Category Archives: NHS reorganisation

Government policy on Accountable Care Organisations remains confused and confusing. The Health Select Committee’s recent grilling of Simon Stevens and Stephen Barclay shed little light on critics’ concerns, while the relative responsibilities of the Accountable Care Organisation and its commissioners remain murky, and subject to legal proceedings.

What is clear, however, is that Accountable Care Organisations will be responsible for deciding most of the issues that really matter to the public in the provision of health and care services. This will be even more the case if commissioning is on the basis of long term health outcomes. It will be Accountable Care Organisations which take the difficult decisions about thresholds for treatment that we know are currently pushing more and more patients to seek private treatment to avoid lengthening NHS waiting lists.

Map of Accountable Care Organisations

  1. South Yorkshire and Bassetlaw
  2. Frimley Health and Care
  3. Dorset
  4. Bedfordshire, Luton and Milton Keynes
  5. Nottinghamshire
  6. Blackpool and Fylde Coast
  7. West Berkshire
  8. Buckinghamshire
  9. Greater Manchester (devolution deal)
  10. Surrey Heartlands (devolution deal)

Accountable Care Organisations will also be hybrid providers of both health and care, and therefore, able to redefine various care packages and draw on both health and social care legislation to legitimise how they are to be funded. Simply spouting that healthcare will remain free is no reassurance at all; there are many services at the hospital/community interface that can be classed as either health or care, depending on who is providing them.

Yet because ACOs are to be established by a commercial procurement process their legal form cannot be specified. They can be partnerships that include private health and care providers, and private insurance and property companies, which will make money from charging. We could easily end up in a situation where it is in the financial interest of an Accountable Care Organisation to progressively reduce care provided free from public funds, in favour of means tested care packages.

The commercial partners within the Accountable Care Organisation would no doubt step forward to fill the gaps so created with services and offers of insurance policies. This is not some fevered fantasy – look what is already happening in dental care. And just because Manchester and Dudley, the two frontrunner ACOs, are NHS based does not remove this threat for even the near future. Other vanguards make great play of their public private partnerships.

Nor does the recent assurance from David Hare, chief executive of NHS Partners Network, that private providers “are not expecting to be commissioned” to take on responsibility for running any Accountable Care Organisation contracts “in the immediate future” address the real threat. And indeed, why should he?

The clear and present danger posed by the Accountable Care Organisation model on offer is that it can import organisations focused on profit making into the heart of NHS decisions about who provides what, and at what cost to patients and families, and cement those arrangements in place for 10-15 years.

History doesn’t repeat itself but it often rhymes

The story of the Private Finance Initiative should make us pause and reflect. Originally sold as a pragmatic public-private partnership to build and run much needed hospitals, the recent National Audit Office report confirmed that not only has the NHS paid well over the odds for many projects and been fleeced on related services, including insurance and fees for external advisors, but now finds itself tied to long term service contracts that it can’t afford, but can’t afford to get out of.

This sorry history should surely convince us that if there are opportunities to profit from the NHS, they will be ingeniously and enthusiastically exploited by those whose priority is profits rather than public service. Yet the Accountable Care Organisation contract will create these same irreversible long term opportunities.

It might make sense to seek fox advice on henhouse security, but not to put them in shared charge of the coop under a management agreement that cannot be reversed, even when chickens mysteriously start to go missing.

There is a simple way to deal with these concerns. Accountable Care Organisations should be set up as democratically accountable public bodies. Scotland and New Zealand have done this. The argument that legislation is impossible in the present climate has been used to justify introducing complex long term commercial contracts, with all their attendant dangers, as the only way out of the fragmented commercial morass that successive NHS Acts have created.

But at the recent Health Select Committee hearing, Labour MPs offered cross-party cooperation on simple legislation to block these dangerous loopholes. That both the minister for health and Simon Stevens ducked this offer may simply reflect a disintegrating policy on autopilot.

In the wake of Carillion and the PFI it seems scarcely believable that such long term contracts are seen as the answer to anything. The alternative of simple legislation needs to be vigorously pursued. Accountable Care Organisations are far too dangerous to introduce without water-tight safeguards.

Article first published by the Health Service Journal

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The interim Parliamentary Review, published in July 2017, observed the the Welsh NHS and social care has been subject to many well-considered reviews since devolution. They all shared the common fate of not to achieving transformational change as they never successfully made the transition from the page to the front line. In an attempt to address this it recommended that Welsh health and care services should concentrate on a limited number of significant innovations, evaluate the outcomes and implement the most successful ones with a sense of urgency.

Despite this the Final Report (January 2018) itself produces ten “high level”recommendation (with many supplementary “supporting actions”) over-ridden by what the Review calls “The Quadruple Aim” of improving population health, improving the quality and experience of care, better engagement with the workforce and increase value for investment through innovation, elimination of waste and implementation of best practice. This represents a massive “whole system” challenge and one wonders if this Final Report will itself become a victim to the fate as its predecessors and for the same reasons.

At the heart of the final report is the challenge of delivering a health and care service that will meet the growing pressures it faces despite the continuing under-resourcing of public services in a era of never ending austerity. The unstated conclusion is that the high level recommendations linked to the Quaduple Aims will achieve the type of efficiencies that are needed to deliver a sustainable service.

Everything suggests that this is a heroic assumption. Health care funding has historically grown at an annual rate of over 3.5%. Annual efficiency gains in excess of 1.5% are exceptional despite desktop exercises which claim that a vastly greater efficiency improvement potential. Despite the very many useful insights and recommendations that the Final Report provides there is nothing in it that would indicate that it will deliver where others have failed.

But even if this report is not capable of delivering everything there are many key recommendations that the Welsh Government needs to take on board to improve health and social care performance in Wales.

The Final Report strongly reiterates the views of SHA Cymru and the Nuffield Trust that the Welsh Government needs to be more actively involved in the executive delivery of policy as well as the setting of the strategic direction for health and social care in Wales. While it is crucially important that Welsh Health Boards deliver locally sensitive services their relatively small size make them captive to many “localist” vested interests which makes it almost impossible for them to implement the strategic decisions which are required in Wales.

Local health boards seem to be have an disproportionate focus on acute services. SHA Cymru has pointed out that following the abolition of the internal market in Wales most of the health board senior management came from acute NHS trust backgrounds which very much flavoured the direction that policy would flow and that non-executive health board members were failing to provide sufficient challenge to this approach. This was not helped by the failure of the Welsh Government itself to emphasise importance of a holistic approach. And as budgets became ever tighter it has become even more difficult to move the agenda beyond the immediate priorities of firefighting the latest high profile crisis.

In response the Final Report makes a number of recommendations including that the Welsh Government should use a range of initiatives and financial incentives to mould the activities of health boards. This intention is laudable but it is arguable if the recommendations will be sufficient to achieve the required outcomes.

Considerable emphasis is placed on the importance of delivering more cohesive health and social care. The introduction of Integrated Medium Term Plans are welcomed but are seen as been being excessively verbose and mistaking policy quantity for quality. Many obstacles remain to greater integration with the report not acknowledging the fundamental problems that exist between a free or means-tested service and the substantial cultural differences that now exist between sectors that are delivered though the NHS and local government. The progress that Local Service Boards and Regional Partnership Boards are achieving is recognised and the Social Services and Well-being Act (2012) has provided an important legislative catalyst for change. But the Review does not ask if the Welsh Government needs to consider whether a more prescriptive legislative approach is what is needed to achieve the more accelerated progress that is needed.

Wales needs a shared infrastructure to start to make this happen. IT systems have to reach across all health and social care. Common, shared pathways with national standards are needed while still capturing both local and individual sensitivities. This will require Welsh Government investment to achieve the qualitative change and staff skilling to make it happen.

Compared to the Interim Report more attention is given to health inequalities though it still remains a fairly peripheral issue in the overall scheme of things. The wider importance of public health measures are emphasised in passing through this is outside the Review’s terms of reference. Health boards are urged to make greater use of epidemiological data to inform and to recognise the importance of very early years in their planning but there are no practical recommendations on how “to follow the money” or to identify and evaluate the processes and outcomes that will diminish the effect of the continuing “inverse care law”.

There is a very strong emphasis on the need to use the patient experience to measure service quality and inform the planning process. Linked to this is the need to involve clinical and other front line staff. It is vital to empower individuals and communities to achieve a good health and well-being and it recognised that those with the greatest need and who are most disadvantaged are often most likely to find this difficult to achieve. This is a task where health boards and local authorities could usefully work together to achieve the best results.

Most of what is in this Final Report is highly commendable though it is much broader in scope than the streamlined, targeted and readily implementable actions that the Interim Report felt was needed. Equally it is totally unrealistic to believe that it will achieve the step change in Welsh and social care performance that obviate the need for substantial public service investment in both services.

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Reflections on where we are now and where we need or would like to be

Context
• well recognised that NHS is great – commonwealth study said so twice;
• indeed, other countries look to us enviously
• but things have got more difficult since 2010

 

Our special relationship …

Trump's attack on the NHS

Some high level data – interesting but spurious?

International comparisons

 

Health care spending 1980-2015

Public spending on health in Europe

Ranking health systemsHealth Care System Performance Rankings

 

AUS CAN FRA GER NETH NZ NOR SWE SWIZ UK US
OVERALL RANKING 2 9 10 8 3 4 4 6 6 1 11
Care Process 2 6 9 8 4 3 10 11 7 1 5
Access 4 10 9 2 1 7 5 6 8 3 11
Administrative Efficiency 1 6 11 6 9 2 4 5 8 3 10
Equity 7 9 10 6 2 8 5 3 4 1 11
Health Care Outcomes 1 9 5 8 6 7 3 2 4 10 11

Source: Commonwealth Fund analysis 2017

There are other challenges ….
Particularly workforce ones

  • Demographic ‘time bombs’ in workforce…
  • Average 25% vacancies in nursing workforce
  • Impact of Brexit – already
  • Quality and capacity/capability, too
  • Related to funding and available workforce

You need sufficient activity to make it safe and effective so is there an inevitable need for reconfigurations

  • A&E/EM
  • Maternity and Paediatrics
  • Cancer
  • CVA & CHD
  • Primary care

An interesting question – not least for socialists ….

  • When we’re ill, we know where we’d rather be treated?
  • We know which GP practice to join?

Or is this just like dilemmas over education:

  • Selective education solution?
  • Or, all local schools should be good schools?

Current ‘solution’ – STPs/ACOs&ACSs/Integrated Care Systems

  • 44 STPs  created by stealth – no legislation, and a reluctance to legislate
  • A damaged brand
  • Political opposition – P and p

Is it about

  • Sustainability
  • Quality
  • Integration

Or is it about privatisation, USA style ACOs & ACSs / HMOs, Any willing provider etc.
Or, have we always had an element of private provision?

Some examples

  • Worcestershire and Staffordshire maternity services?
  • Birmingham’s health system?
  • Coventry and Warwickshire

Coventry & Warwickshire

Coventry and Warwickshire has a combined population of just under 1 million
• 2/3 Clinical Commissioning Groups
• 4 NHS Provider Trusts
• 2 Social Care Local Authorities – Coventry City Council and Warwickshire County Council
• 4 Warwickshire District Councils
• Various system challenges

Concordat between Coventry and Warwickshire Health & Well Being Boards
• Ambition to develop sustainable services and bridge a funding gap of £267M by 2020/21
• Various work-streams, including:

  • Stroke
  • Maternity services
  • A&E/EM
  • Governance – political and public engagement

Coventry & Warwickshire Sustainability and Transformation Plan (Better Health, Better Care, Better Value)

Health and Well being Board Concordat

Governance structure

Most recent announcement – Integrated Care Systems

Sustainability and Transformation Partnerships become Integrated Care Systems

  • National contract
  • Commissioners and providers encouraged to collaborate
  • Still no statutory basis
  • A&E targets loosened till 2019?
  • Referral Time to Treat 52 weeks wait to be halved
  • Cancer, Primary Care, Mental Health  & Learning Disability

Things a Labour Government would need to sort …

  • Increase spend as % of GDP – how much?
  • (Strong) hypothecation?
  • Introduce a national care service or simply implement a version of Dilnot?
  • Scrap the internal market and public private partnerships?
  • Eliminate differences between foundation trusts and non-foundation trusts?
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The National Audit Office documents only failure in its ‘Reducing Emergency Admissions’ report

On 1 March 2018, the National Audit Office published a damning report on successive failed initiatives to reduce emergency admissions at NHS hospitals in England. The National Audit Office scrutinises public spending and holds Parliament to account and improve public services. Apparently the Department of Health  wants elective and emergency admissions to be reduced to 1.5% (whatever that means). The NHS England mandate is however extremely weak in the admissions arena. – ‘…to achieve a measurable reduction in emergency admissions by 2020’.

Cost is a big issue here and reducing mortality and patient pain and suffering makes no appearance in the 54 page report. The current annual cost of emergency hospital admissions is £13.7 billion. This cost has remained static over recent years. Between 2015/16 and 2016/17 emergency admissions increased by 2.1 %. So all attempts over recent years to reduce emergency admissions have failed.

The elephant in the room here is the oft quoted 2009 McKinsey & Co theory that 40% of patients admitted to hospital should not be there. The theory continues with the notion that Out of Hospital/community care/intermediate services could ‘replace’ these hospital admissions. NHS England states that currently 24% of emergency admissions could be avoided.

79% of the growth in emergency admissions from 2013/14 to 2016/17 was by people who did not stay overnight in hospital. Reducing beds (bed use) is clearly a key factor as staying overnight in hospital is expensive. The emergency admissions’ increase is mostly of older people.

It’s pretty clear that attempts to reduce the impact of emergency admissions have failed. These reduction programmes include the urgent and emergency care programme, the new care models, the Better Care Fund, RightCare and Getting It Right First Time.  Re-admittance rates rose by 22.8% between 2012/13 and 2016/17.

In October 2017 the Department of Health admitted that £10 billion spent on community care ‘could have been better used’ and that ‘programmes to focus on community care had stalled’.

The Department of Health, NHS England and NHS Improvement all admit that they have no idea why there are local variations in hospital emergency admissions. NHS England is not happy with emergency admission data, and the lack of linked data across healthcare and social care.

On page 10 of the report we find ‘…the challenge of managing emergency admissions is far from being under control’.

There are enormous amounts of data analysis on performance, beds and intermediate care.

The number of days that beds are used by people admitted as emergency admissions has increased from 32.4 million in 2013/14 to 33.59 million in 2016/17 – an increase of 3.6%. The majority of bed days (96% in 2016/17) are used by people who stay for two days or more after being admitted as an emergency admission.

The recommendations in the report are stunning and include:

  • Establish an evidence base
  • Disseminate learning on new care models effectively
  • Link primary, community health and social care data
  • Figure out why there are local variations in emergency admissions
  • Figure out how community services will support reductions in emergency admissions
  • Introduce an Emergency Data Care Set to improve data on daycase emergency care
  • Publish data on re-admissions.

View the NAO report 

 

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2018 marks the seventieth anniversary of the founding of the NHS, but also the fiftieth anniversary of the 1968 Green Paper that marked the beginning of a series of attempts to reorganise the NHS that lasts up to today. What were these other reorganizations about, and did they work?

A most basic organisational challenge the NHS continues to face is the split between NHS, GP and community health services (including social care). This was the result of a political compromise in the founding of the NHS. The big idea in 1968 was bringing NHS organisational boundaries in line with those of local government. However, it did not succeed, failing again to due to political constraints. The split between the three areas of the NHS continues to cause us so many problems is testament to the force that past decisions about organisational forms can continue to hold over us, decades later.

Any discussion about the NHS inevitably takes us to the question of funding. In the 1950s there was a government inquiry examining why the NHS was costing so much more than anticipated. What it showed is that the NHS is, comparative to other health care systems, remarkably inexpensive. We still haven’t really learned that lesson. Apart from above-trend increases in funding in the 2000s, the NHS has continued to lag behind its neighbours in funding healthcare, year after year. This seems to get somewhat lost when politicians make lazy claims about how ‘unaffordable’ the NHS is.

Since the 1980s, the two big reorganizational ideas have been about management, and about markets. In the 1980s general managers were put in hospitals to try and make the NHS more ‘business-like’, and that didn’t seem to make much difference other than to increase management pay. This led to an ‘internal market’ for care, in which public providers competed with one another for care contracts to try and bring the discipline of competition into the NHS. Apart from some innovative changes the way GP practices worked, the internal market seemed to do little other than introduce new functions such as care purchasing which did little to improve services.

When they came to power in 1997, Labour promised to abolish the internal market on the grounds that it was wasteful and bureaucratic. Labour also embraced the Conservative ‘Private Finance Initiative’ (PFI), which allowed it embrace a radical building plan for new hospitals, but without breaching their own budgetary rules. However, PFI deals were often negotiated locally, and where poor bargains were struck, this left the hospitals involved with substantial funding deficits running over decades.

In January 2000, the Prime Minister committed to increasing NHS funding to the European average, taking his cabinet (and Chancellor) by surprise, but, for a short period in the NHS’s history, giving it sufficient resources to avoid winter crises and reduce waiting lists. Then devolution happened, and the paths of the home countries started going down different routes. In England, performance management and markets reigned. In Scotland, a more collaborative route was taken. At the end of the decade, evaluations suggested that there was actually little difference in reported health outcomes between the two, again asking questions about whether reorganisations actually improve things at all.

Labour’s performance management changes included hospitals and GP surgeries. The hospital system was widely gamed, and seemed to lead to managers ‘hitting the target but missing the point’ at best, and at worst was probably a causal factor in the horrific events at Mid-Staffordshire with staff becoming so driven to hit targets that they forgot about patients. The early years of the GP performance system appeared to show promise, with GPs being consulted upon and engaging strongly with the system, but policymakers then extending it and introducing more bureaucracy until it became deeply unpopular. It has already been abolished in Scotland.

Labour’s new market for care created greater scope for private providers to enter in England, and paved the way for an extended version of it appearing from the coalition government after 2010, leading to huge controversy and expense. What is remarkable is how little there was to show of this reorganization by the end of 2017 – much of the attempt at driving further competition in the NHS has been slowly abandoned in the face of budget pressures and high profile cases of private provision failure. Reductions in budgets, have, however, led the return of winter crises and budget overspends.

The NHS is all about its staff, but relationships between the government and clinicians have gone through cycles of antagonism and co-operation. In the 1970s industrial action and threats to the provision of services dominated, with governments fearful of challenging doctors. In the 1980s staff protests continued, but with the government taking a harder line, until they ignored the doctors completely in introducing the internal market in the 1990s. The doctors got their revenge though, teaching the government the lesson that it is one thing to make policy, and entirely another to implement it. Labour’s funding increases in the 2000s appear to have led to a period of co-operation, before the 2010 coalition government’s reorganisation leading to a groundswell of opposition. Since then relationships between Secretary of State Hunt and the doctors, in renegotiating employment contracts or in demanding a ‘7-day NHS’ at a time of reduced budget settlements, have seldom been friendly. The basic lesson of industrial relations in the NHS, again not learned by politicians, is that it unwise to introduce new policies unless you have the co-operation of those that you will need to implement them.

By 2018 we’ve had 50 years of NHS reorganization. Mostly, it hasn’t really made things better. Indeed it is hard to see what lots of it was actually for. We still haven’t managed to find a way of overcoming the tensions of the tripartite split. We know we need more collaboration between local government and the NHS, especially as the demands on social care services increase and the lack of funding for it has real consequences for services currently paid for by the NHS. However, for many of us the boundary between health and social care is an artificial one that does not serve our needs.

What does seem to have made a difference is increasing the funding for the NHS in real terms in the 2000s, with a range of measured improvements coming along soon after, but which are in danger of disappearing in the more austere environment of the 2010s. If there is a big lesson from the history of the last fifty years it is that health reorganizations often do as much bad as good, but increasing the funding of the NHS has a much better chance of improving healthcare for us all.

A version of this article was first published on the Social Policy Association website

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There is wide agreement that it would be beneficial to integrate social services and local NHS community services.  This could provide “wrap around care” and look after elderly and vulnerable people in a community setting. Such a system could reduce hospital admissions, but the reason for doing it is to improve the welfare of patients. Such scheme are already working well in Durham and other parts of the country.

Where there is not agreement is when such a system could be constrained within a strict financial envelope . A possible consequence could then be the outsourcing of management and the reconfiguration of hospital services.

The SHA does not believe in outsourcing or relying on the private sector unless absolutely necessary. Privatisation of particular parts of an integrated system could undermine the very integration which is desired. Compulsory tendering as prescribed in the 2012 act wastes a considerable amount of NHS time, and can leave the NHS open to legal challenge by a private provider with large pockets which will involve considerable unnecessary expense. Nor is the motive for integration to constrain costs but to improve the welfare of patients.

At present the average patient receives half their total expenditure in the final year of their life.  There needs to be a rebalancing. The elderly and frail should be properly cared for  but some clinical intervention is unnecessary.  More should be spent on the young. This would help reduce health inequalities.

The present system puts too much power in the hands of the acute trusts. There should be  a transfer to community and public health (as recommended by the Selbie Report for the North East)

The national NHS needs to ensure proper standards but organisation of a local integrated system should be jointly in the hands of local authorities and NHS organisations. Possibly a not for profit trust or social enterprise. The management of such a system should give equal weight to the NHS and local authorities, with a neutral chair, perhaps along the lines of an elected commissioner.

GPs should be integrated into a local system.The present  private contract system could be replaced by salaried GPs, Many now prefer this way of working.

There are serious concerns about the state of some care homes.  The provision and management of care homes should be integrated into the system set out above. This would lead to much closer relations between GPs, hospitals and care homes.

Research and innovation is very important.  Hospitals in the North of England are very good at innovation, but undersell themselves.  Universities should work closely with the NHS as is now promoted by the North Health Science Alliance. Funding tends to focus on the South.  Funding for research needs to be rebalanced regionally. The regions outside London also need to promote their research and innovation more loudly.

Devolution proposals could lead to an integration of health and local government as in Manchester.  This development needs to be evaluated as it progresses.

Conclusion

We envisage a situation where local authority social care, NHS hospitals and community care systems, GPs and Care homes are integrated into one system, run as a not for profit trust or cooperative.  Such a system would need representation from the NHS, Local Authority and independent members on the Board, with possibly a neutral chair who could be elected.

Regional networks are necessary for the effective management of hospitals. A specialist hospital in one part of a region would obviously serve the whole region.  Nevertheless the health and care trusts envisaged here should not be too big. In the North East for example Durham would be a good example, or the proposed North of Tyne authority.

 

 

 

David Taylor-Gooby

Feb 14th 2018

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An update on the work relating to the joining-up of health and social care in Cheshire West and Chester and a view on the next steps. This is a fast moving agenda and often people get just one part of the story.

Jigsaw of services

A fragmented system 

First of all its worth recapping on the fact that health and social care have very similar challenges but remain fragmented. Health fall under the purview of the NHS covering things like GP services, community health services and hospitals. It is ultimately accountable to the Secretary of State and free at the point of delivery. In Cheshire West and Chester, health care is commissioned by two clinical commissioning groups. One for the Vale Royal area covering Northwich, Winsford and surrounding areas and another for West Cheshire covering Ellesmere Port, Chester and surrounding area. Ideally we would like one commissioning geography so we have a common approach across the Borough.

Social care covers support that maintains people’s independence covering issues such as mental health, physical disability, learning disabilities and support to older people. It provides or arranges services following an assessment and is means tested. Its accountability is to local elected Members.

Both health and social care are currently experiencing massive challenges in demand as people get older and conditions become more complex. Funding is not keeping up with this demand.

Something needs to change both in terms of investment and the way services work. I want to emphasise however that its been made clear to us by the Cabinet that the shared public service ethos of the NHS and social care need to be preserved. The answer can’t be to encourage the market to fill the space. Actually the direction we have been given is that collaboration rather than competition is the answer.

One of the major issues is that services can often be reactive and only kick in once somebody is unwell or in crisis. Some of this is because the range of services across health and social care are fragmented and don’t  join up to prevent people from needing intensive support.

Often GP services are not connected up with hospital services. Community services are not joined up with social care. We have separate processes, separate budgets and separate ways of working. This leads to missed opportunities to intervene early to support somebody to lead a healthier and more independent life.  This is not the best use of public resources but also isn’t fair on our residents who can see that the left hand isn’t talking to the right hand.

Local challenges

At the local level we have a number of challenges where we feel the further  joining up of health and social care would make a huge difference.  Obviously it’s great that people are living longer but often this means we will have people living with multiple conditions that require a joined up approach over health and social care.

We have issues with health inequalities and poor lifestyles particularly in our more challenging areas.

  • Our demand at A&E is at very high levels.
  • We have too many delays of residents from hospital to other settings, reducing capacity in our hospitals.
  • Our GPs are under pressure to support the most complex patients.
  • Wider staff are under pressure to deliver the best possible care.

Financially, in the West Cheshire area, it’s been estimated that unless the way we work changes, we face a financial gap, mostly in the NHS, of around £65 million by 2021. We’re fearful this could lead to some form of top down intervention in the NHS where we lose the ability to set our own destiny. This is already happening, to some extent, in the Vale Royal area.

What this means for vulnerable residents

Not joined up services

But these are all organisational challenges. Ultimately the biggest challenge faced is that our residents are not receiving the care and support they need. They can’t understand why things can be so fragmented particularly if they have complex needs.

What integrated care looks like? 

So what would more integrated look like and how could it help? Well this video provides some background. Its been produced by a national health charity known as the Kings Fund and I think is sums it up very well.

Emerging national policy 

This challenge has been recognised by national politicians and the needs for more integrated care was a key feature of the latest Labour Party manifesto.

Some guiding principles 

Labour will focus resources on services to provide care closer to home and deliver a truly 21st century health system. We will work towards a new model of community care that takes into account not only primary care but also social care and mental health…..

The National Care Service will be built alongside the NHS, with a shared requirement for single commissioning, partnership arrangements, pooled budgets and joint working arrangements. We will build capacity to move quickly towards a joined-up service that will signpost users to all the appropriate services at the gateway through which they arrive.

Our response

  • We will focus on change that benefits our residents rather than just structures
  • We will make this local and bottom up. This is not being driven by the STP and we will  take action to avoid this being ‘done to’ us through a top down reorganisation
  • We will ensure full public engagement throughout this process
  • We will not participate in any competitive procurement process or participate in any process that reduces the public service ethos and leads to fragmentation
  • We will make the case for additional funding to NHS England and central Government
  • We will push for one health and social geography that reflects the local authority boundary
  • We will fully engage and protect our staff through this process
  • We will only proceed if there is a sound business case and political support
  • We will ensure that the governance incorporates the local democratic mandate and fully link into the Health and Wellbeing Board

 Its hopefully helpful to set out what we’ve already done around integration and what the next steps may look like.

  • Back in 2013, nine integrated care teams were set up including GPs, community services staff like District Nurses, social workers and support staff. Their job is support people with complex conditions, particularly those at risk of needing hospital care and residential care.
  • We have also worked with NHS colleagues on a single care record to bring together vital health and social care information into one place. This enables to take a joint approach to planning care and avoiding people having to tell their stories many times.
  • We have recently joined up our reablement teams with a similar team in the Countess of Chester. This was designed to ensure people can be supported to get back home as soon as possible.
  • We have pooled around £100m of health and social care funding through something called the better care fund which enables us to make joint decisions on resources to support the public rather than just thinking about the separate resources for each organisation.
  • Our A and E in the Countess has enhanced its services and created a new facility in the hospital to support urgent treatment and avoid admissions where they are not necessary.

We think the next step however is to bring all this good practice together into a much more robust integration programme. This will ensure that the actions we take are better coordinated and implemented with real rigour.

The step after that, some years down the round, may be to develop something called an Integrated Care Partnership. This is where you take integration to its full extent and you would have one budget, one management team, one set of outcomes, one local governance approach, one public sector approach and one clearly defined way of working. In other countries this has been called an accountable care organisation but we don’t use that term as it’s often confused with the American model where the profit motive and the market drive health and care. Clearly that’s not the model we want to follow.

What this means for our residents

Already the joining up of care is benefiting local people. This case study outlines where an integrated approach has delivered a better service that has avoided wasted time for staff and most importantly our residents.

Mary, 85, has memory loss, is deemed “frail elderly” and has an allocated social worker named Ann. Ann receives information regarding a potential safeguarding concern relating to financial abuse by Mary’s family members.

At times, Mary can be reluctant to engage in support from social care, making co-ordinating support for Mary difficult. With integrated care, by carrying out joint visits with health staff, professionals are able to build a trusting working relationship with Mary. By working jointly with the community matron, Ann is able to complete a detailed assessment of Mary’s needs, including looking into the safeguarding concern, using information provided by health colleagues that would not have been available without an integrated approach.

On one occasion, Mary develops a Urinary Tract Infection and becomes extremely confused very quickly. Mary is deemed to be unsafe to remain at home and, working jointly with community matron colleagues, Ann is able to quickly access respite care for Mary to prevent a hospital admission. Mary is now back at home and tells staff she feels well supported.

Full integration programme

We think our immediate next step is to make the case for comprehensive integration programme that will make a real difference on the ground. This would precede any more radical change such an Integrated Care Partnership.

It would involve bringing the health commissioning team in the CCGs together with the local authority commissioning team so we take a common approach. This would perhaps be quicker to do for the West CCG area initially as the commissioning team in vale royal also links into East Cheshire council.

We will develop new care pathways for our residents, working  with clinicians and social workers, so there is real clarity on care can be joined up around individuals. We also want to improve the way our integrated teams operate. Having been in place for around 4 years we want to ensure they have the tools and resources to support people in the community.

A key priority for us to take further joint action to avoid residents being delayed in hospital and not getting home in a timely way. This involves joint ways of working between health and social care, more information sharing, better planning  and more capacity in the community to support local needs.

Our single care record could be enhanced further so that further information can be shared to inform joint working.

Our information, advice and guidance we will look to join this up with the NHS so that our residents know where to go for support. We’ll also be looking to join up our data and intelligence to better target our resources at people with complex needs.

What next? 

Following the implementation of this programme, one possible destination could be an integrated care partnership. This would take integration to its full extent. It would involve health and social care coming together into one unified arrangement.

Integrated care partnership

This would involve joint governance through the health and wellbeing board and a integrated care partnership board. It would be supported by one commissioning team, one management structure and one pooled budget that could be up to half a billion pounds.  The budget and responsibility to pull the system together would sit with one existing organisation. This would very likely be an NHS provider due to legislation and the fact they would be contributing the majority of the resource.

The service delivery would remain in the public sector and involve all local NHS services and some adult social care services. Until the concept has been proven and we have the same geography with health we cant put all services in this arrangement initially. We would also start with any staff being transferred  through secondment rather than TUPE

Where else is this happening?

This model has just been put in place in Salford, a Labour controlled Borough.

Salford Together logo

The area had delivered a very similar integration programme since 2014 and felt that the next step was to take integrated care to its full extent.

In July 2016, local leaders established a new joint commissioning board, comprising city councillors and GPs from the CCG’s governing body, to oversee a larger pooled budget of £236 million for all adult health and care services (excluding specialised services).

Under the new arrangements, the city council and CCG  direct Salford Royal Hospital Trust to deliver or manage a range of adult health and care services. In mid-2016, the council transferred its 450 social care staff to Salford Royal to undertake assessments and contract for the provision of adult social care support. This means that Salford Royal will deliver a large proportion of the services, including acute care, community health care and some social care services in-house.

Potential timescales 

So what does this journey look like in terms of timescales? If Members are supportive we will resource up for a full integration programme as soon as possible. This would be supported by a team with the best talent from across health and the local authority. Its initial focus would be for West Cheshire but we would also look to put in place arrangements with Vale Royal.

Also we will lobby heavily for a single health geography that aligns to the local authority’s boundaries

We can start further work thinking about the feasibility of an integrated care partnership but this will not be the priority. The key focus will be on changing services on the ground. Any business case for a more radical arrangement would need to follow and be a Member decision.

In 2018 we will start to see further changes on the ground, with the majority of the projects delivered by 2019. Only after that point would any integrated partnership go live by which stage we hope to have moved to a single health geography.

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Sustainability and Transformation Plans became Sustainability and Transformation Partnerships by dint of a statement in the March 2017 NHS England Five Year Forward View Next Steps document. As both terms reduce to STP acronyms it’s not all that helpful. For the sake of clarity I will use ‘STP’ in its original ‘plan’ definition in this submission. Accountable Care Systems  are a flavour of generic Accountable Care Organisations. NHS England  has chosen to define and name a range of Accountable Care Organisations which include ACSs, ACPs, MCPs, PACSs and PCHs. If and when these variants are up and running we will discover the unique characteristics of each of them.

The context of the latest changes to healthcare services delivery in England begins with the appearance of a paper written by Oliver Letwin and John Redwood and published in January 1988. Papers written by McKinsey & Co in 2009 and in 2012 for the World Economic Forum in Davos Switzerland, follow on developing ideas for radical reform of the NHS. Reducing the cost of running the NHS and ‘partnering’ with private healthcare suppliers have been on Government agendas now for many years.

One of the key big ideas was that 40% of people who are in NHS residential Acute hospital care should not be there and where they should be is being treated at home and/or in NHS local day care centres. The latter are called, or have been variously called, Out of Hospital services, community care services, and Intermediate Care services. The theory is/was that Out of Hospital services would ‘replace’ 40% of residential acute services and could be provided at a reduced cost.

The 2012 Health and Social Care Act formalised the NHS Commissioner/Service Supplier split and led to the formation of 200+ Clinical Commissioning Groups throughout England. NHS hospitals could sell up to 49% of their services to private clients. In my town (Ealing) and in others the CCG now commissions GP services. Local Authorities retained their commissioning role for purchasing and in some cases delivering social care services. Care/Nursing Homes are now largely privately owned. In Ealing GP surgeries are now commissioned by the CCG to provide Primary Mental Health care services.

The Five Year Forward View  published in October 2014 set a target of reducing annual NHS costs by £22 billion by 2021. The  ‘Next Steps’ published in March 2017 demolished that cost reduction target and replaced it with achieving ‘financial balance across the health service’.

Hospital beds are such a big issue with regard to care delivery that it’s worth noting here that the  Next Steps states that by March 2019 the 100,000 NHS bed population in England will be reduced by between 2,000 and 3,000. In NHS North West London between March 2017 and June 2017 the General and Acute beds in use rose from 3,120 to 3,400. Bed numbers rose by 300 from March 2011 to June 2017. If these trends continue yet another target will be missed.

Sustainability and Transformation Plans

In NHS North West London we were, and still are, taking part in a pre-Sustainability and Transformation Plan project called ‘Shaping a Healthier Future’. Launched in 2012, with a seriously flawed public consultation, this contained ambitious plans for physical healthcare – there was virtually no mention of mental health services and certainly no mention of social care services. (There had been no meaningful previous engagement with the public). The plans included cutting annual costs by 4%, reducing the number of District General Hospitals  and hospital A&E units from nine to five. Out of Hospital services would ‘replace’ 40% of residential Acute hospital care – all in ‘at least three years’. Over five years later no cost reductions have apparently been announced or almost certainly achieved, only two of the four District General Hospitals and A&Es were eliminated and various attempts at Out of Hospital services have had only limited success. Ever since the two A&Es were eliminated in September 2014  A&E performance  has consistently been amongst the worst in England. The most recent Shaping a Healthier Future ignominy – for what has now apparently has become a 14-year project – is that its request for £513 million for building work was turned down by NHS Improvement and NHS England. In the 7 November 2017 rejection letter NHSI/NHSE could find no compelling evidence to support reducing annual Non-Elective or emergency hospital admissions by 99,000 by 2025/26.

Here in Ealing rumours about Sustainability and Transformation Plans began circulating in Spring 2016. An early draft of Footprint 27: North West London Sustainability and Transformation Plan appeared in April 2016. An NHS England vetted version appeared in public in October 2016. Amongst the ‘new’ ideas in the plans was the integration of social care services with healthcare services. This idea immediately became a car crash locally, as Ealing Council and Hammersmith & Fulham Councils refused to sign up. The Council Leaders stated that they had not been given the plan to review. They were given only a short overview with just hours of review time.

One of the basic reasons for creating Sustainability and Transformation Plans is to admit that CCGs are failing as ‘masters’ to the service supplier ‘slaves’. This is apparent in that CCGs and NHS Trusts come together as peers in the Sustainability and Transformation Plan. The NHS bias is clear when one sees a lack of detail of social care services in many plans and the fact that 43 of the 44 Sustainability and Transformation Plan bosses are NHS executive/NHS ‘alumni’.

It seems to be somewhat absurd that in North West London we have two cost cutting, transformation attempts running in parallel. One, the 2012 ‘Shaping a Healthier Future’, only concerned itself with healthcare initially ‘for over three years’ whilst the other, the October 2016 NWL Sustainability and Transformation Plan, covers healthcare, social care and the integration of the two up to 2021.

On 13 June 2016, I attended a public meeting in Ealing run by NHS Ealing Clinical Commissioning Group  on future local NHS plans. The lack of publicity for the meeting meant that out of an adult population of 200,000+ only 20 residents attended. Sustainability and Transformation Plan content was revealed, but under the title of a local care plan. When I was a Director of Healthwatch Ealing we ran an Sustainability and Transformation Plan debriefing in Ealing on 16 November 2016 which was attended by 100 residents.

Accountable Care Organisations

The first reference to Accountable Care Organisations in England I can find is in April 2016. Accountable Care Organisations, conceived in the USA in 2006, are NHS England’s chosen future implementation ‘engines’ for STPs. Shadow Accountable Care Organisations might commence in April 2018, and real ACOs with £1+ billion 10/15 year contracts might commence in April 2019. But not only are NHS date predictions regularly inaccurate, legal action and Parliamentary decisions might delay/prevent this. Dudley Shadow MCP and Manchester Shadow Accountable Care Organisations have both recently ‘paused’ their launches.

In North West London there has been no meaningful engagement with the public with regard to Accountable Care Organisations. As for public awareness, there is so little in the public domain about them and so little in the 44 Sustainability and Transformation Plans that I would guess that 99% of adults in England have no idea about them. As for public consultation, one can hardly consult on topics on which the public has no knowledge.

From what NHS information I have been able to glean about Accountable Care Organisations in England, the cost cutting element (i.e. fixed price contracts) has been largely ignored. Budget setting by Capitated/Population budgets is all well and good. However if no information is forthcoming about how such budgets will be set, there is precious little public scrutiny.

On 5 December 2017 I attended a North West London Joint Health Overview and Scrutiny Committee meeting to which the eight comprising Local Authorities Councillors were invited. At this meeting the two Accountable Officers representing the eight CCGs gave presentations which were minimalist in the extreme. They confirmed that an elderly people Hillingdon Shadow Accountable Care Partnership would start on 1 April 2018 – in less than four months’ time. No details were given about who would run this Accountable Care Partnership, who would be on its board and how and when they might be elected or selected. No clues were given about the Capitated/Population budget or how it might be calculated. No information was disclosed as to how it would clearly usurp the Local Authority in ‘commissioning’ an elderly social care services budget and similarly usurp Hillingdon CCG in ‘commissioning’ an elderly people healthcare services budget. I quote this as an example of how covert the machinations within NHS North West London are around Accountable Care Organisation creation and implementation.

Accountable Care Systems which implement Sustainability and Transformation Plans will effectively assume the role of regional care authorities. Surely for the Accountable Care Systems to be effective they will take on the role of managing the finances (on a fixed price) of healthcare and social care services’ delivery? In this way an Accountable Care System will usurp the roles of CCGs (or CCG collaborations) and Local Authorities  in care commissioning. Will this make CCGs and Council social services commissioners redundant? GP surgeries are being lobbied by NHS England to consider suspending their  contracts and to prepare to get into bed with an Accountable Care Organisation. The BMA is very concerned about this. It warns of the risk of widespread privatisation of healthcare services. One does wonder as to whom Accountable Care Systems will be accountable. Surely it can’t be the CCGs /LAs ‘below’ them – whose very existence they threaten?

It seems really quite odd for NHS England to state that ‘in some areas, a Sustainability and Transformation Plan will evolve into an Accountable Care System’. If ‘some’ why not all STP Footprints? Surely what is good for the goose is good for the gander?

Integrating Healthcare and Social Care Services

At the NHS England ‘Innovation Expo’ in Manchester on 12 September 2017, NHS England Director of Acute Care Professor Keith Willett delivered a withering public attack on relations between Local Authority staff and NHS staff. He bemoaned the fact that NHS and local authority staff consistently failed to engage with each other. They don’t trust each other or understand each other and each have a different culture and jargon. Often they will not share data, so it often has to be re-keyed. On the financial side they each have different costing and purchasing processes. Neither are willing to open up and share their financial books with each other.

He felt it was ironic that 43 of the 44 STP Footprints were run by NHS/healthcare folks – and just one by an local authority/social care executive. This flies in the face of who is the bigger player. For example the NHS has around 100,000 beds whilst in the social care sector there are between 300,000 and 500,000 beds. In term of staff the NHS employs 1.3 million, but there are 1.5 million working in the social care sector.

The Health and Social Care Act 2012 confers health scrutiny functions on elected local authority Members (i.e. Councillors). With local authorities joining NHS bodies as partners in Sustainability and Transformation Plan and Accountable Care Organisations conflicts of interest and divided loyalties are clearly coming to the fore throughout the country. The rubber is constantly hitting the road when an NHS CCG is proposing to close a hospital and the local local authority, as elected representative of the people, is opposing this. It will surely get even more complicated and messy when Accountable Care Organisation consortia involving a local authority as a partner is on the one hand party to a long term, fixed price cost cutting care contract and on the other hand is holding the local healthcare CCG to task for transformations deemed by the local authority to be degrading local healthcare services.

Out of Hospital Services

Out of Hospital Services according to NHS North West London are all those services provided in community settings such as your home by community nurses, at your GP surgery and in (day care) health centres. Out of Hospital services are such a key component of the rationale for Sustainability and Transformation Plans and Accountable Care Organisations that they need their own spotlight discussion. Out of Hospital services, from way back to McKinsey & Co papers in 2009/2012, are seen as the replacement panacea for reducing (expensive) residential Acute hospital care by 40%. The question must be asked as to whether there is any evidence that this target has ever been met anywhere in England at any time on a sustainable basis?

All attempts in NHS North West London to attain and maintain this Out of Hospital services target have failed from 2013 to date. The 2012 Shaping a Healthier Future – pre-STP – transformation business case postulated an annual reduction in residential Acute emergency admissions of 99,000 by 2025/26. (In NHS jargon these admissions are known as Non-Elective admissions). In November 2017 NHSI/NHSE rejected this business case on the basis of the lack of compelling evidence that Out of Hospital services could annually ‘replace’ 99,000 admissions. In Ealing they remained at a steady rate from August 2013 to February 2017, but then rose sharply throughout the summer of 2017.

After five years of abortively trying to reduce Acute admissions with transformational Out of Hospital services, the CCG has decided to go for broke and sign up a single supplier for Out of Hospital services for 10 years. This initiative is no doubt aiming to make big reductions in local admissions so that Ealing District General Hospital can be closed – as yet an unrealised dream of the 2012 NHS North West London project. This 10-year contract is likely to be for around £1 billion, as Ealing’s Out of Hospital 2016 costs were allegedly £127 million. The question that must be asked is whether there is any evidence to suggest that a new single supplier – other than the incumbent NHS supplier – will have any more success at providing Out of Hospital services to replace Acute services? The answer to this must be a resounding ‘no’.

Sustainability and Transformation Partnerships: Engagement

Taking my own Footprint and my own town as examples, I have noticed very little effective engagement within Sustainability and Transformation Partnerships or in their relationships with third parties. Local Healthwatches, bizarrely, act as the paid handmaidens of local CCGs – bodies they should be holding to account. Healthcare activist groups throughout the region are continually having to resort to Freedom of Information requests in order to discover commissioning information and service performance and purchasing data.

Engagement, in its purest form, is qualitative and should take place during the formative stages of plan making. Our Plan was created in secret behind closed doors. No doubt Accountable Care Organisations will also be created and implemented covertly.

NHS NWL Management Consultants and CCG Costs – Value for Money?

Around £200 million has been spent by North West London CCGs on running costs  from 2013/14 to 2016/2017. Over £89 million has been spent  on management consultants variously advising on strategy and implementation since 2009.  One has to ask the question – what value has been derived from spending this public money? In terms of not meeting the stated goals of the Shaping a Healthier Future and the Sustainability and Transformation Plan, consider the following:

Shaping a Healthier Future will improve care both in hospitals and the community and will save many lives each year’ (page8). ‘Most care that is currently delivered in hospitals will still be delivered locally in a local hospital’ (page 40).’Between 484 and 980 hospital beds will be closed (page 44).

In the October 2016 Sustainability and Transformation Plan (it will) ‘transform general practice…ensuring proactive, co-ordinated and accessible care’ (page 7). ‘..for the first two years ..(it will) ..address the financial challenges (page7). It will ‘offer integrated social care outside an acute hospital setting’ (page7).

  • Shaping a Healthier Future has failed to reduce hospital bed numbers. It has not made any announcements about how many lives have been saved because of it (2013 to date).
  • Only one of the three local hospitals has been created
  • Since June 2013 hospital bed occupancy has consistently exceeded the 85% target
  • Since November 2013 five out of the seven surviving District General Hospitals have consistently missed the Type1 A&E 95% 4 hour waiting target
  • It’s not unusual now to wait two weeks to see our local GP. I recall this being a two day wait in 2013
  • No Shaping a Healthier Future or Sustainability and Transformation Plan cost savings have ever been announced. Shaping a Healthier Future replied on 30 May 2017 to my Freedom Of Information request that ‘the Shaping a Healthier Future programme does not hold information on the savings achieved by individual organisations’.

Recommendations

The Five Year Forward View/STP/ACO bandwagon needs to be halted and a cross-Party review initiated immediately.

The Five Year Forward View planning window of five years is far too short. It would be more appropriate to adopt the 15 year planning window approach used by spatial planners in Local Authority Local Plans.

The integration of healthcare services and social care services is more of an aspiration in Sustainability and Transformation Plans than existing reality on the ground. I can’t see this integration being successful without both services being delivered within a single organisation utilising a single business /organisational model. Accountable Care Organisations will just contractually impose this failing business model dichotomy on local societies for 10/15 years.

In an ideal world a new national care organisation would be created – the National Care Service. This would run healthcare and social care services. All NCS services would be free at the point of use. All the PFI hospitals would be bought out of private ownership and become NCS assets. The marketisation of healthcare services would be stopped and the 200+ CCGs closed down. All the care homes previously state owned would be compulsorily purchased by the NCS. New state owned care homes would be built.

The McKinsey & Co dictum that 40% of Acute patients should not be in hospital and can be treated successfully, less expensively and sustainably in the local community has to be trashed, on the basis that no evidence exists to support it. The closure programme for District General Hospitals  and hospital A&Es must be stopped. In areas of high expected population growth (e.g. areas of London) additional hospitals need to be built.

The elephant in the healthcare/social care room is mental health care services. Shaping a Healthier Future incredibly makes no mention of mental health services and Sustainability and Transformation Plans, like the NHS itself, is physical health oriented. Residential mental health centres need to be built in each of the 44 Footprints and thousands more psychologists and psychotherapists need to be trained and deployed.

The NCS would hire a significant number of MBA graduates who would undertake the strategic and implementation research and proposals currently undertaken by third party management consultants. Rather that all each of the 200+ CCGs purchasing this expensive research, the NCS would carry out this work centrally and share it around the country.

Based on a submission to the House of Commons Health Committee Sustainability and Transformation Partnerships Inquiry 2017

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I wish to know Jon Ashworth’s plans to prevent the further privatisation and ‘Americanisation’ of our National Health Service as well as making the case for the need for a vital injection of capital. The whole country can now see the effect of austerity, lack of trained doctors and nurses , the reduction of hospital beds and PFI projects on our NHS.

I was a public governor for three years in a Wirral hospital trust and observed at first hand the amount of public money wasted on private accountancy firms, business bids and plans, advertising , and salaried governors. This money would not have been needed if the foundation trusts, like academies, had not been set up like private businesses, and could have been spend on health professionals and equipment. When I asked the in-house accountant how the Trust could cope with making ‘savings’ year on year without their patients suffering, she had no answer. It was becoming apparent that too few citizens of Wirral were able to afford private healthcare. This situation was not of the making of the Trust’s staff , who all were working to the best of their abilities.

Simon Stevens, who spent several years in the USA working for a private health company, appears to think that splitting England into 44 separate regions, the STP footprints, including our own for Cheshire and Merseyside, is the way forward to save money. This is destroying the NATIONAL Health Service and replacing it with a postcode lottery that can be administered by profit based health companies, often American owned. Stephen Hawking made the headlines by taking on Jeremy Hunt in order to warn the British public. It is imperative for the survival of the NHS and the Labour Party that the Labour Party at all levels speak out loudly to save our NHS. The British public are largely united in their love of the NHS and will not forgive any major party that allows England to wake up to a much shrunken health care system based on the USA model. ‘National Insurance’ should and did once mean that the risk of any British citizen falling ill was spread throughout the whole population.

The beguiling rhetoric of ‘the local solution’ has been accepted by many local Labour councils and city regions. What is about to happen to health and social care in Greater Manchester is extremely worrying and it will be the Labour Mayor and Labour councillors, and not this Tory Government, who will be blamed when their citizens begin to feel the savage reduction in NHS provision. The results of last year’s council elections reflected the disillusion felt with many Labour councils, as the election of the Birmingham Regional Mayor illustrated, so that many were surprised when Labour under Jeremy Corbyn, with a socialist manifesto, actually convinced young people that there was something worth coming out and voting for. If young people see what Labour councils and City regions are allowing the destruction of the NHS to go ahead, without Labour MPs and shadow ministers making the restoration of a NATIONAL health service their most important policy , they will vote accordingly.

I have been asked to choose in a survey, assessed via the internet, whether I thought that the local CCG s should finance hip replacements , (denying these life transforming operations to the elder amounts to physical torture) or IVF treatments, the denial of which amounts to mental torture for younger women. This brings into shark relief the empty benefits of choice on a local scale. Also it allows the Secretary of Health and the Government to shirk their responsibility for the health and well being of British citizens. Mrs May has already said with regard to a problem with NHS provision that it was a local decision. Wirral Labour controlled council will be blamed as well as our Labour MPs .

The Labour Party tends to have its strongholds in the less prosperous old industrial regions of the North and Midlands, as well as the London area. The local solution for health, policing and public services is going to be much worse in poorer areas such as Merseyside. In most Labour areas the vast majority of the population cannot afford private health insurance: even those that can when young and well would be reduced to bankruptcy as in USA if they or a family member developed cancer or suffered long term health problems. How the Labour controlled Manchester city region is able to deal with health and social care , policing , education and other public services is something that affect the outcome of elections in the future. It is of the utmost importance that the Labour controlled Merseyside city region does not accept responsibility for health linking it with social care.

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“Our manifesto was a key reason for our gains in the 2017 general election. Now its ideas need to be developed and radicalized”.
—Shadow Chancellor John McDonnell

At the Labour Conference following the election result, emboldened delegates “voted historically and unanimously for complete renationalisation of the NHS in England” – in the words of Alex Scott-Samuel, Socialist Health Association Chair. Since then shadow health secretary Jon Ashworth has further committed Labour to halting the Sustainability and Transformation Plans (STPs) which devolve the national service into local ‘footprints’ with reduced accountability and the potential for marked reductions in healthcare provision, commercial control of both the public estate and the commissioning function, and a final bridge to a US-style system. Prior to the election in June, Ashworth had only said such plans would be reviewed on a case by case basis, but is now obviously responding to a new confidence among party members.

A month later however, and no doubt partly in response to these developments, ninety MPs signed a letter calling on the Prime Minister to set up a cross-party convention on the future of the NHS and social care in England, saying that only a non-partisan debate would be able to deliver a “sustainable settlement”. One-third of the MPs who signed the letter were Conservatives, and while the exact political balance is unknown, signatories from the Labour Party include Liz Kendall, Chuka Umunna, Hilary Benn, Frank Field and Caroline Flint. They say the failure of normal party politics to secure the future of the system means a consensual approach is the only way to ensure action is taken, particularly given that the government does not command a majority.

And in November – in what seems to be an attempt to give momentum to this critical stage of the ‘transformation’ process – the Commons Select Committee on Health resumed its inquiry into Sustainability and Transformation Plans (now Partnerships), an inquiry that had been suspended owing to the general election.

The annual January chorus of ‘consensus’

It’s worth noting that winter problems in acute care served as a lever for a similar attempt at consensus in January 2016, in which former health secretaries Alan Milburn and Stephen Dorrell joined with former Lib Dem health minister Norman Lamb in calling for a cross-party commission – moves that were sharply rejected by campaigners amidst concern about the lack of ‘red lines’ to protect universal healthcare (and the vested interests of those involved).

A similar coalition tried again in January 2017, with Norman Lamb writing “The public is sick and tired of the NHS and care system being treated like a political football.  People have had enough, and are crying out for an honest discussion and bold solutions to these challenges”.

By then, the House of Lords was already engaged in producing an extensive report into the ‘Long Term Sustainability of the NHS’. That report – though it was somewhat buried by the election – gives us some idea of what to expect from the latest attempts at constructing consensus. And a closer examination – in particular those they invited to submit evidence – gives us some idea of the forces mobilising such cross-party initiatives.

Constructing consensus

The Lords produced their report, ‘The Long-Term Sustainability of the NHS’, in April 2017 after almost a year of sifting through written submissions and oral evidence. When the Lords Committee finally reported back its conclusion stated, “A new political consensus on the future of the health and care system is desperately needed and this should emerge as a result of Government-initiated cross-party talks and a robust national conversation”. More particularly it stated that “service transformation will be key to delivering a more integrated health and social care system”, and while recognising some of the difficulties posed by STPs, and the new care models involved, the report noted the broad support for these plans from those giving evidence.

What’s noticeable about such hearings is the homogeneity of thought among a remarkably cohesive policy community. And while a few deviations were observed, these were largely in terms of application rather than outright opposition. Indeed the evidence that follows suggests the consensus sought by the Lords – not to mention the cross-party conventions – had already been arrived at several years previously, in even less democratic venues, and that the report served merely to ratify this.

London, Paris, Davos, Washington…

In a previous article the author argued that NHS England’s chief executive Simon Stevens’ Five Year Forward View, and, by logical extension, the STPs, had their origins in the World Economic Forum, seen by many as the avatar of the global corporate elite. Indeed two reports produced by the WEF in 2012 on healthcare sustainability advanced many of the constructs, such as service transformation and new care models, latterly pursued by NHSE.

The article also noted that the World Economic Forum reports were the result of a series of meetings organised at different levels. A Steering Board comprising eminent health system leaders offered overall direction, while a Working Group of experts supported the project’s approach and methodology, collating the material from various national workshops held in England, Germany, Spain, Holland, and China.

The identification of participants within these groups could, it was argued, reveal a similar chain of command that was being reproduced at the domestic level. Simon Stevens himself, then working for US insurance giant UnitedHealth, led the WEF Steering Board for the first report, alongside representatives from global consultancies, healthcare and pharmaceutical industries, and from institutions such as the World Bank, the EU, and the World Health Organisation.

And Michael Macdonnell, then a Senior Fellow at Imperial College London, but now strategic director of the STPs, served on the Working Group, while the English stakeholder workshop participants included people now leading local NHS ‘transformations’, alongside luminaries like Milburn and Dorrell.

However some of this analysis needs adjusting as it neglects the extensive role played by the consultancy giant McKinsey, which provided the project team that produced the two WEF reports. The company, whose clients number at least 90% of the Fortune 500, also organised the various stakeholder workshops, and indeed the lead author of the WEF reports, McKinsey’s Tom Kibasi, also presented these to the World Bank in Washington and to the OECD in Paris. This latter point suggests that while the WEF stands as perhaps the apex of the global elite, the agenda and ideas that inform it are continually being disseminated and reinforced in a range of related venues.

Visions ‘remarkable in their consistency’

As far as the WEF’s stakeholder workshops were concerned, the second report noted that the visions expressed by its participants “are remarkable in their consistency. The preferred health system of the future is strikingly different from the national healthcare systems of today, with empowered patients, more diverse delivery models, new roles and stakeholders, incentives and norms”.

Such consistency of vision reflects what may be considered a transnational position. Indeed analysis of transnational capitalist class (TCC) formation argues that reorganisation of capital accumulation has required a parallel reshaping of class relations, with the owners of new forms of production and finance coalescing around global agendas and new relations with nation states. This class is increasingly divorced from serving nationally prescribed developmental goals: instead the aim is to rearrange state institutions and services to serve the global economy. Such analysis also posits a clear hierarchy between business, governmental, and media/scientific/intelligentsia fractions within this class, although, as with Stevens, actors can easily segue between these.

And of course hierarchies exist within fractions as well. The WEF reports, for example, were developed partly in response to an announcement from Standard & Poor’s in January 2012 that it would in future take into account in its national credit ratings the financial sustainability of a nation’s healthcare system. Further privileging of the financial sector, or, more accurately, the financial, insurance and real estate (FIRE) sector, can be seen in the drive to enable its control over healthcare funding mechanisms and the NHS’s physical infrastructure.

Who did the noble Lords want to listen to?

As mentioned, those called to give evidence in the Lords hearings were drawn extensively from the state and intelligentsia fractions of the transnational capitalist class. This includes the leading healthcare think tanks, the Kings Fund, Nuffield Trust and Reform. NHS hospital trusts were represented by Chief Executives of the Shelford Group of Trusts, some of whom, like Dame Julie Moore, were WEF stakeholders, while others, such as Andrew Cash and Mike Deegan, can routinely be found in global consultancy conferences. Cash – head of Sheffield Teaching Hospital – also led the Expert Advisory Panel that supported the Dalton Review on acute sector collaboration, whose core recommendations included the formation of US-style hospital chains and the private management of NHS hospitals.

The former Labour health minster, Lord Darzi, who also sat alongside Stevens in the WEF Steering Board, also gave evidence. As well as being Director of Imperial College London’s Institute for Global Health Innovation, Darzi is also Executive Chair of the World Innovation Summit for Health (WISH) that convenes annually with some 2,500 participants, and is “chaired by a team of experts drawn from academia, industry and policymaking” with “the aim of influencing healthcare policy globally”. WISH’s recent research work has included collaboration with the leading US consultancy, the Boston Consulting Group, on Accountable Care Organisations and value creation in healthcare.

Michael Macdonnell, now acting policy director of NHS England’s STP programme, has been working on ACOs, and the aim is for these to be implemented in each footprint. Macdonnell gave evidence to the Lords Committee, as indeed did Sir Muir Gray who has led the value creation programme, Right Care, within the NHS.  Also present were Ian Forde from the OECD, who has written extensively on the euphemistically titled ‘universal health coverage’ for countries in South America – these involve considerable restrictions on care – as well as the WEF reports lead author, Tom Kibasi himself, though now acting as Chief Executive of the IPPR think tank.

Any possibility of dissent was managed by corralling the union representatives, from Unite, Unison and the BMA, into one short session. Mark Britnell, Chairman of the Global Health Practice at KPMG, on the other hand, was offered a session all to himself, where he informed the Lords panel that he was “one of the 12 members of the World Economic Forum Health Council”. While Britnell’s oft-quoted and careless remark to a private equity conference that the NHS would be shown “no mercy” might have cost him his chance of the NHSE chief executive post, it’s clear he still has clout.

Selection to the hearings is of course all-important, though the Lords give no indication as to how this was arrived at. Undoubtedly offering assistance in this process were two All Party Parliamentary Groups, the APPG on Health, and the APPG on Global Health. The first claims it “is dedicated to disseminating knowledge, generating debate and facilitating engagement with health issues amongst Members of both Houses of Parliament”. The Group also “comprises members of all political parties, it provides information with balance and impartiality and it focuses on local as well as national health issues. It is recognised as one of the preferred sources of information on health in Parliament”.

Several of its Advisory Panel, such as Jennifer Dixon of the Health Foundation think tank, and Sir Cyril Chantler, formerly Chairman of Great Ormond Street Hospital, and now working with the Private Healthcare Information Network, were included in the Lords hearings, as well as organisational affiliates such as the NHS Confederation, the Kings Fund and Nuffield Trust.

The APPG on Health’s current website states that it “is supported by an Associate Membership of 14 of the UK’s leading organisations working in the health sector”. This is misleading. Business affiliates from the past few years include the large conglomerates Abbott, Bristol Myers, Novartis, Merck, Takeda, Pfizer, Optum, Sanofi, and Novo Nordisk. These companies were present at both the WEF’s reports, some in both the Steering and Working Groups, as well as being heavily represented in the stakeholder forums.

The APPG on Global Health on the other hand has a somewhat smaller corporate membership, though this does include the Bill Gates Foundation. Its members however number Lord Darzi, as well as the Lords Ribeiro and Kakkar who were among the dozen core members of the Lords inquiry, as well as its Chairman, Lord Patel.

A new era for Labour?

In June 2014, a Health Service Journal editorial welcomed what it regarded as a hard won consensus in healthcare policy, most notably towards care ‘integration’, reducing reliance on hospitals, and better use of technology. As an example of such a consensus it highlighted a commissioning conference held by the NHS Confederation to which shadow health secretary Andy Burnham had been invited to speak on health and social care integration but had to cancel at short notice. The former chair of the Commons Health Committee, the Conservative MP Stephen Dorrell was also invited to speak at the same session, and the HSJ noted “Mr Burnham’s office let it be known they were happy for the former Tory health secretary to reflect their view on the issue”.

Perhaps one shouldn’t be too surprised. The Miliband-era 10 year vision for the health and social care system was unveiled in the offices of the Kings Fund, and drew extensively on a report – ‘One Person, One Team, One System’, otherwise known as the Oldham Report – that was largely scripted by PwC and KMPG and project managed by Hugh Alderwick, on secondment from PwC.

The labyrinthine details aside, it’s clear that the NHS has come under a sustained offensive from the transnational class. It’s important to note that the business fraction of this class will largely absent itself from overt decision-making channels, such as the House of Lords hearings, to continue the guise of accountability and neutrality. But within such channels the influence of this fraction is pervasive, and the consensus or ‘sustainable settlement’ sought by its supporters is entirely in its favour. However if John McDonnell is to be believed this new era of Labour policy promises something different: in particular a clear rejection of those adherents to a transnational agenda and a genuine pursuit of the wishes of its party members.

This was first published by Our NHS

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Some of us that have worked in and around the NHS for years are getting very worried. Not just about the mismatch between aspirations and funding but because of a malaise deep within the NHS itself – the culture might be one word for it.

Particular concerns come from those of us who examined the STPs and are now looking at plans for ACS/ACOs; and separately but connected – the sudden outburst of plans to outsource NHS services to wholly owned companies.

Parking for now the wisdom of these moves what raises concern is the appalling way the NHS is going about trying to force changes through.  The lack of any robust governance, refusing to consult, badly written documents and obviously implausible plans just being voted through by apparently sensible people.  We even have the Chief Executive of one of the major NHS quangos admitting on his exit that they were managing plans they knew were bonkers.  The NHS leadership and the Ministers can’t even agree on basic issues such as the extent of “additional” funding.  Those same leaders also admit that the system is unable to deliver what it is “Mandated” to do.  Full speed into the iceberg.

Why are people signing up to things they know won’t work?

What on earth is going on?

A select band had the misfortune to look in detail at the STPs.  We have also recently had the task of evaluating plans from multiple Trusts to set up wholly owned companies.  Our immediate reaction is exasperation at just how poorly prepared these plans are (with a few notable exceptions).  The NHS appears to have lost the skills required to write Business Cases and to be able to subject these to proper evaluation and change control.  Many Trusts turn to “consultants” who give them cut and stuck reports of poor quality and limited value which they slavishly follow – what happened to due diligence?  The shelves full of guidance and the endless reports on lessons learned and common causes of failure are simply gathering metaphorical dust.

And let us not forget the infamous Strategic Projects Team that for many were the consultancy of choice; ironically they were not procured through any competitive tendering despite their enthusiasm for markets and competition.  They advised Trusts on magic plans and it took years for them to go from winning awards to being forcibly wound up.  The NHS does not learn

With the wholly owned approach the driving force is now wrapped in the age-old NHS saga – we are being put under pressure, something must be being done, this is something, we are doing it.

When we had at least some form of strategic oversight (through Strategic Health Authorities) there were some with the skills and the clout to push back on the more daft plans that came to their attention.  No more.

Developing the STPs was a master class in how not to develop plans for a whole system change programme.  Keeping things secret, anonymous leadership, refusing to consult organisations that were claimed to be partners, wasting millions on private sector advice to do the obvious was bad enough.  What was worse was that when what were claimed to be plans finally emerged they were pants.  The level of quality varied from poor to awful (OK with 2 or maybe 3 exceptions).  Already analysis by various reputable groups has shown how totally inadequate these plans are.  So they lost the word plan from the title!

Now, yet again plans that have serious financial risks and which require thousands of staff being moved out of the NHS are being pushed through without a Business Case, without having conducted any Options Appraisal, with a refusal to publish the documents and with decisions about spending our money being taken in private  and with a refusal to consult with staff representatives.  Why is that even allowed – what oversight is applied to these Trusts who say they have been given the go-ahead by the Regulator!

So how is this possible?  Where are the system leaders challenging autonomous dysfunction?  Where are the Non Executive Directors who ask tough questions?  Where are the Trust governors who refuse to sit back and allow stuff to get forced through?  Where is the oversight of commissioners?  And even – what happened to common sense?

Maybe we know the answer.  It is back to that word culture.  In the NHS the toxic culture of bullying with all that implies is rife.  Successful NHS leaders do what they are told, even when they know it won’t succeed.  In fact for many, their tenure is so short they will have moved before failure occurs.

So what of the latest wheeze, to let the NHS lead on setting up Accountable Care Organisations responsible for the planning and delivery of the care needs of large populations?

Well, based on the above no STP/ACS/ACO should be permitted if it has leadership drawn from the NHS.  It is time we found proper leaders, willing to engage and consult, able to speak their own minds and there to genuinely represent the best interests of the patients and public.

 

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

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

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

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

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

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

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

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

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

The issues are many and complex and solutions have consequences.

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

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

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

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

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