ESON Presents Written Evidence to NHS NWL Bosses Which Demonstrates that NWL’s SaHF, STP and ACO Ambitions are Unattainable

On 6 and 7 February 2018 a submission, written by the Ealing Save Our NHS (ESON) research team, was delivered by hand to the Directors of Finance at NHSI (London) and NHSE (London). These two people had written to the two NHS North West London (NWL) CCG Accountable Officers on 7 November 2017, rejecting the NHS NWL SaHF business case. This ‘Shaping a Healthier Future’ business case – ImBC SOC1 – was rejected because of the lack of evidence presented to support the assertion that annual emergency (so called  Non-Elective or NEL) admissions could be reduced by 99,000 by 2025/26. The business case asks for £513 million for building work, which would be needed – state NHS NWL – to eliminate Ealing District General Hospital.

The 6 February 2018 ESON letter pulls together evidence to show that this annual NEL reduction of 99,000 is quite simply completely unattainable. View the letter at:

www.ealingsaveournhs.org,uk

‘Refreshing NHS Plans for 2018/19’- Moving the Goal Posts and Changing the Names Yet Again

This February 2018, 31 page document issued jointly by NHSE and NHSI is another tsunami of confusing jargon. STP became Sustainability and Transformation Partnership in March 2017. Now we are back to STP being Sustainability and Transformation Plan. Two new (new to me) funds have appeared – the Commissioner Sustainability Fund and the Provider Sustainability Fund.  NHS bosses often, apparently, invent these funds to provide grants to organisations in order to help them in saving on costs. Reading ‘Alice in Wonderland’ might help you make sense of this clearly dysfunctional habit.

Our old property friend Naylor appears early on page 7 when we are told that ‘..the STP having a compelling estates and capital plan’. On page 8 we are reminded of a public consultation (closing 20 March 2018) on reducing prescribing of over-the-counter medicines for 33 minor, short-term health conditions as well as vitamins and probiotics.

On page 9 we see’…allow for 2.3% growth in non-elective admissions’. This is yet another nail in the £513 million NHS NWL SaHF ImBC SOC1 coffin.

More pie in the sky is found on page 9. ‘Our expectation is that Government will roll forward the goal of ensuring that aggregate performance against the four-hour A&E standard is above 90% for the month of September 2018, that the majority of providers are achieving the 95% standard for the month of March 2019 and that the NHS returns to 95% overall performance within the course of  2019. Are there any NHS front-line staff who actually believe these goals will be met on these dates?

On page 10 more beds and/or a 3.5% reduction of NHS and social care Delayed Transfer of Care /DTOCs (bed blocking) are sanctioned. Another target also appears for Referral to Treatment Times. The new aim is for the number of those people waiting 52 weeks for treatment to be halved by March 2019.  However no 2018/19 winter weather forecast or predictions of the incidence of new strains of flu are included in the document.

Page 10 again – ‘…need to consider the capacity require to deliver growth in non-elective and elective activity and the impact on the workforce’.

The Re-naming of Parts

On page 12 Integrated Care Systems (ICSs) make their big entrance – explicitly replacing Shadow Accountable Care Systems (ACSs). How renaming makes any difference to a product or service offering is way beyond my understanding. Greater Manchester and Surrey Heartlands ICSs get plugs in here – I really do wonder whether either of them welcomes this spotlight. ICSs will replace STPs. It can’t be a co-incidence that there are two active Judicial Reviews questioning the ‘Accountable Care’ approach. How convenient that NHS bosses should swap out ‘Accountable Care’ and replace it with ‘Integrated Care’ right now.

On page 13 Capitated /Population Budgets seem to have got their marching orders. Could this be anything to do with one of the currently active Judicial Reviews one wonders? It states ‘All ICSs will work within a system control total, the aggregated required income and expenditure position for Trusts and CCGs within the system’. This statement is clearly missing a Local Authority (LA) social care component. But this is but one of many instances where NHS healthcare ‘trumps’ LA social care.

I could go on and on page by page, but I’ve picked out some gems:

+ STPs must be ‘stretching and realistic’. Whatever does ‘stretching’ mean in this context? Scalable or elastic maybe?

+ CCGs will have to submit new plans. Again oddly and worryingly there is no mention of new LA plans. How does/will healthcare and social care integration actually work?

+ Annex 1 contains a shocker. Just 131 new mental health beds will be opened in England April 2017 to March 2018. Parity of esteem anybody?

+ Since 2015 there have been just 770 additional GP trainees.

More at;

www.england.nhs.uk/publication/refreshing-nhs-plans-for-2018-19/

Surprise, Surprise! NHS Staff Retention is a Problem

‘Health Services Journal’ has reported that the NHS regulator NHSI is now working with 70 English NHS Trusts trying to improve staff retention. Is this really the role of a regulator one might ask? No doubt some good work is being done here in trying to make up for national cuts in training and education; ‘enhancing’ retire-and-return –to –work schemes; and promoting flexibility around rotas and career development.

With 11.4% of nurses leaving London NHS Trusts it might be a good idea for an NHS body to research in detail why this is the case. Anecdotally it seems that nurses are leaving because they are unhappy in their jobs. This is not rocket science.

However this initiative, if known by front line staff, might just annoy those overworked, understaffed, stressed-out hospital teams. For many of them time off for training and education is but an ageing dream.

It’s Government/DoH/NHS England policies that are leading to staff leaving the NHS. Quality and quantity of service needs to be designed into policies – it’s not something that can be re-engineered in dysfunctional policies.

This all seems like trying to wipe an elephant’s bottom with a piece of confetti, when what should be going on is trying to figure out why the animal has chronic diarrhoea and treating that condition in a sustainable fashion.

The NHS London North West Healthcare University Trust and the West London Mental Health NHS Trust have both volunteered to receive this NHSI human resource counselling.

DLA, PIP, ESA, AA, CA, UC and WCA – Theory and Practice

In this new, coming golden age of cradle to grave care (integrated healthcare and social care) there is acronym soup served up in care and care related benefits. Crudely below I’ve summarised what they seem to be all about and I’ve collected some data on how it is all working out:

DLA –  Disability Living Allowance.

Introduced in 1992, it’s money for people who have extra care or mobility needs. DLA can be claimed by under 16s and those who were 65 or over on 8 April 2013. It’s means tested and tax free.

PIP – Personal Independence Payment.

Replaced DLA during 2013 -2015 for those 16 to 65.

ESA – Employment and Support Allowance.

For those who can’t work because of illness.

AA – Attendance Allowance.

Money for those people over 65 who have care needs and need help with activities of daily living. Not means tested and tax free.

CA – Carer’s Allowance.

£62.70/week. It’s means tested and taxable. The people you care for must be receiving DLA, PIP or AA and you must be caring for them at least 35 hours/week.

UC – Universal Credit

UC replaces six means-tested benefits and tax credits – Jobseeker’s Allowance, Housing Benefit, Working Tax Credit, Child Tax Credit , ESA and Income Support. Announced in 2010 the phased, national rollout began in 2013 and in Ealing in February 2018.

WCA – Work Capability Assessment.

The Department of Work and Pensions’ (DWP’s) test as to whether welfare claimants are entitled to sickness benefits.

+ The Conservative Government’s austerity is hurting or killing the sick and the disabled according to The Canary web site. Between October 2013 and October 2014, 46% of people who previously had DLA either lost money or had their claims stopped under PIP. 164,000 mentally ill people lost their PIP money in 2017.

+ Over £100 million has been spent on ESA and PIP appeals since October 2015. 87,500 PIP claimants had their decisions changed at mandatory reconsiderations, whilst 91,587 won their appeals at tribunal. In the first half of 2017, 60% of PIP appeals went in the claimant’s favour. In 2017/18, 68% of ESA appeals were won by claimants.

+ Between December 2011 and February 2014 almost 90 people a month were dying after the DWP told them they were fir for work. 590 cases of suicide have been linked to WCAs.

+ We are in the fourth year of UC and we have yet to see a full business case for this huge reform. The original key assertions were that UC would help people back into work and by 2017 save £5.5 billion on annual benefit costs. The original rollout costs were budgeted at £2.2 billion. This has now ballooned to £15.8 billion, the annual cost savings target date moved to 2021, and the UC national coverage will now be completed by late 2022.As with grandiose NHS cost savings programmes, grant funding is always paid out to help with transition. In the case of UC this amounted to £1.5 billion in 2017. However in 2016, the Office of Budget Responsibility forecast that the best annual cost savings by 2021 would only be £1 billion. The notorious six week wait for first payment is soon to be reduced to five weeks. In 2017, 19% of claimants waited longer than six weeks. The Labour Party has made repeated claims that the Government has not provided any evidence to back up its original assertion that UC would help people back into work. However research has shown that UC leaves working families are worse off than under the old system.

Notes from the Trenches and Elsewhere

+ CQC has announced that London North West University Healthcare University NHS Trust has performed ‘worse than expected’ in three core areas of its Maternity services compared to its peers. This is a sad postscript to the closure of the well-performing  Maternity services at Ealing Hospital in 2015.

+ ‘Pulse’ Reports that NHS England admits that the national target of recruiting 600 extra GPs from EU countries by 31March 2018 has been/will be missed by 470

+ NHS London North West University Healthcare Trust only recently adopted ‘University’ into its name. But which University and why? Maybe adding ‘University’ to your name is felt by NHS branding gurus to add an academic ‘gloss’ to the organisation. However perusing the 15 person Board I’ve found a Professor David Taube of Imperial College Academic Health Science Centre (AHSC). Imperial College (IC) seems to have continuing ‘imperial’ ambitions. Some contrast to my 1960s days at London University when IC folks were largely beer swilling, rugby playing engineers! A recent non-exec recruit to the LNWUHT Board is Ruwan Weerasekera – a Managing Director of the Union Bank of Switzerland. How this fits with healthcare is at best puzzling and at worst worrying.

+ Meltdown at the Liverpool Community Health NHS Trust (LCHT) in 2014 provides salutary guidance in spotting dysfunctional healthcare leadership. Analyst Richard Vize has unravelled a litany of fear, intolerance, disbelief and insecurity over a four year period. Dr Bill Kirkup carried out an independent review. He identified an inexperienced and bullying leadership obsessed with achieving Foundation Trust status, irrespective of the effect on patients. Two NHSs CCGs and NHS England pushed LCHT to achieve significant savings. In one year LCHT tried to deliver 15% cuts, apparently oblivious to the risks. Appalling treatment of staff led to a collapse in morale and sickness absence rose. Reporting of serious incidents was discouraged. CQC failed to spot the problems and it was only when staff contacted Labour MP Rosie Cooper that alarm bells were rung in Government. The LCHT Chief Executive resigned but has been employed in the NHS ever since. She’s currently on the Betsi Cadwaladr NHS Board in North Wales. LCHT Chair Ms Frances Molloy also resigned and now runs a Liverpool-based charity that has NHS contracts. It would seem that nothing succeeds quite like failure.  

+ An estimated 60,000 people marched through central London on 3 February 2018 in the ‘NHS in Crisis’ event. It was organised by Health Campaigns Together and The People’s Assembly. British media coverage of the event was poor but Donald Trump publicised it! 54 related events were held on the same day all over England.

There were lively questions from the floor.  At the end of the meeting dozens of us joined together for a photoshoot in support of migrant NHS workers.  We held up posters saying “We’re PROUD of our Migrant NHS workers”. Because we are.  With all the pressures facing the NHS, one of the nastier policies followed by the government is to pretend that the problems are caused by migrants, both patients and staff.  We are in solidarity with all NHS staff and we demand the NHS carries on being for all who need it, not for those with money, or those who are deemed worthy of care.

Ealing Save our NHS, Public Meeting,13th February 2018, Excerpts from Ealing Save Our NHS on Vimeo.

[gmedia id=28]

6 February 2018

We are a group of concerned North West London (NWL) residents, who have invested considerable time and effort in studying regional and local plans for healthcare services in this area. In November 2017 a letter written by NHSI/NHSE London to NHS NWL CCG Accountable Officers came into our possession. The letter asks for further evidence based assurances before committing financial resources to the SaHF ImBC SOC1. At the heart of these concerns is the lack of evidence to support an annual Non–Elective (NEL) admissions reduction of 99,000 by 2025/26.

Read the rest of the letter here and the letter to Colin Stanfield regarding A&E perfomance :

[pdf-embedder url=”https://ealingsaveournhs.org.uk/wp-content/uploads/2018/02/ESON-NHSI-Letter-6-FEB-2018-FINAL.docx.pdf” title=”ESON NHSI Letter 6 FEB 2018 FINAL.docx”]
[pdf-embedder url=”https://ealingsaveournhs.org.uk/wp-content/uploads/2018/02/Letter-to-Colin-Standfield-re-The-Lost-£190-million-and-AE-Performance-2-1.pdf” title=”Letter to Colin Standfield re The Lost £190 million, and A&E Performance (2) (1)”]

ACOs, ACSs, ACPs – Start/Stop – It’s all a Shambles

House of Commons STP/ACO Inquiry, House of Commons ACO meeting, two ACO Judicial Reviews, 149 MPs sign up to ACO Early Day Motion, nine Shadow ACSs and goodness knows how many Shadow ACPs ‘paused’- hard to imagine a worse healthcare/social care futures’ shambles.

Hammersmith & Fulham has its own challenges with its GP Federation and five NHS Trusts talking big about a healthcare/social care contract of up to £300 million per year for a population of maybe 212,000. Press publicity reports an ‘alliance agreement’ being signed in April 2018, but the absence of public endorsements by the Local Authority (the social care people) speaks volumes.

Professor Allyson Pollock gave some 85 NHS activist leaders from all over England much food for thought in Laura Pidcock MP’s brilliant ACO meeting in Parliament on 22 January 2018. One of her stunning revelations was about the dichotomy of healthcare and social care patient groups. Sure enough I then did my home-based research on Ealing. 426,000 healthcare patients on 76 GP surgery lists (Ealing CCG 2016) and a 358,445 (social care) population in Ealing (GLA 2017).

Add to this the out of area registration scheme that allows any healthcare patient to register with any GP surgery in any part of the country – assuming the receiving GP surgery will accept them. Then add to this the online Babylon ‘GP Choice’ scheme, which is out of area registration on steroids! Apparently 12,000 patients in less than three months have – via Smartphone app video consultations – left their ‘geographic’ GP surgery and joined Dr Jefferies & Partner’s GP surgery in Fulham, West London. Allegedly this surgery ‘cherry picks’ its new patients – so no-one is accepted with complex mental health problems, frailty, dementia, pregnancy or drug addiction.

So…..integrate that Mr Hunt!

Last week also revealed progress by the #JR4NHS Judicial Review team in winning an important concession from NHS England (NHSE). There will now be a 12 week national, public consultation on ACOs. No ACO contract will be signed until that consultation has taken place. The judge has promised a full hearing ‘as soon as possible after 14 March 2018’. However Secretary of State Hunt still plans to push through new regulations to legitimise ACOs but apparently not now during the next four weeks. Government and NHSE claim that £90,000 has alreadyben incurred in legal costs, which #JR4NHS could have to pay. Advisors to #JR4NHS warn that the £180,000 raised so far needs to grow to £350,000 to £400,000 to cover possible costs. To donate go to:

www.crowdjustice.com/jr4nhs-round3

NHSE has stated that the public consultation will ‘provide further clarity about ACOs’ role and purpose’. I don’t know about ‘further’ but ‘some’ might be good. No doubt the whole thing will be a stitch up just like the 2012 NHS North West London (NWL) ‘Shaping a Healthier Future’ consultation. We won’t be given an opportunity to say if we like or want ACOs. Another bizarre aspect is that NHSE says that an ACO is not a new type of legal entity and that it will not affect the commissioning structure of the NHS. (It doesn’t say whether it will affect the social care commissioning structure of Local Authorities). If all this were ‘true’ why are new regulations being drafted to ‘legitimise’ ACOs?

On 29 January 2016 NHE announced that the ‘second wave’ of ACSs would be delayed and re-named. The phrase ‘integrated care’ gets a mention. So…new dates and new names – but the same old concerns about disintegrated care and degraded health and social care services.

Desperate Attempts at Trying to Justify Closing Down Ealing District General Hospital (DGH) and its A&E Unit

After failing to get £513 million for building work in NHS North West London (NWL) in November 2017, NHS regional bosses appear to have been trying to find some ‘new’ numbers which they might utilise to have another go at getting the cash. These bosses, especially those still wedded to the incomplete and failing 2012 NHS NWL ‘Shaping a Healthier Future’ (SaHF) project, still maintain they need this cash in order to downgrade Ealing DGH and shut down its A&E unit.

The sticking point for these bosses and their army of management consultants is trying to convince the regulator (NHS Improvement – NHSI) that by treating patients at home and at GP surgeries/day care ‘hubs’, 99,000 emergency admissions across NWL can be eliminated annually by 2025/26. This ‘replacement’ approach is so called Out Of Hospital (OOH) services. NHSI wants NHS NWL to supply evidence to support its case.

Let’s examine NHS data to try and discover whether this evidence exists.

Emergency admissions in NWL (virtually all of which are so called Non Elective Admissions – NELs) are higher now than in 2013. To put the annual NELs reduction aspiration in perspective, here are the NELs totals over recent years –

October to September:

+ 2013/14 – 195,000

+ 2014/15 – 190,000

+ 2015/16 – 200,200

+ 2016/17 – 216,000

There has been no successful reduction in bed numbers since 2011 (when we started collecting the data). In fact in March 2011 there were 3,150 General and Acute beds in use in NHS NWL. In September 2017 that number stood at 3,400. Hospital bed occupancy rates are higher now than they were in 2013.

Hospital bed blocking (so called Delayed Transfer of Care – DTOC) is endemic. In Ealing DTOCs are higher now than they were in 2013. In terms of social care DTOCs in Ealing, they have risen steadily since April 2014 (100 days delay/month) and in July 2017 reached over 900 days delay/month. ‘Get West London’ research reveals that the 75+ population in Ealing has grown by 2,200 since 2012. During that time 50 care home beds and 41 nursing home beds have been lost. Ealing Council’s social care budget has been reduced annually in recent years. In 2013/14 it was £127 million. In the current year it’s £94 million.

Let’s now look at ambulance redirections in NWL – so called Intelligent Conveyance. During the period April 2016 to September 2017, no ambulances were redirected to Northwick Park Hospital. The same was almost true of Hillingdon Hospital except  for 30 times in January 2017 and a handful of times in June 2017. However redirections of ambulances to Ealing Hospital happened every month with 70 in November 2016 and 90 in April 2017. Just where would the sense be to shut down Ealing Hospital A&E?

As for meeting the Type 1 (T-1) 4 hour performance target, no NHS NWL hospital has ever got near to consistently meeting or exceeding the 95% target since Central Middlesex and Hammersmith Hospitals’ A&Es were shut down in September  2014. In January 2017 NHS Northwick Park and Hillingdon’s A&E 4 hour performance slumped to around 50%. By December 2017 neither hospital reached 60%.

Out Of Hospital (OOH) services have been the SaHF ‘replacement’ strategy for removing 40% of patients from hospital Acute beds, for well over four years. SaHF has consistently said that there would be no changes to hospital services until OOH services were in place. OOH services were not in place when the two hospital A&Es were closed in September 2014 – with disastrous, on-going results. And OOH services are scarcely apparent even now. The best NHS NWL bosses can seemingly come up on OOH services amounts to 2,700 hospital admissions prevented in Brent in 2017, and 1,400 hospital ‘admission avoidances’ in Ealing in 2017. Given that NHS NWL SaHF has been trying to develop OOH services and reduce hospital admissions since 2012 it is hardly a recommendation that over five year’s work has resulted in an annual reduction of just 4,100 emergency admissions/NELs.

Apparently NHS Ealing CCG has thrown in the towel in trying to ‘commission’ NHS service suppliers to develop, run and manage OOH services in Ealing. Later this month a business case will probably emerge in an attempt to justify outsourcing Ealing OOH services to a single supplier for 10 years. Apparently this contract value could reach £1 billion. All our attempts to find out the OOH services specification have been frustrated. Apparently Virgin Care is one of the interested parties. No doubt this is all part of the Accountable Care/integrated care bandwagon.

However other rumours swirl around whether ‘austerity’, land values and land sales might be the keys to what happens next. The £513 million request is enshrined in a NHS NWL business case labeled the ImBC SOC1. This bid largely relates to so called outer NWL. There is another NHS NWL business case backed bid, still not submitted, for inner NHS NWL London labeled ImBC SOC2 for £377 million. There are allegations that NWL will only be granted SOC1 or SOC2. In terms of land sell offs clearly inner NWL land will generate far more cash than outer NWL land sales. After all London Mayor Khan’s so called London Care Devolution seems to be mostly about ‘estates’. There clearly is some sensitivity about land values/sales value as Freedom of Information attempts to access this data (so called Naylor 2) are clearly being obstructed.

Nursing Recruitment in NHS North West London is at Crisis Point

NHS Digital’s quarterly recruitment update for North West London (NWL) must ring alarm bells everywhere. In April, May and June 2017, 2,545 nurses and midwives vacancies were advertised. However only 42 new recruits were taken on – that’s just 1.65% of those they were seeking.

Nationally the statistics also make for very depressing reading. One in 10 of all nurses quit each year. The overall number of vacancies for all types of healthcare staff, which hospitals across England advertised to fill in July to September 2017, hit 87,964.

Over 36,000 Hospital Beds in England Closed  Since 2000 : All kinds of Flu Kick In and the NHS is in Meltdown

A&E waiting times have shot up. Patients on trolleys in hospital corridors has become common place. Elective surgery throughout England has been cancelled nationally for a month. Anecdotally I heard that the A&E unit at Ealing Hospital has been under unprecedented pressure. One report also stated that for a recent 21 consecutive day period there were no available beds at Hillingdon Hospital.

Experts are now saying that ‘Australian Flu’ is not the main culprit, but it’s just one of a number of flu types affecting many of us. Shortage of A&E units, doctors, nurses and beds are the main causes of mayhem in NHS hospitals.

The latest NHS Unify 2 data makes for chilling reading. It shows that the number of A&E attendances year on year has remained remarkably stable. For Type 1 A&E attendances at Ealing Hospital and Northwick Park Hospital in November 2017, the number of patients was just 2.81% more than in November 2016.

In NHS North West London the plan for the next three years includes over 25,000 NHS staff being terminated. 600 hospital beds to be closed. By 2025/26 Non-Elective (i.e. emergency) hospital admissions (so called NELS) will, apparently, be reduced annually by 99,000. Ealing District General Hospital (DGH) along with its A&E will closed by 2021. Instead of being treated in residential Acute hospitals the idea is that these seriously ill people will be treated in some expanded GP surgeries, new ‘Hub’ day care centres and/or in their own homes.

However, the plans are in disarray. NHS NWL asked NHS bosses for £513 million for building work and on 7 November 2017 the NHS Regulator – NHS Improvement (NHSI) – said no. NHSI said no compelling evidence had been presented to justify NHS NWL cutting NELS annually by 99,000 beginning in 2025/26.

NWL stated last month that without this cash Ealing Hospital DGH and its A&E would, in effect, continue to exist. The creation of day care ‘Hubs’ and the expansion of some GP surgeries would be abandoned – without this cash. So far we know of no formal attempt by NHS NWL to create a new business case to support another bid for the £513 million. Since 2009 NHS NWL has spent over £89 million on management consultants. No doubt more cash is being thrown again right now at management consultants in order for them to unearth (probably non-existent) ‘evidence’ in an attempt to justify massive cuts in emergency hospital admissions.

Why is NHS Ealing Clinical Commissioning Group (ECCG) Trying to Outsource Out Of Hospital (OOH) Services for 10 years?

Why does ECCG want to outsource OOH services at all? Is it because ECCG, along with the other seven CCGs in NHS North West London, has failed to implement the OOH strategy outlined in the 2012 NHS North West London (NWL) ‘Shaping a Healthier Future’ (SaHF) programme? On page 39 of  SaHF (‘11. Proposals for delivering care outside hospital’) a reduction of 110,000 hospital stays annually is promised along with 48,000 avoided hospital emergency admissions annually. On page 11 SaHF states ‘…it will take at least three years to put…in place’. Now, over five years later, there is still no significant annual reduction in emergency admissions. According to the 2012 SaHF proposal, £120 million was to be invested across NW London to enable this OOH transformation. On 8 September 2017 the ECCG Chair confirmed that OOH NHS NWL spend for 2017/18 is £729,283,000 with OOH NHS Ealing costs at £121,794,000.

The 10 year contract length is interesting. CCGs have three year contracts. Healthwatches normally have three year contracts. NHSE has a five year ‘Five Year Forward View’. So why 10 years? The crunch date is of course 2021 when annual healthcare ‘losses’/’debts’ costs have to be paid off. So no doubt this fixed price ECCG OOH contract will be signed at, let’s say,  20% of current costs i.e. all things being equal at around £100 million per year. Although initial ECCG statements posited a 1April 2018 start date this seems now unlikely to be met.

The estimate in my 15 November 2017 newsletter of the potential size of the ECCG OOH 10 year contract was £1billion. However until (and if) we see the details of the Invitation To Tender it will be difficult to firm up this figure.

On 19 September 2017 and 4 October 2017 ECCG invited interested parties to come to talk to it about an OOH OH contract. A recent Freedom of Information request response has revealed who attended. 25 different organisations attended – 12 of them attended both events! There were nine NHS Trusts and nine private healthcare service suppliers who attended. The private companies were Allied Healthcare, CHS Healthcare, Connect Health, Homelink Healthcare, NRS Healthcare, Philips, Shaw Healthcare, Specsavers and…..

Virgin Care Services   

Jeremy Hunt MP Has His Cabinet Role Increased to Include Social Care

If this was a plot development in a ‘Carry On Caring’ comedy film I might find it far fetched. Presumably no-one else wanted to take the healthcare (or the social care) job on. My take on Mr Hunt is that he is an attention seeker. He’s always smiling when the cameras are on him. In 2017 he sold his Hotcourses business and pocketed £15 million – so he doesn’t really need the work. He’s had a chequered past. An Admiral’s son, he once worked as an English teacher in Japan and allegedly failed in a venture selling marmalade to the Japanese. He has variously been accused of cheating on his Parliamentary expenses and his tax bill, upsetting Junior Doctors which led to strike action, and constantly misleading the public about healthcare reforms.

In theory a single Government department responsible for cradle to grave care is certainly not a bad idea. However new Primary Government legislation and a massive national relocation of resources will be needed to turn the idea into reality. Social care staff in the 326 Council Authorities will now somehow all ultimately report to Jeremy. Exactly how will that work? Of course by 2025/6 all care might well be delivered by Accountable Care Organisations (ACOs) which will, of course, render NHS organisations and Local Authority social care operations powerless. No doubt Mr Hunt will still be with us then with a new job title of ‘Secretary of  State for Accountable Care’.

Accountable Care Is In For a Rocky Ride in 2018

Accountable Care Organisations (ACOs) will at some point in the future, to put it simply, replace NHS organisations and Council Authorities in determining care budgets and managing care service delivery. ACOs will, according to NHSE’s 2014 Five Year Forward View be the STP delivery vehicles to deliver improved care services. ACOs will appear in lots of flavours including ACS, ACP, MCP, PACS and PCH. A single provider (e.g. Virgin Care) might run an ACO, but so could a cabal/consortium of NHS, public, private companies and charities. This could all kick off with some ‘Shadow’ ACOs in April 2018. However the Full Monty 10/15 year £multi-billion ACO contracts will not happen till at least 2019.

ACOs will be ‘command and control’,cost-cutting  vehicles which deliver care at a fixed price over 10 to 15 years.

Fear kicks in when Jeremy Hunt MP tells us all that ACOs are ‘simply about improving the quality of care the NHS offers’. With a First Class Oxford University degree Mr Hunt is clearly not unintelligent. As a founder of a PR agency, he clearly knows how to mislead by not telling anything like the complete truth. (Believe me I’m an expert on this subject having run my own PR agency for 21 years).

ACO Judicial Reviews (JRs)

There are two of these on the go:

+ The JR4NHS ACO JR, filed on 11 December 2017, has attracted £144,000 donated by over 5,000 people. The grounds of the JR are that ACOs have not been subject to any public consultation, and lack Parliamentary scrutiny and legislation.  High profile supporters include Public Health Professor Allyson Pollock and Professor Stephen Hawking. More at:

http://bit.ly/JR4NHS

+ The ‘999 Call for the NHS’ ACO JR questions the legitimacy of replacing payment by results with a Whole Population Budget. (The latter is better known in the founding home of ACOs – USA – as a Capitated Budget). The JR is led by a West Yorkshire health activist Jenny Shepherd, supported by lawyers Leigh Day, and it was filed in November 2017. The first legal hurdle has been cleared as a judge has granted permission for the JR to proceed. The case will be heard in Leeds High Court on 24 April 2018. £12,000 more is needed to fund this JR. Donations can be made at:

www.crowdjustice.com/case/healthcare4all-stage3/

Labour’s Early Day Motion (EDM) on ACOs

Tory plans, apparently, are well advanced to submit new draft legislation soon to legitimise ACOs in February 2018. In response to this, the Labour Party initiated on 6 December 2017 an Early Day Motion (EDM) 660 on these proposed changes – so that the House of Commons can discuss them. The primary sponsor of the EDM is Jeremy Corbyn MP.161 MPs have signed so far. My MP Virendra Sharma has signed, as have Andy Slaughter MP (Hammersmith), Ruth Cadbury MP (Brentford and Isleworth) and Gareth Thomas  MP (Harrow West). Why is it taking so long for all the other North West London Labour MPs to sign?

Dudley ACO Delayed

Hardly a storming start for the flagship pioneer Dudley ACO. Its start date has been put back 12 months! Dudley CCG, in the West Midlands, is attempting a Multi-Speciality Community Provider (MCP) ACO. The contract value is £5 billion. In August 2017, Dudley CCG announced that a hotchpotch consortium of local GPs and four local NHS bodies was the preferred bidder.

Greater Manchester ACOs are Also Delayed

Another of the top ACO pioneers, Greater Manchester – with its delegated care budget – is also failing to meet its ACO plan dates. VAT complications are being touted as the reason the £6 billion MCP contract has not been awarded to the preferred consortium of existing care providers. ACO number two in Stockport aims to ‘create a new care trust capable of holding an MCP contract’. It has been ‘paused’.

And After ACOs……?

One can’t help but speculate what might come next after ACOs. After all recent NHS history is littered with organisations here today and gone tomorrow. Regional Health Boards and PCTs are long gone. If ACOs ever get off the ground and take over nationally then that’s the end of CCGs and possibly the NHS itself. If ACOs never take off or fly and burn – what will come next?

The BMJ Exposes £5+ Million ‘Sponsorships’ of CCGs – Most of It Undeclared Publicly

The British Medical Journal (BMJ) has announced findings, obtained through Freedom of  Information (FOI) requests, that NHS Clinical Commissioning Groups (CCGs) have overtly and covertly received gifts and payments from a range of commercial organisations. Of the total of £5,027, 818 payments uncovered, only £1,283,767 was declared in public registers.  Bath University and Lund University in Sweden carried out this research.

Amongst the undeclared payments was a £24,000 NHS Southwark CCG project funded by drug companies Bayer, Boeringer Ingelheim and Pfizer. Amongst declared payments was a £75 England cricket match ticket given to NHS Medway CCG by AMP Infrastructure, a property investment company.

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

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

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

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

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

Getting Elderly Patients Out of Hospital

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

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

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

Accountable Care Organisations (ACOs)

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

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

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

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

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

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

+ How will the ACP Board be elected/selected?

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

+ To whom will the ACP be accountable?

Will ACOs Deliver Integrated Care or Just Massive Cost Cutting?

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

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

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

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

There are seven CCG ACOs in various stages of creation:

+ Brent

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

+ Central London

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

+ Ealing

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

+ Hammersmith & Fulham

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

+ Harrow

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

+ Hillingdon

An ACP for 65+ integrated care

+ Hounslow

OOH/PMS ACO leading to an MCP ACO.

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

Community Hubs

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

Out-Of-Hospital Hub Productivity

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

Local Services Update

+ Access to GPs

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

+ Diabetes

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

+ London Ambulance Service (LAS) Prevention of Admission

This is about ambulances taking patients anywhere but to a hospital

+ Home First for Elderly People

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

Ealing District General Hospital Closure

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

+ Reduction in occupied bed days

+ NEL admissions

+ Length of stay

+ Capacity of A&E to manage attendances

+ Capacity to manage admissions, including critical care capacity.

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

Care of the Elderly: STP DA3 Paper

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

Royal College of Nursing: STP Concerns

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

MENTAL HEALTH

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

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

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

October 2016

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

October 2016

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

August 2016

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

‘The Guardian’, 27 November 2017

Is this CQC marking its own homework?

What’s Missing from this Report?

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

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

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

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

More at www.cqc.org.uk

Jam Tomorrow is Promised for Mentally Ill Children

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

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

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

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

More at www.calmclinic.com

Mental Health Services in Ealing

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

LONDON CARE DEVOLUTION

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

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

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

Memorandum of Understanding

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

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

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

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

Devolution Administration and Management

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

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

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

What’s the Budget?

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

Five ‘Devolution’ Pilots

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

+ Haringey

Developing new approaches to public health issues  

+ Barking & Dagenham, Havering and Redbridge BHR)

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

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

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

+ Lewisham

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

+ Hackney

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

Is it ‘Real’?

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

More at www.london.gov.uk

Issue: 55

15 November 2017

This occasional newsletter is researched, written and edited by a group of concerned residents in Ealing, West London who want to preserve our NHS. We view the wholesale engagement of private, for-profit healthcare service suppliers as unnecessary, profligate and dangerous. Increased financial funding is what is needed in our NHS – not financial cuts, closure of vital services or privatisation.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Second Judicial Review is Underway Challenging the Legality of ACOs

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

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

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

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

Patients Going Online is No Solution to the Shortage of GPs

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

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

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

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

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

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

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

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

+ Smartphone appointments or Skype consultations

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

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

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

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

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

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

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

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

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

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

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

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

Issue: 54

1 November 2017

This occasional newsletter is researched, written and edited by a group of concerned residents in Ealing, West London who want to preserve our NHS. We view the wholesale engagement of private, for-profit healthcare service suppliers as unnecessary, profligate and dangerous. Increased financial funding is what is needed in our NHS – not financial cuts, closure of vital services or privatisation.

The Integration of Healthcare and Social Care is a Failure

Failed attempts to integrate healthcare services and social care services go back a long way. The National Health Service Act 1977 under Jim Callaghan’s government encouraged Health Authorities and Local Authorities to co-operate. The Health Act 1999 allowed NHS bodies to pool budgets. Successive governments have again and again tried to pull NHS bodies and LAs closer together.

However, it’s been 40 years of failure.

The House of Commons (HoC) has been busy recently churning out extremely helpful and informative impartial briefing papers on various aspect of care. I’ve drawn heavily on one of these papers in this piece – ‘Health and Social Care Integration: Number 7902, 20 October 2017’.

One assumes the goals of this integration would be better patient/service user experiences, efficiency and cost cutting. The elephant in the room is that healthcare is funded and run by the Department of Health (DoH)/NHS England (NHSE), and social care is funded by the Department for Communities and Local Government (DCLG) and run locally by Local Authorities (LAs).

To continue the history lesson we had the Health and Social Care Act 2012 (‘..duty to encourage integrated working’) and the Care Act 2014 (‘..promote the integration of healthcare provision’). It’s unclear as to how much integration these statutory ‘encourage’ and ‘promote’ initiatives actually achieved.

The Better Care Fund (BCF)

The BCF was announced in 2013. It was to be the primary funding mechanism for integrating health and social care. A key goal was keeping older and disabled people out of hospital. £200 million was immediately handed to LAs. Spending the £3.8 billion BCF should have achieved healthcare and social care integration by 2018 – but it won’t have. In 2015 BCF was judged to be missing its bed reduction, elderly hospital discharge and independent living targets. Rather than saving on costs, costs rose by £200 million. An ‘improved’ version was introduced (iBCF). Another £1.5 billion was thrown at it. In 2017 Local Authorities were granted £2 billion for BCF 2017-2020.

There has been much criticism of BCF. Apparently NHSE has effectively abandoned it. It seems the grant money wasn’t ‘new’ money but ‘old money’ re-purposed. Informed observers found unrealistic levels of bureaucracy and expectations. Only 30% of the BCF money has been spent on social care. There are certainly patches of successful integration throughout England but neither DoH nor DCLG has tried to measure integration ‘success’ or estimate BCF cost savings. BCF was rendered largely redundant by NHS Sustainability and Transition Plans (STPs) published in October 2016.  

Integrated Care Pioneers

Launched in 2014 in 14 local areas, and in an additional 11 in 2015, some piecemeal success has been achieved. However the Policy Innovation Research Unit noted difficulties in accessing external support, and problems with data sharing, payment systems, and procurement provider viability.

Vanguards

50 were established in 2015 – often involving NHS bodies and LAs. A National Audit Office report in 2017 highlighted some early integration successes but whether this success could be scaled up and sustained (post grant-aid), and deliver cost savings is debatable.

Health and Wellbeing Boards (HWBs)

The Health and Social Care Act 2012 required upper-tier LAs to create these boards. The Act mandated HWBs with a duty to encourage integrated working. HWBs are required to produce a Joint Strategic Needs Assessment – which looks at current and future local and social care needs. The King’s Fund in 2014 observed that many HWBs showed limited ambitions for integration.

Devolution

The devolution of health and social care to Greater Manchester was announced in February 2015. Care integration is a major aim. Care budgets (£6.2 billion) were pooled as from 1 April 2016. Although there are local integration successes no major integration ‘successes’ or cost savings have been publicised.

In London, a somewhat less ambitious care ‘collaboration’ agreement was signed by 33 NHS CCGs, 33 LAs, Public Health England and NHS England. There are three pilot integration projects in north east London, Hackney and Lewisham. They began in April 2017 and apparently don’t expect success until April 2019. Care integration across London is not a collaboration goal.

In Cornwall (2015), Liverpool (2016) and Cambridgeshire and Peterborough (2016) moves towards devolved integrated care are underway.

Sustainability and Transformation Plans (STPs)

STPs describe how a region will meet the needs of the NHSE Five Year Forward View (FYFV) objectives published in 2014. Implementing STPs must collectively cut annual healthcare costs by £22 billion by 2021.The integration of healthcare and social care is one of the stated goals for all 44 STPs. However details on the social care side of the integration equation are thin on the ground in many STPs. Given that 43 of the 44 STPs are run by NHS executives this healthcare bias is perhaps understandable. The Local Government Association LGA) and the Public Accounts Committee (PAC) have both expressed concerns about STP care integration. The LGA’s main concern is the lack of involvement by LAs in the creation of STPs, and how STPs will interact with LA Health and Wellbeing Boards’ integration plans. The PAC sees the risk that integration will become sidelined in the pursuit of NHS financial sustainability.

Mental Health

Sadly it’s no surprise that the HoC briefing paper makes no mention of integrating mental health care services with mental health social care services. Ignoring mental health needs has been a national pastime for decades. The NHS and LA care resourcing crisis is probably most acute in mental health.

Accountable Care Organisations (ACOs)

Although completely ignored by the House of Commons briefing, ACOs are clearly planned to be the implementation ‘engines’ for cost cutting and care services’ integration. ACOs will have 10/15 year, fixed price contracts to deliver specific services to specific populations. They will use capitated budgets i.e. a standard, fixed annual budget for each service user. Will these ACOs finally deliver care integration? The answer to that is that no-one knows. Many of the ACS contracts will be £multi-billion ones – and nowhere in the world have ACSs been even attempted on this scale.

ACOs is a jargon littered arena. We have Accountable Care Systems (ACSs), Accountable Care Partnerships (ACPs), Multispeciality Community Providers (MCPs), Primary Acute Care Systems(PACS) and Accountable Care Models. The DoH is hoping to get Parliament to agree to new regulations in February 2018 which will allow ACOs, amongst other things, to commission integrated care services. Pioneer ACOs start date is 1 April 2018 – but the NHS rarely hits its target start dates.

There is precious little evidence (or public confidence) that the STP/ACO approach (by those who know about it and grasp the significance of it) will achieve successful healthcare and social care integration or in fact meet the cost savings targets by 2021 or at all.

Disintegration

Whether healthcare services and social care services are integrated or kept as separate services, is a moot point if the human resources and facilities needed to deliver each of the services are inadequate. Consider:

+ The number of care/nursing home beds is decreasing – because of rising costs and falling revenues

+ The numbers of Acute hospital beds and hospital A&E units are decreasing – because of Government/DoH/NHSE policy

+ There are significant shortages of trainee and trained doctors, nurses, mental health staff, social and healthcare support staff – because of cost cutting, the salary cap, bursary removal, student debt, medical schools’ capacities, overwork and Brexit fears

+ Much of the NHS estate is old, not fit for purpose and needs refurbishing/replacing – however the DoH/NHSE approach is to empty the buildings and sell off the land

+ NHS staff and LA staff don’t understand each other, don’t trust each other and don’t want to share data – according to NHSE Director Professor Keith Willett.

Maybe the sensible approach would be to accept that 40 years of trying and failing to integrate is quite long enough as a learning exercise. What we need is both the healthcare service and the social care service to be adequately funded, resourced, equiped and ‘housed’ with clear handover interfaces between each other.

Yet Another Revolution?

It would take a major revolution to scrap the NHS and Local Authority social care services and replace them with a new National Care Service (NCS) which would provide integrated healthcare services and social care services both free at the point of use. I don’t think we have got to that point where yet another revolution looks like the best option.

However, it maybe that we have already embarked on creating this new care body. As from 1 April 2018, in theory, England will start to be covered by ACOs which presumably will take over from CCGs and LAs in commissioning healthcare, social care (Public Health?) and the integration of the two. This will make NHS CCGs and LA social care commissioning organisations redundant. Now imagine a national organisation being created which would manage all these ACOs. An ‘Accountable Care England’ could be set up and would in effect be this new National Care Service, which would make NHS England and probably the NHS itself redundant. All this is speculation on my part as the ‘cunning plan’ no doubt hatched at the WEF in Davos in 2012 has not yet crept into the public domain.

The DoH Wants Parliament to Give the Green Light to ACOs in February 2018

Consultation is underway, initiated by the Department of Health (DoH), on getting Parliament to ‘bless’ Accountable Care Organisations (ACOs) in February 2018. ACOs will be the cost cutting engines used to implement England’s 44 Sustainability and Transformation Plans (STPs) – and reduce annual NHS costs by 20%. (As detailed above there are plenty of flavours of ACOs being touted by the NHS around England).

NHS patients, social care users or even Local Authorities are not explicity asked to comment. NHS professionals, GPs and GP Practice Mangers are, however, expected to comment by 3 November 2017. (Overworked GP staff must be over the moon about even more paperwork to deal with).

Much of the 21 page ‘Accountable Care Organisations’ document relates to allowing GP surgery GMS and PMS contracts ‘to be suspended’ – this, apparently, will facilitate GPs being able to participate in a ‘fully integrated ACO’. It seems that ACOs will be able to dispense drugs and appliances. Clearly the intention is that ACOs will commission care services along with NHS England, Clinical Commissioning Groups and Local Authorities (or ultimately instead of perhaps?)

In all the 21 pages no reference is made to the primary purpose of ACOs which, of course, is massive cost cutting. Tragic really.

999 Call for the NHS Takes On NHSE with a Judicial Review (JR) Claiming ACOs are Illegal

Health Services Journal (HSJ) has revealed that this JR is now underway. 999 claims that the August 2017 Accountable Care Organisation (ACO) contract introduced by NHS England is illegal. 999 claims the ACO contract breaches the Health & Social Care Act 2012 at sections 115 and 116. These sections relate to the price a commissioner pays for NHS services and regulations around the national tariff. The fixed population budget – or ‘Capitated Budget’ as American ACOs call it – does not link payment to the number of patients treated or to the complexity of the medical treatment provided – as required by the Act.

999 Call for the NHS is a grassroots campaigning network dedicated to restoring a publicly funded, run, managed and provided NHS (www.999callforNHS.org.uk)

Demand For A&E Services FALLING Not Rising at Ealing Hospital and Northwick Park Hospitals and Waiting Times for the Chronically Ill and Seriously Injured is the WORST in England

Colin Standfield has been collecting and collating attendance figures at NHS NW London Hospitals for over four years. The NHS in recent years has made this task more difficult by moving from weekly figures to monthly figures, by lumping Urgent Centre Centre (Type 3) figures with Type 2 and (the most seriously ill and injured) Type 1 figures. Merging Ealing and Northwick Park Hospitals into one NHS Trust (money saving no doubt) has further complicated getting at the facts. Finally timely release of data re A&E attendances and admissions is not a current NHS NWL characteristic.

Here is the damning data for Ealing and Northwick Hospitals combined:

A&E Attendances:

July 2017 Types1, 2, and 3 – 28,701

July 2016 Types 1, 2 and 3 – 29, 034

August 2017 Types 1, 2 and 3 – 26,222

August 2016 Types 1, 2 and 3 – 26,911

With these figures just how can NHS NWL executives continue to use terms like ‘unprecedented demand’? Is it down to lack of basic arithmetic skills? Or is there another explanation?

Is the London North West Healthcare NHS Trust (LNWHT) Financially Sustainable?

In the horror show of today’s NHS in which every part of the organisation (sorry – business) must make a profit and no part can be a cost centre, LNWHT (Northwick Park and Ealing Hospitals) appears to have intractable financial problems. Colin Standfield (again) points out that the LNWHT 2015/16 Annual Report stated ‘…the Trust does not have a financial plan which brings the Trust back into financial balance in the medium term’. In the 2016/17 LNWHT Annual Report, LNWHT is seeking a minimum of £49.5 million ‘additional support’. It further states ‘…the existence of a material uncertainty which may cast doubt about the Trust’s ability to continue as a going concern’. Given there’s no evidence that the £49.5 million ‘support’ has been forthcoming, could LNWHT soon being going into ‘intensive care’ of some kind?

Is The Government Review of the Mental Health Act 1983 Being Led by

the ‘Right’ Person

Over 65 disabled organisations, campaigners and mental health professionals have written to Prime Minister May complaining about the appointment of Profesor Sir Simon Wessely.

Wikipedia details a whole host of reasons why the Professor should not have been chosen. These include claims that the Professor has stated that Myalgic Encephalomyelitis (ME) Syndrome was driven by ‘false illness belief’. His ‘Exercise Therapy’ has been shown to cause 50% of ME sufferers deterioration in function. He has also played an active role in devising the theories of ‘malingering and illness deception’ which underpins Work Capability Assessment (WCA). WCA has had a disastrous impact on the lives of disabled people.

Possibly not then an inspired choice for this role. Based on my 20 years as a mental health carer, my choice would have been the appointment of an experienced and respected psychologist, rather than a controversial psychiatrist. Surely the future of mental illness treatment is more one of talking psychological therapies than drug based psychiatric approaches?