Category Archives: NHS reorganisation

Surveys of members of the British Association of Sexual Health and HIV (BASHH) and the British HIV Association (BHIVA) provide new evidence of pressure on over stretched sexual health services and a sector at ‘breaking point’

 

Access to sexual health and HIV services has been dramatically reduced as a result of changes to the funding and organisation of sexual health services since 2013, according to the medical professionals providing care. Over half (54%) of respondents to a survey of members of the British Association of Sexual Health and HIV (BASHH) reported decreases in the overall level of service access to patients over the past year, with a further 16 per cent saying that access had significantly decreased. In a parallel survey of members of the British HIV Association (BHIVA), three quarters (76%) of respondents said that care delivered to patients in their HIV service had worsened.

With Public Health England (PHE) data showing a 13 per cent increase in attendance of sexual health services between 2013 and 2017 (PHE, June 2018,) it is not surprising that nearly 80 per cent of BASHH respondents (79%) said that they had seen an increased demand for services in the past 12 months. Budgetary pressure means that this demand cannot always be met: more patients are now either turned away or redirected to other parts of the health system.  Six in ten (63%) per cent of BASHH respondents said that they had to turn away patients each week, with 19 per cent saying that they were having to turn away more than 50 patients on a weekly basis. While most were offered the next available appointment, 13 per cent said that patients were referred to another sexual health provider and four per cent that they were redirected to primary care. Clinicians responding to the survey report that many of the patients who are being turned away have symptoms of potential infection.

 

Reduction in prevention, cytology and mental health services

Both surveys revealed significant reductions in services such as the delivery of HIV prevention activities, outreach to vulnerable populations, cervical cytology and psychosexual health services. Three quarters of BHIVA members (75%) said that there had been an impact on access to HIV prevention advice and condoms, with 63 per cent saying access had been reduced; 44 per cent of BASHH members said that HIV prevention services had decreased. Almost half (47%) of BASHH members reported reductions in the provision of cervical cytology functions, reflected by BHIVA members, who also said that cervical screening had been halved (reduced access reported by 49.5%).  This is of particular concern in the context of a fall in national cervical screening coverage and the higher risk of HPV related cancer in women with HIV.

More than 40 per cent (42%) of BASHH respondents reported reduced provision of psychosexual health care, mirrored by a similar number (41%) of BHIVA members, who said that access to psychology input for HIV related mental health problems had been reduced. This is despite the higher risk of mental health issues the HIV population faces. Nearly half of BASHH members (47%) also said that care for vulnerable populations had reduced.

 

STI screening and HIV testing

More than 40 per cent (41%) of BHIVA members said that access to sexual health screening had been reduced, despite HIV positive people being at greater overall risk of sexually transmitted infections.  BASHH members gave a mixed response, with 29 per cent of respondents reporting reductions in STI testing in the past year and 27 per cent increased testing.  The BASHH response regarding HIV testing was similarly mixed, with 21 per cent saying there was a decrease and 26 per cent an increase.

The BHIVA survey showed that it is becoming more difficult for people to test for HIV, with 35 per cent of respondents reporting that there is now reduced access to testing in their own location.  Although 58 per cent of services offered outreach testing, with a quarter of respondents (26%) saying that it was offered locally in another service, more than half (52%) said access to testing in outreach settings was also reduced.  Almost half (47%) of BASHH respondents reported increases in access to online testing in the last 12 months, but it is not yet available in all locations. Although some respondents were optimistic about its role in helping to manage the growing demand for services, others expressed concerns about poor implementation, and suggested it was taking the focus away from face-to-face services.

Funding cuts have also drastically reduced the output of third sector organisations, such as charities and community groups, who have traditionally helped to plug gaps in services with HIV testing, advice and peer support. Nearly 40 per cent of BHIVA respondents said that peer support was no longer offered by their service, with 28 per cent of those that still do saying access to it had been reduced. 70 per cent said that overall the remaining third sector support had worsened, with services stripped back to basics or simply closed down completely.

 

PrEP availability and reproductive health

The roll-out of the PrEP programme through the IMPACT trial has led to increased availability.   Over 70 per cent (71%) of BHIVA respondents said that PrEP is now either available from their service or offered locally by another service (17%) and over 70 per cent (74%) of BASHH respondents reported increased delivery. However, provision remains mixed with 28 per cent of BHIVA respondents saying access is improving, 25 per cent saying it had been reduced, and 11 per cent saying PrEP was not currently on offer locally.

At the same time almost a third (32%) of BASHH respondents reported decreased provision of reproductive health and contraception and a similar percentage (34%) of BHIVA respondents also reported reduced access to these services.

 

Impact of separation of HIV and GUM on staff and services

Changes since 2013 have in many areas led to previously fully integrated clinics that were able to provide a range of services from a single location now being divided between differently funded suppliers.  Patients, particularly people living with HIV, may not be willing or able to travel elsewhere and staff may not be able to access records from other services.

Funding cuts have led to staff not being replaced with a knock-on effect to those remaining and to the level of service they can offer. For example, the loss of Health Advisers and nursing staff can limit support for patients.  More than a quarter (27%) of BHIVA respondents reported that access to partner notification has been affected, yet this is a key method of increasing testing of people at a higher risk of HIV transmission.  Although the majority of services (64%) still maintain counselling for the newly diagnosed, close to 30 per cent said that access is reduced.

Staff morale has been affected, with more than 80 per cent (81%) of BASHH survey respondents saying that staff morale had decreased in the last year, with almost half (49%) reporting it had greatly decreased.  Respondents to both surveys cited the damaging impact sustained budget cuts were having on staff, as well as the pressures and stresses experienced by retendering, restructuring and the loss of experienced colleagues. Some describe the situation as being “at breaking point” and nearly all are worried about the future:  more than 90 per cent (92%) of BASHH respondents said that they were worried, or extremely worried, about the future delivery of sexual health care in England.

 

Commented BASHH President, Dr Olwen Williams: “Providing high-quality free and open-access care for all those that need it has been the bedrock of sexual health in this country for over a century. Whilst we are doing our utmost to maintain standards in the face of record demand and dramatic increases in infections, such as syphilis and gonorrhoea in recent years, these surveys clearly show that continued cuts to funding are taking their toll. Current levels of sexual health funding are quite simply not sustainable and the pressures they are generating are having a seriously detrimental impact on the morale and wellbeing of staff. Without increased support to match the huge growth in demand, the consequences will likely be disastrous for individuals and our public health as a whole.”

Added BHIVA Chair, Professor Chloe Orkin:“Despite the stated ambition of policy makers to reduce health inequalities this will not be possible without robustly funded, sustainable services. Our survey results provide clear evidence that we need to upgrade, not reduce, services if we are to support and protect vulnerable populations. We have made huge strides in the control of HIV, so it is particularly worrying to see that important aspects of HIV care, such as access to prevention services, testing and mental health support, have been reduced. Public Health England (PHE) figures show a 17 per cent fall in new diagnoses, which it attributes to large increases in HIV testing (PHE, September 2018.) It therefore makes no sense to make it more difficult for people to test, as shown by the reduced access to testing in clinics and outreach locations our members report.”

ENDS

Editor’s notes:

  1. Survey responses: The BASHH and BHIVA surveys were both conducted in August and September 2018. BASHH received 291 responses in total, of which 264 respondents were based in England. This press release summarises the responses provided by those members based in England.  BHIVA received 98 responses to the survey, 97 of which were from respondents based in England, which are summarised in this press release.
  2. The British Association for Sexual Health and HIV (BASHH)is the lead professional representative body for those managing sexually transmitted infections (STIs) and HIV in the UK. It has a prime role in education and training, in determining, monitoring and maintaining standards of governance in sexual health and HIV care. BASHH also works to further the advancement of public health in relation to STIs, HIV and other sexual health problems and acts as a champion in promoting good sexual health and providing education to the public.
  3. The British HIV Association (BHIVA)is the leading UK association representing professionals in HIV care. Since 1995, it has been committed to providing excellent care for people living with and affected by HIV. BHIVA is a national advisory body on all aspects of HIV care and provides a national platform for HIV care issues. Its representatives contribute to international, national and local committees dealing with HIV care. It promotes undergraduate, postgraduate and continuing medical education within HIV care.

For further information, please contact either: Simon Whalley, BASHH on 07506 723 324 or simon.whalley@mandfhealth.com or Jo Josh, BHIVA, on 07787 530 922 or jo@commsbiz.com.

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

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

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

 

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

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

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

 

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

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

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

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

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

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

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

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

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On 11 June 2018 the Common’s Health and Social Care Committee published the result of their inquiry into Integrated Care: organisations, partnerships and systems 

Anyone who observes Sarah Wollaston will notice that from time to time she confounds expectations and raises concerns about what her party is doing in government, notably on her strongly worded letters to the Home Office on the treatment of immigrants within the NHS. Although her voting record shows a reluctance to translate strong statements into protest in the division lobby. There was, therefore, a glimmer of hope over her chairing of the committee when she insisted to Jeremy Hunt that the ACO process should be subject to full and proper consultation – to ensure that it complies with the law.  

During the long process of privatising the NHS, there have been moments when the tide could have turned or at least the process could have been exposed to proper evaluation. The greatest and possibly the most disappointing of these moments was the pause before the implementation of the Health and Social Care Act 2012.   

Could Sarah Wollaston’s committee have provided one of these moments? Possibly, but it didn’t. It has failed on every count. 

  1. It was framed to deceive 

The report summary says, ‘Whilst there is not sufficient evidence that integrated care saves money or improves outcomes in the short term, there are other compelling reasons to believe it is worthwhile.,There have been positive early signs from the new care models about the benefits more integrated health and care services can bring to patients. 

It goes on, ‘understanding of these changes has been hampered by poor communication …confusing acronym… poorly understood fuelled a climate of suspicion and missed opportunities to build goodwill for the co-design of local systems that work more effectively in the best interests of those who depend on services. 

The summary sets out the terms of reference for the report. It suggests to the reader that what is in the body of the document is compelling evidence. It states that there are positive benefits from the system they have examined. And finally, it implies a dismissal of the concerns of campaigners on the basis that they are ill founded. It makes clear that such opposition can only arise from misunderstanding and the cumulative effect of those misunderstandings has been harm to patient care which a proper implementation would have had high on its own agenda. 

  1. It had a discriminatory attitude to its participants 

There were two Professors of note in the Inquiry whose qualifications and expertise should have given them considerable weight, coming as they did from opposite sides of the divide on this issue. 

Professor Chris Ham (along with his colleague Anna Charles) of The King’s Fund was a specialist advisor to the inquiry and the report declares his interests, ‘The King’s Fund is working to support Accountable Care Systems in England and some of the money for this work has been provided by NHS England’.   

Chris Ham advised both New Labour and the Tories on Integrated Care. When New Labour ran its NHS Kaiser Beacon projects in 2003 he had a dual role both as advisor to the health department and academic assessor of the outcomes of the project. He is now the CEO of The King’s Fund. The Fund promotes Kaiser Permanente and its work as a role model for integrated care. He was also a key witness to the committee. Chris Ham was awarded a CBE in the June 2018 Birthday Honours List for services to the NHS.  

Professor Allyson Pollock is the co-author of the NHS Reinstatement Bill and one of the claimants in the judicial review JR4NHS. She has been a consultant in Public Health medicine since 1986, has headed up Public Health Policy units at various prestigious universities and has served on the council of the British Medical Association. Her early work analysing the Private Finance Initiative exposed many of the flaws in the process which have since been accepted as standard. Her work lies in the realm of protecting the NHS as a public service.  

When Simon Stevens gave his oral evidence, he was asked by committee member Luciana Berger about the risk of increasing privatisation in the NHS. He had prepared a response which included printed out articles by Allyson Pollock. Rather than addressing the current situation and any implications there might be for privatisation he simply chose to attack Allyson Pollock’s work personally. He refers to an article on Privatisation and Americanisation in the NHS. He uses the fact that Allyson has been writing continuously and has been monitoring the incremental steps towards privatisation as evidence that she is wrong.  

He subsequently says, It is absolutely crucial that NHS care remains free and based on the needs of patients rather than ability to pay. There is nothing that has been proposed about the ability to join up the way health and social care services work that was not established by Parliament as far back as 2006, and in other places that has been working perfectly satisfactorily.”  

He goes so far as to say, If Nye Bevan were sitting here now, I think he would be a strong advocate for the kind of integrated care systems and combined funding streams we are talking about.” 

Whether or not the service is currently or historically working satisfactorily is not a rebuttal of whether or not it is being privatised. However, the report includes in section 40 a warning against removing choice and competition, ‘there is a danger of creating airless rooms in which you simply have one provider who is there for a huge amount of time. That clause is a statement against the basic principle of a publicly owned, publicly provided and publicly managed NHS. 

One member of the committee Andrew Selous MP spoke at the 23 April debate in Westminster Hall on privatisation. In the oral evidence session with Simon Stevens Andrew Selous asked the first question which was, “If we can have in our minds a lady in her mid‑80s, with a number of long‑term conditions, perhaps living on her own with her family around the country, could you explain as clearly as you can how the changes you are making will improve care for this elderly lady in her mid‑80s living on her own?” This reference is to ‘Mrs Smith’, a fictional character used by Chris Ham in his analysis of the Torbay NHS Kaiser Permanente Beacon project. 

In the privatisation debate Andrew Selous praised Chris Ham as an independent expert on the NHS. By contrast he referred to Allyson Pollock as well-meaning but misguided and used Simon Stevens’ attack on her as evidence of her lack of credibility. It’s a distinction which is woven through the report and embedded in the framing: the supportive and friendly witness is, by definition, independent, authoritative, expert; the critics, on the other hand, know not of what they speak, are misguided and misinformed. What concerns they have is portrayed as the result of poor information management and a mistaken attempt on behalf of NHS England and the STP leaders to keep plans out of the public domain until they are completed.  

There is a high-level of cognitive dissonance over this issue as the report fails to infer from the secrecy, leaks and cuts that there is a sound and rational basis for concern. For example, they accept [Section 60], ‘In the run up to the final deadline coverage about the secrecy of plans continued and was accompanied by reports of plans were leaked to the press, in which the focus of the coverage was on proposals to close services, reduce bed capacity and reconfigure hospitals. The STP brand as a consequence was politicised. Chris Ham said, “sadly STPs got off to a very bad start, a very difficult start because of that.  

An inquiry should surely legitimise those questions not seek to undermine them. It may disagree with them and may give good reason for disagreeing but for committee members to publicly cast doubt on the professionalism, expertise and authority of that legitimate challenge is unacceptable. 

  1. It was highly selective in its evidence and timid in its conclusions 

The call for written evidence was based on the committee’s previous inquiry which had been scheduled to take place before the General Election was called in 2017. The original inquiry asked whether Sustainability and Transformation Plans (STP) were working but by the time the committee heard the oral evidence the name of the inquiry had been changed and questions focused on the benefits of integrated care and the practical steps needed to implement it.  

The Royal College of Emergency Medicine, representing one of the areas most significantly affected by the Five Year Forward View and all its subsequent manifestations, put in a written submission which not only challenged the evidence on which the assumptions for changed were based but also were highly critical of the language used in such consultation as had taken place.  

Several submissions came from NW London, where the four local councils organised an independent review into the changes in their area in 2015. Their highest priority was where the cuts were falling and what impact it was having on communities with high levels of deprivation. The submission from Hammersmith and Fulham Council itself was particularly strongly worded, calling the consultation ‘stage-managed’, ‘tokenistic’ and ‘geared towards achieving a set outcome’. They go so far as to state that what has been done actually ‘flies in the face of evidence and feedback received from social care providers’. 

With this background the Committee had little choice but to include some campaigners and challengers to the process to give oral evidence. Tony O’Sullivan from KONP gave examples from his own work of what integrating services really means and how they take a long time and dedicated work to achieve. It bears little resemblance to the top-down organisational and budget merging of ‘Integrated Care’. Allyson Pollock argued on the technical details of accountability and the legal framework.  

Although the terms of reference nominally remained the same, the direction of questioning at the oral sessions was undoubtedly pointed more towards whether integration was a good thing and how it could be made to work rather than examining the problems of the STP process.  

The inquiry sets out its stall as having the patient at its heart. Yet most of this evidence is absent from its report. The concerns arising from the written submissions was largely dealt with under conclusions such as this in section 64:  

STPs got off to a poor start. The short timeframe to produce plans limited opportunities for meaningful public and staff engagement and the ability of local areas to collect robust evidence to support their proposals. Poor consultation, communication and financial constraints have fuelled concerns that STPs were secret plans and a vehicle for cuts. These negative perceptions tarnished the reputation of STPs and continue to impede progress on the ground. National bodies’ initial mismanagement of the process, including misguided instructions not to be sharing plans, made it very difficult for local areas to explain the case for change. 

The oral evidence was dealt with in a more tortured and convoluted way. The report is a mass of contradictions. Far from presenting ‘compelling evidence’ it trips over itself trying to avoid the evidence staring it in the face:  

  • They agree with Allyson Pollock that ACOs need primary legislation. But they would like to trial a few first – how can a trial be run of accountable bodies which need primary legislation, without the legislation?  
  • They agree that the success of integration depends on the strength of local inter-disciplinary working, but accept that the 44 ‘footprints’ which are the boundaries of the Sustainability and Transformation Partnerships are not all well drawn and leave areas incoherent. They make no recommendation to address this.  
  • They accept the need to address the NHS’ financial constraints then admit there is no evidence integrated care does this. Indeed, far from being compelling, the evidence gives their claims the flimsiest of support. 

As an extraordinary rider to the Inquiry’s title change the report effectively dismisses the STPs as no longer having any relevance, notwithstanding the amount of money that has been spent on them and that they were a critical step in the implementation of the 5 Year Forward View. Section 92 says that the Partnerships which have succeeded them are ‘fragile’ and must not (be) overburden(ed) by increasingly making them the default footprint for the delivery of national policies’ despite that being precisely their purpose. 

In short, these contradictions, inconsistencies and timidity means it ends up as a report of no consequence. It tries not to offend but to our mind it fails even that very limited objective. Indeed, there are times when it is hard to supress a laugh as the report says, time and time again, that there is no evidence in support of this plan – but they support it anyway. 

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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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