Last night Hammersmith and Fulham Council held a packed public meeting at which 600 people heard council leader Steve Cowan insist they would not go along with the treasury driven “Sustainability and Transformation Plan” that would decimate first Ealing, then Charing Cross Hospitals.
Julian Bell, leader of Ealing Council, took the same stand – hopefully Ealing will organise a meeting in the new year.
The defiant stand of West London Councils is now being followed by others around England.
The anger and determination to rescue our NHS is growing!

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 at least since Spring 2013 (when NHS A&E performance data was first extracted and analyzed).

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

You can download the files with  the full sets of figures here and here

Issue: 42

November 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.

Mental Health Services in West London in 2015/16 – and Beyond

I recently read the 147 page 2015/16 Annual Report of the West London Mental Health Trust (WLMHT). I also attended the WLMHT AGM on 28 September 2016 and the WLMHT Board meeting on 12 October 2016.

WLMHT is the largest Mental Health Trust in England. It provides mental health services for those who live in Ealing, Hammersmith, Hounslow and Fulham. An unusual feature of WLMHT’s responsibilities is that it also manages the Broadmoor High Secure Mental Hospital in Berkshire. The local population served by WLMHT totals around 750,000 – of which some 500,000 are adults. The WLMHT web site states that its service user population is 62,570. At less than 10% of the total population this is somewhat disconcerting. Estimates of adults suffering from mental health problems in England is 20% of the population. As for children it’s 10%. So it’s reasonable to presume that those in need of mental health care in the four towns number some 125,000.

In 2015/16 it cost £219.7 million to run WLMHT. The headcount as of 31March 2016 was 3,310. There is plenty of data in the report on expenses, income, staff, new buildings, governance, and some service performance metrics. However there is an amazing dearth of quantitative information about WLMHT ‘customers’ i.e. its service users and their experiences. What the report doesn’t tell us includes:

1. What is the breakdown of diagnoses of service users using the DSM-5 classification? (DSM-5 BTW is the accepted worldwide classification of mental disorders)

2. How many people have used the IAPT services? (Improving Access for Psychological Therapies is the NHS service for depression and anxiety)

3. How many people were Sectioned under the Mental Health Act 1983?

4. What were the numbers of people detained under Sections 2, 3, 4 and 5?

5. How many WLMHT service users were discharged into Primary Care (i.e. GP surgeries)?

6. How many who were discharged to Primary Care had to re-enter the WLMHT system?

7. What was the profile of prescribed drug use? How many service users were prescribed  Clozapine, Depot, SSRIs, Risperidome etc?

8. How many psychologists and psychiatrists were employed?

9. How many Acute mental health beds were in use?

10. What was the average waiting time to begin a series of meetings with a psychologist?

11. How many Registered Carers are there?

12. How do all these figures in answers to questions 1. to 11. above compare with 2014/15 figures?

There is no mention in the report about the humiliating climb-down by WLMHT in November 2015 with regard to whistleblower Dr Hayley Dare. In 2013 Dr Dare revealed a culture of bullying and harassment in the Trust. However an Employment Tribunal found against her on the grounds that she had not acted ‘in good faith’. She had to pay £10,000 to WLMHT. Dr Dare appealed and in November 2015 WLMHT finally admitted that Dr Dare had acted in good faith. WLMHT repaid her £10,000 and its legal fees were £130,000. Also missing from the Annual Report  were any details of the fraud investigation launched in 2015 when £millions of unbudgeted expenditure came to light.

There are also only sparse details in the report about the 2015 findings emanating from the 2015 CQC inspection. CQC assessed WLMHT as unsafe, ineffective and poorly led in three of five main areas. WLMHT Chair Nigel McCorkell had stood down in 2014 and Chief Executive Steve Shrubb retired in 2015.

I have been a member of the excellent volunteer run Carers’ Support Group (CSG) for five years. The CSG is based at WLMHT’s Avenue House in Acton. On 11 October 2016 I attended a meeting with over 20 CSG carers and the Trust’s Chief Executive and her Director of Nursing. On 25 October I attended a meeting of 20 CSG carers and two CQC inspectors. The biggest positive revealed at both these meetings by carers  was the high quality of crisis intervention by WLMHT staff. The negatives raised included:

1.Many examples of very poor communication between WLMHT staff and careers.

2.Unsafe discharge of service users from hospital to home.

3. Discharge of service users from WLMHT to GPs who displayed little empathy, mental health knowledge or interest in mental health

4.14 month waiting time quoted to carers for their loved ones to begin treatment with a psychologist

5.No adult Aspergers competence anywhere in the Trust

6.Very little support by the Trust for carers or carer support groups

7. Only eight mental health support workers to support 80 Ealing GP surgeries housing over 200 Ealing GPs

8. Some poorly trained Trust building receptionists – unfriendly and ‘head down’

9. No Trust-maintained information resource for carers. What does the jargon mean? What does Sectioning mean? What are my expectations and rights as a carer?

10. The Trust web site is ‘awful’. Some of the information on it is out of date.

11. Why can’t appointments with clinicians be in the evening or at weekends? This is most important for service users who are managing to hold down daytime jobs

12. Many carers have never seen Care Plans for their service users

13. At a Work Capability Assessment in July 2016 the service user’s medical history was over three years out of date and did not include any details of his 2013 Sectioning.

In the ‘Future Plans’ section of the report there is a mention for the NW London Sustainability and Transformation Plan (STP). However no indication is given about the massive cost cutting STP agenda or the challenges inherent in STP’s aim of integrating mental healthcare with mental social care. I was pleased to see at least a mention of the work to come on Accountable Care Partnerships (ACPs). However no details or explanations are given about ACPs. The Trust is likely to be one of over ten NHS Trusts, NHS CCG, GP federations , Local Authorities, private and charitable care organisation partners all joined together in a private ACP consortium. This ACP will have a ten year fixed price contract to deliver mental care services to over 500,000 people. It will be the ACP and not WLMHT which will assign budgets, set priorities and determine strategy.

In November 2016, CQC will carry out a full on site inspection of WLMHT. This is unusual as a full inspection also took place in 2015. Let’s hope CQC finds significant improvements.

£1.1 Trillion Accountable Care Partnership Contracts to be Signed by 2021 – With No Parliamentary Mandate

Accountable Care Partnerships (ACPs) will be consortia of NHS Trusts, NHS CCGs, Local Authorities, GP federations, and private and charitable care organisations. ACPs are devices for care delivery being introduced in Sustainability and Transformation Plans (STPs). By 2021, apparently, all healthcare and social care services will be delivered by ACPs. The 44 STPs in England will collectively cut national annual care costs by £22 billion by 2021. ACPs, with 10 or 15 year fixed price contracts, will be the delivery vehicle for these cuts. The fixed prices will be determined by the ‘capitation’ method (more on this below).

At an NHS ACP briefing on 5 September 2016 I was told that in NW London there would be in total five ACPs serving specific populations of between 500,000 and one million. So let’s say one of the ACPs will serve the Primary Care needs of adults. There are around 1.6 million adults in NW London. In 2013 the annual per head healthcare budget for all patients in England was £2,350. Around 25% of that was for Primary Care. Now, taking cost cutting into consideration, let’s say the annual per head cost for ACP Primary Care for adults would be £500. So the capitated annual budget for this ACP would be £800 million. And the 10 year contract value would be £8 billion. Sadly you are unlikely to have read any of this in the latest version of the NW London STP.

The published NHS annual healthcare budget for 2016/17 for England is £107 billion. The 2016/17 social care and public health budget is £25 billion. Put these together and it comes to £132 billion. The target is to reduce that by £22 billion by 2021. So ACPs delivering all care services must have an annual contracts’ value of £110 billion. If all the ACPs are just 10 year contracts then the collective ACP contracts’ value would be £1.1 trillion.

None of these ACP arrangements has been discussed in Parliament. No Parliamentary Bill has proposed these STP /ACP mechanisms. No Act of Parliament mandates any of the STP/ACP or the astronomic use of public money to fund these ACP private partnership contracts.

Judicial Review anyone?

Young People Seeking Help for Anxiety Up Annually by 35%

The NSPCC’s Childline counselled 11,706 young people for anxiety in 2015/16. This was up 35% from 8,642 children in 2014/15. Seven times more girls than boys called about anxiety.

Number of Girls Cutting Themselves Annually Rises 385% to 2,311 in Ten Years

NHS England and NHS Digital reports that self-harm amongst children has risen dramatically over the last ten years. The biggest rises involve girls under 18 years of age. Poisoning is up 42% at 13,853 girls, cutting is up 385% and those attempting to hang themselves is up from 29 to 125. The number of boys cutting themselves also rose by 286% to 457.

One does wonder whether the increased incidence of self-harm amongst children reflects an increase in the reporting of such incidents by the children and by their parents and carers. Maybe it is caused by societal factors or maybe it reflects a failure in parenting, schooling and mental health and social care services. Young Minds, the UK’s leading children and young peoples’ mental health charity, blames inadequate specialist support. It cites cuts in social care workers, educational psychologists, parenting classes and mental health services in schools.

The Government has promised to invest an extra £1.4 billion into care for troubled children by 2020.

Police Use of Sectioning for Mental Health Patients Up by 50%+ in 10 Years

Police Officers used Section 136 powers 28,271 times to detain mentally ill people in 2015/16. This is an increase of more than 50% since 2005/6. The NHS mental health services are clearly massively under resourced because it is ideally these NHS bodies which should be Sectioning and detaining – not the Police.

Health Ombudsman Publishes Damning Report on Unsafe Discharge From Hospital

The Parliamentary and Health Service Ombudsman (PHSO) issued a report on unsafe hospital discharges in September 2016. The report is a follow-up of the May 2016 PHSO report on the most serious unsafe hospital discharge cases from 2014/15.

The new report’s conclusion is that the incidence of unsafe discharge from NHS hospitals is too high. Factors exposed in the report include:

+  The wholesale incompatibility between healthcare and social care funding

+  The inadequate funding of social care

+  Better Care Funding (for integrating healthcare and social care services) is not freely available as it is reliant on savings from the New Homes Bonus

+ Failure to involve carers and relatives in decisions to discharge patients

+ Night discharges are potentially dangerous

+ The relationship between early discharge and readmission

+ Variations in discharge procedures across England

+ Problems of delays in discharging older people

+ The Government’s policy and vision for comprehensive integration of healthcare and social care services is as yet unsupported by H.M.Treasury fiscal plans.

Perhaps the establishment of the Discharge Programme Board and the new Healthcare Safety Investigation Branch will help. However it’s clear to me that heroic local efforts alone will not of themselves eliminate unsafe hospital discharges. New Government care funding policy and new Government care funding are urgently needed.

Accountable Care Partnerships (ACPs) will be consortia of NHS Trusts, NHS CCGs, Local Authorities, GP federations, and private and charitable care organisations. ACPs are devices for care delivery being introduced in Sustainability and Transformation Plans (STPs). By 2021, apparently, all healthcare and social care services will be delivered by ACPs. The 44 STPs in England will collectively cut national annual care costs by £22 billion by 2021. ACPs, with 10 or 15 year fixed price contracts, will be the delivery vehicle for these cuts. The fixed prices will be determined by the ‘capitation’ method (more on this below).

At an NHS ACT briefing on 5 September 2016 I was told that in NW London there would be in total five ACPs serving specific populations of between 500,000 and one million. So let’s say one of the ACPs will serve the Primary Care needs of adults. There are around 1.6 million adults in NW London. In 2013 the annual per head healthcare budget for all patients in England was £2,350. Around 25% of that was for Primary Care. Now, taking cost cutting into consideration, let’s say the annual per head cost for ACP Primary Care for adults would be £500. So the capitated annual budget for this ACP would be £800 million. And the 10 year contract value would be £8 billion. Sadly you are unlikely to have read any of this in the latest version of the NW London STP.

The published NHS annual healthcare budget for 2016/17 for England is £107 billion. The 2016/17 social care and public health budget is £25 billion. Put these together and it comes to £132 billion. The target is to reduce that by £22 billion by 2021. So ACPs delivering all care services must have an annual contracts’ value of £110 billion. If all the ACPs are just 10 year contracts then the collective ACP contracts’ value would be £1.1 trillion.

None of these ACP arrangements has been discussed in Parliament. No Parliamentary Bill has proposed these STP /ACP mechanisms. No Act of Parliament mandates any of the STP/ACP or the astronomic use of public money to fund these ACP private partnership contracts.

Judicial Review anyone?

Issue: 41

October 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.

The Ealing STP Now Appears, But It’s Called ‘Ealing local plans’

On 29 September 2016 I first got to see the Ealing Sustainability and Transformation Plan (STP). I and many others have been searching for it for many weeks. The purpose of the plan is presumably to describe how, when and where future less costly healthcare and social care services will be delivered in Ealing – 2016 to 2021. This plan was submitted to NHS England (NHSE) on or before 30 June 2016. The somewhat oddly titled document displays two logos on its front cover. Neither of these logos belong to the NW London Footprint (our regional STP body) or the London Borough of Ealing (LBE) (our local commissioner of social care services). Clearly LBE has no ‘ownership’ of this document or its contents. The Ealing Clinical Commissioning Group (ECCG) logo appears along with a new one on me, ‘Living Well in Ealing’. Google cannot locate the existence or mission of this enterprise.  

I defy anyone to find the Ealing STP on the ECCG web site.

However the convoluted URL below will link you to its secret location:

www.ealingccg.nhs.uk/media/33990/ealing_ccg_local_plan_working_document_2016_.pdf

Here follow my initial comments and observations on this ten page, but 5,500 word, document:

Readability

The document is very difficult to read. Most of the text is rendered in a tiny type size. Some of the text is presented vertically, not horizontally. The text appears against a coloured background. Why could it not have been rendered in a ‘normal’ 12/14 point type size, all of it horizontal, all black text against a white background over 30 pages?

Understandability

I counted 20 unexplained acronyms, with no supporting glossary.

Viability

Presumably this document purports to be a freestanding proposal outlining five years of care service changes for over 300,000 people across 21 square miles. If this is the case then where are the pointers towards any evidence to justify and support these changes?

According to the STP there’s clearly an enormous amount of work scheduled to be completed by 31 March 2017. In the coming six months are there really the resources and cash available to successfully complete this work? Also there’s no hope of any successful outcomes unless those paying for the changes and new services (National Insurance payers) are fully involved in planning and implementation. With just three weeks to go before the final draft is submitted to NHSE, this involvement, if it even happens, will be too little, too late.

Is It Appropriate?

This plan is not written for patients or users of social services in Ealing. It is not written from a service user’s perspective. If it were it would explain in jargon-free or in a jargon-explaining fashion something along the lines of the following:

What is going to change and why and when with regard to my GP, our local hospital, ambulance services, my local pharmacist, and physical and mental healthcare and social care for mothers, children, adults and the elderly.

Cost Cutting?

STP is about significant cutting costs over the next five years. If £1.3 billion has to be saved across the eight  NW London boroughs by 2021 then pro rata in Ealing the cost savings must be £162.5 million. However there are no financial details whatsoever in this document. I find this unfathomable. Why not tell the truth about why all these changes are about to be made?

Ealing Hospital

There is no information on the facilities to be provided at the hospital over the next five years. The 2012 ‘Shaping a Healthier Future’ (SaHF) plans were to demolish the Major Hospital and replace it with a new Local Hospital on the site. Is this no longer the plan – or is there another secret plan?

Hospital Beds

There is no information on reduction of hospital/acute beds. Earlier NW London STP plans and rumours quoted bed reductions of variously 500 and 592. Will there be no reduction in local Hospital/Acute beds? Or is there another secret plan?

Mental Health

There’s no mention of the emerging ‘Ealing Mental Health Strategy’. There’s also clearly, currently a mental health epidemic among girls and young women. Two recent authoritative national surveys lead us to believe that 4,800 14 year old girls and 5,000 16 to 24 year old young women in Ealing have significant mental health problems. There is no reference to resources and new processes to help these women or in fact to any contingency planning for epidemics in Ealing.

On page 7 this statement appears:

‘Development of local mental health tariffs’

Tariff means paying a tax. Who pays? Is it the service user?

Southall and Areas of High Deprivation

The most deprived areas in Ealing are in Southall. Southall is mentioned once in the document. There do not appear to be any special provisions, local facilities or service developments in/for areas of high deprivation.

Social Care

There is not much in the document explicitly about social care. It’s by no means clear how healthcare, free at the point of use, and means tested social care will be integrated throughout Ealing.

On page 7 this statement appears:

‘Joined development of social care market development’.

I know what each of the seven words mean but put together in this way I have not the faintest idea what they mean.

Accountable Care Partnerships (ACPs)

ACPs will be the care delivery vehicle for all care services in Ealing probably by 2021. There will be five ACPs in NW London, each of them a 10 year fixed price contracts. NHS bodies, Local Authorities, and possibly private care companies and care charities will join together in consortia/networks which will bind them together legally. ACPs will provide specific care for specific populations of between 500,000 and one million people. ACPs will be the main vehicle for cost cutting. Not to spell all this out in the Ealing STP (and the NW London STP) is disgraceful.

Ealing’s STP identifies three of the five NW London ACPs – revamped Primary Care services, Long Term Conditions’ management, and prevention/self help services.

Seven Day Working

No details on how this will be achieved in Ealing.

Staff Levels Now and Over the Next Five Years

Virtually no details on this. No reference to whether and when the well known shortages of staff will be made up or perhaps made worse….nurses, doctors, GPs, Psychologists, District Nurses, Paediatricians, Health Visitors etc, etc. However by 31 March 2017 we will have 400 Social Workers in Ealing which I can only presume is an increase on today’s number.

‘Strong Public and Partner Engagement’

This what is stated on page 2. ‘Engagement’ is qualitative and takes place during the formative process of plan making. It’s clear that over the last eight months ECCG and LBE have been engaging. However I know of no Ealing citizen who has been engaged by ECCG/LBE in any meaningful way in the creation of the draft Ealing STP. Asking handfuls of Ealing residents about their aspirations for care service improvements  – especially after the 30 June draft had been submitted – is and was a futile, ‘box-ticking’ exercise.

What Might Ealing STP Success or Failure Look Like?

If the 2012 NW London SaHF project is anything to go by the Ealing STP is unlikely to be implemented on time or in full. SaHF was a cost cutting failure and the Ealing STP may similarly fail to attain its (secret) cost cutting targets. However if its cost cutting targets were to be attained there’s a real possibility that achieving this would entail staff cuts, reduced levels of service and facility closures. What this might almost certainly mean would be increased pain and hardship especially for the deprived in our town.

Appalling STP Public Meeting in Brent on 26 September 2016

I attended this STP public meeting which was organised by Brent Council and Brent Clinical Commissioning Group (CCG). Two of the five North West London ‘Footprint’ bosses spoke at the meeting. They were Carolyn Downs, Chief Executive of Brent Council and Local Authority STP lead in NW London, and ex-advertising executive Rob Larkman who is Chief Officer for Brent, Harrow and Hillingdon CCGs.

The STP aspirations were summarized as closing the ‘gaps’ in health and wellbeing, care and quality, and finance and efficiency. Ways to close these gaps will be prevention, self-help, more home care and less hospital care. Also care for those with long term conditions, and for old and mentally ill people would be improved.

What was sadly missing in the presentations was detail on:

+ The Brent STP

+ How the Brent STP relates to the NW London STP

+ Five years of cost cutting

+ Loss of 500+ beds

+ Changes to access to GPs

+ How integrating healthcare and social care will be implemented

+ Seven day working

+ Care staffing levels

+ Any mention of Accountable Care Partnerships (ACPs) – the future delivery vehicle for all care services and cost cutting

+ Evidence to support the STP.

No-one will ever argue with efforts to improve healthcare and social care. However it’s quite clear that many who spoke in the audience had serious doubts as to whether the money, staff and facilities would be available to make improvements.

Carolyn Downs seemed surprisingly ignorant about the national STP dimension. She stated that just two STPs out of 44 nationally had been published. In fact seven regional STPs have been published. It was news to me that when the initial STP submission was made by NW London each of the eight CCGs/Local Authorities submitted their own STPs. Given that Ealing and Hammersmith & Fulham Councils failed to sign up to the NWL STP, one could only wonder at the time what these local STPs actually contained.  

In the Q&A the issue of ACPs was raised twice. Rob Larkman gave hopeless answers to the questions. In his answers he failed to explain the nature of ACPs and refused to identify their supreme importance for care service delivery in the future.When asked about capitated budgets for ACPs he just waffled. One wonders whether he was genuinely ignorant about the ACP details or he was being deliberately economical with the truth.

Doctor Kong, a GP from Harlesden, was on the panel. She is Chair of Brent CCG. She repeatedly gave her spirited opinion that healthcare and social care would become integrated because everyone was so committed to make it happen. An ex-Brent Councillor in the audience said that in the 1980s we were all committed to make healthcare and social care work together. But commitment was not enough to bring about improvements then and she doubted it would be in the future. She also said that getting people to do what they were supposed to do has always been a problem. She asked how the performance of the new services would be monitored. This question was bizarrely (not) answered by a diatribe on the STP community engagement strategy!

Questions were asked about social care costings, delivering out of hospital services and improved provisions for respite for carers – but no clear answers emerged. This meeting was described as ‘community engagement’. How such a label could be attached to this event is baffling – given that the draft Brent STP was delivered to NHSE on or before 30 June 2016.

150 From All Over England attend National HCT Conference ‘Challenging the STP’

On Saturday 17 September 2016 I attended this STP conference in Birmingham organised by Health Campaigns Together (www.healthcampaignstogether.com). Attendees were all activists who have serious reservations about the clandestinely created Sustainability and Transformation Plans (STPs).

The Shadow Health Minister Dianne Abbott MP was the keynote speaker. It was important that she attended. She spoke very cogently about STPs and showed much greater commitment to rescuing the NHS than her predecessor Heidi Alexander MP.

John Lister, Director of London Health Emergency, opened the conference with his usual vigour. He said that STPs were about massive cost cutting all dressed up in ‘happy talk’. There are serious mismatches between what is talked about in the STPs and what is happening on the ground right now. There is no capital budget for STPs. Maybe off-balance-sheet PFI2 debt will be the source of STP capital. As for the private sector, there have been some recent high profile private healthcare company project failures, along with care homes struggling financially and some recent closures.

He made reference to the NW London STP – one of the first to enter the public domain. John cited the lack of detail on how the cuts and reconfigurations were to be achieved. No evidence is provided to convince anyone that the plan is achievable. He also pointed out that we still await the appearance of the final business case document justifying NW London’s STP precursor – the infamous 2012 ‘Shaping a Healthier Future’ (SaHF) strategy. The much delayed SaHF business case was up until recently promised by 18 September 2016, but recent jungle drums tell us it’s now due in January 2017.

STP case studies followed for Manchester (DevoManc flavoured STP), West Midlands and Shropshire. Of the 44 STPs which have been created only seven have become public. They include STPs from NW London, Hampshire and the Isle of White, Dorset, the Black Country, Shropshire and Devon. Shropshire is perhaps the most successful STP campaigning group. They managed to delay planned A&E closures and really seem to have connected with their local GP Local Medical Committee. At one CCG meeting 100 of their supporters attended. They have also published a 38 page response to the Shropshire STP.

There were useful workshops on STP analysis, campaigning experiences, building alliances and involving political parties. It’s perhaps no surprise that many areas of England over the last 3/4 years have suffered STP-like ‘dress rehearsals’ very akin to NW London’s SaHF. Examples include ‘Healthier Together’ in Manchester and ‘Future Fit’ in Shropshire.

The question and answer sessions along with informal chats with attendees confirmed some facts and revealed some ‘gaps’. It’s clear that there is little awareness of the nature and possible impact of Accountable Care Partnerships (ACPs). However one attendee for Liverpool felt that ACPs will be the enabling vehicle for selling off parts of the NHS. There was no clarity in trying to find out who would receive the capital receipts from selling off NHS land and how that money could be spent. There was a distinct healthcare flavour to this event and perhaps an unfortunate lack of content on social care. Apparently in 2013 we had 140 A&E hospitals in England. When the STPs are complete we will only have between 40 and 70 of them left. At the end of the event we all discussed and voted on a Joint Statement. This can be viewed on the HCT web site.

Accountable Care Partnerships – the Future For Healthcare and Social Care Service Delivery in England

The chosen vehicle for delivering all future State care services is Accountable Care Partnerships (ACPs).

On 5 September 2016 I attended a presentation on ACPs. It was delivered by David Freeman who is the ACP boss for CWHHE – a consortium of five London NHS Clinical Commissioning Groups (CCGs) which includes Ealing CCG. What follows below is mostly what I gleaned from or had confirmed by Mr Freeman.

ACPs will be networks/alliances/consortia of NHS bodies and Local Authorities often joined by CCGs and sometimes by private care suppliers, care charities and voluntary care bodies. The problems ACPs will be aiming to address are fragmentation, misaligned incentives, unclear access and long term system sustainability. ACPs will be set up to provide specific care services for specific populations. Typically these populations will be aggregations of GP patient lists. ACP contracts will be fixed price and long term. ACP revenue will be calculated on a per capita basis. For example, if the ACP commissioner decides the specific service to be provided should cost £100 per head annually and there is a specific targeted population of 500,000, the annual sum paid to the ACP would be £50 million.

There are currently 50 ACP pilots (called Vanguards) operating in England since 2015. On average there are seven partners in each ACP. By no means incidentally 32 of these ACPs have CCGs as partners. 11 of the ACP pilots involve private companies as partners. However news about the Vanguards is worrying. Of the transformation funds promised to them this year, only a third has actually been paid out to them.

In NW London up to five ACPs will sometime in the future deliver all State care services. Up to five ACP contracts will be created. No final decisions have apparently yet been made as to what each ACP will be delivering. ACPs will serve populations of between 500,000 and one million. ACP contracts will be for ten years. Quite confusingly two ACPs have already been identified – one for older people and Brent’s own ACP for ‘end-to-end care for adults’. How these fit into the overall NW London picture for five ACPs is unclear. The first ACP contract is scheduled to begin in April 2018. Full ACP coverage of all care services across all our region will be achieved sometime, unspecified, in the future.

The business type to be adopted by ACPs has apparently not been decided. Suggestions include alliances, joint ventures or Accountable Care Organisations (a US style business type). CWHHE will not dictate the business type to be adopted by ACPs, preferring the partners to agree one amongst themselves.

Ealing CCG has recently published a 124 page document on ACPs. Apparently this was written by a management consultant employed by PA Consulting. There are also many STP documents in the public domain – including drafts of the NW London STP and the Ealing STP. However nowhere in all these documents can I find answers to these questions:

+ The Health and Social Care Act 2012 created a market system with a strict separation of commissioners e.g. CCGs and service suppliers e.g. NHS Trusts. So how can it be legal for CCGs and NHS Trusts to be peer partners in ACPs? The conflicts of interests are glaringly obvious.

+ What will happen if an ACP runs out of money/exceeds its fixed budget?

+ How it can be possible or sensible to remove clinical and financial responsibility for care from public NHS and Local Authority bodies and hand that responsibility over to untested, private partnerships?

CCG health bosses have produced a plan outlining changes to healthcare and social care services over the next five years. But as Eric Leach explains below they are too shy to admit they intend to make massive cuts including the A&E and hundreds of beds.

The plan apparently is the Ealing ‘local’ version of the NW London Sustainability and Transformation Plan (STP). 

There are bold aspirations in the plan for improving mental and physical illness, cancer/heart/respiratory illness outcomes, social isolation, Long Term Conditions, Primary Care and end-of-life care.

However across NW London £1.3 billion cost savings must be achieved by implementing the STP over the next five years. But the Ealing STP does not tell us what Ealing’s contribution to these cost savings will be.

The plan tells us nothing about any planned changes at Ealing Hospital or Clayponds Hospital. Southall has some of the most deprived areas in England. Southall is mentioned once in the plan and care service improvements in deprived areas not at all.

There are no details on staff numbers except that there will be 400 social workers in Ealing by 31 March 2017. There are no commitments to making up the shortfall in staff numbers in roles including nurses, doctors, psychologists, physiotherapists, paediatricians and health visitors.

The Government has made it clear that it wants healthcare and social care services to be integrated and for healthcare to be provided seven days a week. The plan does not state how and when these goals will be attained.

All healthcare and social care services in the future will be delivered in Ealing by Accountable Care Partnerships (ACPs). The plan does not explain what ACPs are and how they will operate. ACPs will be consortia of NHS bodies, Local Authorities and private and charitable care organizations. Each ACP will provide a specific service to a specific group of people. In NW London there will be five ACPs. Each ACP will serve between 500,000 and one million people. ACPs will enjoy 10 year, fixed price contracts. The Ealing STP names three ACPs – Primary Care services Long Term Condition management and prevention/self help services.
The phrase ‘Strong Public and Partner Engagement’ appears on page 2 of the Ealing STP. Final versions of all STPs have to be submitted to NHS England by 21 October 2016. The Ealing STP only emerged into the public domain on 29 September 2016. The public’s involvement in creating the Ealing STP will be more ‘shotgun wedding’ rather than ‘strong engagement’!

The Parliamentary and Health Service Ombudsman (PHSO) issued a report on unsafe hospital discharges in September 2016. The report is a follow-up of the May 2016 PHSO report on the most serious unsafe hospital discharge cases from 2014/15.

The new report’s conclusion is that the incidence of unsafe discharge from NHS hospitals is too high. Factors exposed in the report include:

+  The wholesale incompatibility between healthcare and social care funding

+  The inadequate funding of social care

+  Better Care Funding (for integrating healthcare and social care services) is not freely available as it is reliant on savings from the New Homes Bonus

+ Failure to involve carers and relatives in decisions to discharge patients

+ Night discharges are potentially dangerous

+ The relationship between early discharge and readmission

+ Variations in discharge procedures across England

+ Problems of delays in discharging older people

+ The Government’s policy and vision for comprehensive integration of healthcare and social care services is as yet unsupported by H.M.Treasury fiscal plans.

Perhaps the establishment of the Discharge Programme Board and the new Healthcare Safety Investigation Branch will help. However it’s clear to me that local heroic efforts alone will not of themselves eliminate unsafe hospital discharges. New Government funding policy and new Government funding are urgently needed.

On Saturday 17 September 2016 I attended this STP conference in Birmingham organised by Health Campaigns Together. Attendees were  activists from all over England who have serious reservations about the clandestinely created Sustainability and Transformation Plans (STPs). STPs are all about cutting costs, closing acute hospital services and beds, and changing the ways healthcare and social care are delivered.

The Shadow Health Minister Dianne Abbott MP was the keynote speaker. It was important that she attended. She spoke very cogently about STPs and showed much greater commitment to rescuing the NHS than her predecessor Heidi Alexander MP.

John Lister, Director of London Health Emergency, opened the conference with his usual vigour. He said that STPs were all about massive cost cutting all dressed up in ‘happy talk’. There are serious mismatches between what is talked about in the STPs and what is happening on the ground right now. There is no capital budget for STPs. Maybe off-balance-sheet PFI2 debt will be the source of STP capital. As for the private sector, there have been some recent high profile private healthcare company project failures, along with care homes struggling financially and some recent closures.

He made reference to the NW London STP – one of the first to enter the public domain. He cited the lack of detail on how the cuts and reconfigurations were to be achieved. No evidence is provided to convince anyone that the plan is achievable. He also pointed out that we still await the appearance of the final business case document justifying NW London’s STP precursor – the infamous 2012 ‘Shaping a Healthier Future’ (SaHF) strategy. The much delayed SaHF business case was up until recently promised by 18 September 2016, but recent jungle drums tell us it’s now due in January 2017.

STP case studies followed for Manchester (DevoManc flavoured STP), West Midlands and Shropshire. Of the 44 STPs which have been created only six have become public. They from NW London, Hampshire and the Isle of White, Dorset, the Black Country, Shropshire and Devon. Shropshire is perhaps the most successful STP campaigning group. They managed to delay planned A&E closures and really seem to have connected with their local GP LMC. At one CCG meeting 100 of their supporters attended. They have also published a 38 page response to the Shropshire STP.

There were useful workshops on STP analysis, campaigning experiences, building alliances and involving political parties. It’s perhaps no surprise that many areas of England over the last 3/4 years have suffered STP-like ‘dress rehearsals’ very akin to NW London’s SaHF.

The questions and answers sessions along with informal chats with attendees confirmed some facts and revealed some ‘gaps’. It’s clear that there is little awareness of the nature and possible impact of Accountable Care Partnerships (ACPs). However one attendee from Liverpool felt that ACPs will be the enabling vehicle for selling off parts of the NHS. There was no clarity in trying to find out who would receive the capital receipts from selling off NHS land and how that money could be spent. There was a distinct healthcare flavour to this event and perhaps an unfortunate lack of content on social care. Apparently in 2013 we had 140 A&E hospitals in England. When the STPs are complete we will only have between 40 and 70 of them left. At the end of the event we all discussed and voted on a Joint Statement. This is now available on the HCT web site.

Ealing Save our NHS – Tony O’Sullivan Speaks on the Current Threats from Ealing Save Our NHS on Vimeo.