my Nan earlier. A woman of limited means who experienced catastrophic care costs because she developed dementia. My family is not a rich family. We are not a poor family either. We are like many families up and down the country. When I was growing up my dad decided to take us on a two week holiday to Spain each year, instead of paying into a pension. He’s never bought a brand new car in his life but he never let his children go without either. The costs of care which fell upon my Nan and my family, fell randomly.

Is it right that a woman of limited means who dies of dementia at 85 passes nothing meaningful onto her family when a wealthy man who dies of a heart attack at the age of 60 does? What about those who plan their financial futures having invested in expensive tax advice to avoid the costs of care? It is my view that these are deeply political questions.

In order to adequately fund the NHS and care system in the future, the truth is that a political party needs to be elected to Government having stood on a manifesto that sets out honestly and clearly how we pay for elderly care and how we manage in a fair and transparent way the rising costs of new treatments, new drugs and new technology.

No matter how well researched, well intentioned, well-reasoned the recommendations from an independent commission, someone at some point will have to take a tough decision.

When I think about the cross-party work that has been done on this in the past, I think I can also be forgiven for being cautious. Take the discussions that took place between by predecessor, the Rt Hon Friend the Member for Leigh and the then Conservative and Liberal Democrat Opposition prior to the 2010 election. Just weeks out from the election, the Conservatives pulled the plug on those talks and accusations of “death taxes” were suddenly being hurled – so much for a grown up debate to answer the difficult questions. Take also the attempt at cross-party agreement in the last parliament which led to some of the Dilnot proposals on capping the costs of care. These proposals were in the Conservative Party’s manifesto, but were swiftly kicked into the long-grass just weeks after the election. I’m not sure that attempts to take the politics out of inherently political decisions have worked.

Even if we take something which should be straightforward – a new runway for example – an independent commission hasn’t exactly led to consensus on how to proceed – just more delay. As the well-respected Nuffield Trust has said: “Experience shows that independent commissions into difficult issues can have little impact if their recommendations do not line up with political, local or financial circumstances.”

How we pay for elderly care is one of the most difficult decisions facing our generation. The truth is it will require political leadership. A political party needs to own the solutions and be determined to make the case for them. I am not ashamed to say that I want the Labour Party to lead this debate. I want us to build on some of the excellent work that has already been done in this area, in particular that of Kate Barker and The King’s Fund. And I want us to spend time talking to people up and down the country about the kind of health and care service they want to see and to have a frank and honest discussion about what some of the different options to pay for that service might be.

I must also be honest though and say that I think it was a profoundly political decision in the last parliament to cut the amount of money available to councils to pay for adult social care. I say gently to the Hon Member for North Norfolk that he stood at that dispatch box opposite and defended the cuts that his Government were making to social care – he dismissed many of warnings that my hon friend the Member for Leicester West was making when she was the Shadow Care Minister about delayed discharges, about cuts to home care, and reductions in other vital services like meals on wheels and home adaptations. So I don’t think it is either realistic or right to pretend we don’t have fundamental differences on this issue.

Any attempt at finding consensus must begin with an acknowledgement of the damage done to social care over the last five years.

The public are crying out for some honesty in this debate. They understand the pressures created by rising demand and new technologies and they want to be treated like adults. To suggest that this can be all neatly sewn up by an independent commission with the politics taken out of it sounds attractive but I worry it just won’t deliver. For the millions of people who depend on our NHS and social care system, we can’t afford to have yet another Parliament where we fail to grasp the nettle. I know this proposal is well intentioned but I fear it is not the answer.

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It looks as if the era of markets and competition within the NHS has come to an end. The vanguards and devolution experiments are challenging the traditional boundaries. Many pages of planning guidance contains no mention of competition – Monitor is being morphed into something else entirely. Commissioning as has been tried through its various guises is adapting further in different ways in different places. Integrated providers and hybrids of commissioner/provider are now possible. New kinds of organisational bodies could be taking over the role as strategic commissioner of integrated services.

So – much thought is being given to future structures.

At one end of the debate is the proposal to fully reorganise the whole NHS back to its 1970’s. At the other end of the debate are those who see progress through evolution; through relationships and people with structures and even legislation being almost irrelevant. Also many fear another top down reorganisation which would be costly and damaging to relationships and so far has never worked.

Going into the last election the Labour Party was in the latter camp – it believed that its policy objectives could be achieved by removing the market structures and making the existing organisations and structures work in a different way. This now appears to be what is actually happening in the real world NHS.

All agree that there should no longer by a market or a purchaser provider split but the two camps differ on the role for planning and/or commissioning. Those in the reorganisation camp don’t really explain how services are to be planned or how the money will flow through the system, we have different systems in Wales and Scotland but both have some form of commissioning – both have some services which are either private, franchised or otherwise outside the core public service provisions – and of course social care is privatised and commissioned everywhere. Some services are better planned and provided across a larger population than the local and so decisions have to be made by someone about how costs are shared or allocated.

In the evolution camp then there is the acceptance that the provisions of some services will remain in the non-public sector (at least for the medium term) and that GP services, pharmacy, dentistry have to be commissioned. So in the evolutionary model there is still a split between the planners and service management of the providers, although this does not mean there has to be separate organisations! Arguably in any system there is a split between commissioning and provision, the issue is how to manage the commissioning bit and ensure accountability.

It is relatively simple to see how most primary care, community care, urgent care and social care services can be organised on a local basis. There could be either a separate health authority, or simply just the existing local authority, planning and providing all the necessary services – they are essentially local in character. So too are many services provided through a District General Hospital. It is a great pity the care system was not set up in this way in the first place but the wrong team won the argument about the role of local democratically elected local councils!!!

But with more careful thought it’s clear that some emergency, hospital and mental health services do not fit into such a local pattern – specialised services certainly don’t. This was even recognised long ago when the major teaching hospitals were allowed a great deal of autonomy outside the main management structure.

Funding for core services can be addressed through weighted capitation but for some services different models are necessary just as some developments and major projects require their own separate funding streams.

Under the reorganisation model all the existing NHS Trusts and Foundation Trusts like Barts, Royal Marsden or Salford Royal could no longer continue as separate organisations. They would somehow have to be fitted into the local health authorities (one for each major local authority areas) or into a regional authority. Already in some places there are developments so that one body provides a wide range of social care alongside both acute and primary care services and also undertakes most of the commissioning responsibilities (from both CCG and local authority). So far those proposing the reorganisation approach have not provided any details about how the transition would be made or what the impact would be on the real organisations that would have to be broken up in some way.

Under the alternative approach, the one favoured by the SHA, there would be no market based commissioning but there could still be separate organisations that provide services. This is the situation in non-market Wales where three major provider bodies were allowed to continue after the market was removed – this appears to work well enough.

In the evolved model there would be some organisations that had their own separate identity, their own board and accountability through the commissioning relationships with one or more commissioning bodies. These bodies will still be part of the NHS and subject to direction by the secretary of state who would have the overall legal and political responsibility for the service. In the SHA version these bodies would be like Foundation Trusts having a two tier governance structure and non-executive directors.

The weakness of the evolved model which retains separate provider bodies is that it is harder to ensure that it is exempt from any externally imposed competition rules. The Efford Bill set out how this could be done by restoring the role of the secretary of state, abolishing the market related parts of the current legislation and by restoring the NHS contracts. Most agree this is enough but it’s hard to ever be 100% sure. Equally it is also possible that any post reorganisation structure could be vulnerable to manipulation but also any incoming government committed to privatisation and markets could simply pass new laws for yet another reorganisation!!!

So two big policy issues are. How does the money flow through the system? And. What role is there for hospitals and independent Trusts of some sort?

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As news arrives from Cambridge of yet another privatisation inspired project going horribly and expensively wrong let’s hope people in Staffordshire, South Warwickshire, Southport and elsewhere are thinking long and hard.

The Stafford Cancer contract saga is long running and is now so hopelessly flawed that it should simply be wound up. The use of a complicated procurement process which was supposed to be about a competitive dialogue between various qualified providers bringing new ideas has ended with a negotiation with the obvious NHS providers. The attempt to outsource commissioning has been unpicked.

It matters because even if everything else is ignored (and it should not be) then the commissioners and providers of cancer services are to be locked into a complex legally enforceable contract for ten years. So for ten years as the rest of the NHS tries hard to evolve and develop collaboration through vanguards, devolution and other imaginative attempts to make services better the cancer services in Staffordshire and Stoke will be locked out; bound together by the guesses made now.

It is fair to accept that when the saga began there were the best of intentions; you can accept that cancer services in the area were not as good as they should have been. What would have helped would have been some kind of root cause analysis of why this was the case. Still, work began quite purposefully on what better services should be like and some consultation and engagement took place.

Embedded in the ideas being developed was to use a lead provider model, where some of the commissioning decisions are moved from the commissioner to a lead provider who takes on the role of integrating services. Nothing wrong with the idea although it shows a weak commissioner. Anyway the project got approval from NHS England. As was said at the time:-

Five of Staffordshire’s Clinical Commissioning Groups (CCGs) are teaming up with Macmillan Cancer Support to transform the way people with cancer or those at the end of their lives are cared for and supported.

The project will look at commissioning services in a new way – so that there would be one principal organisation responsible for the overall provision of cancer care and one for end of life care.

Then it came to light that the commissioners were to use a competitive tendering approach to find the lead provider. What they were asking for is set out below as taken from the contract noticei. In the Financial Times it was reported that:-

The NHS is embarking on its biggest and most wide-ranging outsourcing of services so far by inviting companies to bid for £1.2bn in contracts to provide frontline cancer treatment in district hospitals and care for the terminally ill.

The deals could see the private sector delivering all cancer and end-of-life treatment for children and adults across Staffordshire and Stoke on Trent. This will involve diagnosis and treatment such as radiology, radiotherapy, breast screening, chemotherapy, nursing and surgery for patients in hospitals, hospices and at home.

Two years later a lengthy process using FoI has now established that there is no proper record of how the decision to use competitive tendering was taken, no proper business case was prepared (even though this was a contact for over £600m), no options appraisal was carried out into the best method to use and there was no attempt by the CCGs involved to follow their arrangements to involve service users in decisions about how services are organised. The whole process was built on sand.

Fast forward to today and we have the CCGs involved through the procurement/project process negotiating with the NHS providers of the services and carrying out due diligence. It is possible that by early next year the contract could be ready for signature.

Hopefully before signing anything the CCGs will wake up and insist on a full (final) business case and publish it and get some independent expert assurance of what is in the case as would be required in any such major exercise involving £600m. Even then once the actual details of what the contract requires are established then there has to be a proper engagement with the service users taking more months.

But why bother? The failure of the contract in Cambridge hangs over the Staffordshire experiment. There, after much negotiating a contract was finally agreed with just the NHS providers that were left and it failed within a matter of months.

Come on Staffordshire give it up.

i A two-stage, ten-year contract to transform the provision of cancer care in Staffordshire and Stoke. Stage 1 will be fee based, for up to two years, and requires a prime provider to manage all the services along existing cancer care pathways with a view to: managing and improving data quality and collection to establish detailed baseline information about activity and costs; understanding patient and payment flows; achieving a limited set of service outcomes focused on improving the patient’s experience of the service and ensuring equality of access and treatment. Achievement of the Stage 1 aims will trigger the commencement of Stage 2.
In Stage 2 the provider will assume responsibility for the provision of cancer care, in expectation of streamlining the service model. Performance will be against ambitious clinical and service outcomes, with payment based on achieving stipulated outcomes. Service provision (Stages 1 and 2) will initially be for four tumour sites (bladder, lung, prostate, breast) with a requirement to provide services in respect of all tumour sites by contract year 5.

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