Issue: 68
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.
Ealing Out Of Hospital (OOH) Services Outsourcing Contract: More Questions Than Answers
Rumour and speculation are rife about who might bid for and who might win this contract. The names of four London NHS Trusts have been mentioned. We are still no nearer discovering the real reason why this 10 year, £450 million minimum/£1.2 billion maximum, single supplier contract has even been proposed. The Invitation To Tender (ITT) was issued on 22 March 2018. If awarded, this contract is likely to be the longest and potentially most lucrative NHS outsourcing contract ever awarded in England. It could make the local commissioner – the NHS Ealing Clinical Commissioning Group (ECCG) – quite famous.
Quite simply, OOH services in Ealing might be described as some of the day care services currently provided inside Ealing Hospital, outside Ealing Hospital and not provided in GP surgeries. Virtually all the OOH social care services included in the initial 36 services’ specification are outsourced to private operators by Ealing Council.
Is It to Reduce OOH Services Costs?
No – says ECCG. Cost saving would be accrued by reductions in Non-Elective Admissions (NELs) to hospitals says ECCG. NELs are mostly accident and emergency admissions. The NELs volumes have remained pretty much at the same level in Ealing and North West London (NWL) since we have been monitoring NELs starting in April 2013. It will take some special magic for the appointed single supplier of OOH services in Ealing to significantly reduce the Delayed Transfers of Care (DTOCs or ‘bed blocking’) predominantly caused by lack of social care capability or mental health beds
Is It to Improve the Quantity and Quality of OOH Services?
No explicit claims have been made or evidence provided to support such improvement by ECCG, the NHS NWL Collaborations of CCGs, the NHS NW Sustainability and Transformation Partnership (STP) , NHS NWL ‘Shaping a Healthier Future’, NHS England or NHS Improvement.
Why is it a 10 Year Contract?
We can find no answer to this one.
Is It to Cut Down ECCGs Workload?
If a single supplier is to manage and resource 36 (and maybe 60) OOH services in Ealing over a 10 year period it makes little sense that ECCG would be micro-managing service delivery (i.e. ‘commissioning’) as well.
Is It A Trojan Horse for a Pioneer Integrated Care System (ICS) in Ealing?
ECCG says it’s not an ICS (ACO in ‘old money’), which implies the budget will not be set using a ‘Whole Population/Capitated Budget’ and fixed price approach.
Who Will be Writing the Responses to the ITT?
No doubt it will be management and healthcare consultants. More £millions of public money sacrificed on the altar of marketisation.
When Do Responses to the ITT Have To be Submitted?
Initially this was to be by 23 August 2018, with an earlier deadline of 19 July 2018 for submitting a completed ‘Selection Questionnaire’. However as the procurement documents were delayed till 4 May 2018, there is a ‘revised procurement closure date and associated deadline for submission of tenders’.
Are There any Precedents of Any Similar NHS Outsourcing Contracts?
Ominously the answer is yes, in Cambridgeshire in 2015. A five year £800 million NHS outsourcing contract ended expensively after just 8 months of operation. The contract was for a single supplier to manage and deliver community healthcare services to adults and elderly people in Cambridgeshire from 2015 to 2019.The company running it, called UnitingCare, pulled out saying that the contract was not financially sustainable. Warning signs appeared early on in the performance of the contract. Uniting Care had boldly promised estimating savings of £178 million by 2020. However they requested £34 million of extra funding from the local CCG – just four weeks into the contract going live.
UnitingCare was a consortium of Cambridge and Peterborough NHS Foundation and Cambridge University Hospitals NHS Foundation Trust. The local CCG chose UnitedCare because it was the lowest bidder.Unsuccessful, more expensive bidders were Virgin Care and Care UK. Both the Government Committee of Public Accounts and the National Audit Office were severely critical of the lack of commercial skills exhibited by the commissioning NHS CCG.
Are Integrated Care Systems a Bad Idea Poorly Implemented?
Integrated Care Systems (ICSs) appeared on our radars in January 2018. They were a new name for Accountable Care Systems (ACSs). The justification for the renaming was never explicit, but many of us assumed what was behind it was that Accountable Care sounded too ‘American’.
In May 2018 NHS England announced four more ICSs to add to the existing 10. The timing of this was appalling. The highly rated Judicial Review on ACS/ICS legitimacy by JR4NHS had just enjoyed its two days in the Royal Courts of Justice. The 12 week public consultation on ACS/ICS promised by NHSE in February 2018 has still failed to materialise. The ACS/ICS enabling Parliamentary legislation the Government planned for February 2018 also never happened. The four new ICSs are Gloucestershire, Suffolk and North East Essex, West, North and East Cumbria, and West Yorkshire and Harrogate.
According to ‘Heath Service Journal’ none of the original 10 ICSs have reached an agreement with NHSE/NHSI about finances. Technically the arguments are about ‘Control Totals’ which seem to be the financial targets to be attained by end of March 2019. The sticking point is apparently that ‘organisations are unwilling to risk losing their sustainability funding if a neighboring Trust or CCG fails to meet its financial plan’. Not much peer trust or respect at work then.
None of these 14 ICSs are any more than talk and good intentions. There are, apparently, no signed ICS contracts. If any of them were ‘real’ then NHS Clinical Commissioning Groups would be winding up as they would have lost their commissioning roles for healthcare. Local Authorities would be re-structuring as they would have lost their social care commissioning roles.
Only an idiot would argue against the principle of integrating healthcare services and social care services. But with the current organisational structures and with the proposed ICS structure, the component care bits just do not ‘fit closely and seamlessly together’. The size and content of any NHS patient database is very different from its Local Authority (LA) social care service user database. The NHS and LA payment protocols, financial regimes, management accountability, cultures, IT and even vocabularies are alien to each other.
The vast majority of social care services are outsourced to the private sector and are means tested. NHS healthcare services are largely ‘insourced’ and are free at the point of use. Finally, NHS bodies and LAs don’t seem to trust each other enough to open up their financial books to each other. What both healthcare services and social care services do have in common is that they are both under-funded and under-resourced.
If ICSs are implemented as advertised, this spells the end of the NHS. 44 private ICSs will run healthcare and social care services throughout England on fixed price, long term contracts. NHS Trusts, private care homes, private healthcare providers, NHS staff, NHS buildings etc will all be just resources which the ICSs may deploy or dispose of.
The Mass Transfer of Property from Public to Private Ownership: The NHS ‘Journey’
Consider the following:
+ University College London Hospital Foundation Trust recently boasted a £76 million surplus after asset sales and a Sustainability and Transformation ‘bonus’. (‘Health Service Journal’).
+ The NHS is planning to develop Royal Free Hospital nurses’ homes into luxury flats. (‘The Guardian’).
+ The Health and Social Care Act (2012) sanctioned NHS Property Services Ltd (PropCo). This company now owns the property which was previously owned by NHS Strategic Health Authorities and NHS Primary Care Trusts. The company is a private one which is wholly-owned by the Secretary of State for Health, Jeremy Hunt MP.
+ Public-Private ‘Project Phoenix’ will create six major regional public/private property deals by June 2019. The companies formed by these deals will be ‘off balance sheet’.
They will sell publicly owned property and replace it with private rented property. They will be the cash-raising vehicles for Sustainability and Transformation Partnerships.
+ Sir Robert Naylor carried out the review of NHS property which led to the creation of Project Pheonix. He thinks the fire sale of NHS property could raise £5.7 billion.
Much of this information was gleaned from Jessica Ormond’s piece at www.opendemocracy.net
GPs Under Attack! NHS plans to Reduce 8,000 GP Surgeries/Practices to 1,500 GP ‘Super-Hubs’
‘Pulse Today’ has documented the Government/NHS saga which could decimate the GP Surgery/Practice population in England. It all started with Tony Blair’s introduction of the GMS contract for GPs in 2004. This began the trend towards larger practices or federated models of working. The APMS contract followed which allowed multi-nationals like UnitedHealth and groups of GPs to run practices.
The Sustainability and Transformation Partnership (STP) and the Integrated Care System (ICS) juggernauts are now aiming to reduce our 8,000 GP practices down to 1,500 GP ‘Super-Hubs’. We now have the very real prospect of the ‘family doctor’ concept disappearing forever.
Annual Number of Re-Admissions to A&E Units on the Rise: Pneumonia Sufferers Re-Admissions Up 72.5% Over the Last Six Years
The Nuffield Trust and the Health Foundation have published research on annual re-admission numbers to hospital A&E units since 2010/11. Re-admission within 30 days has risen 19.2% over the last six years. The re-admission number for 2016/17 was 1.158 million patients. In the case of blood clots, pneumonia and bed sores the annual rate rose by 41.3%. The rise for pneumonia was a very worrying 72.5%.
Allegations that patients are being discharged too soon have been made by the Society of Acute Medicine. Under-staffing and under-bedding are seemingly forcing hospital staff to get patients out of hospital as quickly as possibly – and for over one million patients last year possibly too quickly.
458,000 NHS Patients Abandoned as 134 GP Surgeries Closed Down in 2017
In 2017, 57 GP practices along with 77 GP satellite surgeries closed down leaving 458,000 patients with no registered GP. Since 2013, 445 GP practices/satellite surgeries have closed leaving over one million patients without a GP.
‘Diagnosis Critical’ Report Advises that More Money and Care Integration Alone will Not be Enough to Provide Care For All
This 46 page report, published in June 2018, launches an inquiry into health and social care in England. It’s published by a new economic think tank called the Centre for Progressive Policy (CPP). There’s plenty of useful, well presented data, backed up by lots of relevant referenced papers.
The report asserts that more money alone will not satisfy the NHS constitutional core standards for improving cancer services, A&E performance or the number of elective admissions. (It fails – as does the NHS – to reference mental health services standards).
It points out the dichotomy of separate healthcare and social care workforces and opines that integration of the two will fail to address the needs of an aging population. It quotes a National Audit Office report which stated the NAO had studied 20 years of integration initiatives and found ‘no compelling evidence to show that integration in England leads to sustainable savings or reduced hospital activity’.
It is critical of the 2014 NHS Five Year Forward View and the 2017 update on the grounds of finance, performance, missed targets and productivity.
There are valuable insights into deprived areas care needs and the uneven geographic distribution of elderly social care needs. There is plenty of discussion on a range of new funding models which might generate more cash for care services. CPP is keen to ‘tackle social determinants of health as part of health and social care re-design’.
The current and future roles of Clinical Commissioning Groups (CCGs), Sustainability and Transformation Plans/Partnerships (STPs) and Integrated Care Systems (ICSs) are hardly mentioned at all in this report. On the face of it this is an odd omission.
There will be a range of ‘engagements’ in 2018/19 with a final report due in May 2019.
CPP is wholly funded by 77 year old, multi-millionaire Lord David Sainsbury, who is Chancellor of Cambridge University. CPP has an advisory board of 14 people, all of whom are unknown to me. More at www.progressive-policy.net
78% of Local Authorities Social Care Services Close to Collapse
A survey of 152 Local Authorities (LAs) by the Association of Directors of Adult Social Services has revealed that 78% of them are close to collapse in providing residential care homes and domiciliary care. 44 LAs said that companies had given up contracts because they were losing money.
In 2017 £2 billion was injected into the care system by Jeremy Hunt MP, Secretary of State for Health and Social Care. In July 2018 he is expected to publish a plan to reform social care.
