“SHAPING A HEALTHIER FUTURE”

It’s Time to Abandon the Failing NHS NW London SaHF Healthcare Project

In the Summer of 2012 NHS North West London published proposals which they claimed would improve healthcare services and costs. These proposals were called ‘Shaping a Healthier Future’ (SaHF). The proposals noted that changes were already underway and that it would take ‘over three years’ to complete the changes, which involved reducing the number of Major Hospitals from nine to five, closing four hospital A&E units, reducing the number of Acute hospital beds and replacing 30% of Acute hospital care with care outside hospitals.

Four and a half years later we have to ask:

+ Have the proposals been implemented?

+ Have service improvements and cost cutting aims been met?

This paper attempts to answer both questions.

SaHF Has Not Cut Costs

SaHF planned to cut costs by 4% each year. NHS North West London spent £3.4 billion in 2011/12 which means that three years of cost cutting should have reduced spending by £408 million. However there have been no SaHF announcements or press release about cost saving. No doubt if any cost savings had been achieved SaHF would have proudly announced them.

On 22 February 2017, Ms Tessa Sandall, NHS NW London CCGs’ Managing Director was asked in a public meeting what the SaHF cost savings amounted to. She replied that she did not know. When asked for a ‘rough estimate’ she declined to answer and it appears that SaHF implementation has resulted in zero cost savings.

Healthcare Services Have Not Improved During the SaHF Project

Accident & Emergency (A&E) services are key to a seriously ill patient’s survival.  In the face of public opposition, the 2012 proposals specified the closure of four hospital A&E units. Only two however have been closed which were at Central Middlesex Hospital and Hammersmith Hospital. They were closed in September 2014. Despite claims in SaHF that these closures would somehow “improve” services, hospital A&E performance throughout NW London immediately plummeted and has never recovered. North West London hospital A&E units are regularly some of the worst delays for urgent cases in England with Hillingdon Hospital often featuring as having the worst performing A&E unit in the country.

“Out of Hospital” Care: When and Where?

SaHF promised seven day a week “Out of Hospital” care to replace cuts inside our hospitals, although the proposals were vague about exactly what it would consist of. Sadly, this promised care has simply not been delivered for either physical or mental health. So-called ‘Health Centres’ were supposed to be provided for ‘networked’ GP services such as therapy, rehabilitation, diagnostics or specialist imaging. But where are these ‘Health Centres’?  They don’t seem to exist!

SaHF also promised improved access to GPs, but locally, regionally and nationally we are all having to wait longer to see our GPs. SaHF told us that our GP will co-ordinate care across all services and will have overall responsibility for our health and this is clearly not the case. Instead, in many parts of NW London so called ‘Referral Facilitation Services’ determine whether your GP referral for you to see a specialist/consultant/hospital department is granted or not.

Mental Health Services Have Not Improved

The largest mental health NHS Trust in North West London is the West London Mental Health Trust (WLMHT). In 2015 and 2016 the Governments Care and Quality Commission carried out full inspections of thus Trust and both inspections rated the WLMHT poorly. In fact the December 2016 inspection report rated 9 of the 11 mental health services as ‘Requiring Improvement’.  With one in five adults suffering from mental health problems this casts WLMHT and SaHF in a very poor light, to say the least.

Incredibly the 2012 SaHF proposals made no explicit mention whatsoever about improving mental health services. If for no other this reason, the SaHF proposals were completely flawed from day one and should never have been begun.

The SaHF Business Case: Four Years Late – Unfinished, Unrealistic and Unprofessional

In 2012 residents searched in vain for a detailed SaHF business case. It could not be found. It was only in December 2016 that a partial, detailed SaHF business case emerged. Amazingly the SaHF ‘over three years’ project was mysteriously now a ten-year project. There has been no convincing explanation and no public consultation on that massive project extension!

Entitled ‘Strategic NHS NW London Outline Case Part 1’ the document contained a request for money for NHS building work in ‘outer’ North West London. Apparently SaHF wants H.M. Treasury to hand over £513 million for this building work. Sometime in the future an additional £377 will be requested for ‘inner’ North West London NHS (Part 2) building work. To give some impression of just how unrealistic this request for capital funding actually is one only has to study Chancellor Hammond’s Budget proposals in March 2017. For NHS building work over the next three years across the whole of England the Chancellor has allocated just £325 million.

Surely the NW London Sustainability and Transformation Plan (STP)

and the SaHF Can’t Co-exist?

In December 2015 NHS England announced a Five Year Forward View on healthcare and social services. This required all regions to produce a five-year plan to improve services and cut £22 billion off annual care costs by 2021/22. These regions were designated ‘footprints’ and there are 44 of them.

NW London’s footprint published its STP in October 2016 with an annual cost savings target of £1.4 billion in 2021/22. Integrating healthcare and social care services, improving mental health services and illness prevention are key elements of STPs. The future delivery vehicle for the cuts and the changes for care delivery improvement will be Accountable Care Organisations (ACOs). ACOs in NW London will be private consortia of Local Authorities, NHS CCGs, NHS Trusts and federations of GP surgeries. These ACOs will enter into 10 year, fixed price care delivery contracts to deliver specific services to specific populations.

The NHS SaHF project – unlike the STP – completely ignores social care, integrating healthcare and social care, mental health services and illness prevention. SaHF makes no reference to ACOs, which in future will be the sole care delivery vehicle. SaHF is run by Clinical Commissioning Groups with no formal management roles for Local Authorities, NHS Trusts and GP surgery federations. In fact SaHF follows the commissioner/supplier split laid down in the 2012 Health & Social Care Act. On the other hand, the STP requires Local Authorities, CCGs, Trusts, GP federations and other public and private bodies to all work together. These bodies will work together as peer partners in private ACO consortia and the commissioner/supplier requirements of the 2012 Health and Social Care Act will be completely ignored.     

The truth is that the STPs are also a vehicle for massive cuts to both the NHS and social care.  But on top of that, it is perverse, utterly confusing and unproductive for NHS NW London management to attempt to run SaHF and the STP in parallel. STP is part of a 2016 national initiative and hasn’t had a chance to succeed or fail as yet. However, the SaHF is a 2012 regional initiative which has been shown to be a failure over the last four years.  It’s time to bury SaHF so that NHS staff, GPs and Local Authorities can attempt to make the STP work – a daunting enough task in itself!

Issue: 46

March 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. Process improvement is what is needed in our NHS – not revolution.

400 Turn Up to ‘Save Our NHS’ Public Meeting at Ealing Town Hall: NHS Bosses Refuse to Participate

It was standing room only at the London Borough of Ealing’s (LBE) ‘Save Our NHS’ public meeting on 15th February 2017. NHS bosses were invited to attend the meeting – but declined LBE’s offer. As well as politicians, the platform speakers were James Guest, Chair of Healthwatch Ealing and Eve Turner, Secretary of Ealing Save Our NHS. James highlighted that in total 865 hospital beds are to be removed across north west London. Eve lit up the evening with her passion and commitment to continue to confront the lies NHS bosses have fed us all and to fight against the planned, massive cuts in finance, beds and staff.

What was revealed to the audience were details of planned cost savings, staff cuts, reduction in hospital beds, the downgrading of Ealing and Charing Cross Hospitals, and closure of A&E units. Facts and anecdotal evidence emerged about the current and future impact of savage cuts to social services. One patient had been discharged from hospital and sent for convalescence at Clayponds Hospital. Subsequent discharge from there was to the local Premier Inn Hotel – for four weeks!

Major issues raised at the meeting included delays in seeing GPs, waiting times at A&E, delayed elective surgery and inadequate mental health and social services. All residents were urged to quiz their GPs about future Primary Care arrangements. There was a general consensus that Ealing GPs had been consistently silent about any possibly negative aspects of planned cuts and changes.

It was pointed out that the latest healthcare and social care proposals  – the North West London Sustainability and Transformation Plan (STP) – followed the approach of the failing 2012 NHS NW London  ‘Shaping a Healthier Future’ (SaHF) plan. (One major difference however between SaHF and STP is that STP attempts to cut costs and improve healthcare and social care services. SaHF only tries to improve and cut costs for healthcare).    The Leaders of Ealing and Hammersmith & Fulham Councils confirmed that they had refused to sign up to the STP.

We heard horror stories from NHS staff about days when no carers and no A&E beds were available. Hillingdon Hospital A&E performance continues to be the worst in England. Councillor Aysha Raza pointed out that when Ealing hospital is downgraded many more patients and their loved ones will have to travel to Northwick Park Hospital in Harrow. She has researched the difficulties for Southall residents travelling to Northwick Park. It’s three buses and an overall journey time of 1 hour and 45 minutes!! She was not alone in criticising Dr Mohini Parmar, who seemingly runs Ealing Clinical Commissioning Group, SaHF and the STP. Aysha has noticed that Dr Parmar’s favourite technique when confronted in public with difficult questions or requests for evidence is to announce that ‘a piece of work is underway to provide/answer this’. However such work never seems to emerge as a report in the public domain.

North West London Councillors Quiz Care Planners

On 20 February 2017 I attended, as an observer, a meeting of the North West London Joint Health Overview & Scrutiny Committee. In theory two Councillors from each of the eight Local Authorities attend these six-monthly meetings. At any one time there were no more than ten Councillors attending. Claire Parker led the small team of NHS NW London bosses. On the agenda were big topics – the £513 million capital request for NHS SaHF building work in outer NW London, and the NW London STP.

Quite frankly some of the Councillors questions and observations were banal and irrelevant. However a few of them were brilliant. Councillor John Coombs from Richmond outlined that in Germany STP proposals had been implemented over the last two years. They were failing in spite of the fact that Germany has more doctors, nurses and hospital beds per 1,000 population than England.. Here in England the NHS  has cut hospital beds for years and plans to cut many more. One third of all our doctors are approaching retiring age. We have fewer trainee nurses. The Government is cutting back on immigration. Pharmacies (which could take some pressure off GPs) are being closed down. And we plan to reduce spending as a percentage of GDP on healthcare and social care over the next five years. Just how can these SaHF/STP proposals succeed? A spontaneous round of applause broke out from the spectators’ gallery. Ms Parker was clearly rattled by this and blurted out that there are problems but there’s plenty of waste in the care system and massive savings can be achieved by eliminating waste. I’d be surprised if anyone in the room found this a credible response.

The SaHF cash request, which might eventually find its way to H.M. Treasury, breaks down into £69 million for GP surgeries’ enhancements, £141 million for Out Of Hospital /Hubs and £303 million for Acute sites. The NHS expects to receive £9 million from selling off land on the Ealing Hospital site and £7 million from other land sales. No clues are provided as to where a new healthcare facility might be located on the Ealing Hospital site or when and where demolition will take place. Best estimate for when a new healthcare facility will open on the site is November 2022. The NHS bosses are keen to call the new facility a ‘Local Hospital’. What it will actually be is a Day Care Centre with some ‘Frail elderly beds’.

Painful statements which NHS bosses uttered include:

+ ‘ If we don’t get the £500 million – there is no plan B’

+  ‘We have more work to do on clinical models’

(Isn’t 4 years long enough to have sorted this out?)

+  ‘The ‘Evening Standard’ article about job cuts was wrong. We won’t be reducing staff numbers. The information came from draft documents’

(The fact is that the 7,753 jobs cuts by 2020/21 was contained in the formal response by the NHS to a Freedom Of  Information request)

+ ‘ The 2012 SaHF plans did not include any provision for illness prevention, mental health or social care services’

+  ‘We are not closing beds to save money’

(If this is true – why are they doing it?)

+  ‘The NHS NW London estate (i.e. its properties) is in worse condition than anywhere else in England’

(How can this have happened? Surely CCGs, Trusts, NHS England and now defunct PCTs should hang their heads in shame)

At the end of the meeting the Chair Councillor Mel Collins asked Ms Parker if the SaHF/STP proposals were either about residents’ health or cutting costs. She replied ‘residents’ health’. Just how refreshing would it have been if she had answered truthfully along these lines ‘They are about cutting costs. We have to reduce our annual spend by £1.4 billion by 2021. However we will do everything we can to provide the best care we can from 2021 with just 60% of the money we are currently spending each year’.

NHS NW London Clinical Commissioning Groups (CCGs) Argue With Themselves About Staff Cuts

Recently an activist with Brent Patient Voice submitted a Freedom of Information request to NHS bosses about future care staff STP cuts across NHS NW London. The detailed reply quoted 7,753 job losses by 2020/2021. The ‘Standard’ newspaper picked up and ran the story.

Incredibly the self styled ‘Combined CCGs of NW London’ responded to these reported cuts as follows:

‘We have no plans to reduce the overall number of health and care staff across NW London – in fact the total number is likely to increase to reflect increasing demand.’

Is this a case of the left hand not knowing what the right hand is doing? Or is someone simply lying?

New Health Centre on Ealing Hospital Site by November 2022?

Under the auspices of the failing 2012 ‘Shaping a Healthier Future’ (SaHF) project the NWL CCG supergroup now say that what they call ‘Ealing Local Hospital’ will be built on the Ealing Hospital site by November 2022. As SaHF has missed all previous deadlines we should take this date with a pinch of salt. More salt is needed to believe that H.M. Treasury will sign off ‘in principle’ £500 million of capital spending needed for this (and other building projects) by February 2018. However the so called ‘Full Business Case’ will not be created and submitted before September 2018 – with Treasury re-blessing expected by April 2019.

As for the new facility, it won’t contain a traditional A&E unit. No blue light ambulances will visit. There will be no Intensive Care beds or consultants, no Maternity unit, no Paediatrics unit. It will primarily feature lots of GPs, diagnostics, outpatients, an Urgent Care Centre and ‘extended services for frail elderly people’- whatever that might mean.  Apparently there will be 50 beds for the frail elderly.

There are no details on where this new, small facility will be built on the site or when the Major Hospital building that is Ealing Hospital will be demolished.

West London Mental Health Trust (WLMHT) Receives Poor CQC Ratings in Two Consecutive Years

The Care Quality Commission (CQC) carried out a full inspection of WLMHT in November 2016. Its report was published on 9 February 2017. The report does not make pleasant reading. CQC rated 9 of the Trust’s 11 services as ‘Requires Improvement’. Staff recruitment and retention, patients’ physical health needs, acute ward capacity, poor inpatient environments, and governance processes were cited as areas needing improvement. CQC did find some improvements since its inspection and critical report in 2015. These were in staff morale, better incident reporting, working with partners, creating a single point of access, enhanced assessment and treatment teams and a new Primary Care mental health service.

It’s not as though all London mental health Trusts are performing as badly as WLMHT. In December 2016, CQC rated South West London and St George’s Mental Health NHS Trust as ‘Good’ in 8 out of 10 services, and Barnet, Enfield and Haringey Mental Health Trust as ‘Good’ in 5 out of 10 services.

The NHS Better Care Fund – Yet Another Expensive, Cost-Cutting Failure

The NHS Better Care Fund (BCF) was first announced in June 2013. £5.3 billion was to be spent on transforming local health and social care services by pooling resources. Major goals were reducing the number of hospital admissions and making annual cost savings of £1 billion. In November 2014, the National Audit Office (NAO) branded the BCF plan a ‘shambles’. It could find no evidence as to how these cost savings were going to be achieved. The BCF went ‘live’ on 1 April 2015.

In November 2015 the Government froze the BCF at £3.8 billion.

So what has BCF achieved? According to the NAO very, very little:

+ The BCF target of reduced hospital admissions was 106,000. In fact over the BCF period hospital admissions have risen by 87,000!

+ The BCF has not achieved any cost savings. In fact the BCF has cost an additional £311 million!

+ Better co-operation between NHS healthcare bodies and Local Authorities social care organisations has been observed

+ There have been no announcements or measurements of ‘better care’.

BCF is another clear example of gross incompetence by Government, the Department of Health and NHS England. One hopes whoever was responsible for designing, goal setting and managing BCF will apologise, resign or be sacked. Norman Lamb MP when serving as a Government minister helped draw up these plans. He is quite obviously one of the culprits.

Issue: 45

February 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. Process improvement is what is needed in our NHS – not revolution.

NHS North West London Healthcare Services – The Future Disaster in Numbers

Number of Staff, January 2017:  48,258

2017/2018    18/19 19/20      20/21

Staff Reductions (cumulative)

3,658             5,222 6,592    7,753

155 NHS STAFF WILL BE FIRED, ON AVERAGE, EVERY MONTH FOR THE NEXT 50 MONTHS

Outpatients

    Cut by 222,370 up to 2020/2021

Elective Admissions

    Cut by 34,437 up to 2020/20/21

Non Elective Admissions

    Cut by 64,175 up to 2020/20/21

Figures courtesy of an FOI response received by a Brent health campaigner.

Most of England Has Just One Massive Healthcare Care Cost Cutting Plan – But North West London Has Two!

In the summer of 2012 NHS North West London launched its ‘Shaping a Healthier Future’ (SaHF) project. It was an ‘..over three year’ programme of cuts and restructuring  which would achieve annual savings of 4% each year. SaHF involved downgrading four Major Hospitals (one of which is Ealing Hospital), closing four of the nine hospital A&E units, cutting the number of Acute hospital beds and replacing them with ‘Out-Of-Hospital’ (OOH) arrangements. However no annual cost savings have been achieved (by now they should exceed £400 million), just two of the A&E units were been closed (in September 2014) and A&E performance has been some of the worst in England ever since. Hospital Acute beds have been cut, but replacement OOH arrangements are nowhere to be seen.

Over a 10 month period in 2016 the NW London Sustainability and Transformation Plan (STP) was conceived in secret by over 200 civil servants. The STP is a five year cost cutting plan for care services. Its financial goal is to reduce the annual running costs for care services throughout the region by £1.3 billion by 2021. The STP’s mission is similar to SaHF but there are significant differences. STP covers both health care and social care services and the integration of the two. As such, Local Authorities are thrown together with NHS bodies to sort this out. SaHF however is just about healthcare; STP aims to mandate recent new strictures like seven day working and parity of esteem for the physically and mentally ill – neither of which were SaHF goals – in fact mental health is hardly mentioned at all in the SaHF. The STP also mandates  the creation of brand new, long term fixed private partnerships called (generically) Acountable Care Organisations (ACOs). ACOs do not feature in SaHF at all.

Many of us, watching the SaHF fail in 2015/16, presumed that it would be quietly retired and be replaced by its newer big brother the STP. But…no. December 2016 saw SaHF come roaring back with a 356 page business case. We had been waiting for this business case for some three years. Sadly this was only Part 1 of the business case – asking for just £513 million for building works in ‘outer’ NW London. Part 2 – aimed at building works in ‘inner’ NW London asking for £314 million – has yet to be published. To my astonishment Part 1 tells us all that SaHF has now become a 10 year project!

On 25 January 2017 Ealing Council Councillors met SaHF (and STP) bosses in public  for three hours to scrutinise Part 1 of the SaHF business case. The catchy title of the business case is ‘Shaping a Healthier Future: Strategic Outline Case (SOC) Part 1’. The publishers are a non-statutory body who call themselves ‘NHS North West London Collaboration of Clinical Commissioning Groups’.

A common complaint by Councillors was their struggle to understand much of the jargon and financial complexities. Some said that on the doorstep their constituents knew absolutely nothing about the proposed cuts and changes to local healthcare services. Councillors variously voiced their opposition to the downgrading of Ealing Hospital. Some could simply could not understand how this downgrade would improve healthcare for Ealing residents. Others worried about what would happen if H.M.Treasury refused to hand over the cash for building work. Others felt that Ealing residents would endure pain and worse travelling to remote hospitals after Ealing Hospital ceased to be a Major Hospital.

Councillors also wrestled with the concept of  ‘Hubs’. Hubs seem to be collections of GP surgeries (20,000 patients/hub). It’s possible that there will also be some social services and some mental health services residing in a Hub. Apparently Ealing will have three Hubs. One will be in/at Ealing Hospital site, with a new one in the north, probably on the GSK site in Greenford and a new one in the east probably on the site of Acton Health Centre. Each of the new Hubs will cost £20 million to build. SaHFers then referred to Hubs as Health and Wellbeing Centres. Councillors went nuts. One name or the other they cried. Let’s have Health & Wellbeing Centres they demanded. It was made clear that no more GP businesses were to be created. The SaHF business case described a future facility at Ealing Hospital as a ‘Local A&E’. Councillors struggled to get their mind around the idea that any hospital’s emergency unit with no Intensive Care and no arriving blue light ambulances could ever be labeled  ‘A&E’.

There were a number of instances when Councillors pressed for more evidence or risk assessment data and were fobbed off with promises to carry out further research /data gathering. Some Councillors understandably were dumbfounded by this. SaHF has had over three years and spent millions of pounds with management consultants designing and implementing these SaHF changes. Even though the SaHF business case (Part 1 only) is three years late, is it still incomplete?

SaHF stated that in 2025/26 there would be 22,000 fewer hospital admissions. Presumably this is an annual figure. No clues were provided as to how this figure for nine years hence had been calculated.

Healthwatch Ealing (HE) presented an update on its response to the business case. Chair James Guest reprised his oft stated reservations about the exclusive adoption of a ‘top down’ design approach. What was needed was a ‘bottom up’ approach to validate the ‘top down’ high level assumptions. This would begin with a detailed description and analysis of the current services and patient volumes at Ealing Hospital and grow into where these services and patient activities will be relocated. Other concerns highlighted included lack of evidence re ‘efficiency’ and Acute beds’ reduction proposals, patient access and transport issues, lack of overarching accountability, too few Hubs and Hubs in the wrong place, and lack of clarity and detail about the new provision of Frail Elderly Beds on the reconfigured Ealing Hospital site. The Councillors welcomed the HE report and SaHF agreed to respond in writing to it.

The most surreal part of the meeting was when the SaHF PR person did a sales pitch on ‘engagement’. The person also handed out copies of a questionnaire. SaHF wants to know how Ealing residents would like the £513 million to be spent. This is so insulting to Ealing residents. SaHF has published a 356 page business case to support the spending of this money on building works. It’s already decided how this money is to be spent.

NHS North West London Hospital A&E Performance Continues to be the Worst in England

Latest available A&E performance figures (November 2016) for the sickest patients (Type 1) reveal that four of the NHS NW London Hospital Trusts were amongst the ten worst performing in England. On one dreadful day (29 November 2016) Hillingdon Hospital managed to treat just 41% of Type-1 patients within four hours.

However NHS NW London top management continues to be in denial about this dreadful performance. On 11 January 2016 Dr Mark Spencer, Medical Director, on being confronted with these horrific performance figures said:

‘As ever, the NHS’s priority in NW London , as elsewhere, is on treating the sickest A&E patients first, whilst endeavouring to reach the 95% standard for all patients  whenever possible, even in winter’.

But…There Could be Much Worse to Come

The current A&E chaos still awaits the completion of the 2012 cost-cutting NHS NW London ‘Shaping a Healthier Future’ (SaHF) programme. SaHF promised us the closure of four hospital A&Es – but so far has closed just two, and both of those were in September 2014.

The NHS mantra underpinning SaHF is that 30% of those people occupying hospital beds should not be there. This percentage was first spouted by the NHS’s favourite management consultants McKinsey & Co in 2009. The way the logic goes is that if you have fewer people filling beds in hospital you can get rid of lots of those expensive hospital beds. Nationally 13,822 NHS hospital beds have been eliminated since 2010.  Our cost-cutting Sustainability and Transformation Plan (STP) wants to close another 500 Acute beds by April 2020.

Lies, Damned Lies and NHS Hospital A&E Attendance Data

Lying by politicians has reached unprecedented levels with regard to attendance levels  at NHS hospital A&E units. Secretary of State Jeremy Hunt MP told Parliament in December 2016 that A&E attendance levels were up 30%. Sarah Wollaston MP, Chair of the Health Committee, also said in December 2016 that there were ‘unprecedented levels of demand’ at NHS hospital A&E units.

But, these statements are completely untrue.

Colin Standfield has been collecting, collating and analysing NHS hospital A&E attendance figures for 3.5 years. For all attendances in London the uplift April 2013 to November 2016 is 6.15%, but the population rose by 3.69%. Throughout England for all attendances the uplift is 6.5%, but the population over the three years rose by 2.37%.

The actual increase across England in real terms is 4.13%.

As for NHS NW London generally and Northwick Park and Ealing Hospitals specifically, A&E attendance levels have reduced slightly over the three year period.

Are these politicians consciously lying? Maybe they are just spouting whatever NHS England and the Department of Health are telling them. So…is it NHSE and the DoH who are consciously lying?

Ealing Clinical Commissioning Board (ECCG) Governors’ Meeting 18 January 2017

I sat through almost three hours of this meeting. The meeting content variously astonished, depressed and surprised me. The NHS ECCG currently decides how our money is spent by the NHS to provide for secondary/hospital care for Ealing residents. However of the 20 Governors the three dominant members are part of the five person team which decides on how money is spent on secondary/hospital care for much of North West London. The fivesome run the consortium of five of the eight NHS NW London CCGs. They also run the NHS NW London 2012-2022 cost cutting project ‘Shaping a Healthier Future’ (SaHF) and the 2016-2021 NW London cost cutting project the Sustainability and Transition Plan (STP). SaHF and the STP are often presented as being the same but of course they aren’t. When any one of the three big bosses speak they may be speaking as ECCG, the NW London CCG consortium, SaHF or STP – or in fact as all four.

Engagement with the public is very poor at ECCG meetings. No hard copy of the documents to be reviewed/approved is provided. We were not even given an agenda. The ECCG had no interest in discovering who we were. No names or email addresses were collected, so even if answers were forthcoming at the meeting or afterwards there was no way the answers could be sent to any of us. Quite pathetic.

Ealing GPs apparently will soon be asked if they want to be controlled by NHS England or the ECCG. If they choose ECCG we will have the bizarre situation where the GP led ECCG will determine the finances and potentially the professional lives and deaths of 200+ GPs at 80 GP surgeries. This really cannot be right. It’s like giving your young children the right to determine how much pocket money they receive!

Apparently only 11% of those needing physiotherapy were receiving it within four weeks.

Local activists at the end of the meeting raised issues about the A&E crisis in Ealing and throughout NW London. The complacency which radiated from the ECCG Governors was appalling. ECGG would not accept that there was a local A&E crisis. ECCG said that each hospital collected A&E performance date in its own particular way. This made meaningful data aggregation across hospitals and across the country an impossibility. So according to the ECCG/CCG consortium/SaHF/STP measuring and comparing A&E performance data is a futile exercise. Unbelievable.

When questioned about bed blocking Clare Parker, one of the NHS bosses, said there were plenty of beds in North West London – 2.2 million in fact. I found this quite offensive. Some of these home beds would obviously be unsuitable from a clinical/medical perspective. For example the elderly, the mentally ill and substance abusers often live chaotic lives in unhygienic situations. Thousands of poor people are living in bed and breakfast accommodation throughout NW London. Also, more than 8,000 people slept rough in London during 2015/16. Ms Parker also blurted out that there were 4,000 acute beds in NW London. I found this surprising as the health emergency researcher John Lister counted just 3, 449 beds way back in 2012. However at 4,000 beds we have just over 2 beds per 1,000 (GP registered) population. The World Health Organisation recommends a minimum of 5 beds per 1,000. France has 6.4 beds and Germany 8.2 beds.

The issue of offering patients at Charing Cross Hospital the opportunity to have their operations at remote private hospitals was raised. One of the big issues was that these private clinics had no intensive care services on site and if an emergency arose delays in getting to an NHS acute hospital could prove fatal. . Incredibly what emerged was an amazing queue of 400 Charing Cross patients awaiting operations for over 52 weeks.

I tried in vain to ask my question, but was never invited to speak. The question I would have asked was one identified by eagle eyed Brent Patient Voice’s Robin Sharp:

‘Appearing for the first time in the 22 October 2016 version of the STP was £108 million savings from Local Authority Social Services. Can you please explain how these savings will be achieved?’

If I had asked the question I suspect the chances of my receiving a content bearing response would have been zero

Healthwatch Hounslow Annual General Meeting.

On 24 January 2017 I attended the Healthwatch Hounslow (HH) Annual General Meeting (AGM). We were told about many meaningful research activities. We also heard about extensive patient engagement. Staff and volunteers were thanked over and over again for their efforts. However, quite bizarrely, there was no written AGM report, no written financial report or any financial details, and no election of officers.

Hounslow CCG did a presentation on the NHS NW London Sustainability and Transformation Plan (STP). Two things not mentioned were the 900 hospital beds to be lost and annual savings of £1.3 billion to be achieved by April 2020 i.e. in just 38 month’s time.

Hounslow and Richmond Community Healthcare NHS Trust (HRCH) made a presentation. This was largely about how closely HH and HRCH worked together. Seemed a bit odd when the Healthwatch mission is to hold commissioners and suppliers to account.

Another presenter was a private company – LHM. LHM runs patience experience projects for HH – at what cost was never revealed. Maybe this is a good use of public money or maybe it isn’t.

None of the presentations mentioned the massive local A&E performance and bed blocking crisis. No mention was made of the ailing 2012 NHS NW London ‘Shaping a Healthier Future’ (SaHF) project. It is SaHF which has brought about the A&E crisis and has failed to make the promised aggregated annual savings of over £400 million.

Healthwatch Ealing asked from the floor what the impact on Hounslow residents might be when the implementation of the STP closes Ealing Hospital A&E. How would the STP deal with the inevitable increase in demand at West Middlesex Hospital? Sue Jeffers Managing Director of Hounslow CCG talked about various refurbishment and small expansions at West Middlesex Hospital. HCCG also referred to the future STP development of the six community healthcare hubs in Hounslow. As ever in such discussions NHS management failed miserably to explain how glorified GP surgeries (hubs) could in any way replace 24/7 hospital Acute care with co-located Intensive Care consultants. She didn’t even try the other approach which is to suggest that such care could be replaced by care at home. Her final throw away line was about the December 2016 NHS NW London SaHF business case (part one only) which stated that ‘outer’ NW London SaHF building work would need some £0.5 billion in capital from the Government. I am not alone in doubting that H.M. Treasury will agree to handing over this cash to the failed NHS NW London SaHF project.

In seven weeks time the same company which runs Healthwatch Hounslow will take over running Healthwatch Ealing for the next three years. Only time will tell whether they do a good job or not. There are many Healthwatch Ealing members who are very unhappy with how the STP will damage healthcare and social care services in Ealing. Let’s hope under the new administration these members remain active and help shape the local Healthwatch Ealing agenda for years to come.

Issue: 44

January 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. Process improvement is what is needed in our NHS – not revolution.

NHS North West London Wants £827 Million for Building Work

On 15 December 2016 Ealing Clinical Commissioning Group (ECCG) approved a ‘business case’ for future NHS building work in ‘outer’ North West London for £513 million. The business case only entered the public domain on 6 December 2016. Its appearance has been awaited for three years.

In order to make cuts in annual healthcare spending of £1.4 billion in NW London beginning in 2020, for ‘outer’ NW London building works the NHS wants £377 million of public money invested. By 2026 it wants an additional £136 million. (For ‘inner’ NW London a further £314 million will, apparently, be requested some time in the future).

These figures are extracted from a 257 page NHS document called ‘Strategic NHS NW London Outline Case Part 1’. This relates purely to the £513 million building works planned in ‘outer’ NW London. Surprisingly the document is also associated with the failed 2012 NHS NW London ‘Shaping a Healthier Future’ (SaHF) project. SaHF was announced in 2012 as ‘at least’ a three year project but has now ballooned into a ten year one.

Healthwatch Ealing and Ealing Save Our NHS raised many concerns at this ECCG meeting – none of which were sensibly or adequately addressed. SaHF promised to make 4% cost savings every year, close four hospital A&E units and replace Acute hospital services with ‘Out of Hospital’ community services. SaHF has failed to achieve any of these ambitions. However what it has achieved is a massive drop in hospital A&E performance across the region from September 2014 to date. It achieved this during a period when A&E demand has remained static. Clare Parker, Chief Officer NHS CWHHE CCGs, did not deny that the savings had not been achieved and also had the bare faced cheek to deny the A&E collapse.

The public money will, apparently, be spent on building community healthcare hubs (£140million), replacing the Major Hospitals at Ealing and Charing Cross with effectively ‘super hubs’ (£300million), and enhancing some GP surgeries (£69 million).

The location of these future hubs is very disturbing. Hounslow with 265,000 residents and a Major Hospital will have six hubs. Ealing with 342,000 residents and no Major Hospital will now, apparently, have just three. None of these are located in the areas of high deprivation at South Southall and Northolt. In the original SaHF proposals six hubs were proposed for Ealing. Dr Mohini Parma, GP surgery boss, NHS ECCG Chair and NW London Footprint boss, somewhat pathetically and unsuccessfully tried to suggest there were more than three hubs planned for Ealing.  

Missing from this business case are analyses of existing and projected Acute admissions and A&E attendance, and capacity planning data on ambulance services and public transport. No details are provided on the investments in GP surgeries. There is also very little timescale data. There are many references in the document to the so far unapproved NW London Sustainability and Transformation Plan (STP). This is all very confusing as SaHF is a 2012 healthcare services transformation/cost cutting plan over ten years whilst the STP is a 2016 healthcare and social care transformation/cost cutting plan over five years. No compelling evidence is provided to suggest that there will be an adequate return on the public capital invested.

I find the business case to be inadequate. I find it hard to believe H.M. Treasury will release hundreds of millions of pounds to an organisation which has failed to successfully implement SaHF cuts and improvements over the last three years. NHS NW London in 2012 promised us ‘(SaHF) changes that will improve care in hospitals and the community’. The two million residents have been very badly let down by these failed promises.

Broadmead GP Surgery Survives to Fight Another Day

Broadmead Surgery in Northolt was under threat of closure until incumbent GP Dr James Swain, his staff, his patients, the Patients’ Participation Group, local NHS staff, Steve Pound MP and Healthwatch Ealing mounted a campaign.

The initial NHS proposal was for ‘list dispersal’ (i.e. GP surgery closure). However at a meeting of the NHS Local Joint Primary Care Co-Commissioning Committee on 15 December 2016 this proposal was dropped and a new proposal for ‘re-procurement’ was agreed. What this means is that Dr Swain can compete in an open tender with others for a new five year APMS GP contract. It is hard to envisage that anyone else could successfully compete against the incumbent for this contract given Dr Swain’s surgery growth record, range of services and massive popularity with his patients.  

This is a rare victory for common sense by NHS management.

North West London STP Set In Concrete Now from April 2017 to March 2019

According to NHS England, STP-based service contracts for North West London were signed on or before 23 December 2016 with NHS providers for the period 1 April 2017 to 31 March 2019. Apparently these contracts are based on the ‘final’ STP version as of  21 October 2016.

So….public engagement and public consultation on our local STP for years one and two is over – before it ever even began!

One does wonder exactly what is in these contracts. Are they fixed price? Are there social care delivery contracts? Are there contracts which cover integrated healthcare and social care service delivery? Two years’ NHS healthcare spending alone in NW London amounts to over £7 billion. Who exactly has ‘commissioned’ these services? It’s not the statutory CCG or Local Authority commissioning bodies. Is it in fact NHS England? Or is it the nebulous  non-statutory body referred to as a ‘transformation’ group thrown together by the eight NW London CCGs. Google can’t find who serves on this group except for Dr Mohini Parmar who leads it and four named clinical directors.

You might think that a group that will purchase over £10 billion STP care services for NW London by April 2020 might have its own STP web site. On such a site one might expect to find a constitution and minutes of meetings at which discussions were held as to how much to pay to whom for what. Also one might find copious evidence to support ‘transformation’ and details of meetings discussing the content, finance and operation of the five Accountable Care Partnerships to be formed. Sadly none of this exists.

Could  2017 Be the Year When the Tidal Wave of Opposition Sweeps Away the STPs?

As we enter 2017 there is much speculation and concern as to how Brexit and a Trump US Presidency will affect our lives. What’s scary about Brexit and Trump is that there are no plans. As for the NHS and social care services, what is even more scary is that there are plans – the Sustainability and Transformation Plans (STPs). Also people voted for Trump and Brexit. But no such luck with the 44 STPs which are being foisted upon the people of England.

I first became really concerned about the NHS in 2012 and began this newsletter in May 2013. In 2012 I was pretty ignorant about the NHS structure and its jargon. I naively thought that the NHS North West London ‘Shaping a Healthier Future’ (SaHF) plans were just a local cost cutting/hospital closing initiative. However now I and thousands across England understand how the NHS now works and what the STPs cost cutting ‘common purpose’ actually is.

In late 2012 I joined an Ealing Trades Union activist group which was opposing the SaHF plans. This group – Ealing Save Our NHS (ESONHS) – is now very strong. Healthwatch Ealing – after ignoring patients’ concerns for three years – is now a potent patient voice. The Seniors Action Group Ealing (SAGE) is now re-energised in its current and future concerns for Ealing’s elderly. Many of us have joined our GP surgery Patient Participation Groups (PPGs) and will be both asking STP questions and explaining STP consequences in the local patient forums.

Throughout NW London activists groups are sharing information and supporting each others’ campaigns of protest. Links are particularly strong between groups in Hammersmith, Lewisham, Brent, Harrow and of course Ealing. There’s also a flourishing NW London activist co-ordinating body.

At a national level there are two well supported bodies – Health Campaigns Together (HCT) and Keep Our NHS Public (KONP). HCT has led the country in discovering and publishing the ‘secret’ STP proposals.

The 44 STPs, if and when approved by NHS England and the Department of Health, will need capital budgets for building work. NHS NW London wants £827 million. If this is a representative figure then nationally H. M. Treasury will be asked to stump up over £36 billion by 2020. If this cash is to be raised through PFI-type deals then this must be robustly resisted. It could saddle UK taxpayers with 30 years of debt totaling over £250 billion.

On the cost cutting front no doubt Accountable Care Organisations (ACOs) of many flavours will be created. These private consortia will work to long term, fixed price budgets in order to reduce annual healthcare costs by £22 billion by April 2020. To achieve this in 39 months will surely be impossible without massive downgrades in service levels. This brutal butchery will cause unnecessary hardship, pain and death.

Summary of letter sent by Dr Mark Porter Chairman of the BMA to all English MPs.

The chairman of the BMA has written a letter to all English MPs with concern of the conception, lack of adequate consultation of the medical profession and haste in the STP implementation.

The idea that an overarching organisation (STP) will bring together the various components of the NHS (Trusts) and local authorities responsible for Social Care and will be able to provide higher quality medical & social care at lower cost is unconvincing.

The lack of consultation and rushed time table, Mark Porter suggests is a smoke screen to save money. The evidence that health will improve is not adequately documented.

The General Practitioners (GPs) who are at the heart of the reorganisation have not been fully consulted and some have no knowledge of the STPs.

Thus the BMA has reservations as to whether the STPs will offer a more coordinated joined up health and social care system with a proposed 16% budget cut.

Issue: 43

December 2016

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. Process improvement is what is needed in our NHS – not revolution.

Former NHS Commissioning Boss Says STPs are a Mess

Julia Simon left her post as Head of Commissioning Policy Unit, NHS England in September 2016. On 1 December 2016 she spoke at a public meeting in Brent organised by Brent Patient Voice. She gave a very clear description of the recent history of  State healthcare and social care services in England. She gave credit to Simon Stevens (NHS boss) for creating his Five Year Forward View (FYFV) in October 2014 that all relevant partners agreed with. The 44 draft Sustainability and Transformation Plans (STPs) attempt to implement the FYFV across England. The FYFV/STP aspirations are all about treating more patients in the community or at home instead of in hospital and integrating healthcare and social services.

Ms Simon is concerned that the STPs’ content and the STP processes are flawed. She says it’s all about saving money. Where’s the evidence she asks that the proposed changes will improve healthcare and social care and will significantly reduce costs? The timescales for reducing costs and for producing the STPs are very tight. Are they realistic? She’s also worried about the lack of engagement with patients and the public in the creation of the STPs. She has recently reviewed a number of draft STPs and she questions how decisions have been made and how priorities have been set.

Julia believes that creating a market in healthcare was a mistake. She also believes that care homes becoming private is having a devastating effect.  Government reductions in social care funding are resulting in cost cutting in care homes and the consequential decline in quantity and quality of care.

Julia Simon has taken a brave stance in not only resigning from the NHS STP hierarchy but speaking out about her STP concerns. Let’s hope she’s not the last senior NHS leader to realise that they are on the wrong side of the argument.

Northolt GP Surgery to be Closed Down. NHS England Says It’s Too Small

The Broadmead Surgery in Northolt, Ealing is highly regarded by patients and staff. It has a very active patient Participation Group and it also runs a carers’ group. The surgery is operated by Dr James Swain who is a young and innovative GP. He opened his surgery in 2010.

NHS England and Ealing Clinical Commissioning Group (ECCG) want to close down the surgery. They say it doesn’t have enough patients and if it were to be closed other local GP surgeries  could benefit from absorbing Dr Swain’s patients.

It seems that ‘Big Is Beautiful’ for GPs in the coming world of STPs.  What is planned is for federations of GPs to work with NHS Trusts, CCGs and Local Authorities in Accountable Care Partnerships (ACPs). These ACPs will be private consortia providing care ‘at scale’ for 100,000s of patients in long term fixed price contracts.

Suffice to say that Dr Swain and his patients are fighting vigorously to save their invaluable ‘small’ healthcare service.

Hammersmith & Fulham Council Begin Legal Action Against the NW London STP

Hammersmith & Fulham (H&F) Council Leader Stephen Cowan announced at a 29 November 2016 public meeting that the Council had submitted a ‘pre-legal action letter’ re the NW London STP to the NHS CCG in early November. We understand that Ealing Council is supporting this action. It’s rumoured that the grounds being claimed for Judicial Review are the lack of consultation/engagement. H&F Council has been threatening legal action ever since it refused to formally sign up to the draft NW London Sustainability and Transformation Plan (STP) in June 2016.

The public meeting ‘Save Charing Cross and Ealing Hospitals’ was organised by H&F Council and attracted hundreds of attendees in Hammersmith Town Hall. An intriguing platform speaker was a local GP, Dr David Wingfield. He is the Chairman of the H&F GP Federation. The Federation represents the interests of all GPs working in the 30 H&F GP surgeries. Dr Wingfield was sceptical about the achievements of 2012 NHS NWL SaHF project and some of the NWL STP. He felt that saving Charing Cross Hospital was not enough – something had to be done with the local GP service as it was ‘all over the place’. He mentioned that the Federation was working with the NHS West London Mental Health Trust, the NHS Imperial College Healthcare NHS Trust and the local Healthwatch. However what he didn’t say was that this ‘working with’ is the precursor  to the formation of a private consortium involving these bodies and others to create an Accountable Care Partnership(ACP). This consortium will be granted a £billion+, 10 year, fixed price contract to deliver specific care services to a specific population of hundreds of thousands of residents. These NW London ACPs, being fixed price, will be the means by which annual care costs will be reduced by over 25% (£1.3 billion) by 2020/21. It’s not clear to whom this ACP – or indeed any ACP – is accountable.

Of course none of these ACP details are contained in the NWL STP. I’ve glanced at another five STPs and the ACP details are not specified in these either. This means that legal action against STPs based on the legitimacy and accountability of ACPs is probably impossible.

NW London Hospital A&E Units Failing Patients

Latest NHS figures for September 2016 show that Hillingdon Hospital A&E provided the worst service for seriously ill (Type 1) patients in the whole of England. The combined Type 1 figures for Northwick Park Hospital and Ealing Hospital A&E units were 11th worst nationally. Charing Cross and St Mary’s Hospitals’ combined A&E performance came out 12th worst.

NW London A&E performance plummeted in September 2014 following the closure of both Central Middlesex Hospital and Hammersmith Hospital A&E units. Since this date A&E performance throughout NW London has never materially improved.

This consistent poor performance is all the more worrying given the fact that there has been no increase in demand for A&E services in NW London since at least Spring 2013 (when NHS A&E performance data was first extracted and analysed).

Thanks to Colin Standfield for continuing to extract and analyse this NHS data.

Consternation Across England About Proposed or Suspected Healthcare and Social Care Cuts and Closures

Across the whole of England secret plans are being drawn up in an attempt to improve healthcare and social care services and to cut annual spending on healthcare and social care by £22 billion by 2020.The financial savings are seemingly to be achieved primarily by reducing the number of  Major Hospitals and A&E units, increasing care for people in the community or at home, illness prevention, integrating healthcare and social care, changing the roles of GPs and setting up consortia of private and public bodies to deliver all our care services. Sustainability and Transformation Plans (STPs) are to be the instruments of this austere care delivery reformation.

Locally, regionally and nationally there is a growing fury about the known content and suspected content and implications of the 44 STPs. Apparently all draft plans were submitted for review to NHS England by 21 October 2016. So far 38 drafts STPs have been published or have leaked into the public domain or to the press. Some of these are June 2016 versions and some are 21 October 2016 drafts. By far the most analysed June 2016 draft STP is the one for NW London. At least four substantial reports on the NWL STP have been written and published. The London Boroughs of Ealing and Hammersmith & Fulham commissioned John Lister, Roger Steer and Sean Boyle to write a report, Brent Patient Voice authored a report and Save Our Hospitals:Hammersmith & Charing Cross and  Healthwatch Ealing have also published reports.

I have attended two national demos/ rallies, two national meeting of the Health Campaigns Together alliance and a national meeting of Keep Our NHS Public in recent months. The topic was STPs. STP activists variously attended from Yorkshire, Cornwall, Birmingham, Liverpool, Manchester, Oxford, Grantham, Brighton, Sussex, Derbyshire, Hampshire, Isle of  Wight, Banbury, Hampshire, Shropshire and of course from all over London.

So far 13 Local Authorities (LAs) have refused to sign off/endorse their regional STPs. These are in South West London, North West London and West Yorkshire. They are Croydon, Kingston, Merton, Richmond, Sutton, Wandsworth, Ealing, Hammersmith & Fulham, Leeds City, Bradford, Kirklees, Calderdale and Wakefield. These refusals are probably symptomatic of the administrative and financial conflicts inherent in attempts to integrate NHS free at point of use healthcare services with means tested LA delivered social care services. Proposals to downgrade Major Hospitals and close hospital A&E units are also a very big factor.

On 14 November 2016 STP concerns were featured on BBC TV and ITV. On 21 November a critical study of 42 of the STPs  by the doctors’ Union – the BMA – featured in the ‘Daily Telegraph’, ‘Daily Mail’ and the ‘Daily Mirror’.

Most citizens in England know few facts about the STP intentions for their communities as their draft regional STPs have not been published. The regional draft plans which have been published are difficult for lay people to understand. They contain lots of undefined acronyms and unexplained initiatives. They are filled with laudable aspirations about improving everyone’s health and welfare. There is very little information in any of them about how the variously labeled future private consortia of NHS bodies, GP federations, Local Authorities and private care companies will operate. These future bodies are variously referred to as Accountable Care Organisations (ACOs), Accountable Care Partnerships (ACPs), Multispeciality Community Providers (MCPs) and Primary and Acute Care Systems (PACS). It will be these new, untested bodies – operating under fixed price, 10 or 15 year contracts – who will exclusively deliver all public care services in the future and who will be charged with slashing costs – to achieve a 25+% reduction in annual care costs by 2020/21.

From what people have gleaned from the contents and intentions of STPs, here’s a flavour of some of their concerns:

+ The changes proposed will not be effective and our care services will deteriorate  

+ The high level of secrecy around the creation of the STPs has made many citizens suspicious about their true aims and objectives

+ The loss of Major Hospitals and hospital A&Es will result in increased pain and death

+ Loss of hospital beds

+ Increased time/distance to travel for acute care is unacceptable

+ Financial cuts will inevitably involve reducing the numbers of care staff

+ No confidence that there will be effective integration of healthcare services and social care services

+ The role of ACOs is completely underplayed and unexplained in the STPs

+ There are currently serious doubts as to the financial sustainability of Local Authority social care services  – and STP cost cutting does nothing to alleviate these doubts

+ No evidence that replacing acute hospital care with out-of hospital care – in the local community or at home – will be effective or will cut costs

+ Cost cutting will result in reductions in the quality and quantity of care

+ STPs describe the greatest proposed changes to the NHS  since its formation in 1948 yet they have not been debated in Parliament and they are not mandated in any Parliamentary Act

+ Lack of capital funding

+ Mental health care services will deteriorate

+ Some hospital Maternity units will close

+ Some hospital Cancer units will close

+ De-stabilisation of GP practices – with increased GP workloads and possible reductions in GP funding and the GP surgery population

+ STPs will create ACPs which will contractually bind together Commissioners and Service Suppliers as peers in long  term commercial agreements. These arrangements completely trash the Health and Social Care Act 2012 regulations which mandated ‘master’ and ‘slave’ relationships between Commissioners and Service Suppliers.

+ Without significant funding and additional healthcare beds and social care beds the care needs of the growing elderly population will overwhelm the care system

+  ACPs will take budget and financial management responsibility away from CCGs and Local Authorities

+ Little information about social care services ‘transformation’

+ Recent local attempts at cutting costs and ‘improving’ care services have been unsuccessful

+ No engagement with citizens during the formative process of plan making