Issue: 54
1 November 2017
This occasional newsletter is researched, written and edited by a group of concerned residents in Ealing, West London who want to preserve our NHS. We view the wholesale engagement of private, for-profit healthcare service suppliers as unnecessary, profligate and dangerous. Increased financial funding is what is needed in our NHS – not financial cuts, closure of vital services or privatisation.
The Integration of Healthcare and Social Care is a Failure
Failed attempts to integrate healthcare services and social care services go back a long way. The National Health Service Act 1977 under Jim Callaghan’s government encouraged Health Authorities and Local Authorities to co-operate. The Health Act 1999 allowed NHS bodies to pool budgets. Successive governments have again and again tried to pull NHS bodies and LAs closer together.
However, it’s been 40 years of failure.
The House of Commons (HoC) has been busy recently churning out extremely helpful and informative impartial briefing papers on various aspect of care. I’ve drawn heavily on one of these papers in this piece – ‘Health and Social Care Integration: Number 7902, 20 October 2017’.
One assumes the goals of this integration would be better patient/service user experiences, efficiency and cost cutting. The elephant in the room is that healthcare is funded and run by the Department of Health (DoH)/NHS England (NHSE), and social care is funded by the Department for Communities and Local Government (DCLG) and run locally by Local Authorities (LAs).
To continue the history lesson we had the Health and Social Care Act 2012 (‘..duty to encourage integrated working’) and the Care Act 2014 (‘..promote the integration of healthcare provision’). It’s unclear as to how much integration these statutory ‘encourage’ and ‘promote’ initiatives actually achieved.
The Better Care Fund (BCF)
The BCF was announced in 2013. It was to be the primary funding mechanism for integrating health and social care. A key goal was keeping older and disabled people out of hospital. £200 million was immediately handed to LAs. Spending the £3.8 billion BCF should have achieved healthcare and social care integration by 2018 – but it won’t have. In 2015 BCF was judged to be missing its bed reduction, elderly hospital discharge and independent living targets. Rather than saving on costs, costs rose by £200 million. An ‘improved’ version was introduced (iBCF). Another £1.5 billion was thrown at it. In 2017 Local Authorities were granted £2 billion for BCF 2017-2020.
There has been much criticism of BCF. Apparently NHSE has effectively abandoned it. It seems the grant money wasn’t ‘new’ money but ‘old money’ re-purposed. Informed observers found unrealistic levels of bureaucracy and expectations. Only 30% of the BCF money has been spent on social care. There are certainly patches of successful integration throughout England but neither DoH nor DCLG has tried to measure integration ‘success’ or estimate BCF cost savings. BCF was rendered largely redundant by NHS Sustainability and Transition Plans (STPs) published in October 2016.
Integrated Care Pioneers
Launched in 2014 in 14 local areas, and in an additional 11 in 2015, some piecemeal success has been achieved. However the Policy Innovation Research Unit noted difficulties in accessing external support, and problems with data sharing, payment systems, and procurement provider viability.
Vanguards
50 were established in 2015 – often involving NHS bodies and LAs. A National Audit Office report in 2017 highlighted some early integration successes but whether this success could be scaled up and sustained (post grant-aid), and deliver cost savings is debatable.
Health and Wellbeing Boards (HWBs)
The Health and Social Care Act 2012 required upper-tier LAs to create these boards. The Act mandated HWBs with a duty to encourage integrated working. HWBs are required to produce a Joint Strategic Needs Assessment – which looks at current and future local and social care needs. The King’s Fund in 2014 observed that many HWBs showed limited ambitions for integration.
Devolution
The devolution of health and social care to Greater Manchester was announced in February 2015. Care integration is a major aim. Care budgets (£6.2 billion) were pooled as from 1 April 2016. Although there are local integration successes no major integration ‘successes’ or cost savings have been publicised.
In London, a somewhat less ambitious care ‘collaboration’ agreement was signed by 33 NHS CCGs, 33 LAs, Public Health England and NHS England. There are three pilot integration projects in north east London, Hackney and Lewisham. They began in April 2017 and apparently don’t expect success until April 2019. Care integration across London is not a collaboration goal.
In Cornwall (2015), Liverpool (2016) and Cambridgeshire and Peterborough (2016) moves towards devolved integrated care are underway.
Sustainability and Transformation Plans (STPs)
STPs describe how a region will meet the needs of the NHSE Five Year Forward View (FYFV) objectives published in 2014. Implementing STPs must collectively cut annual healthcare costs by £22 billion by 2021.The integration of healthcare and social care is one of the stated goals for all 44 STPs. However details on the social care side of the integration equation are thin on the ground in many STPs. Given that 43 of the 44 STPs are run by NHS executives this healthcare bias is perhaps understandable. The Local Government Association LGA) and the Public Accounts Committee (PAC) have both expressed concerns about STP care integration. The LGA’s main concern is the lack of involvement by LAs in the creation of STPs, and how STPs will interact with LA Health and Wellbeing Boards’ integration plans. The PAC sees the risk that integration will become sidelined in the pursuit of NHS financial sustainability.
Mental Health
Sadly it’s no surprise that the HoC briefing paper makes no mention of integrating mental health care services with mental health social care services. Ignoring mental health needs has been a national pastime for decades. The NHS and LA care resourcing crisis is probably most acute in mental health.
Accountable Care Organisations (ACOs)
Although completely ignored by the House of Commons briefing, ACOs are clearly planned to be the implementation ‘engines’ for cost cutting and care services’ integration. ACOs will have 10/15 year, fixed price contracts to deliver specific services to specific populations. They will use capitated budgets i.e. a standard, fixed annual budget for each service user. Will these ACOs finally deliver care integration? The answer to that is that no-one knows. Many of the ACS contracts will be £multi-billion ones – and nowhere in the world have ACSs been even attempted on this scale.
ACOs is a jargon littered arena. We have Accountable Care Systems (ACSs), Accountable Care Partnerships (ACPs), Multispeciality Community Providers (MCPs), Primary Acute Care Systems(PACS) and Accountable Care Models. The DoH is hoping to get Parliament to agree to new regulations in February 2018 which will allow ACOs, amongst other things, to commission integrated care services. Pioneer ACOs start date is 1 April 2018 – but the NHS rarely hits its target start dates.
There is precious little evidence (or public confidence) that the STP/ACO approach (by those who know about it and grasp the significance of it) will achieve successful healthcare and social care integration or in fact meet the cost savings targets by 2021 or at all.
Disintegration
Whether healthcare services and social care services are integrated or kept as separate services, is a moot point if the human resources and facilities needed to deliver each of the services are inadequate. Consider:
+ The number of care/nursing home beds is decreasing – because of rising costs and falling revenues
+ The numbers of Acute hospital beds and hospital A&E units are decreasing – because of Government/DoH/NHSE policy
+ There are significant shortages of trainee and trained doctors, nurses, mental health staff, social and healthcare support staff – because of cost cutting, the salary cap, bursary removal, student debt, medical schools’ capacities, overwork and Brexit fears
+ Much of the NHS estate is old, not fit for purpose and needs refurbishing/replacing – however the DoH/NHSE approach is to empty the buildings and sell off the land
+ NHS staff and LA staff don’t understand each other, don’t trust each other and don’t want to share data – according to NHSE Director Professor Keith Willett.
Maybe the sensible approach would be to accept that 40 years of trying and failing to integrate is quite long enough as a learning exercise. What we need is both the healthcare service and the social care service to be adequately funded, resourced, equiped and ‘housed’ with clear handover interfaces between each other.
Yet Another Revolution?
It would take a major revolution to scrap the NHS and Local Authority social care services and replace them with a new National Care Service (NCS) which would provide integrated healthcare services and social care services both free at the point of use. I don’t think we have got to that point where yet another revolution looks like the best option.
However, it maybe that we have already embarked on creating this new care body. As from 1 April 2018, in theory, England will start to be covered by ACOs which presumably will take over from CCGs and LAs in commissioning healthcare, social care (Public Health?) and the integration of the two. This will make NHS CCGs and LA social care commissioning organisations redundant. Now imagine a national organisation being created which would manage all these ACOs. An ‘Accountable Care England’ could be set up and would in effect be this new National Care Service, which would make NHS England and probably the NHS itself redundant. All this is speculation on my part as the ‘cunning plan’ no doubt hatched at the WEF in Davos in 2012 has not yet crept into the public domain.
The DoH Wants Parliament to Give the Green Light to ACOs in February 2018
Consultation is underway, initiated by the Department of Health (DoH), on getting Parliament to ‘bless’ Accountable Care Organisations (ACOs) in February 2018. ACOs will be the cost cutting engines used to implement England’s 44 Sustainability and Transformation Plans (STPs) – and reduce annual NHS costs by 20%. (As detailed above there are plenty of flavours of ACOs being touted by the NHS around England).
NHS patients, social care users or even Local Authorities are not explicity asked to comment. NHS professionals, GPs and GP Practice Mangers are, however, expected to comment by 3 November 2017. (Overworked GP staff must be over the moon about even more paperwork to deal with).
Much of the 21 page ‘Accountable Care Organisations’ document relates to allowing GP surgery GMS and PMS contracts ‘to be suspended’ – this, apparently, will facilitate GPs being able to participate in a ‘fully integrated ACO’. It seems that ACOs will be able to dispense drugs and appliances. Clearly the intention is that ACOs will commission care services along with NHS England, Clinical Commissioning Groups and Local Authorities (or ultimately instead of perhaps?)
In all the 21 pages no reference is made to the primary purpose of ACOs which, of course, is massive cost cutting. Tragic really.
999 Call for the NHS Takes On NHSE with a Judicial Review (JR) Claiming ACOs are Illegal
Health Services Journal (HSJ) has revealed that this JR is now underway. 999 claims that the August 2017 Accountable Care Organisation (ACO) contract introduced by NHS England is illegal. 999 claims the ACO contract breaches the Health & Social Care Act 2012 at sections 115 and 116. These sections relate to the price a commissioner pays for NHS services and regulations around the national tariff. The fixed population budget – or ‘Capitated Budget’ as American ACOs call it – does not link payment to the number of patients treated or to the complexity of the medical treatment provided – as required by the Act.
999 Call for the NHS is a grassroots campaigning network dedicated to restoring a publicly funded, run, managed and provided NHS (www.999callforNHS.org.uk)
Demand For A&E Services FALLING Not Rising at Ealing Hospital and Northwick Park Hospitals and Waiting Times for the Chronically Ill and Seriously Injured is the WORST in England
Colin Standfield has been collecting and collating attendance figures at NHS NW London Hospitals for over four years. The NHS in recent years has made this task more difficult by moving from weekly figures to monthly figures, by lumping Urgent Centre Centre (Type 3) figures with Type 2 and (the most seriously ill and injured) Type 1 figures. Merging Ealing and Northwick Park Hospitals into one NHS Trust (money saving no doubt) has further complicated getting at the facts. Finally timely release of data re A&E attendances and admissions is not a current NHS NWL characteristic.
Here is the damning data for Ealing and Northwick Hospitals combined:
A&E Attendances:
July 2017 Types1, 2, and 3 – 28,701
July 2016 Types 1, 2 and 3 – 29, 034
August 2017 Types 1, 2 and 3 – 26,222
August 2016 Types 1, 2 and 3 – 26,911
With these figures just how can NHS NWL executives continue to use terms like ‘unprecedented demand’? Is it down to lack of basic arithmetic skills? Or is there another explanation?
Is the London North West Healthcare NHS Trust (LNWHT) Financially Sustainable?
In the horror show of today’s NHS in which every part of the organisation (sorry – business) must make a profit and no part can be a cost centre, LNWHT (Northwick Park and Ealing Hospitals) appears to have intractable financial problems. Colin Standfield (again) points out that the LNWHT 2015/16 Annual Report stated ‘…the Trust does not have a financial plan which brings the Trust back into financial balance in the medium term’. In the 2016/17 LNWHT Annual Report, LNWHT is seeking a minimum of £49.5 million ‘additional support’. It further states ‘…the existence of a material uncertainty which may cast doubt about the Trust’s ability to continue as a going concern’. Given there’s no evidence that the £49.5 million ‘support’ has been forthcoming, could LNWHT soon being going into ‘intensive care’ of some kind?
Is The Government Review of the Mental Health Act 1983 Being Led by
the ‘Right’ Person
Over 65 disabled organisations, campaigners and mental health professionals have written to Prime Minister May complaining about the appointment of Profesor Sir Simon Wessely.
Wikipedia details a whole host of reasons why the Professor should not have been chosen. These include claims that the Professor has stated that Myalgic Encephalomyelitis (ME) Syndrome was driven by ‘false illness belief’. His ‘Exercise Therapy’ has been shown to cause 50% of ME sufferers deterioration in function. He has also played an active role in devising the theories of ‘malingering and illness deception’ which underpins Work Capability Assessment (WCA). WCA has had a disastrous impact on the lives of disabled people.
Possibly not then an inspired choice for this role. Based on my 20 years as a mental health carer, my choice would have been the appointment of an experienced and respected psychologist, rather than a controversial psychiatrist. Surely the future of mental illness treatment is more one of talking psychological therapies than drug based psychiatric approaches?
