Chance to Publicly Scrutinise NHS North West London Healthcare Purchasers is Wasted.

One of the few ‘in public’ NHS NW London-wide meetings at which elected Members (i.e. Local Councillors) examine NHS healthcare performance and plans took place on Tuesday 5 December 2017. It was a meeting of the NHS North West London Joint Health Overview and Scrutiny Committee (JHOSC). This is a fairly rare event taking place perhaps only twice each year.

16 Councillors from the eight NHS North West London (NWL) Local Authorities were invited to attend this JHOSC meeting but only four of them turned up. None from Ealing and none from Brent for example. More members of the public attended than elected Councillors in NWL. The strange location of the meeting did not help. It took place in Twickenham, Richmond at 9:30am. Richmond isn’t an NHS NWL borough, but some of its Councillors did turn up.

The NWL Collaborations of CCGs bombarded the attendees with 90 pages of seven papers. The two Accountable Officers for NHS NWL CCGs Ms Clare Parker and Mr Rob Larkman were in attendance. Juliet Brown also attended. She is Local Services Transformation Director. Clinical support was provided by Dr Le Brooy, the new NHS NWL ‘Shaping a Healthier Future’ (SaHF) Medical Director. (Her predecessor Dr Mark Spencer has moved out of SaHF into healthcare management consultancy).

Many of the Councillors’ questions were ‘thin’ on content. This was possibly because they had not had time to study the 90 pages and/or they had insufficiently followed and researched the five year SaHF cost cutting /service transformation to-ings and fro-ings. One Councillor never spoke at all during the 2.5 hour meeting.

Getting Elderly Patients Out of Hospital

Dr Le Brooy, a senior geriatrician, led the NHS attack here under the banner of ‘Front End Frailty Services’. The plan is to admit as few as possible elderly people into hospital. Evidence from Sheffield, Leicester and Poole was quoted. The whole approach can clearly only work if significantly expanded home-based and community-based healthcare and social care support services are in place.   

The nirvana quoted was multi-disciplinary teams working together to assess old peoples’ needs and to offer an alternative to hospital admission. These team members include mental health practitioners, geriatricians, pharmacists, dieticians, speech and language specialists, frailty nurses, social care decision makers and therapists. One does wonder whether this is happening now? Will it happen consistently in the future given the continuing shortage of staff across the board? Is this just pie in the sky?

Dr Le Brooy admitted that there was a shortage of geriatricians . The Chair expressed concern of anecdotes about elderly people being discharged from hospital over night and delivered to empty homes.

Accountable Care Organisations (ACOs)

Mr Larkman and Ms Parker delivered inadequate presentations on ACOs. They ran through some of the usual ACO mantras of fragmentation, misaligned incentives, access, population needs and joined up health and social care services. They mysteriously failed to mention that ACOs will be fixed price, long term contract beasts which will force through massive cost cutting.

They provided sketchy details about the Hillingdon elderly peoples’ Accountable Care Partnership (ACP) which is apparently the most advanced regional ACO. This will apparently feature the Hillingdon CCG and the London Borough of Hillingdon (LBH) working together. Rumour has it that LBH is not co-operating with the CCG on the NHS NWL Sustainability and Transformation Plan (STP) for which ACOs/ACPs are supposedly the STP implementation ‘engines’. What Parker/Larkman failed to tell us all (and none of the Councillors asked) was:

+ What is a Capitated Budget? This is not defined in the NHS NWL ACO Glossary provided – which is the world’s smallest glossary defining just three terms. A Capitated Budget (sometimes called a Population Budget ) is where an annual budget is set by assigning a cost/head for a defined patient population (eg £2,500 per elderly person) and multiplying that by the number of  65+ people within that defined population (eg 40,000 in Hillingdon). In this example the annual Capitated Budget would be £100 million. Over 10 years that would be a £1 billion contract.

+ What is the Capitated Budget set for 2018/19 ( i.e. how much annual cash per elderly head has been allocated?)

+ How will the Capitated Budget be calculated  for 2020/21? My guess will be it will be the 2019/20 annual cost, less say 20%, divided by the number of older people

+ Who will run the Hillingdon ACP? (Has he or she been appointed already?)

+ How will the ACP Board be elected/selected?

+ How long will the ACP contract  run for? Ten years probably.

+ To whom will the ACP be accountable?

Will ACOs Deliver Integrated Care or Just Massive Cost Cutting?

What they did say was that ACOs will result in better integrated care and help in the areas of education and housing. Helping with education is a bit of a stretch – but helping with housing is just beyond belief. NHS NWL ACO priorities are elderly people, adult long-term mental health conditions and Diabetes. The Trojan Horse for ACOs is apparently the Whole Systems Integration Care (WSIC) programme ‘which for four years has been integrating healthcare and social care teams’. Has it really one wonders? Will ACOs deliver the £1.4 billion savings across NHS NWL by 2021? And it they do to what extent might healthcare and service care levels fall through the floor?

Grant funded ACO Vanguards’ performance is quoted as evidence.  This is a bit thin as none of them have reduced admissions to A&E, but some have reduced the growth in A&E admissions.

There’s also mention in passing, of a ‘Multi-speciality  Community Provider’ (MCP) ACO being put together in Hammersmith & Fulham (H&F). Again this seems somewhat doomed as H&F Council is very publicly not supporting the NHS NWL STP.

The printed ACO paper did reveal a lot more information. Apparently the ACO contracts will be at least 10 years long. None of them will commence in ernest before 2019.

There are seven CCG ACOs in various stages of creation:

+ Brent

An MCP ACO is being developed to deliver the WSIC model of care planning.

+ Central London

Working with Westminster City Council and partners a Primary Care Homes ACO is in development which will morph at some point into an MCP ACO

+ Ealing

‘The Ealing Standard’ Out of Hospital (OOH)/ GP services, single supplier 10 year ACO

+ Hammersmith & Fulham

An MCP/Primary & Acute Care System (PACS) is being created to start in 2019. It covers OOH and Primary Medical Services (PMS)

+ Harrow

An ACO for WSIC is being developed for a segment of the 65+ population

+ Hillingdon

An ACP for 65+ integrated care

+ Hounslow

OOH/PMS ACO leading to an MCP ACO.

The final ACO slide contains the killer phrase ‘(ACO) providers take control, commissioners become much more strategic…’. The former is worrying and the latter is meaningless.

Community Hubs

The target is 27 Hubs. 18 of them need £141 million of funding. In Ealing two of these will need £21.1 million (Ealing East) to open in 2019 and £14.6 million (Ealing North) to open in 2021. Both will be funded by the Local Improvement Finance Trust (LIFT). LIFT is seven years old and is the NHS PFI/PPP model (60% private cash and 40% public cash). Acton Health Centre is to close and the site to be sold for £2 million.

Out-Of-Hospital Hub Productivity

22,000 Non-Elective (NEL) hospital admissions will, apparently, be avoided by the use of Hubs. However the NEL annual admissions reduction target is 99,106. Evidence to support this target includes data from ChenMed in the USA. This was one of the sites visited on the McKinsey & Co organised NHS NWL fact finding trip a couple of years ago. This case study features a fleet of 60 vans/courtesy shuttles and 36 specially built Primary Care ‘hubs’. Practioner list sizes are up to 450 – unlike NWL General Practioners’ average list size of 1,700. So the efficacy of this evidence is debatable. Evidence is also presented from Canada.

Local Services Update

+ Access to GPs

In November 2017 21,000 additional appointments were offered, 60% of these were used by patients

+ Diabetes

30% of all hospital beds have patients suffering with Diabetes in them. Diabetes, allegedly, accounts for 30% of all emergency admissions

+ London Ambulance Service (LAS) Prevention of Admission

This is about ambulances taking patients anywhere but to a hospital

+ Home First for Elderly People

One in three hospital patients is medically fit to leave hospital. ‘Home First’ is a multi-discipline team approach to getting the medically fit out of hospital In the first six months of operation (since May 2017), Home First, allegedly, removed 600 patients from NHS NWL hospitals to somewhere else.

Ealing District General Hospital Closure

This transformation will apparently follow the same process as was used to close Maternity and Paediatrics. Key transformation metrics will be:

+ Reduction in occupied bed days

+ NEL admissions

+ Length of stay

+ Capacity of A&E to manage attendances

+ Capacity to manage admissions, including critical care capacity.

No closure date was given. The silence from the non-attending Ealing Councillors was deafening.

Care of the Elderly: STP DA3 Paper

The NHS NWL CCG cabal is clearly working with the West London Alliance (WLA) – a cabal itself of West London Local Authorities. This is probably some kind of work-around given the intransigence of Ealing, Hammersmith & Fulham and Hillingdon Local Authorities. Ealing CCG and WLA both operate out of the same building in Ealing! Lots of data on A&E, hospital mortality, and bed days in here.

Royal College of Nursing: STP Concerns

The JOHSC had received a letter from RCN and wanted to discuss it with NHS bosses. The RCN went into some detail about its concerns, which included lack of evidence, poor engagement, planning behind closed doors, funding, workforce strategy and job security. The NHS bosses seemed largely unconcerned and tried to point out it had engaged with nurses.

MENTAL HEALTH

The CQC ‘Review of Children’s and Young People’s Mental Health Services: Phase One Report’ is a Major Disappointment

This 42 page document was published in October 2017 – 10 pages of it are a list of references. In many ways this is a useful document, but it contains some startling statements and some glaring omissions. I am encouraged but unbelieving that ‘most mental health services for children are ‘good’ or ‘outstanding. This is in the face of:

+ NSPCC Childline: 11,706 young people counselled for anxiety in 2015/16. Up 35% from 2014/15

October 2016

+ NHS England/ NHS Digital: Children self-harming annually up 385% over 10 years. Girls under 18 years of age poisoning themselves is up 42% at 13,853 girls.

October 2016

+ Department of Education: One in three 14/15 year old girls suffering from mental illnesses. A ten year study of 30,000 girls.

August 2016

+ 32 NHS Trusts: 60% of children referred for specialist mental health services are not receiving treatment. 50% increase in A&E admissions for under-18 year olds self-harming, 2011-2016

‘The Guardian’, 27 November 2017

Is this CQC marking its own homework?

What’s Missing from this Report?

Why is there nothing in the report on Sectioning under the Mental Health Act, the incidence of Delayed Transfer of Care, Out of Area Placements, self-harming and suicides?

There’s virtually nothing in here about family carers, and starting, supporting and funding volunteer led carer support groups. Psychologists hardly get a mention either. Although finance may not be strictly part of the CQC brief, the absence of any commentary about inadequate finances and consequent inadequate staff and facility resources makes the report less than credible.The Expert Advisory Group does not include a service user or a family carer representative.

Because social care is not provided by the NHS, this report does not review children’s mental social care services. There is a very strong argument for reviewing both children’s mental healthcare and social care services together. After all the FYFV/STP approach is to integrate healthcare and social care services by 2021.

The picture this colourful and pretty report paints is far too ‘comfortable’ for me. Instead of coming right out and suggesting some service provision is awful, it limply suggests variable quality of services. The growing mental health problems for teenage girls surely criy out for more money, improved resources and sustained and ‘loud’ attention. This report fails miserably on that score.

More at www.cqc.org.uk

Jam Tomorrow is Promised for Mentally Ill Children

A Government Green Paper, bizarrely launched on a Sunday (3 December 2017), proposes pilots, limited ambition and possible future cash to help mentally ill children at school. £215 million could be spent on creating mental health support teams operating in schools and colleges. However, pilots to assess the effectiveness of the approach will have to demonstrate success before cash will be spent to assemble these teams. The limited ambition is that only 20% of England might have such teams in place by 2022/23.

Allegedly thousands of people could be recruited to mental health support teams which could provide treatment to children in or near schools and colleges. But…..who will recruit and train these people? Just when and where will the training and the treatment take place? Every school and college will be encouraged to appoint a leader for mental health. Secretary of State for Health Hunt thinks that teachers will be able to spot those pupils who are anxious and/or depressed and report them to the mental health leader. It’s a nice idea but will it actually work – even at the few schools ‘on stream’ in 4/5 years. time?

Will Mental Illhealth Sufferers Be Helped by £85 Self-Help Videos?

Free, online, questionnaire led triage is being offered online by ‘Calm Clinic’. The depressed, anxious and the seriously mentally ill can fill in the questionnaire then submit it. Something or somebody then decides, on the basis of the answers, to offer the submitter the chance to purchase self-help videos for £85.

More at www.calmclinic.com

Mental Health Services in Ealing

Sadly this month I have had to use these services. I have found the much vaunted Single Point of Access (0300 1234 24) of very little help. On the morning of Monday 20 November I called the number and asked to speak to a mental health clinician. None was available. I called the Ealing Recovery Team East at Avenue House in Acton. Over two attempts the phone was not even answered.

LONDON CARE DEVOLUTION

London Healthcare and Social Care Devolution: More about Building Luxury Flats, Jobs for the Boys and Cost Cutting Than Improving Services

On 16 November 2017, the Mayor of London/London Assembly re-announced care devolution to London – first launched in December 2015. It doesn’t take long when reading the press release (line 6 in fact) to find the Mayor  banging on about £11 billion NHS land sales some of which will fund more new homes (mostly luxury/unaffordable flats no doubt).

Line 1 – the headline – states  ‘….devolution deal to improve health and care…’. No evidence is provided to support this groundless assertion. There are no annual budget or current annual care financial figures to be found anywhere in the release. There is no explicit reference to building new District General Hospitals to cope with the projected 1.3 million increase in London’s population by 2024.

Memorandum of Understanding

The 28 page Memorandum of Understanding tells us, unashamedly, that the focus of the devolution deal is prevention, health and social care integration and estates. This apparently stems from a March 2015 accord within the London Health and Care Collaboration Agreement. What is truly astonishing is that not one of these focuses is:

improving healthcare services, improving social care services, mental health, health and social care inequality, an ageing population, population growth, hospital beds, A&E access and performance, GP access and performance, staff recruitment, retention and shortages, domiciliary care access and performance, and care/nursing home access and performance.

The fact that ‘estates’ outranks all of the above is obscene and should make grown men weep.

79 ‘partner’ organisations are expected to work together. There’s no clarity as to how the 32 Local Authorities, The City of London, 32 NHS CCGs, the GLA and 14 national State bodies will all work together. Oddly missing as partners are NHS Hospital Trusts, NHS Mental Health Trusts, GP Federations, the NHS London Ambulance Service, the five STP/Footprints, NHS CCG Collaborations and the care Unions. On page 9 we first encounter ‘new payment mechanisms’. We also encounter ‘Accountable Care Systems’ on this page for the first and bizarrely the only time.

Devolution Administration and Management

NHS England employs 6,500 staff so pro rata for a devolved NHS London it would need over 1,000 staff to run the healthcare aspect and even more to manage social care and care integration across London. And when the five mega Accountable Care Systems (ACSs) and no doubt the various Accountable Care Partnerships ACPs), Multispeciality Community Providers (MCPs) and Primary and Acute Care Systems (PACSs) come into operation even more management resource will be needed.

There will be plenty of new non-clinical jobs/roles. New bodies to be created and staffed include the London Health Board, the London Workplace Board, the London Health and Strategic Partnership Board, the Partnership Delivery Group, the Partnership Commissioning Board and the Development Programme Board.

Supporting the ‘deal’ is a 28 page document which contains much of the aspirational meanderings to be found in most Sustainability and Transformation Plans (STPs). However some of the ‘new’ waffle is quite annoying. It begins by stating that London is facing unique health and care challenges. Of course this is nonsense as the capital’s care problems must surely closely resemble those in Birmingham, Manchester and Leeds. There are clear signals that a London care regulator will be created. There are few financial figures and these relate to land sale values figures. There’s reference to a ‘2,500 extra housing development’. Why – one must ask? One wacky section discusses illegal tobacco, counterfeit alcohol and gaming machines. Worthy subjects, but surely somewhat out of place.  Another figure which appears is 43% of mental health sufferers are unemployed. The devolved care deal will, apparently, help these people. With no clues as to how much the mental health and mental social care budget will decrease (it surely will not increase) this is cruel and unusual punishment to raise these false expectations.

What’s the Budget?

You can’t really choose which sweets you might buy until your level of weekly pocket money has been set by your mum. So – just how much cash will the devolved London care body get? Annual spend figures for healthcare and social care in London are not readily available to me. It might be useful to crudely extrapolate from the Greater Manchester (GM) experience. The delegated annual budget for healthcare and social care in GM is £7.7 billion. This will be reduced by £2 billion in 2021. There are 2.8 million residents in GM. There are 8.63 million residents in London. Using the GM ‘pattern’, London might get an annual budget of £23 billion which in 2021 might be cut by £6 billion. Trying to deduce it another way, the 2017/18 expected annual NHS spend is £124 billion. Pro rata for London would be £20.6 billion. The NHSE Five Year Forward View annual healthcare cost cutting by 2021 is £22 billion nationally and London’s population is about one sixth of England’s so the reduction in healthcare could be somewhat in the region of £3.5 billion.

Five ‘Devolution’ Pilots

Just living for one year (2016/17) – according to the press release – these pilots explored a range of issues – only tenuously devolution related:

+ Haringey

Developing new approaches to public health issues  

+ Barking & Dagenham, Havering and Redbridge BHR)

Plans were made for an Accountable Care Organisation (ACO) aimed at Primary and Secondary care integration with a focus on early intervention and managing the chronically ill. The 50,000 residents’ ACO could go live in 2019/20

+ North Central London (Barnet, Camden, Enfield, Haringey and Islington)

The focus was on estates’ issues, testing new approaches to collaboration on asset use

+ Lewisham

Given it’s about integrating healthcare and social care this is standard STP stuff

+ Hackney

This seems to be standard STP care integration work with an emphasis on prevention.

Is it ‘Real’?

This is no pan-London plan. It talks about implementing these five devolution ‘learning’ pilots. Within the non-pilot areas- i.e. 22 London boroughs – ‘further devolution will be subject to the appetite of those areas’. This is, of course, very wishy-washy. This isn’t wholesale devolution – it’s more of ‘if you fancy some of this then join in sometime’. I’m not aware of any Primary Legislation/Act of Parliament which supports this ‘handing over of power – if you fancy it’. Is it, in fact, a diversion and yet another confusion to be stacked up on the existing, unstable pile of ‘new’ care organisations, initiatives and aspirations. This pile includes CCGs, CCG Collaborations, Footprints, NHS NWL ‘Shaping a Healthier Future (SaHF), STPs, ACOs, A&E closures, outsourcing to private companies, downgrading District General Hospitals, the ‘mirage’ of Out of Hospital/Intermediate Care services, and the failed NHS NWL  £513 million bid for building work.

More at www.london.gov.uk

Issue: 55

15 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.

£1 Billion+ Out Of Hospital (OOH) Services Contract Up for Grabs in Ealing: Or Is It?

Private healthcare companies must be licking their lips at the prospect of winning this ten year contract from the Ealing Clinical Commissioning Group (ECCG). ECCG is looking to hire a single supplier to ‘co-ordinate and manage’ these 31 services. This appointment would be yet another attempt to deliver on the NHS North West London 2012 ‘Shaping a Healthier Future’ (‘SaHF’) project. This initially ‘over three years’ project aimed/aims to improve healthcare services, downgrade some District General Hospitals and remove some Acute services and replace them with OOH services.

Last year it cost £127 million to run OOH services in Ealing. Given the imperative of cost cutting, an annual payment of some £100 million to this ‘outsourced’ NHS or private supplier would seem likely.

However these financial figures did not feature in a recent public ‘engagement’ event run by ECCG in Ealing Town Hall on this upcoming OOH contract. On 31 October 2017 over 60 people sat through almost three hours of presentations and workshops covering such issues as principles, care delivery, Single Point of Access – SPA (telephone not face-to-face) and expectations of a single supplier. ECCG Managing Director and two ECCG Deputy Managing Directors ran the meeting.

There is currently no certainty about exactly which OOH services will be included in the contract. However in the draft list were residential rehabilitation, physiotherapy, community nursing, primary care mental health, and Dementia support. Some of these service contracts are coming to the end of their life. Over the coming months and years each of these services could be provided by different NHS or private suppliers. It’s clearly going to take some time to hire and deploy this single supplier. The earliest start date quoted was January 2019.

There were lots of interesting observations and questions raised by the audience, but few interesting responses and answers from ECCG. Lots of attendees made it very clear that they did not want a private supplier gaining the contract. Some residents expressed astonishment that in 2012, as part of NHS NW London’s ‘SaHF’ project we were promised ‘world-class healthcare outside hospital’. In 2012 we waited two days to see our GP – now we have to wait three weeks. Also SaHF promised us that networks of GPs would be our first point of access – not a telephone service! The SPA also made little sense to some as we have had an SLA for mental health for two years and a NHS 111 telephone point of access. Surely that’s three points of access. Also given that Ealing has a high proportion of non-English speakers, surely any Ealing healthcare telephone service needs multi-lingual support.

In the 2014 NHS England Five Year Forward View and in the October 2016 NHS NW London Sustainability and Transformation Plan (STP) the delivery of social care and the delivery of integrated healthcare and social care are key attributes. ECCG never mentioned social care once – never mind integrated healthcare and social care services. Also not mentioned was the fact that with less money, services would probably be rationed. In NHS speak this is usually referred to as ‘demand management’. Again this phrase and the topic were not mentioned.

NHS NW London SaHF Business Case and £513 Million for Building Work Turned Down

Just 24 hours later a bombshell exploded with ‘Health Service Journal’ (HSJ) announcing that the final NHS NW London 2012 SaHF business case, involving a request for £513 million building work funding in ‘outer’ NW London, had been turned down by NHS Improvement (NHSI) on 28 September 2017. (NHSI is the NHS’s operational and financial regulator which ‘absorbed’ the previous major regulator NHS Monitor and other minor regulators in 2016).

Surely the ECCG MD and the ECCG Deputy MDs knew about this rejection. The whole basis of ‘outer’ NHS NW London OOH ‘transformation’ – the ability of Ealing OOH services to ‘replace’ some of the Acute care beds’ to be eliminated at Ealing Hospital, the creation and re-purposing of the three Ealing  NHA OOH ‘hubs’, the expansion of certain GP surgeries, the expansion of NHS NW London District General Hospitals (DGHs) to replace some of the eliminated Acute care beds at Ealing DGH – were all dependent on this business case and securing the £513 million.

Over 60 residents and NHS staff had three hours of their lives wasted on 31 October 2017 by three highly paid NHS ECCG executives. These three ladies went through the motions of a public ‘engagement’ exercise on OOH services and their outsourcing presumably already knowing that the capital funding request had been rejected over four weeks ago.

Some £70 million has been spent by SaHF with management consultants on formulating and implementing this now rejected business case over the last five years. This really is scandalous.

After press reports hitting TV and online media, NHSI came out of hiding, toned down its criticism and said that the business case trajectory was OK, but the numbers were not credible. At a public ECCG meeting on 8 November 2017 (the Primary Care Commissioning Committee) ECCG Chair Dr Parmar rather arrogantly dismissed the business case rejection by saying ‘we need to refresh the numbers’. More work and fees for McKinsey & Co, Deloitte et al are in prospect no doubt. It’s important to note that the hurdles the £513 million business plan has to clear are NHSI (second attempt), the Department of Health and H.M.Treasury.

Reports of staff leaving and staff shortages at Ealing Hospital are ongoing. Ever since the 2012 SaHF project labelled the District General Hospital ‘for downgrading’, clinical management has grappled with significant staff retention and staff recruitment challenges. Now to discover that SaHF never had a credible business case must make many experienced, overworked and dedicated Ealing Hospital staff very angry.

A Second Judicial Review is Underway Challenging the Legality of ACOs

’The Independent’ of 4 November 2017 reported that three healthcare professionals and a prominent public health academic had instigated legal action against the Department of Health. The foursome are seeking a Judicial review (JR) to stop Health Secretary Jeremy Hunt MP and NHS England from creating Accountable Care Organisations (ACOs).

ACOs will hold fixed price, long term contracts to implement the 44 Sustainability & Transformation Plans (STPs) throughout England. The ACO/STP approach is the Government’s current tactic to involve private care companies, to make large cost savings and to deliver and integrate healthcare and social care services.

Professor Allyson Pollock, the high profile public health academic jointly sponsoring the JR, is quoted as saying ‘..the Government is acting beneath the statutory radar in attempting the Americanisation of our healthcare and this fundamental re-organisation by stealth’.

This JR is separate from – but running in parallel with – the ‘999 Call for the NHS’ JR which claims the August 2017 ACO contract introduced by NHS England is illegal.

Patients Going Online is No Solution to the Shortage of GPs

We have a desperate GP retention, shortage and recruitment situation in England:

+ 400 GPs are quitting the NHS every month (‘Financial Times’ 10 July 2017)

+ 12.2% of GP vacancies are unfilled (‘Pulse’ May 2017)

+ A national shortage of 3,900 GPs (‘The Sun’ 12 May 2017)

+ 40% of GPs are approaching retirement (iNews 17 February 2017)

+ ‘Almost half of the 10,000 EEA doctors in the NHS are considering leaving the UK’ (BMA  March 2017)

+ It takes on average 7.4 months to recruit a GP partner (Commons Public Accounts Committee).

NHS England wants to give GPs £45 million to make them available online. Existing online ‘solutions’ being piloted include:

+ Smartphone appointments or Skype consultations

+ ‘NHS Online App’ which enables patients to ask GPs questions, receive text alerts with a link to doctors at an Urgent Care Centre for ‘red flag’ symptoms out of hours

+ ‘eConsult’ where patients answer questions about symptoms on their surgery web site, which are then reviewed by a GP within 24 hours

+ ‘GP at Hand’ service which promises 24/7 video consultations on smartphones – within two hours.

The latter ‘GP at Hand’ service, recently announced, has been condemned by the Royal College of GPS, the BMA and at the England LMC conference. An Internet enabled patient can get to ‘see’ a GP in two hours, whilst a telephone only patient has to wait, on average, 13 days to see a GP.

The problems many medical practitioners and commentators are identifying are related to the seeming priority being given to online/smartphone patients over telephone patients.  The approach apparently favours 28 year olds over 82 year olds. Also, put even more practically if a GP is diagnosing/treating 20 year olds from 3am to 7am he/she will not be available to diagnose/treat 80 years olds at noon later that day.

With a declining GP workforce the online/smartphone ‘care model’ and its promotion by NHS England amounts to unacceptable inequitable access to NHS branded services.

NHS North West London Has Spent a Gigantic £88+ Million on Management Consultants since 2009/10

Health data researcher and activist Colin Standfield has recently revealed that NHS NW London has spent £88,655,158 on management consultants since 2009/10. It’s quite along list of consultants who have benefited from this NHS largesse. They are: McKinsey & Co, Deloitte, PriceWaterhouseCooper (PWC), KPMG, PA Consulting, Moorhouse, Carnhill Farrar, GE Healthcare Finnamore, 365 Response, The Anna Freud Centre, Osca Agency, Mott McDonald, Qi Consulting, M&C Saatchi, Sky High Technology, Finnamore & Oak Group, Private Public, LCA/Consolidated PR, Baker Tilley, and Consard.

McKinsey & Co are the clear winners in take home remuneration. On one topic alone – ‘Whole Systems Integrated Care’ – it earned £8,755,621 during 2013 and 2014 by creting three reports on the topic. This topic – healthcare and social care services’ integration – is the challenge which is yet unmet in NW London, London and throughout England.

The first question that must be asked is why NHS NW London could not have done this McKinsey work (and in fact all the management consultancy work) in house? After all the salary costs/budget for the eight NHS NWL Clinical Commissioning Groups is at least £40 million per year. With this money one could hire lots of clever people with healthcare and social care experience, MBAs, first class Degrees, Masters and PhDs.

The second question to ask is were these management reports shared with other Footprints? Given that all the 44 Footprints must achieve healthcare and social care services’ integration via their 2016 five year Sustainability and Transformation Plans (STPs) in the world of the sensible these NHS NWL commissioned McKinsey reports would be shared amongst the other 43 Footprints. However from my years in the world of business, sharing of management consultant reports does not happen. So, we have the distinct prospect that, as dealing with healthcare and social care services’ integration is a national problem, each of the 44 Footprints has commissioned management consultants locally to advise them. If this is the case and NHS NW London’s McKinsey bills are typical, the care integration consultancy bill for London’s five STPs could be over £40 million and nationally some £352 million.

The third question to be asked is why didn’t the Department of Health or NHS England carry out this generic transformation research or commission it and then hand it over to the 44 Footprints?

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?

Issue: 53

17 October 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.

What, When and Where is Out Of Hospital (OOH) Care?

According to the 2012 NHS North West London ‘Shaping a Healthier Future’ (SaHF) programme OOH is:

‘All those services provided in community settings such as in your home by community nurses, at your GP surgery and in health centres. It also includes all the ways that you can ‘look after yourself better’. According to SaHF it could include services in a ‘Local Hospital’. Apparently GPs will be at the heart of delivering OOH.

OOH seems to be pretty much the same as ‘community based services’, ‘community services’ and ‘Whole Systems Integrated Care (WSIC)’. All four terms are seemingly used interchangeably throughout ECCG/NHS NW London publications.

After five years of trying to deliver SaHF OOH, NHS Ealing Clinical Commissioning Group (ECCG) has decided to ‘throw in the towel’ and outsource OOH for 10 years to some as yet to be appointed ‘single lead supplier’. ECCG wants a single point of access for the 76 different service providers involved. A 35 page ‘Prospectus’ about community services has been published. Private briefings were delivered by ECCG to interested parties in late September and early October 2017.

On the subject of SaHF health centres, we might usefully review where SaHF is with healthcare ‘hubs’. There were going to be five in Ealing originally but this then went down to three. Clearly one new hub will be in Greenford at some point by 2023 using developer taxes from the Greystar mixed use development on the old GSK/J. Lyons site. (This hub will be shared with Hillingdon’s residents). One of the others will be what’s left (by 2021) of Ealing General District Hospital after all its life saving services and facilities have been closed down. The other will be a new build (or re-purposed) facility somewhere in East Ealing.

Some questions and observations which come to mind include:

+ Why a 10 year contract? Surely the typical NHS ‘tenure’ contact period is five years. It’s five years for CCGs, STPs and NHSE’s Forward View.

+ If this single lead supplier approach to OOH/Community Services is so right for Ealing, why will it not apply across the whole of the NHS NW London/NWL CCGs’ cabal domain?

+ If this single lead supplier approach is so right why was it not part of the five year NHS NW London STP?  None of the five STP Delivery Areas is for OOH services.

+ If the single lead supplier who is chosen is a private company then some of the money that would have been spent on OOH services will be creamed off as profit.

+ Why the continued secrecy about the location of the East Ealing hub?

+ Surely the current flavours of the month for business models are the Accountable Care Organisations (ACOs). There are plenty of them, including ACS, ACP, MCP and PACS. Why isn’t the ECCG OOH business model one of the flavours of ACO?

+ How will the contract value be calculated? Again, the current ACO approach is using a  ‘Capitated Budget’. Using this approach you take the GP list population of 426,000 and multiply that with a cost/head/year (e.g. £1,000) and you then multiply that by 10 (years) and arrive at eg £4.26 billion.

+ On 16 December 2016 NHS NW London SaHF announced it was asking H.M. Treasury for £513 million for building work in ‘Outer NW London’. Some of this cash would be used to build/re-purpose/extend hubs and selected GP surgeries throughout Ealing. It’s 10 months later and no response has been forthcoming from H.M. Treasury. Presumably without these new/expanded facilities the new NW London OOH single lead supplier will not be able to actually deliver what’s needed come contract start date of 1 April 2018.

UCC Outsourcer Vocare Ltd Suffers the Indignity of its St Mary’s Hospital UCC Going into CQC ‘Special Measures’ and Being Sold For a Song to Totally PLC

In July 2017 St Mary’s Hospital Urgent Care Centre UCC) in Paddington was rated ‘inadequate’ by the Care Quality Commission (CQC). Up until April 2016 the UCC had been run by hospital staff. But Central London Clinical Commissioning Group (CLCCG) took the contract away from the NHS and gave it to Newcastle based Vocare Ltd. CQC has now placed the UCC in ‘Special Measures’.

Vocare is a supplier of UCC, 111 NHS telephone and GP out-of-hours services. No stranger to controversy, Vocare caused public concern when confidential documents became public in 2012 revealing it was experiencing ‘issues’ with its 111 NHS North East telephone service. It was also fined £141,281 for failing to meet NHS Tees contract conditions for a GP out-of-hours service.

Almost co-incidentally (or possibly not) London based Totally PLC has purchased Vocare Ltd in October 2017 for £11 million. In 2015/16 Vocare had a turnover of £77 million. These two figures only stack up if Vocare was making only small profits or worse it was in all kinds of trouble. Mere speculation, of course, on my part as a retired businessman.

Totally is a small AIM listed company. It missed the deadline for filing its 2015/16 accounts at Companies House. Totally’s web site lists Declan Gilhooly as Head of Finance but Companies House, again, show that he left the company in March  2017, having been in post for just five months.

One does wonder what kinds of due diligence was undertaken for CLCCG to hire Vocare in the first place. In the Tot–ally acquisition of Vocare we see just one of the liabilities of the NHS awarding a contract to a private company. That a company can be bought by another company and the NHS and citizens have absolutely no say or oversight on the suitability and financial probity of the new service supplier.

Thanks to Anne Drinkell, Tony Brewer and Colin Standfield for information and research on CQC, Vocare and Totally.

The National Mental Health Crisis

+ Health Secretary Jeremy Hunt MP has promised that sometime over the next four years an additional £1.3 billion will be invested annually in mental health services. This money is needed now. Also there is no commitment for extra money after 2021. It is just not credible to run a national mental healthcare service using such a short planning window as five years.

+  One in six adults in the UK are currently suffering from mental health problems. That adds up to 8 million adults (Mind, Mental Health Foundation (MHF)). To put the scale of this into context, in 2015 it was estimated that 2.5 million people were living with cancer in the UK (Macmillan).

+ 1.2 million people each month use the NHS mental health services. (NHS Providers, 2017). This suggest that many suffers are not presenting themselves to GPs.

+ 50% of adults aged 55 or over have experienced mental health problems. 7.7 million suffered with depression and 7.3 million suffered with anxiety. (YouGov research for Age UK, October, 2017)

+ One in ten children currently have mental health problems. (MHF). There are one million children with diagnosable mental health problems. (Centre for Economic Performance (CEP)).

+ 80% of young homeless people have a mental health condition. (National Audit Office, 2017)

+ In 2014/15, 1,180 students left university early because of mental health problems. In 2009/10 the number was 380.

+  Mental health problems are the largest burden of disease in the UK. They are 28% of the total. Cancer and heart disease are each 16% of the burden. (MHF, 2015).

+  In 2015/16, the NHS plan was to spend £11.7 billion on mental health services. No-one is quite certain whether all this money was actually spent on mental health commissioning. (NHS England). However assuming this was the mental health spend, this represents just 10% of the total annual NHS spend.

+ Of the 3,500 ‘locked rehab’ mental health patient beds, 2,500 are in the very expensive, ‘unscrutinisable’,  private sector. (The Guardian, 16 October, 2017)

+ Only 15% of adults with depression and anxiety disorders are offered National Institute for Health and Care Excellence (NICE)-recommended psychological therapies. (CEP).

+ The number of people detained under The Mental Heath Act 1983 has increased every year since 2007. (The Guardian, 11 October 2017).

+ Mental health patients having to travel miles – sometimes 100s of miles – for ‘out-of-area placements’, because no beds are available locally, have increased by 40% in two years. (NHS Providers).

+ Only 25% of children with mental health disorders receive NICE-recommended treatment. (CEP).

+ There are just 1,440 NHS mental health hospital beds for children in England. (NHS England, 2017). In 2014/15, 10,132 children were admitted to hospital for a mental health illness. (Public Health England).

+ 37% of girls aged 13 and 14 years old had three or more symptoms of psychological distress. (Department of Education, September 2016).

+ Mental health research receives 5.5% (£115 million) of the total health research budget (MHF). Cancer Research UK (CRU) alone spent £666 million on research in 2016/17. (CRU).

+ 10,000 mental health jobs have been axed since 2010. (The Guardian, November, 2016)

+ 70 million days are lost from work each year due to mental illness. (MHF, 2015).

+ Bad mental health costs our economy £10 billion each year in extra physical healthcare due to mental illness. (CEP).

+ Nationally Police receive half a day’s training in mental health.

+ In 2015/16 the Met Police handled 115,000 telephone calls relating to mental health. This volume of calls is up by a third since 2011/12. (Labour Party FOI response, August 2017)

Ealing’s Mental Health Crisis

+ There are 420,000 patients registered with Ealing’s 76 GP surgeries. (Ealing GP Federation). Ealing GPs now provide mental health Primary Care. (Ealing Clinical Commissioning Group). 78% of Ealing’s population (327,600) are adults. (London Borough of Ealing). This means that 54,600 Ealing adults are currently suffering from mental health problems. If they were all to present themselves to an Ealing GP surgery, each surgery on average would/could be swamped with 718 mentally ill adults. If we do the same calculation with children, each surgery would have 92 mentally ill children potentially presenting themselves.  

+ There are just 33 Acute mental health beds in Ealing at St Bernard’s Hospital.

+ Ealing Police have been complaining about the lack of available Ealing Hospital beds for patients Sectioned under the Mental Health Act.

+ By 2021, Ealing Hospital will have no A&E services so there will be nowhere in Ealing for mental health patients to be referred/assessed or be medically cleared before they could be admitted to St Bernard’s Hospital 136 suite (for those sectioned under the Mental Health Act).

+ There is no NHS Mental Health Mother and Baby Unit in Ealing.

+ West London Mental Health NHS Trust (WLMHT) provides Secondary mental health services to Ealing residents. For each of the last two years it has received a poor CQC inspection report. In 2017 nine of its eleven core services were rated ‘Requires Improvement’ (CQC).

+ Staff numbers at WLMHT have still not recovered to their 2014 level of 4,000. In 2017 they are 3,325 (WLMHT Annual Reports).

+ A WLMHT Director’s total remuneration in 2016/17 was between £455,000 and 460.000. Her pension pot at 30 March 20917 stood at £1.619 million (WLMHT 2016/17 Annual Report).

ECCG Signs Up With 7 Other CCGs As Regional Healthcare  Purchasing ‘Partner’ With Seemingly No Parliamentary Legitimacy for Joint Commissioning

Starting at 8:45am in Ealing Town Hall on Wednesday 27 September 2017, I sat through 90 minutes of a public Ealing Clinical Commissioning Group (ECCG) meeting in which – unusually – some difficult questions were asked by members of the ECCG Governing Body.

Under discussion was a 12,000 word CWHHE paper on regional CCGs working together. CWHHE is a cabal of north west London CCGs – Central London, West London, Hammersmith & Fulham, Hounslow and Ealing. Ever since the Health and Social Care Act 2012 created CCGs, ECCG has been quite obsessed about working with other CCGs. Various CCG cabal flight formations have been attempted over the last five years. I’ve have often wondered why they were doing this and whether these CCG ‘super groups’ had any statutory legitimacy.  

Now, apparently, these CCGs want to organise more formally so they can collectively purchase healthcare services across their various geographies in NHS NW London. This is all very confusing  For 4.5 years I have sat in public ECCG meetings and been preached to about how local GP led CCGs made of local GPs with local healthcare knowledge were purchasing local services. Now these local GPs will gang up together to purchase regional healthcare services.

The CWHHE paper tells the reader that the reasons for acquiring this regional purchasing role are responding to patients, improving patient care, increased collaboration benefits, supporting Primary Care purchasing, sharing capacity and capability, and enhanced clinical leadership. To this end CWHHE wants to create two new posts – an Accountable Officer for the region and a Chief Financial Officer for the region. I suspect with a healthcare purchasing budget of £100s of millions these posts will command huge salaries.

CWHHE CCG’s Chief Officer Clare Parker’s take on this was that it’s all about the patient perspective, an ageing population, challenges for GPs and money. Dr Mohini Parmar, the local CCG boss and regional STP boss, chipped in with reasons of patient flows, finance and effective work.

The regional purchasing ‘function’ is to be run by a CCG representative committee of 17 or maybe 24. An independent chair would be appointed for at most the first 12 months.

Over a period of an hour there were a torrent of questions – many of them ineffectively answered – covering finance, organisation, legal issues, conflicts of interest, balancing local concerns with regional concerns, duplication, accountability, public access and regional purchasing policies. Clear answers to some of these questions were thin on the ground. Dr Parmar’s and Ms Walker’s favourite response was ‘…that’s a really interesting/challenging governance issue…’.

One persistent questioner (whose identity is not revealed on the ECCG web site) kept asking ‘where’s the glue that will make all this happen?’ She never got her answer.

Lay member Philip Young made some seven points, most of which seriously questioned the viability, accountability and effectiveness of the CCG/regional board dichotomy. His most impassioned plea was along the lines of ’..how do we stop CCGs imploding if regional decisions go against them’.

I observed that what was being created was some kind of regional health board. Oh no said Parmar/Parker. I then said in my experience when businesses merged the new merged entity had to make decisions which at times would not benefit one or more of the merge businesses. But, said Parmar/Parker, we are not merging businesses. I pointed out that I was not aware of any primary Government legislation which supported what was being proposed in this meeting. No response from anyone to that one. My final comment was that I had recently studied the South Yorkshire and Bassettlaw (SYB) STP Proposals to create a regional Accountable Care System with each of the constituent  CCG towns forming Accountable Care Partnerships. If what was being proposed by ECCG for the region was on similar lines to SYB why not be honest enough to admit this. Oh no – this is not anything to do with Accountable Care Parmar/Parker said. This final comment had a hollow ring to it as sitting in the public space with an anonymous presence was David Freeman. In 2016 he was billed as NHS NW London’s Accountable Care expert and is now billed as NHS NWL’s ‘Director of Development’.

Missing from the deliberations was any mention of social care. The STP and ‘Shaping a Healthier Future’ were each mentioned once. Mental health was mentioned just twice and attracted Dr Parmar’s possibly massive understatement of ‘..needs some more working through…’.

Finally Dr Parmar strongly hinted that CWHHE was regarded as a national ‘thought leader’ in CCG collaboration and the move towards joint commissioning. Make of that what you will.

Under Pressure Ealing GPs Now Have a New 107 Page Contract To Wrestle With

When I last worked for someone else – in the early 1980s – my

‘contract’ was two pages of paper on which my role was defined and the terms and conditions of my employment were spelt out. In my own business (1983 to 2004) the longest client contract we signed was 10 pages long. How things have changed.

The 76 Ealing GP surgeries historically signed a ‘contract of employment’ with NHS England (NHSE). But they don’t all ‘enjoy’ the same contract. There are three contract types and they are General Medical Services (GMS), Personal Medical Services (PMS) and Alternative Provider Medical Services (APMS). Not simple eh? To further complicate things, in 2017 Ealing Clinical Commissioning Group (ECCG) ‘acquired’ these contracts from NHSE.

Now these surgeries have another contract to deal with, as well as their GMS/PMS/APMS contract. This new ECCG contract is an 107 page long work-in-progress and is (bizarrely) called ‘The Ealing Standard’ (TES). In implementing this contract (sorry standard) ECCG says that patients can expect improved access, better health outcomes, a more resilient General Practice, consistency, and long term sustainability. (The last expectation makes me wonder just what ‘short term sustainability’ might actually look like).

NHSE has grant funded Ealing GPs with an additional 11.8 million from March 2018 to 2021. There are other bits of cash also – £1.7 million extra up to 1 April 2017 and £11.4 million from then to 30 March 2019. If I understand the figures (possibly unlikely) on a pro rata basis each GP surgery will receive an additional £80,000 of funding each year for the next four years.

Some features of this TES contract and the machinations around it include:

+ Immediate opening hours and appointments available to see a doctor or a nurse from 8am to 8pm at just three of the 76 GP surgeries in Ealing. This only applies to the 430,000 patients registered at the 76 GP surgeries.

+  The whole raft of extra work demanded (except improved access at three surgeries) will have to start on 1 April 2018.

+ By April 2020, all Ealing GP surgeries will be operational 8:00am to 6:30pm Monday to Friday.

+ Half Day closing is abolished

+ There is an ECCG Steering Group charged with making all these changes come about. At 21 strong it would appear to be too large.

+ The Local Medical Committee (LMC) has submitted 84 written queries about the standard. (LMCs are the statutory bodies which represent the interests of GPs and GP surgeries)

+ Future payments to GP surgeries will be based on the Thatcherite principle of meeting targets. Keeping it complicated there are three different payment regimes:

• Capitation-based
• Activity-based
• Prevalence-based

+ The NHS jargon for targets is KPIs (Key Performance Indicators). Some of the KPI weightings are mind-bogglingly vague and esoteric. They include effective care, difficulty to implement, patient experience, clinical impact elsewhere, financial impact elsewhere and collaborative working.

+ There are 23 care ‘standards’and 51 KPIs related variously to them. ‘25% of capitated activity is subject to a KPI payment’ (whatever that actually means). There are KPIs for ‘access’ and also the threats of ‘mystery shoppers’ There are pages and pages on payment distribution, schedules, monitoring and disputes. The level of complexity is surely not helpful, sensible or justifiable.

+ ‘Standard1: Adult mental health: serious long term mental illness & complex common mental illness.’

There are 3.5 pages of detailed ‘standard’ expectations of GP performance which, after 20 years of my wrestling with Primary and Secondary mental health services in Ealing, I find to be totally unrealistic. Anecdotal evidence reveals that many Ealing GPs are not trained to diagnose and treat serious, complex mental health conditions. The evidence also suggests that a significant number are not disposed to want to attempt to deal with the mentally ill. This is all very dangerous ‘pie in the sky’.

+ There is a ’Homeless Standard’. This is aspirational and in places unrealistic. It’s expected a GP will discuss the person’s housing status, financial issues, legal issues, reconnection, educational and employment support. I find this hard to accept as a professional healthcare role for a GP. Surely these are social care issues which should be handled by a trained social care specialist. Would a GP have time to do this anyway? BTW the published TES tariff for ‘care for homeless is £16:25p for 10 minutes of consultation’…..

+ There are long prescriptive ‘standards’ on medicines, safety, optimisation, drug monitoring, patient experience, diabetes, respiratory disease, cardiovascular disease, musculoskeletal health, Ring pessary, care planning and co-ordination, end of life care, wound care, phlebotomy, Dementia, cancer screening, immunisation and vaccination, health improvement in children, self care and learning disabilities.  

+ ‘Standard 22: Demand Management’.This is jargon for refusing NHS healthcare to a patient. TES states ‘The NHS is not obliged to provide every treatment that a patient, or group of patients, may demand’. What a fatuous red herring this is. The Hounslow CCG web site, apparently, explains the rationale and mechanics of treatment refusal. And of course we have the well established Ealing Referral Facilitation Service by which a GP can overrule your GP’s referral to a consultant or to a hospital.

+ There are education and training requirements

+ There are numerous ‘capacity’ targets.

+ Omissions from the TES list include requirements for maternity, HIV/AIDS, liver disease, sexually transmitted diseases, Tuberculosis and mental health carers.

My overall feelings about the contents of the 107 page TES include:

+ Will they inspire, depress or put off existing Ealing GPs and potential future Ealing GPs?

+ How did Ealing GPs manage without these requirements in the past?

+ How much extra clinical and administrative work will TES demand?

+ Anecdotal evidence suggests the Ealing GP Practice Managers are fully extended as it is. Will Ealing GP surgeries have to pay for additional administrative resources?

+ Is TES more about saving money than improving services? Or is it, like the failed NHS NW London Shaping a Healthier Future’ and the stuttering NHS NW London STP initiative, an amateur attempt likely to fail on both counts.

Issue: 53

October 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.

Has  NHS England awarded Six Integrated Care (ACO) Contracts to Five Foreign, Private Companies?

Veteran NHS analyst John Lister and 38 Degrees are both quoting ‘Healthcare Europa’ who apparently stated that Simon Stevens has awarded six Footprint/STP Accountable Care Organisation (ACO) contracts to six private healthcare companies. The only company named in the publication is OptiMedic of Hamburg. OptiMedic describes itself as an Accountable Care development and delivery company with a close working relationship with Imperial College Healthcare Partners (ICHP). Ealing Clinical Commissioning Group is one of the 20 ICHP partners. The other five private ACO companies are apparently American.

I wonder whether one of the five American companies is Centene Corporation of St Louis, Missouri. Via outsourcer Capita, Centene has been awarded a £2.7 million ACO contract in Nottingham. Centene is heavily involved in running Medicaid programmes in 20 American States and has annual revenues of over $40 billion.

A Cabal of NW London CCGs Rushes to ‘Enable’  Regional Bosses to Run Regional Commissioning

A sudden rush of hastily convened local CCG meetings has been set up in Ealing and in  other NW London towns in order, seemingly, to ‘bless’ the concept of a single ‘Accountable Officer’ (AO) and a single Chief Financial Officer (CFO) for the region. In Ealing the meeting starts at 8:45am! Ealing’s CCG region seems to be an amalgam of Central London, West London, Hammersmith & Fulham, Hounslow and Ealing.

It’s always amazed me why these cabals of CCGs exist at all. Surely the CCG dream was local GPs purchasing local services armed with their local knowledge. Now we are about to have a single regional AO and CFO for 2.1 million people. Why?

Could it be that this is all under the radar manoeuvring as part of setting up a regional  ACO or multiple ACOs across NW London?

Ealing CCG and London Borough of Ealing (LBE) Involved in International Trawling For Interest in Bidding for £Multi-Million Care Contracts

Research into the EU publication ‘European Procurement’ by Oliver New of Ealing Save Our NHS has revealed that Ealing Clinical Commissioning Group (ECCG) and LBE

are touting for private companies across the world to potentially bid for the following:

Date:     Contracting Body:  Service:                            Value:           Duration    

01/2017:      H&F CC Telemedicine:                 £15M Unspecified

12/2016:        LBE:   Home Care            £22M 10 years

09/2017:        ECCG Out-Of-Hospital *          Unspecified 10 years

09/2017  NWL CCGs          Care Home Services **  £130M Unspecified

*Potential suitors pitching to ECCG in Ealing on 19 September and 4 October 2017

**Potential suitors pitched to the NWL CCG cabal on18 July 2017.    

Not much of this has been heavily publicised (or publicised at all) by the contracting bodies. Such secrecy fuels the flames of distrust between citizens and those elected to represent us and those appointed by Government to serve us.                            

NHS England Director Professor Keith Willett Thinks NHS Folks and Social Care Folks Don’t Understand or Trust Each Other

On 12 September 2017 I attended a packed audience in Pop-Up University, PUU5 Stream at the NHSE Innovation extravaganza in Manchester. The topic was ‘Local Government and the NHS: are they serious about working together’. The main speaker was Professor Keith Willet. Professor Willett is an NHS veteran. He is the NHSE Director for Acute Care and leads the transformation of urgent and acute care services across England.

His comments lit up the ‘pop-up’ room.

He kicked off by pointing out that £1 billion had been removed from financing social care services over the last six years. Then he threw in the organisational mismatch between appointed NHS folks and Elected Members’ controlled Local Authority (LA) social care folks. He then said that Local Authorities were a Venn Diagram. People like me in the audience with just ‘O’ Level Maths were confused. In the comfort of my home some days later I asked Google to define a Venn Diagram:

‘A diagram representing mathematical or logical sets pictorially as circles or closed curves within a enclosed rectangle (the universal set), common elements of the sets being represented by intersections of the circles’.

I can only conclude that this mathematical reference was the rather serious Professor’s attempt at humour. What came next was no joke. He stated that the culture, language, attitudes and bureaucratic differences across both care worlds are immense. Tribal concerns dominate. Both care worlds need to mature and build understanding and trust together. Everywhere ‘co-production’ was being attempted.

NHS people don’t understand Social Care people – he claimed. No-one in the audience jumped up to dispute this.

He then threw out some questions about the size and ‘primacy’ of both care sectors:

Who has the most beds, the most staff and the most power? The numbers he then came out with were very revealing:

+ NHS – 100,000 beds: Social Care – anywhere between 300,000 and 500,000 beds

+ NHS staff – 1.3 million: LA  Social Care staff – 1.5 million

+ 7,500 independent GPs: 8,500 Social Care domiciliary staff

+ NHS STP bosses – NHS 44: LA Social Care – 1.

As for Delayed Transfer of Care, 10 days in hospital for an elderly person results, on average, in a 10 year reduction in life expectancy. (Wow!)

Then came his pleas:

+ Why can’t we (healthcare and social care) share information? Why are we continuously and continually re-keying the data?

+ Why do we have too many different financial/costing/purchasing approaches – some per head, some as block contracts , some as activity based costings etc, etc?

+ NHS and Local Authorities can only work together if they trust each other – but do they?

+ Everybody needs to open up their financial books and openly share the data – but do they….will they?

The NHSE Innovation Expo held at Manchester Centre on 11/12 September 2017 must have cost someone (us?) a fortune. 170 exhibitors, 264 free-to-attend conference presentations across 16 streams.

Will South Yorkshire and Bassettlaw’s Accountable Care System and its Five

Accountable Care Partnerships be Ready to Launch For Real on 1 April 2018?

STP Footprint no:9 is South Yorkshire and Bassettlaw (SYB). Its Sustainability and Transformation Plan (STP) is scheduled to be implemented with an Accountable Care System (ACS) and five Accountable Care Partnerships (ACPs) on 1 April 2018. Operating now is a Shadow ACS and (possibly) five Shadow ACPs, which are variously described in a 30 page ‘Memorandum of Understanding: Agreement’ (MOU) dated June 2017.

The MOU tells quite a lot, but a lot is also missing. These first thoughts on omissions and observations include:

1. The goals and aspirations contained within the MOU are indeed worthy ones. However from my perspective it is the mechanics and details on how these aspirations will be met which are suspect or indeed missing from the MOU.
2. When and how will the Capitated Budgets (‘population budgets’ in SYB-speak) be set for the SYB ACS and the five SYB ACPs?
3. What are the annual 2021 cost saving targets for the SYB ACS and the five SYB ACPs. (On a pro rata basis, SYB’s annual share of the NHSE FYFV national annual £22 billion savings would be some £600 million).
4. What sophisticated software will SYB deploy to run the SYB ACS and the five SYB ACPs?
5. Who will be the CEO of the SYB ACS business and the five SYB ACP businesses?
6. Who will choose and appoint the six Accountable Care CEOs?
7. Will the six Accountable Care contracts operating from 1 April 2018 be for 10 or 15 years?
8. To whom will the SYB ACS CEO report?
9. How can any rational person have any confidence in this MOU which admits not to be a plan or a legal contract or to have any statutory basis. The SYB MOU throws around the words ’partner’ and ‘partnership’ like a drunk chucking confetti around at a wedding party. My business background reminds me that partnerships are all about sharing profit, loss and risk. I am astonished at the possibility that 28 public bodies would enter into formal business relationships with each other to share profits, losses and risk – especially given that the MOU content consistently trashes some of the strictures of the Health and Social Care Act 2012.
10. It’s a sobering thought that if SYB is viewed as a thought leader/pioneer of ACSs in England it still needs capital and revenue grants to support it until 31 March 2019
11. There is plenty of motherhood and apple pie in the MOU. For example on page 6 it states ‘…to enable safe, sustainable and equitable hospital services across SYB..’. Surely such a platitude is outside the gift of the SYB ACS? For starters, with national NHS staff vacancies running at 85,000, on a pro rata basis SYB has staff vacancies of 1,913. The National Care Homes Association estimates we will soon need 71,000 more care places. On a pro rata basis that means SYB is short of 1,613 care places. Hospital bed blocker monitors please note. On the mental health hospital bed blocking front, 17,509 bed days were lost nationally in October 2016. Annualise that and you get to 211,100 bed days lost. Pro rata that for SYB and you get to 4,797 hospital bed days lost annually owing to the inability to discharge mentally ill patients.
12. At 1.12 we read about ‘…an altruistic approach to each other as partners working as one’. This all very inspiring but it surely cannot be the basis for an operational and organisational strategy. ‘…putting the needs of individuals, patients and the public before organisations…’ is clearly a recipe for organisational chaos.
13. The MOU is remarkably ‘light’ on including and defining Local Authority (LA) and social care roles and responsibilities. At 1.17 there is a reference to ‘separate and specific agreements with …local statutory organisations’. One of the big national goals of STPs is the integration of (NHS) healthcare services and (LA) social care services. These NHS/LA agreements will be complicated and contentious to draft, agree and implement. No wonder the MOU steers clear of them!
14. At the end of Section 6. is an extraordinary ‘Overarching Principle’ – ‘All organisations will retain their current statutory responsibilities’. How that sits with the ‘altrusitic approach’ set out in 1.12 beggars belief. Imagine you are a cricket club groundsman. Because, through an ‘altruistic approach’ by club management, you help the coaching staff, help with making the players sandwiches and spend time looking for a lost cricket ball, you fail to apply the heavy roller to the pitch by 6pm – and you end up being fired.
15. At 7.03 the MOU drives a coach and horses through the Health and Social Care Act 2012 by replacing the commissioner/service supplier split with ‘…collaboration and integration’.
16. At 8.2 we at last have some substance on cost savings with references to reducing system demand (cancelling some GP referrals) and efficiency improvements. At 8.4 reference is made to ‘…reduce demand on A&E and acute beds’.
17. At 8.3 GPs get another mention. Expanding ‘multidisciplinary care’ is emphasised – although when it came to specifics about numbers of (additional perhaps) clinical pharmacists, mental health therapists, physicians associates and GP nurses – it was a ‘TBA’.
18. At 8.5 mental health is featured. ‘Alternative Commissioning’ and ‘System Commissioning’ are referred to. The latest (August 2017) issue of ‘NHS Care Models: ACOs and the NHS Commissioning Systems’ makes no reference to either of these terms. One can only suspect that alternative commissioning might mean involving the private sector.  System commissioning may refer to ACS commissioning I suppose.
19. Mental health provision in SYB is strange. There are no NHS Mental Health Trusts providing Secondary mental health services for 1.5 million residents. Consequently there is no mental health partner on the SYB ACS ‘board’.
20. At 7.4 ‘Financial’ one might reasonably expect some figures here – maybe grant income, maybe Shadow ACS/ACPs actual or projected cost savings for 2017/18. but… no such luck. However there is a reference to a ‘..basket of efficiency indicators’ but there is no MOU commitment to adopt one……
21. Why is there not even one care home group partner in the SYB ACS?
22. Why is there no GP Federation partner in the SYB ACS partnership?
23. Where does this organisational distinction between an ACS and an ACP come from? ACSs seemingly are single supplier-run whereas ACPs are run by consortia.
24. I see no clues as to how the five ACPs relate to (report to?) the Footprint/STP ACS
25. The MOU keeps referring to itself as a ‘framework’ without defining what it means by this. Dictionaries are not much help here and ‘outline of anything’ can mean anything you want it to mean I guess.
26. To give you some idea as to how complex and unwieldy the SYB/Footrprint/STP/ACS/ACPs management is and will be, there are 55 members on the Collaboration Partnership Board.

NHSE Tries to Position Accountable Care Organisations Within the Context of Clinical Commissioning Groups

NHSE in August 2017 published ‘ACOs in the NHS Commissioning System: Accountable Care Organisation (ACO) Contract Package – Supporting Information’. It is quite an extraordinary 25 page document. Right up front it states that ACOs will not change Clinical Commissioning Group (CCG) statutory functions – and then spends over 20 pages effectively refuting this.

In defining CCGs role in the ACO world, NHSE excludes the key word ‘purchaser’ completely! The document talks about working with grant-aided NHSE Vanguards which suggests to me that it’s a make-do document with a short life.

‘Pooled Budgets’ are discussed, under the aegis of the NHS Act 2006. An opportunity exists in the Act for NHS (healthcare) and Local Authority (social care) budgets to be ‘pooled’. However the document does point out that changes to Section 75 of the Act are needed for full ACO operational flexibility.

Now to the meat of the story. The bulk of the document is made up of two Annexes. In Annex A are listed and described a whole host of historic CCG responsibilities and how ACOs will ‘relate’ to them. In short ACOs will have a major role in ……subcontracting services, allocating CCG-level resources (through ‘Capitated Budgets’), configuring and providing services, implementing patient-centred strategies, addressing health inequalities, managing supply chains, creating and managing demand management, re-designing services, improving service quality, decision making relating to funding routes, pathway planning, ensuring patient choice, enabling personal health budgets, managing subcontractor contracts, sub-contractor quality management and responding to patient complaints.

Annex B maps out how ACOs can jump statutory CCG fences, crawl through regulatory NHSE tunnels and negotiate around the Act of Parliament Local Authority bollards.

Various ACO healthcare and social care flight formations are listed along with the tortuous list of potentially adverse Primary legislation weather patterns which need to be avoided when filing ACO Flight Plans.

Hundreds of residents joined a demonstration to Save Ealing and Charing Cross Hospitals. Two separate marches – from Southall and Acton – converged at Ealing Common for a rally with music and food stalls.

Ealing Save our NHS Backs Ealing and Hammersmith Councils Rally from Ealing Save Our NHS on Vimeo.

Issue: 52

September 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.

City and Hackney Clinical Commissioning Group (CHCCG) to Test the Legality of STPs (and ACSs) in The Courts

At last someone is going to law to test the legitimacy of a Sustainability and Transformation Plan (and consequentially its implementation engine an Accountable Care System). CHCCG is asking the Courts to decide whether its Footprint’s STP has any legal status or power to compel CCGs or other ‘partners’ to comply with major decisions. What kicked CHCCG into this action was a cabal of five Footprint CCGs wanting a single ‘Accountable Officer’ for all the seven CCGs in the Footprint.

Legal opinion from lawyers Hempsons includes the following:

‘The current health and care legislative framework is a brick wall that STPs and ACSs run into when they try to share decision making and join up services. It is designed for an inherently non-integrated, competitive, quasi-market’.

Watch this space!

Jonathan Bell, Chief Financial Officer , London North West Healthcare NHS Trust (LNWHNT), Total Remuneration, Financial Year Ending 31 March 2017:

£715,000 to £720,000

Extract from LNWHNT 2016/2017 Annual Report – page 106.

I thought at first that no editorial comment was required – but of course it is. The average annual remuneration in London is around £34,000 – outside London it’s around £22,000. So however hard and long hours worked by Mr Green those fire fighters, ground staff, caretakers, GP receptionists, PCSOs, nurses, teachers, journalists, junior doctors, grave diggers, hospital porters, bus drivers, and mid-wives working either in London or outside London earn at most 20 times less than Mr Green.

However, in an initiative the timing of which is almost beyond satire, LNWHNT has announced it is looking for 350 people to work for no remuneration whatsoever. The Trust’s Voluntary  Services Manager Shirley Hunte told the ‘Kilburn Times’ that LNWHNT was looking for people aged between 18 and 96 years old. (96??). They were expected to freely give of their time to welcome patients and visitors, help patients at meal times, and be patient companions providing interaction and guidance.

Now LNWHNT already ‘employs’ 200 volunteers in its four hospitals. From my experience some of these volunteers are retired professionals who have altruistic motives to help society. Some are lonely elderly people who enjoy the company. But surely the main point here is that we should be collecting and allocating adequate funding so that we are helped by paid, qualified and ideally experienced professionals. I paid my National Insurance for over 43 years and healthcare should be not only be free for me at the point of delivery, it should be delivered by a professional. What if there is some tragic accident in the hospital involving a volunteer? Could the volunteer be sued? Do volunteers take out insurance to cover this? I doubt it.

Notes From the Trenches

I recently visited Ealing Hospital accompanying a homeless, rough sleeper friend who had chest pains. He was weak and had to queue on his feet to be registered for triage at the Urgent Care Centre (UCC). Why is this? Why not a time  stamped, numbered, ticketing system so that patients could sit down and wait to be registered? Four burly Policemen had someone covered in blood and in custody and two of the Policemen also had to queue to have the miscreant registered. Madness.

After 5 hours of triage, heart and blood tests and diagnosis we had a happy ending as my friend had an infection and was given antibiotics and a puffer to help him breathe. The staff in the Chest Pain Unit were brilliant. However other experiences at Ealing Hospital on that day included:

+ A UCC person (private supplier Greenbrook Healthcare employee I guess) told my friend that subsequent to being treated in the hospital he should not come back but should visit his GP. My friend said he didn’t have one. She then told him that he needed proof of address and a passport to be registered and treated by a GP. This sounded wrong and during the day I checked this out with the NHS online. She was wrong – it’s the right of anyone (homeless or not) to register with a GP in England. The only caveat is if the GP list is full. He was give details of 10 local GP surgeries none of whom stated their list was full. A re-training issue here for Greenbrook

+ I picked up a copy of a free, full colour, 16 page tabloid called ‘Our Trust’. It was branded London North West Healthcare NHS Trust (LNWHT) but it did also bang on about the LNWHT Charitable Fund. I did find the pleas to give time and money variously to the Trust and its charity somewhat distasteful. After all I paid National Insurance for all those years for free healthcare from LNWHT and from the other 222 English NHS Trusts

Just what is the purpose of this publication? At whom is it aimed? On page 2 we have a bizarre piece penned by a LNWHT Human Resources Director on ‘..our new values..’. This is so offensive as I was reading this tosh standing in a District General Hospital which was given a death knell in 2012, had its Maternity closed in 2015 and its Paediatrics and children’s A&E closed in 2016. This from a key service supplier of an NHS region which promised and failed to save 4% on annual costs – but declined to admit this publicly until forced to by a Freedom of Information request. The phrase ‘..knowing the cost of everything but the value of nothing…’ springs to mind

There is some useful information in this publication but I feel I am being ‘sold to’. Surely not everything is as very wonderful as portrayed about Ealing, Northwick Park, Central Middlesex and St Mark’s Hospitals? What about transparency? What happened to honesty? If this is to be a regular quarterly publication we should all question whether this is a good use of public money. The Trust is one of the major service suppliers in the NW London STP Footprint which by 2021 has to reduce annual spending by £1.3 billion.  Just exactly how does spending money on this PR puff publication assist the cost saving mountain to be climbed?

+ Triage in the UCC is still in a public area. It’s at a counter a bit like a motorway toll booth or a McDonald’s drive through station. Surely triage must be housed in a personal interview room and not in the reception area? Also the person carrying it out must announce his/her status as someone qualified to carry out triage

+ I had a look at the Ealing Hospital UCC service supplier Greenbrook’s web site. It has an NHS web site address – www.greenbrook.nhs.uk  How can that be? Did the NHS purchase Greenbrook? I guess it must have done – although I don’t remember reading any press reports about this

+ £2:60/hour for car parking. Only new £1 coins accepted – and of course no change given. The ever wonderful ‘Friends Café’ (staffed by volunteers)  understandably ran out of change as countless non-mobile phone literate patients and loved ones wrestled with finding the right coins to feed the hungry parking machine beasts.

Medical Student ‘Drop Out’ Rates and the Number of Students with Untreated Mental Health Problems are Way Too High: 1,200 Drop Out Over  the Last Five Years

‘The Sunday Times’ of 27 August 2017 revealed FOI discovered data about the ‘drop out rate’ of medical undergraduates throughout England. It’s 10% and over the last five years. 1,200 did not complete their degree courses. This comes at a time when there are reports of increased mental health problems amongst medical students.

In September 2016 a DoE ten year study revealed that 37% of 14/15 year old girls exhibited three or more symptoms of psychological distress. This percentage was significantly lower for boys. In October 2016 NHS England and NHS Digital reported that self-harm had risen dramatically over the last ten years. The biggest rise was girls under 18 years of age. 13,853 girls poisoned themselves – a rise of 385%. Again the figures were lower for boys.

Set these almost epidemic levels of teenage mental health problems against the general chronic shortage of psychologists and the limited psychological support available in universities. What you get is that too many 18+ year old medical students – especially girls – are struggling with mental health problems, receiving inadequate treatment and failing to complete their degree courses.

Government Asks the Impossible of Local Authorities re: Social Care ‘Bed Blockers’ in Hospitals.

The Department of Communities & Local Government’s (DCLG’s) own figures reveal that social care funding given to Local Authorities (LAs) fell by 8.4% over the period 2010/11 to 2016/17. The cash loss was £1.3 (from £15.7 billion to £14.4 billion). From 2010 to 2017 the population of England rose by 2.1 million – from 52.6 million to 54.7 million (Office of National Statistics).

In August 2017 DCLG and the Department of Health (DoH) wrote to all LAs telling them to get social care ‘bed blockers’ out of hospital beds as soon as possible, otherwise they would be punished. Of the 152 LAs with social care responsibilities, 42 are required to reduce bed blocking by 60% or more. If they fail to reach the targets set they will receive reduced (or no?) extra social care grant funding in 2018/19.

No doubt those LAs who fail to meet these targets will be increasingly underfunded in 2018/19 and be unable to have social care bed blockers discharged from hospital – as the LA will have no cash to fund care home beds or care at home. As the government (McKinsey & Co) dogma is the reduce hospital beds by 40% anyway this will create a massive social care crisis. As ever with this Government, the largest number of sufferers, losers and life threatening service users will be the poor, the physically and mentally disabled, the vulnerable and the homeless.

The Brilliant 2014 ‘Barker Report’ on the Future for Care Services

Every now and then I stumble onto something which I like and want to support and promote. I was TV channel hopping early evening on 21 August 2017 and landed on the Parliamentary Channel. There, large as life, was Chris Ham boss of the King’s Fund talking about ‘Barker’ this and ‘Barker’ that.

I did some research on ‘Barker’ and tracked down the September 2014 report on the ‘Independent Commission on the Future of Health and Social Care in England’, chaired by business economist Kate Barker. It just blew me away.

Key Findings:

+  Single, ring-fenced budget for the NHS and social care, with a single Commissioner for local services

+ New care and support allowance – removing the battle lines between the NHS and Local Authorities

+ Much simpler pathway through health and social care which would benefit service users and carers

+ More equal support for equal need, making most social care free at the point of use

+ Rejection of new NHS charges and private insurance options in favour of public funding.

Policy Implications:

+ Significant re-engineering of Central and Local Government needed to facilitate a single, ring-fenced budget and a single Commissioner

+ Between 11% and 12% of GDP for care will be needed annually as  soon as possible to facilitate change and meet care needs

+ National Insurance contributions need to be increased to meet the annual £5 billion uplift to improve social care entitlements

+ Wealth taxation must been seriously considered as the means of generating additional resources that will be needed for health and social care services in the future.

Why oh why have these sensible recommendations not been implemented or at least investigated further by the Civil Service?

Private Hospitals Get £52 Million Tax Break: No Such Luck for NHS Hospitals

One in four private hospitals in this country (123 of them) are registered charities and as such have received rate relief amounting to £52 million. So says $177.5 billion turnover US retail pharmacy and healthcare company CVS Health  (www.cvshealth.com).

Nuffield Health, Britain’s third largest healthcare charity by income, will save £12.7 million in non-payment of business rates over the next five years. However in the NHS,  the University Hospitals of Birmingham Hospital Trust, for example, faces an increase of £2 million on its business rate for 2017.

US Accountable Care Organisations (ACOs) Have  Squandered Over $100 Billion on Software Investments – With Zero Return On Investment

US healthcare data warehousing products and services specialists Health Catalyst has strongly suggested that over $100 billion has been wasted on developing software to support Capitated Budget driven ACOs.

Health Catalyst’s opinions bear some weight as its software currently supports some 65 million patients throughout the USA. The company identifies five critical information system software elements for future ACO success. They are:

+ An Electronic Medical Record (EMR) used in a consistent and meaningful way across the Acountable Care (AC) enterprise to document patients’ healthcare status and treatment and support safe, evidence based care

+ A Health Information Exchange (HIE) to enable the sharing of patients’ clinical data across disparate EMRs in the AC enterprise

+ An Activity Based Costing (ABC) system to enable detailed, patient-specific collection of cost data that in turn enables the AC organisation to precisely understand cost of production and revenue margins in Capitated payment models

+ A Patient Reported Outcomes (PRO) system to enable the complete understanding of clinical outcomes and quality, from the patient’s perspective. This is not a patient satisfaction system – it is a critical outcomes assessment system, tailored to the patient and their protocols of treatment

+ An Enterprise Data Warehouse (EDW) system which is central to enabling the analysis of data collected in the information systems described above – and more. Without the EDW, the data collection systems described above are relegated to small or non-existent Return On Investment (ROI). It is the exposure and integration of the data in the EDW that liberates the ROI from those systems. It is common for EDWs to realise ROI as high as 450% in two years.

It seems the US market for EDW products is a rich one with over 40 vendors. However none of them, apparently, support ABCs and PROs (see above). In the UK it will be interesting to see whether indigenous software emerges to support ACO/ACS operations. Entering this world of sophisticated critical ACO/ACS information systems will not be for the faint hearted and only for those with deep pockets.

Health Catalyst has also developed a ‘Healthcare Analytic Adoption Model’. In this model at the bottom of nine levels (Level 0) are ‘Fragmented Point Solutions’. At the top of the model is Level 8 (Cost per Unit of Health Reimbursement & Prescriptive Analytics). Level 8 is also labeled ‘Contracting and Managing Health’. Level 0 is labeled ‘Inefficient , inconsistent versions of the truth’. One suspects that many NHS grant funded ACO/ACS experiments are currently at Level 0.

See www.healthcatalyst.com for more information

Greater Manchester (GM) Integrated Healthcare and Social Care Project is a ‘Work in Progress’

On 9 August 1944 I was born in Fairfield Hospital in Jericho, Bury, Lancashire – now in Greater Manchester. This small hospital may not survive in the progressive new world of CCGs, STP, ‘Healthier Together’, devolution and ACSs. That’s my personal baggage out of the way and now let me summarise what I learnt in Manchester, Salford and north Cheshire in August 2017:

+  No-one I met had any confidence that the £7.7 billion projected annual GM healthcare, public health and social care bill would be reduced by £2 billion by 2021.

+  There is little or no talk about Accountable Care Systems (ACSs) or in fact about the STP.

+  There were few words of praise for CCGs and there were clear doubts about their competences or in fact their probity

+  A feeling of ‘us all sort-of being it together’ did come across. The massive Labour Party domination in GM is, on balance, a big plus in trying to get NHS bodies, GPs and Local Authority bodies to work together

+  No surprises though to find deep seated Manchester v Salford wars, and Manchester city’s domination of proceedings

+  NHS bodies clearly have the whip hand in any integration initiatives

+  Social care and mental health did not figure prominently in the early proposals. I struggled to find out what the annual GM social care spend is. Annual Public Health and social care spend is £1.5 billion). There has been some turbulence in one of the mental health Trusts

+  There are pockets of successful healthcare and social care integrations, but none seem to declare any cost saving metrics

+  There are clearly some local successes which include medical records creation, maintenance and creative use of telemedicine in care homes, and Ambulance Service triage. But these are thin on the ground and by no means universally applied across the 493 square miles of GM

+  It’s felt that GM Mayor Andy Burnham genuinely supports the Devo-Manc Health project

+  The three NHS Vanguards in GM (Stockport Together, Salford Together and Salford and Wigan Foundation Chain) seem to be viewed as somewhat inconsequential grant funded ‘experiments’

+  A generally held view is that after-care and community support is inadequate. Following hospital discharge there’s evidence of a lack of co-ordination between primary care and secondary care and a shortfall in District Nurses and Health Visitors

+  There’s clearly an over-reliance on private care providers

+  The ‘normalisation’ of healthcare and social care integrated, cost-saving services across the region seems a long way off. It’s surely going to be over a year before even the beginnings of designing a process to set a C apitated budget for one or more ACSs will be feasible

+  What drives changes is the 2014 NHS ‘Healthier Together’ project. This is not all that different to the 2012 NHS ‘Shaping a Healthier Future’ (SaHF) project inflicted upon North West London. The cost saving plan is to maintain four major hospitals – three of which are confirmed but the fourth has been acrimoniously fought over. Threats and worries about down grading District General Hospitals and hospital A&E closures are all too apparent in press reports

+  It’s intriguing that the quoted GM annual healthcare spend for 2.8 million residents is £6.2 billion. However for NW London’s 2.1 million residents the annual healthcare spend quoted in the 2012 SaHF was £3.6 billion.

Ealing and Hammersmith and Fulham Councils announced their intention to organise a petition demanding to keep our respective Borough’s major hospitals open and fit for purpose. See the highlights of the launch event held outside Ealing Hospital last Friday, 11^th August.

Link to petition

Ealing Save our NHS – Ealing and Hammersmith petition launch from Ealing Save Our NHS on Vimeo.