Issue: 53

17 October 2017

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

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

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

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

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

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

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

Some questions and observations which come to mind include:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The National Mental Health Crisis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Ealing’s Mental Health Crisis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

+ Half Day closing is abolished

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

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

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

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

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

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

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

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

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

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

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

+ There are education and training requirements

+ There are numerous ‘capacity’ targets.

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

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

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

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

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

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

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

Issue: 53

October 2017

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

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

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

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

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

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

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

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

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

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

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

Date:     Contracting Body:  Service:                            Value:           Duration    

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Then came his pleas:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Issue: 52

September 2017

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

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

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

Legal opinion from lawyers Hempsons includes the following:

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

Watch this space!

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

£715,000 to £720,000

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

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

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

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

Notes From the Trenches

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Key Findings:

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

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

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

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

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

Policy Implications:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

See www.healthcatalyst.com for more information

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Link to petition

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

Issue: 51

August 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.

44 Months To Go Until  National NHS Costs Will Have Been Reduced by £1.83  Billion Every Month

£22 billion annual cost savings beginning in the Financial Year ending 31 March 2022 is the ACS/STP/Footprints/Simon Stevens FYFV/NHS England/UK Government target.

The first eight pioneer STP/Accountable Care Systems (ACSs), which will deliver these monumental savings, don’t commence until 1 April 2018. The other 36 STP/ACSs will clearly have shorter grant-aided pioneering periods until they begin the cost saving for real commencing 1 April 2021.

ACSs (ACOs generically) are completely untested in England. The concept (originating in the USA) is after all only some 10 years old. ACOs have tended to be much smaller than those about to be attempted here. Cost savings results in the USA have been mixed – as have ACO experiences in Spain and New Zealand.

Does anyone actually believe reaching this £22 billion cost saving target in FY 2021/22 is in any way possible? Isn’t this a massive ‘throw of the dice’?

In NHS NW London a much less ambitious cost saving project (healthcare only – no social care or healthcare and social care integration) has been unable to identify any cost savings whatsoever (FOI response 30 May 2017). This project, ‘Shaping a Healthier Future’ was designed in 2012 and has been in its implementation phase for over four years.

Who actually believed that such a target is/was desirable?

What is the point of creating publicly paraded performance targets which are ‘unhittable’?

Just what do these impossible-to-attain financial targets say about us as a nation, say about this government and say about all of us? ‘Cloud Cuckoo Land’ comes to mind. What kind of inspiration or role model is this for our children?

It seems to me to be a form of national self harming. Impossible goals in a society being increasingly populated by the poor, the disadvantaged, the home-alone elderly, the physically ill and disabled, the sick, the mentally ill and disabled and the vulnerable who are all finding daily quality of life increasingly impossible.

A terrible rumour is emerging from the ashes of Grenfell Tower. Allegedly, 40 people have been found dead in just one flat. Now this could have been a party in progress or it could have been that the flat was ‘home’ for 40 people. If the latter is true just how healthy was that? How is it that the Tenant Management Organisation (TMO), an arm of the Local Authority, allowed this density of living to exist? No doubt there was planning guidance which was aimed at stopping this. But that clearly did not work. Yet another ‘pie in the sky’aspiration.

No point in rules or edicts which are not able to be implemented.

The time for reform is now. But it won’t happen by creating and publicly trumpeting futile and unrealistic plans to reduce our annual national healthcare costs by 20% starting in just 44 months time.

A mentally and physically healthy society is a productive one.

Ealing CCG Enters ‘The Twilight Zone’ by Expecting Already Stretched Ealing GPs To Deliver The Long Awaited 2012 SaHF ‘Out of Hospital’ Services

Ms Neha Unadkat, Deputy Managing Director Primary Care & Integration, Ealing Clinical Commissioning Group and Ms Tessa Sandall, Managing Director, Ealing Clinical Commissioning Group have jointly authored a July 2017 ECCG Business Case for Primary Care.

In 2012, NHS North West London launched its ‘Shaping a Healthier Future’ (SaHF) programme. SaHF was/is all about cost savings allied to (page 8) ‘…changes that will improve care both in hospitals and the community…’. Page 36 of the SaHF explains ‘Proposals for delivering care outside hospitals’. SaHF, we were told on page 11, was ‘..at least a three year (programme)’

Well…here we are almost five years later and reading yet again about proposals for delivering care (that was in 2012 delivered in hospitals) Out of Hospitals (OOH).

Here are some headlines from the 115 pager:

+  ‘…improve the resilience of general practice..’

+  Delivery of 23 standards (!)

+  GPs will deliver paediatric phlebotomy (drawing blood from children), winter resilience and dementia contracts and ‘Out of Hours’ services

+ ‘The Strategic Commissioning Framework for Primary Care Transformation in London’ lists 17(!) service specifications for GPs

The bottom line is that GPs, for a bit more cash no doubt, will be expected to fill the huge gaps which will open up as beds and staff are cut in hospitals. This is going to be a disaster. Even the ECCG business case admits that:

‘Primary care in Ealing is under unprecedented strain, with a rise in the number of appointments and increasing numbers of practices who report that their current workload is unmanageable or unsustainable…the number of registered patients per FTE GP in Ealing is significantly higher than the London and England averages’.

‘The current GP workforce in Ealing is ageing and facing a ‘retirement bubble’ which has the potential to put the system under a strain’.

But a bomb shell exploded at the Ealing Council Health and Adult Social Services Standing Scrutiny Panel meeting on 26 July 2017. Out of the blue and buried inside the 422 pages of printed material for the meeting is on page 287 – ‘Commissioning a Lead Provider for Out of Hospital Care’. This is just for Ealing and the lead provider will take over in April 2018 WITH A TEN YEAR CONTRACT.

Now there are pages and pages of stuff on this but being brutal the question has to be asked:

Who or what mandated a ten year contract?

This duration is new to the Ealing healthcare scene. New GP surgery contracts , the  ECCG contract , and the Healthwatch Ealing contract do not enjoy ten year tenures. My contention is that this ten year component has either come from Government or from private healthcare suppliers. If it’s Government the only future show in town will be an Accountable Care System (ACS) vehicle for OOH. Services. If the ten year requirement came from private healthcare suppliers it’s likely that exploratory talks have already begun with the likes of Virgin, HCI, BMI, Ramsay, Spire, Nuffield, United Health, UKSH, Care UK, or Circle.

It’s going to be very messy….

NHS Bosses Are Still Maintaining  That Ealing Hospital is Not Closing

Our regional NHS bosses are clearly still confused about the massive differences between the well established concept of a full service hospital i.e. a District General Hospital (DGH) and the newly invented NHS North West London concept of a ‘Local Hospital’.

On the Ealing Hospital site, where the major development activities are the building of residential tower blocks, we still have a DGH. DGH features on site include adult A&E, Intensive Care consultants and beds, Operating Theatres and a total of 309 hospital beds.

By 2021, NHS bosses tell us that Ealing ‘Local Hospital’ will replace Ealing DGH. To be brutally honest keeping to time is not an NHS speciality so that date might just slip or it all might come about earlier. This ‘Local Hospital’ will apparently house GPs and nurses and offer some diagnostic, therapeutic, out-patient and day care services. It will offer an expanded ‘Frail/Elderly’ service for which 50 hospital beds will be available. That will be the sum total of beds in this New Age glorified First Aid Post.

The NHS has produced a terribly disingenuous leaflet dated July 2017 entitled ‘What You Need to Know About Ealing Hospital’. The scale of deception is so great that a detailed critique is probably unnecessary. I will distribute a scan of this leaflet when I distribute this newsletter.

Why can’t NHS bosses have the guts to tell the truth?

The much respected Leader of Hammersmith & Fulham Council Councillor Stephen Cowan recently summed up this semantic confusion between DGH and Local Hospital by stating:

‘It’s like having your home demolished only to have it replaced with a shed. And being told it is a ‘local home’.

15 Favoured Sustainability and Transformation Funds (STPs) Get £325 Million in Grants To Help With Their Building  Works

On 19 July 2017, the Government and NHS England announced that 15 STPs will share £325 million for building works. The biggest winners include the STPs for Dorset, Greater Manchester, Cumbria, Derbyshire, Leicester/Leicestershire & Rutland, Nottinghamshire and Milton Keynes/ Bedfordshire & Luton. Here are some summary details of some of these STP grant winners:

Dorset STP

Recently granted Accountable Care System (ACS) grant-aided status, Dorset STP will get cash for building Urgent Care facilities.

Greater Manchester STP

Another recent ACS grant winner, gets £50 million for concentrating facilities for urgent and emergency care at four hub sites across Greater Manchester.

Cumbria STP

Cumbria has won £30 to £50 million to build a brand new Cancer care unit at Cumberland Infirmary in Carlisle.

Derbyshire STP

Up to £30 million is granted  to ‘create an Urgent Care Village’ at the Royal Derby Hospital with GP services, a frailty clinic and mental health facilities’.

Leicester, Leicestershire & Rutland STP

£30 to £50 million for a 15 bed in-patient unit at Glenfield General Hospital to improve children’s and young people’s mental health service integration with other care services. Also Intensive Care beds expansion at University Hospitals of Leicester..

Nottinghamshire STP

Another ACS grant-aided area – £10 to £15 million for across the board service expansion.

Milton Keynes, Bedfordshire & Luton STP

Yet another ACS grant receiver, this STP grant is for building a new Primary Care hub.

Worringly there are no explicit references to cash for building work associated with social care or the integration of healthcare and social care. Regionally there must be a concern that NHS North West London’s request for £513 million for building works features nowhere in this Government/NHSE announcement. The fact that the NHS NWL cash demand was/is under the aegis of its 2012  ‘Shaping a Healthier Future’ (SaHF) project will probably cut no ice with the bean counters. This is probably in spite of recent NHS evidence that NHS NWL is one of the more financially prudent STP footprints.

Secret NHS Cost-Cutting Plans Labelled ‘Capped Expenditure Process’ (CEP) Will Ration Care, Cut Staff Numbers, Close Hospital Wards and Possibly Hospitals

As part of a new national savings drive, the CEP will withhold grant-funding to those NHS bodies which fail to meet financial targets. Service shrinkage, extended waiting times, job losses, and bed/ward/hospital closure will surely follow.

‘The Guardian’ quotes the content of a leaked document which states that the CEP might lead to service reduction/losses at The Royal Free Hospital and Great Ormond Street Children’s Hospital. North Middlesex Hospital in Enfield is at risk of downgrade or closure.

NHS Still Rated the Best, Safest and Most Affordable Healthcare Service in the Developed World

The Commonwealth Fund (CF) health think tank has, for the second consecutive time, found the UK to have the best healthcare service in the developed world. This brilliance is even more remarkable given that at 9th out of 11 nations the percentage of GDP we spend on healthcare is only 9.9%. The US spends 16.6% of its GDP on healthcare and France 11.4%.

In the 11 individual categories UK came top in ‘safest care’, ‘care processes’, ‘affordable care’ and ‘most equitable care’. On the bad news front we came 10th out of 11 in ‘healthcare outcomes’. Survival rates for breast, bowel cancer and strokes are relatively very poor.

Someone Leaks the NHS Guidance to the Eight  ‘Starter’ Accountable Care Systems (ACSs)

The authoritative Health Service Journal (HSJ) has got hold of a draft NHS guidance document for the eight pioneer, grant-aided ACSs. ACSs will be the future delivery vehicles for STPs. In just 44 months time an ACS world throughout England will deliver £22 billion savings on national, annual NHS costs…….. The phrase ‘pigs will fly’ comes to mind.

The guidance is laced with US management consultancy jargon. It requires the ACS pioneers to ‘assertively moderate demand growth’. I guess if you were talking about this in the pub you might express this as ‘don’t treat all those in need’. Also mentioned are ‘potentially ratings’. Understanding what that means is way beyond both my Intelligence Quotient and my Emotional Quotient.

Each ACS must pass various tests before February 2018 in order to get its grant cash and to attain ‘Full ACS Status’ as of 1 April 2018. But surely ‘Full ACS Status’ must mean an absence of grant-aid. Such stripping of financial support to the ‘ACS Super 8’ isn’t envisioned, apparently, till 2021. So, with respect, this ‘VIP’ type status is a case of form over content.

ACS s will only get their money if they identify who is ‘accountable’ at the ACS for ‘delivery and value for money’ and who will manage ‘financial; and outcome oversight’. ACSs must meet performance targets for cancer, urgent and emergency care, primary care and mental health. This will be interesting to behold, as currently NHS Trusts are largely consistently failing to meet existing performance standards. However I don’t know what the ACS performance standards are/will be.

In the HSJ review of the guidance there are no references to social care service, social care performance targets and healthcare/ social care integration. This must be a concern for all of us.

NHS Improvement will appoint a ‘lead regional director’ for each ACS. More jobs for the boys (and girls) no doubt. ACSs will soon surely have to become self-standing (not grant aided), private cost-slashing consortia with huge 10/15 year contracts, Unless primary legislation is enacted through Parliament, surely these £billion+  turnover corporates will just ignore some regional pen pusher ‘boss’.

The First Managing Director Appointed to Run an ACS

According to Health Services Journal (HSJ) Wendy Saviour has been appointed and is in post now as Managing Director, Nottingham Accountable Care System. Her role and status is somewhat similar to that of  Jon Rouse who is Director of the Greater Manchester devolution area (so called Devo-Manc Health). HSJ say a similar ‘arrangement is being developed int Surrey Heartlands’.

Ms Saviour and Mr Rous were appointed and are employed by NHS England. This is a far cry from the grandiose ACO/ACP intentions trumpeted variously earlier this year and in 2016. What was envisioned then was the formation of private consortia of public bodies (NHS and Local Authorities), private organisations (GP Federations and private healthcare/social care companies), charities and voluntary bodies. These consortia/partnerships/networks would clearly have management boards who one might have thought would have procured their own CEO/MD. But no….we have micro-management from the healthcare side of the care institutions. So much for devolution and local, regional autonomy. Does NHSE and the Department of Health really believe in this ACO/ACS approach? Is this the solution mapped out five years ago at the World Economic Forum in Davos? Or is there at least one more iteration of the CCG/STP/ACO/ACP/ACS merry-go-round yet to come?

Could Greater Manchester (Devo-Manc Health) become a Cost-Cutting, Care Services’ Improvement, Healthcare/Social Care Integration ,STP/ACS Success Story?

I visit my home city on 15 -17 August 2017 to find out. Full details in our September 2017 newsletter. If anyone has any supporting evidence or even gossip on this topic, please email me.

CHPI Report Warns That Implementing STPs Will Mean Lack of Appropriate Staff and Volumes, Too Few Beds, Poor Elective Care and Care in General, and Dysfunctional Healthcare/Social Care Integration

Vivek Kotecha has authored an impressive Centre for Health and Public Interest (CHPI) report on likely STP outcomes, which was published in June 2017.. His background makes impressive reading in itself. Vivek has a BSc Economics (Hons) from LSE and is a Chartered Accountant. He worked as a manager at NHS Monitor and NHS Improvement, prior to which he was a management consultant with Deloitte for four years.

Vivek paints a worrying assessment on the impact that implementing the 44 STPs is likely to have on staff, beds, Elective care, Public Health, across the board healthcare, and the integration of healthcare and social care.

It’s a fairly quick read at 18 pages. Some of his conclusions:

‘There will be fewer hospital beds per population, fewer GPs and GP surgeries, more patients will be seen by less qualified staff, the availability of treatments for non-emergency conditions will be more limited and the eligibility thresholds for others will be raised. Rationing non-emergency care, the withdrawal of services and/or reducing cost by reducing quality will be the only options. There is strong risk that NHS care will diminish in both availability and quality. The risks to patient safety from overcrowding and understaffing will get worse. The situation will be aggravated if the reorganisation of services is itself insufficiently funded or poorly implemented’.

Vivek makes no reference to the STP delivery ‘mechanism’ – Accountable Care Systems (ACSs). NHS bosses are seemingly keen to keep ACS deliberations under the radar and many STPs make scant reference to them. With 1 April 2018 start dates for the eight ‘phoney’ grant-aided, four year ACSs and some other STP ACSs (theoretically), it will be some time before ‘forensic’ research can reveal whether ACSs could improve care and achieve significant cost savings.

More at http://chpi.org.uk

The 2014 NHS Five Year Forward View (FYFV): Do the Numbers Add Up?

In May 2017, CHPI’s Vivek Kotecha brilliantly and forensically analysed the 2014 FYFV financial figures and could not get them to add up. The financial modeling for all this is mind bogglingly complex for non-bean counters. First he analysed the ‘funding gap’ (popularly touted as £30 billion by 2020/21 – but according to Vivek it could be much higher than this) in the context of additional government funding and productivity and efficiency savings. Whether the funding gap can be closed or not, Vivek puts down to whether the expectation of projected 2-3% NHS annual efficiency savings are realistic.

This itself relies on some key assumptions, which are:

+  There will be sufficient funding for transforming service delivery

+  The growth in healthcare provided in acute hospitals will decline

+  Hospitals will make 2% cost savings every year

+  NHS pay restraint for permanent staff will continue

+ The total cost of agency staff will fall by 4% a year

+  Investments in Public Health and illness prevention will help to cut costs

+ The provision of social care will prevent patients being unnecessarily admitted to and kept in hospital.

He then goes on to examine what the implications are for the NHS if the above assumptions on closing the financial gap are wrong. His conclusion is:

‘… the STPs have to assume that the overall calculations made by NHS England within which they are operating are realistic – that the numbers add up. If this is not the case the plans will not work. Instead of the intended improvement in care there will be a decline in quality and access and a growing risk that services will collapse. Our analysis suggests that the numbers do not add up’.

More at http://chpi.org.uk

Lack of Ventilators and Nurses Is Causing Too Many COP Deaths

A report by The National Confidential Enquiry into Patient Outcome and Death has revealed that NHS patients needing Non-Invasive Intervention (NIV) oxygen are receiving ‘shocking’ levels of care.

353 NHS patients – many with Chronic Obstructive Pulmonary (COP) disease – were subjected to in-depth examination. The results show that four out of five patients were receiving ‘less than good’ care.

NIV oxygen is meant to reduce the risk of dying from 20% to 10%. However it’s ‘really troubling’ that the UK death rate is 34% – whereas in Spain it’s 18% and in France it’s 10%. Two out of five hospitals at some point have been unable to cope with NIV demand because of lack of a ventilator. Fewer than half of hospitals are able to provide the staffing ratios of one nurse to two NIV patients. Research also revealed that doctors were often ‘really poor’ at documenting patient use of NIV oxygen – probably because of under staffing.

More at www.ncepod.org.uk

Issue: 50

July 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.

ACCOUNTABLE CARE SYSTEMS: SPECIAL EDITION

Accountable Care Systems (ACSs) are Now Flavour of the Month

The always excellent ‘Health Service Journal’ (HSJ) analysed potential care reforms under a future Conservative Government in its 30 May 2017 issue. At the time the HSJ article was written and published most observers predicted that the future Conservative Government as of 9 June 2017 would have a huge majority. This turned out not to be the case so some of the controversial reforms detailed and picked over below may be delayed or may not now come about.

The article led on the fact that NHS England (NHSE) is preparing to announce the first set of the newly christened ‘Accountable Care Systems’ (ACSs) – see below. (The NHS’s 12 month nomenclature ‘journey’ began with the US-style ‘Accountable Care Organisations’ in summer 2016, which then morphed into ‘Accountable Care Partnerships’ and is currently ‘ACSs’!). Still we shouldn’t get too hung up on the naming merry-go-round – but we should focus on the potentially chaotic impact of ACSs. On 15 June 2017 NHSE duly rolled out the pioneer ACSs – details on this later in the newsletteron. The HSJ author is Dave West and in his very extensive review and analysis he identifies many stumbling blocks to achieving ACS nirvana.

First though let’s just refresh ourselves with what ACSs are all about:

+ The major STP delivery vehicles for significant financial cuts and improved ways of working in delivering healthcare and social care services

+ In fact, it’s now clear that eventually all STPs will become ACSs

+  Consortia of NHS Trusts, CCGs, Local Authorities, GP Federations, charities, voluntary bodies and private companies

+ 10/15 year fixed price contracts to deliver specific services, to specific populations at a price calculated on the basis on an annual ‘capitation’ amount (£xxx/head multiplied by the population number)

+ Service suppliers are paid a bonus if they can demonstrate successful cost cutting

+ Attempting to deliver integrated healthcare and social care

+ Attempting ‘…to solve the problems of fragmentation, misaligned incentives, duplication of efforts, unclear access and long term system sustainability’

+  The trashing of the Health & Social Care Act 2012 ‘marketisation’ model of commissioners and service suppliers  

+  Ringing the death knell for CCGs, as ACSs will hold sway across most of the care service landscape and will determine who gets paid for what and how much.

+ ACSs will be major private organisations holding £billion+ contracts

+ As with PFIs we might see ACS contracts traded and changing hands over time

Dave categorises the stumbling blocks into groups. I have attempted to summarise his enlightened scrutiny and added some of my own comments:

Organisational Structure/Business Type

Just what kind of organisational structure(s) will ACSs adopt? Also what business type will they operate under?  (At an NHS NW London ACP seminar in September 2016 David Freemen (ACP boss of five CCGs) stated that in his region each 10 year ACP (now ACS) would choose its own business type (e.g. alliances, joint ventures, PLCs, PPPs?). BTW he envisioned five ACSs in NW London – all of which would be functional and not geographic.

ACS Details

Where are the ACS details? Various Local Authorities (including Ealing, Hammersmith & Fulham, and Liverpool) refused to sign up to their STPs because of the paucity of details. Councils in Staffordshire, Devon, and Oxford have voiced serious concerns about funding challenges and lack of information inherent in their STPs. All Councils have battered social care budgets which are under threat from the equally cash-strapped healthcare bodies. Is the Master/Slave relationship between healthcare and social care commissioners and services suppliers truly to be ‘consigned to the dustbin of history’?

How do GPs and GP Federations fit into this? What about patient choice? If there are multiple ACSs across the same geography, just how will they co-exist? And if not all healthcare and social services are delivered through ACSs, how do the non-ACS ‘legacy’ service suppliers relate to the ACSs? No doubt CCGs will soon atrophy and be powerless – so who would ‘commission’ these legacy non-ACS services?

Social Care

Current social care funding, policy and service level quality is a shambles. Future social care funding, plans and policies are in chaos

Are ACS Solutions Viable?

Re-organisation will probably not create ‘accountable care’. Scrutiny and evidence is needed to verify that ACS ‘solutions’ are likely to ‘solve’ the current problems.

Accountability and Governance

Under the current proposed arrangements, local accountability for money spent and service improvements is clearly missing. A massive re-organisation (back to PCT-type directly allocated budgets) might help here. Where is the governance structure for ACSs and for STPs themselves for that matter? Almost any ‘stay the same’ or ‘revolutionise how we do things’ is unlikely to address the fact that funding is not meeting unavoidable cost pressures.

No Immediate Universal Roll-Out of ACSs

Surely launching a few ACSs across England – which embody untested funding/allocation models – is a huge risk even if they all succeed (which is unlikely given previous ACO-type attempts). It is by no means clear just how ACS success might be ‘measured’. It won’t make accountability any clearer – and we’ll have a patchwork quilt of ‘good, early’ regions with ACSs and ‘bad, later’ regions with no ACSs. Seven million English citizens could benefit from these early ACSs – if they succeed. This leaves 58.5 million citizens being serviced by (sometime) later ACS service configurations.

No Parliamentary Scrutiny

At last someone has suggested submitting the STP/ACS approach to parliamentary scrutiny (not before time either). If what comes out of this is intelligent scrutiny, it must be worth doing. If the MPs and the Lords throw it out – so be it. But if they bless it (and hopefully improve on it), then at least we might move nationally in a co-ordinated, legal fashion.

Administration Costs

Scrapping CCGs won’t save us that much cash. Running the CCGs in England ‘only’ costs us £1.2 billion. After scrapping the commissioner/service supplier model, you still have administration costs. Trailblazer DevoManc has an annual administration budget of £8 million for example. Thus would translate to £152 million across England in a post CCG world.

CCGs Merging Before Dying

CCGs could merge. (In Ealing where I live our CCG is on its second marriage with other adjacent CCGs!). Dave West sees financial risks of distraction and disruption caused by CCG mergers. In the world of NW London CCGs there are clear conflicts of interest. Ealing CCG should be concerned more about not closing Ealing District General Hospital than the CCG NW London ‘Collaboration’of eight CCGs should be. The (non-statutory) CCG collaboration should be more concerned about attempting to provide healthcare service equitably to 2.1 million people across the whole of North West London.

Overhead Slashing

Accountants will always be keen on merging and eliminating costly duplication of services like HR, admin, PR, IT and expensive management. However merging NHS England (NHSE) and NHS Improvement (NHSI) might not make either organisation more effective. Some have also suggested throwing Health Education England and Public Health England in with NHSE and NHSI. This would create a centralised monster of some 15,500 staff. Mergers can also be very messy with long running ‘tribal’ battles being fought over, often for years. There are reports of continuing staff turmoil at NHSI. This follows the creation of NHSI over 14 months ago through the merger of Monitor, the NHS Trust Development Authority and some other smaller NHS patient safety, change management and management development specialist bodies.

And anyway Dave West sensibly states that ‘most of these people should rightly be put back in separate, credible local and regional tiers.

Brexit and a Labour Government – Game Changers?

Brexit may (or may not) deliver us from the European Commission’s Compliance and Competition Rules. If a Labour Government should come to power it has promised to repeal the Health and Social Care Act 2012. Should that possibility heave into view I’m sure HSJ/Dave West, I and others will put the Labour care services proposals under the microscope.

Mental Health – the Bridesmaid and Never the Bride

The herd of elephants in the room not mentioned by Dave West/HSJ is mental health. The Tory manifesto promised £1billion extra cash by 2021 The pro rata rate across the 60 NHS Mental Health Trusts would mean a 16.8% increase in income for my regional Mental Health Trust (WLMHT). Now that could be beneficial and the current four year wait by patients in WLMHT for a programme with a psychologist might be reduced – if trained pychologists were to become available. However should an ACS take over providing mental health and social care services, would the extra money be given to WLMHT or to the ACS? If it’s the ACS, the annual capitation amount determined by the ACS would determine how much cash was given to WLMHT.

Eight ‘Blessed’ ACSs Set Out on a Journey to Who Knows Where

Like the Pilgrim Fathers leaving Plymouth bound for the ‘unknown’ New World in 1620, Accountable Care Systems (ACSs) set out in England bound for who knows where on 15 June 2017. As Simon Stevens – NHS England’s boss – waved goodbye to these ACSs, he confused onlookers by changing the mission statement from what he had first trotted out with consultants McKinsey & Co at the World Economic Forum (WEC) meeting in Davos in 2012. Instead of 10/15 year contracts he gave them  four year, grant-aided contracts. Instead of robust fixed price cost cutting mandates, he gave them each (pro rata) £14 million in annual grants. He promised that in time all 44 Footprints would morph into Accountable Care Systems..

Just who are the eight grant funded ACS ‘experimenters’? Let’s now have a peek at what we know about them. I’ll also throw in what I know of the ACS manoeuvering in the devolved Greater Manchester (‘Devo-Manc Health’) project – which Stevens describes as having ‘advanced arrangements’. There’s also the Northumberland ACS, and the potential ACS in West, North and East Cumbria. Finally we’ll pick over the bones of the ACS failures at Cambridge and Peterborough and Torbay and South Devon.

South Yorkshire and Bassetlaw ACS

This will be one of the first ACSs to becomes operational. Its aim is to ‘…link local hospitals together to improve their clinical and financial viability’. The consortium line up is seven NHS hospital trusts – covering 15 hospital sites, which employ 45,000 staff and service 2.3 million residents. It calls itself an ‘Acute Care Federation’.The nascent ACS (an NHS ‘Vanguard’ site in 2015) claimed benefits already achieved include saving almost £1 million by pooling purchasing and using a shared IT system.

Frimley Heath ACS

Known as Frimley Health and Care System (FHCS) it is a massive consortium of 30 public and private care providers. Five CCGs, five GP Federations, 10 Local, District and County Authorities, two Ambulance trusts, five mental health and community providers (including Virgin Care) are included. 750,000 residents will have all their health and social care service needs provide by the FHCS ACS. Cuts to hospital services are on the menu and replacement by our old friend ‘out-of-hospital services’. The logistics, management and political skills needed to orchestrate 30 mostly public bodies will be immense. It all may prove insurmountable.

Nottinghamshire ACS

The Nottingham ACS is made up of over seven public bodies and the private healthcare company Circle Health. It appears to be the merged entity of two NHS Vanguard sites. The consortia calls itself ‘The Greater Nottingham Transformation Partnership’. Its plan is ‘to deliver whole system integration of hospital, social and primary care with a single outcomes -based capitation contract’. Data sharing between primary, secondary and GP service  providers is a key feature of the plan.

Blackpool and Fylde Coast ACS

Two CCGs, two NHS Foundation Trusts, Lancashire County and Blackpool Councils have united as the ‘Local Health Economy’. The focus is supporting patients with long-term conditions, more community support and ‘patient centred services’.  In October 2015, the consortium received an NHS England ‘Transformation Fund’ grant of £4.26 million. Apparently 1,000 people were being cared for as from 1 April 2016. Plans to extend the project to embrace Pennine Lancashire, Central and West Lancashire  and Morcambe Bay were announce on 31 March 2017.

Dorset

Three Hospital Trusts are partnering together in this ACS. Its aim is to establish sustainable models of care for in and out-of-hospital care. A key goal is meeting the needs of local people 24

Luton, with Milton Keynes and Bedfordshire

This ACS is not one of the 2015 NHS Vanguard sites. The ACS is made of  3 CCGs, 4 Local Authorities and 12 NHS bodies. But there is dissension in the ranks. The Mayor of Bedford and Council leaders complained that they were pressurised to sign up to the ACS. They refused.  A Governor of Luton and Dunstable University Hospital also went public and voiced his concerns about STP/ACS service closure plans and increasing bureaucracy in care delivery.

West Berkshire

Another ACS which has no Vanguard heritage. NHS Trusts and CCGs are partnering to organise primary care into larger GP practice ‘hubs’. Some outpatient services will move from hospitals to hubs. There will be increasing services provision for the frailest. Mental health services will be expanded. Separate providers will be required to integrate their services.

Buckinghamshire

No Vanguard heritage. This ACS comprises 3 Hospital Trusts, 1 Ambulance Trust, 2 CCGs, 1 County Council, and 1 GP Federation. Its aims are fairly bland i.e. improvements in local health and care. When ACS details were leaked in December 2016, complaints were made by a local GP, Oxford Patient Voice and the Oxford East MP. Major complaints were about secrecy and lack of public debate.

Greater Manchester

Devo-Manc Health is the biggest, most advanced (and most complex) ACS in England. The ACS plan was launched in December 2015. It’s integrated healthcare and social care services on a grand scale – 2.8 million people, 37 statutory bodies, 100,000 staff and 563 care homes.

In March 2016, Greater Manchester took control of an annual care services budget of £6 billion. NHS England chipped in with a ‘transformation’ grant of £450 million over five years. But, here’s the killer…by 2021 annual savings of £2 billion have to be achieved. So here we are 15 months later and there seems to be little or no announced progress on cost reduction, care integration or service improvements.

Have 37 statutory bodies, including six different business models ever worked successfully together on any project in England?

Dudley

Dudley CCG launched its procurement process in December 2016. The Invitation to Tender asked for responses from organisations to run integrated population health and social care services for over 30,000 people. The ACS ‘flavour’ is labelled a ‘Multi-speciality Community Provider’. The intention is that a single entity will deliver services including community based physical health for adults and children, some outpatient services including GMS, PMS and APMS (flavours of GP contracts), local enhanced services, Urgent Care Centres and GP out-of-hours care, while adult social care services will be phased in. GPs can, bizarrely, choose to opt in or opt out of participating in the ACS.

Healthcare providers were invited to bid for the ACS contract in June 2017, with a submission deadline of 15 July 2017. The 15 year contract, worth up to £5.4 billion, is expected to go ‘live’ on 1 April 2018.

Surrey Heartlands

Simon Stevens announced a devolution agreement in Surrey Heartlands in June 2017, comparing it to the deal arrived at with Greater Manchester. The agreement ‘will bring together the NHS locally with Surrey County Council to integrate health and social care services’.

Cambridgeshire and Peterborough

This was the first ACS-type car crash in England. This £800 million older people and community services five year project collapsed in December 2015. It ‘lived’ for just eight months. The consortium partners were Cambridge CCG, Cambridge University Hospitals NHS Foundation Trust and Cambridge and Peterborough NHS Foundation Trust. The failure is variously attributed to ‘failure to reach agreement on contract cost’ and ‘lack of financial sustainability’. The two Trusts shared ‘unfunded costs ‘(i.e. losses) of £16 million.

Torbay and South Devon

Here the  initial consortium line up was South Devon and Torbay CCG, South Devon Healthcare Foundation Trust, Torbay and South Devon Foundation Trust, Torbay Council, South Western Ambulance Services Foundation Trust, Devon Doctors Ltd and community pharmacies. The plan was to develop new Urgent Care Centre facilities in two areas. Primary care records were to be shared with the out-of-hours urgent care provider. Set up in October 2015, it planned to use a system provided by Kaiser Permanente (KP). KP is an American healthcare and hospital gaint with sales in 2015 of $60.7 billion.

But…it’s all going wrong. Torbay  and South Devon Foundation Trust has pulled out of the ACS claiming its dislike of the risk sharing aspect of the contract. Torbay Council has revealed a £12  million overspend by the ACS and has warned of substantial risk to the Council.

Whatever Happened to Social Care?

The total NHS England grant, over four years, propping up the chosen eight ACSs is £450 million. Stevens emphasises that these eight ACSs are in’…areas of national priority such as cancer, mental health, primary care and reducing the strain on A&E. In the HSJ report of the Stephens’ announcement, it’s very concerning that none of all his ‘care’ platitudes mention social care. Was this deliberate or an error?

ACS Failures So far Concern Finances – Never Mind About Service Quality or Quantity!

What is missing from the Stevens announcement or in publicly available details on the extended line-up of ACSs are vital ‘ACS life or death’ settings of the annual capitation fee to be charged. For example in the Frimley ACS  if the annual capitation amount is set at £500, then the annual ACS budget for the 750,000 residents’ health and social care would be £375 million. The total four year budget would be £1.5 billion. If the capitation amount is doubled to £1,000 then the annual budget is £750 million and the four year budget is £3 billion. As the oft-quoted ‘Alzira  Model’ (ACS) in Spain showed us throughout 1997 to 2012 – the capitation was set too low (204 Euros) and the ACS (RSUTE consortium) failed. Compensation paid out by regional government was 69.3 million Euros. The ACS consortium was re-constituted (RSUTE II) at a higher, and progressively higher, capitation amount (379 Euros in 2004 up to 639 Euros in 2012). Under the RSUTE II consortium there were doctor shortages, a doctors’ strike and continued staff dissatisfaction. According to a study carried out by the Universities of Zaragoza/Manchester and Manchester Business School, there were allegations that the  consortium ‘cherry picked’ the most profitable medical and surgical specialities. At the same time it was referring HIV and other chronic disorders to other non-RSUTE II hospitals. The annual bill for regional government was very high.

Now it’s no surprise, in a way, that the Cambridgeshire and Peterborough ACS and the Torbay and South Devon ACS allegedly failed because of financial problems. The third ‘strike’ against English ACSs was the indefinite postponment of the Northumbria ACS. It was due to go ‘live’ on 1 April 2107 – but didn’t. What brought this one down was Northumberland CCG’s coming clean and admitting it had annual debts of £41 million.

North West London ACSs Not Amongst the ‘Chosen’ Ones

On a parochial level I do find it interesting and uplifting that none of the ‘Accountable Care Partnerships’(ACSs in June, 2017-speak)  for caring for the elderly mentioned in the October 2016 North West London’s (NWL’s) STP have been selected for early grant funding and implementation. Could it be that the inspired, committed and continuous opposition in NW London by activist groups is having an impact? Ealing Save Our NHS, Hammersmith & Fulham’s (H&F’s) Save Our NHS Hospitals and Brent Patient Voice deserve particular praise here. Also Council Leaders Steve Cowan (H&F) and Julian Bell (Ealing) must also take some credit in slowing down the STP steamroller by refusing to sign up to the NWL STP.

When Will Grants be Replaced by Cost Savings?

In all the surviving ACS and ACS-type projects, few metrics can be found in the public domain which measure cost savings or service improvements. All the ACSs seem to be propped up with NHS England grants. With just three years to go before Stevens’ 2014 Five Year Forward View goals must be realised, when will these chosen few, early adopter ACSs actually achieve  significant (grant free) cost savings? When will there be transparently measurable service improvements? Just how much will the early and late ACS s contribute to the Holy Grail of £22 billion annual NHS cost savings across England by 2020?

Naylor Review Encourages the NHS to Sell Off Land to Property Developers In Order  to Fund its own Building Work and Equipment Needs

Published in March 2017, the Naylor Review analysed how efficiently the NHS uses its land and property. The NHS owns 1,200 sites worth up to £11 billion. Naylor recommended that some should be sold to fund improvements to the rest. He estimates that £2.7 billion could be raised by property sales. The review came back into prominence as the Conservatives confirmed its support of the review in the run up to the 8 June 2017 General Election.

The review falls over itself by saying, in effect, the NHS needs cash so badly for building work and equipment it must sell the family silver.  Naylor thinks the NHS needs around £10 billion to partly fund Simon Stevens’ Five Year Forward View (FYFV) and partly to repair and repurpose existing NHS buildings. The ‘independent’ review follows the FYFV/NHS Sustainability and Transformation Plan (STP) mantras. Naylor recommends that H.M. Treasury match funds and sale revenues the NHS achieves. One could call this incentivisation.

Data Analysis

The supporting data analysis report prepared by Deloitte contains plenty of esoteric, financial gymnastics. It also, bizarrely, mentions ‘Affordable Housing’. Naylor, Deloitte, DoH, the NHS and the Government have absolutely no control as to how Local Authorities will evaluate Planning Applications on land sold off by the NHS. For Ealing residents the Deloitte report gets interesting on page 39. The STP sanctioned sale of NHS land in North West London is listed here. This clearly includes selling off large parts of the Ealing Hospital and Charing Cross Hospital sites. (The Guardian of 16 June 2017 quotes seeing NHS plans which would reduce the  Charing Cross Hospital site to just 13% of its current size).

Ealing Hospital Site ‘Regeneration’

So we have the prospect of much of Ealing Hospital site being demolished and property developers building private flats on the site. Typically these private flats will be sold throughout the world. And some of them will eventually be occupied by the owners, some by renters and some not at all – as the purchase will just be an aspect of someone’s investment portfolio. The site (actually including and originally owned by St Bernard’s Mental Hospital) already boasts 100s of new flats and flats under construction. The infrastructure, including schools, sewage, power supply, water supply, broadband, drainage and car parking is already very stretched. As Ealing has already exceeded its 2012 Local Plan home building targets up to 2026, it’s likely that a legal challenge would emerge if 100s more flats were given planning permission.

Use the Sale Cash for New Homes for NHS Staff?

The NHS Federation, which represents 560 health service organisations, responded to the Naylor Review by asking for the ‘spare’ £2.7 billion raised through NHS landsales  to be used to build up to 40,000 affordable homes for doctors, nurses and other key staff. Currently NHS staff struggle to buy homes or find affordable tenancies close to their place of work. The NHS is currently suffering from severe shortages of doctors, nurses, psychologists, psychiatrists and other mental health staff.  This does seem an admirable suggestion. For the Ealing Hospital site, there would be much local support for building homes for local healthcare workers, rather than luxury flats for foreign investors who might not actually live in or rent out the properties. You never know but Ealing Council planners might even support the NHS Federation plan and the ‘homes for health staff’ initiative might become a reality.

‘Project Phoenix’- Fire Sale of NHS Land Via PPPs

Naylor expects PPPs, being hatched way down under the radar by ‘Project Phoenix’, to be the route to private capital. However some historic context will help to lay all this out:

Community Health Partnerships (CHP) is a wholly owned subsidiary of the Department of Health (DoH). CHP currently provides public sector investment in the NHS primary and community estate through the Local Improvement Finance Trust (LIFT). LIFT, launched in 2000, has generated £2.2 billion worth of investment. In late 2015, the DoH asked CHP to examine what role Public/Private Partnerships (PPPs) could play in implementing STPs and moving on from LIFT. A project team was formed comprising a number of NHS bodies. PwC was, of course, on the project team. The team’s mission  was dubbed ‘Project Phoenix’.

As part of the project, England has been split up into six regions. London and the south-east will comprise one giant and very valuable area. The first public sector tenders are expected to be published very soon in the ‘Official Journal of the European Union’  (OJEU). The first PPP is expected to go live in late 2017.

PPPs need their own health warning. They follow on from PFIs which have had a chequered history in the NHS  Many STPs (and the NW London SaHF cost cutting project) have been ‘bent’ by taking into consideration long term PFI contract debts. It costs the NHS some £2 billion each year in PFI debt repayment. Barts Hospital – with 41 years still to go on its expensive PFI contract – chalked up £135 million annual losses in 2015. PPPs have had their own spectacular failures. The London Underground PPPs’ collapse is probably the most well known. Launched in 2004 with two private consortia –Metronet and Tube Lines – each with 30 year PPP contracts. The two PPPs fell apart in 2010, with the Government (i.e. us tax payers) having to pick up and pay for the very expensive pieces.

Who is Robert Naylor?

Just who is Sir Robert Naylor one might ask? There’s precious little I could find in any public records about his education, qualifications or early adult employment. However it’s notable that his dad was the boss of Reading Hospital. He went in 2000 from being the boss of a Birmingham Heartlands Hospital to become the boss of University College London Hospital (UCLH). Over time he became boss of not just UCLH, but five other hospitals. He was knighted in 2008. In 2009 he was picked out as the highest paid NHS executive. By 2011 he was toppled from the number one spot and earned £262,500/year. In April 2012 he featured in the World Economic Forum (WEF) meeting where McKinsey & Co orchestrated the healthcare sustainability meetings which begat the FYFV (2014) and STP/Accountable Care developments (2016). In 2016 he retired from running six hospitals. He’s a property developer and owns a hotel and other properties. .

Ealing Save our NHS celebrate the 69th Birthday of the NHS from Ealing Save Our NHS on Vimeo.

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No longer having the election on our minds means that Ealing Save Our NHS is back to its ‘day job’, fighting to keep a fully resourced hospital in the London Borough of Ealing.

This year, as before, we were present at Hanwell Carnival in Ealing. This is the oldest one day carnival in London and we had a stall in Elthorne Park where it took place and a float in the carnival parade from Hanwell Community Centre to Elthorne Park.

Fun was had but, more importantly, thousands of leaflets were given out and many people were engaged in conversation on the threats to hospital services.

Ealing Save our NHS at Hanwell Carnival from Ealing Save Our NHS on Vimeo.

Issue: 49

June 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.

Ealing Tories in Denial About Ealing Hospital Closure

Ealing Central and Acton Conservative candidate Mrs Joy Morrissey recently did a ‘flounce’ and refused to appear at a local General Election hustings. Her reason for her non-appearance was her allegation that Ms Rupa Huq, the incumbent MP, had lied about her in local campaign literature. One of the claimed lies concerns Ealing Hospital. Mrs Morrissey says that the hospital is not closing. Ms Huq says it is. Mrs Morrissey is threatening to sue Ms Huq. Maybe she’ll also sue me for some of what you are about to read.

I first lived in Ealing in 1967. I’ve since lived in Ealing continuously since 1974. Ealing Hospital has been operating since 1992 as an NHS District General Hospital. As such it has offered an A&E unit, trauma care, Emergency surgery, Intensive Care, Obstretrics, Maternity and Inpatient Paediatrics. This service line up lasted for 23 years. However in 2012, the Government/NHS NW London plans (‘Shaping a Healthier Future’ – ‘SaHF’) mandated the closure of Ealing Hospital as a District General Hospital. The closure process on the ground started in 2015 with the closure of Maternity. It continued in 2016 with the closure of In-patient Paediatrics and Children’s A&E. The belated SaHF business plan which related to Ealing Hospital appeared in December 2016 (actual, catchy title ‘STP: Implementation Business Case – Strategic Outline Case Part 1 (ImBC-SOC1’). Listed in this businesscase are the healthcare services which will be retained/created on the Ealing Hospital site over the next five years.

The new healthcare facility will contain 50 beds. (Currently there are 309 beds available. In 2012 there were 327.) These beds will be used primarily by the elderly frail in a new Frail/Elderly unit. All operating theatres will close. There will be no Intensive Care consultants and no Emergency consultants. There will be no A&E services i.e no ‘Type 1’ services for the very seriously physically or mentally ill. What will be left will be a large GP surgery staffed by GPs and nurses offering ‘Type 3’ services for the not seriously ill, some day care services, diagnostic services, physical therapies and the Frail/Elderly unit. By November 2022 Ealing District General hospital will be closed and……

‘BLUE LIGHT’ AMBULANCES WILL NEVER TAKE THE SERIOUSLY ILL OR SERIOUSLY  INJURED TO THE SITE WHICH USED TO HOUSE EALING DISTRICT GENERAL HOSPITAL.

After loudly trumpeting that she would not show up at hustings, Mrs Morrissey did show up at one on 30 May 2017.  The event was held at St Mary’s Church, Acton and some 180 people heard her demonstrate her poor grasp of even the basics of local healthcare commissioning. Perhaps being confused by the fact that the Ealing Clinical Commissioning Group (ECCG) is housed in Ealing Council’s Perceval House, she declared that the ECCG was a Local Authority body. Of course in reality this CCG and all the other 210 CCGs in England are NHS bodies.

Bizarrely it has also just come to light that Mrs  Morrissey , using the name Joy Boden, had previously a  film acting career in America. She had somehow, oddly, failed to disclose this.

Details Emerge of a 2012  World Economic Forum (WEF) meeting in Davos, Switzerland which reveal the Global Lineage of the STP Mantra

The WEF has been described as ‘….the most comprehensive planning body of the transnational capitalist class’. WEF leader members are the CEOs of the top 1,000 transnational corporations. Senior academics and ‘experts’ are also sucked into the WEF as ‘Forum Fellows’.

At the annual WEF meeting in Davos in early 2012 the WEF Sustainability team debated that resolving the conflicting goals of fiscal austerity and good health were necessary for economic growth. The base input to this debate were two papers authored by the management consultants Mc Kinsey & Co:

+ ‘The Financial Sustainability of Health Systems’

+ ‘Sustainable Health Systems Visions, Strategies, Critical Uncertainties and Scenarios’

The ‘medicine’ doled out in these papers will be familiar to seasoned STP researchers – rationing, mandating private insurance, increasing tax revenue and more services delivered with fewer resources. ‘Sustainability’ is to be achieved through transforming supply, with payment innovations related to value rather than volume, financial incentives, ‘turbo-charging’ health and social care service performance. Throw in digital technology, prevention and integrated pathways and we have the full set of STP and Accountable Care Organisation (ACO) mantras.

(Jeremy Hunt, our Secretary of State for Health recently said that STPs were ‘…local plans developed by local people’. What an outrageous whopper that is!!!!)

High class, transnational, management consultants’ jargon literally oozes from the 2012 McKinsey papers. Such gems include ‘capital-light settings’, shifts to ‘leveraged talent models’ and ‘capacity reduction in higher cost channels’. According to McKinsey this shift ‘must be accompanied by capacity reduction in high cost channels’ and the new systems ‘must become more agile and leverage the opportunities for more self-care’.

In these two McKinsey reports are many of the basic components which Simon Stephens, head of NHS England trotted out in his October 2014 ‘Five Year Forward View’ ((FYFV). Stephens was not only in attendance at the 2012 WEF Davos meeting, he was leading the Sustainability team! Flexible roles carried out by less qualified, cheaper staff; cutting Acute bed numbers, selling off parts of the NHS estate – it all stems from the McKinsey-led ‘cutsfest’ papers at WEF Davos 2012.

You might wonder whether the attendees at this meeting could be people we are familiar with. Not half. What a cast of characters:

+ Simon Stephens

He was attending as a senior officer for the world’s largest private healthcare corporation – UnitedHealth ($148.8 billion revenue in 2016). He is leading the STP charge in England after being head hunted from UnitedHealth in 2014. The head hunter was Odgers, run by Baroness Virginia Bottomley, an ex-Secretary of State for Health and Jeremy Hunt MP’s cousin. (What a cosy family affair)

+ CEOs of leading healthcare/pharma companies including Apax Partners ($46 billion to invest in 2017), Novartis ($49.4 billion revenue pharma company – 2015), Merck ($39.4 billion revenue pharma company – 2015), Kaiser Permanente (‘integrated managed care consortium’ – $60.7 billion revenue – 2105. One of its systems was integral to the Torbay and South Devon Integrated Care ACO – set up in 2015 it collapsed in 2017)

+ The World Bank, the World Health Organisation and the European Community

+ Michael MacDonald – then Senior Fellow at Imperial College’s Centre for Global Health Innovation. He’s now Director of Strategy at NHS England

+ Julie Watts

Group CEO of BMI Healthcare since November 2014. BMI Healthcare had annual revenues of £834 million in 2012

+ David Mobbs

Was the boss of Nuffield Health, which was a private hospital chain charity. Revenues of £575 million, and he earned £860,000/year. A scandal erupted in 2011 about the size of his remuneration and the fact that the company only paid £100,000 in Corporation Tax. He eventually resigned in 2015

+ Ron Webster

A leader in the West Yorkshire STP

+ Amanda Doyle

A leader in the Lancashire and South Cumbria STP

+ Alan Milburn

Secretary of State Health 1999 – 2003. Since 2013 he has been a senior figure at PwC  who are one of the leading outsource STP authors/managers with at least seven of the 44 STPs in harness. He’s also a member of the European Advisor for Bridgepoint Capital. Bridgepoint has invested 480million Euros in Care UK.

+ Sir Bruce Keogh

NHS Medical Director 2007 – 2013. Since 2013 he has been National Medical Director of NHS England.

+ Stephen Dorrell

Secretary of State for Health 1995 – 1997. Chair of Government Health Select Committee 2010 – 2014. A leading healthcare executive with KPMG since 2014. Chair of NHS Confederation and Chair of Laing Buisson, a UK leader in healthcare research and information.

+ Robert Naylor

CEO of UCL Hospital since November 2000. Knighted in 2008 . He’s the highest paid NHS executive. On 31 March 2017 the so called Naylor ‘Review of NHS property and Estates’ was published by the Government. He identified £5 billion of NHS land to be sold off, including the Ealing and Charing Cross Hospital sites.

+ Julie Moore

CEO of NHS University Hospitals Birmingham. Made a Dame in 2012, she has been Birmingham and Solihull STP boss since May 2017

+ Liz Kendall

Shadow Care Minister 2011 – 2015. Came fourth in the Labour Party leadership contest in 2015. A strong and vocal advocate for the role of private healthcare suppliers in the NHS.

Others include Mark Newbold, Niti Pall, Paul Bate, Paul Corrigan and Nick Seddon. I could expand and explore these people’s future NHS roles in England since 2012 – but I think the reader has already got the picture.

What is now blindingly obvious is that the STP cost/service cutting and operational re-engineering of care services in England has been globally fashioned over many years. In England the whole NHS privatisation bandwagon got rolling in January 1988 with the publication by the Centre for Policy Studies of a report:

‘Britain’s Biggest Enterprise: Ideas for the Radical Reform of the NHS’

Priced at £1:95p this infamous polemic was authored by the MPs and now Tory Party grandees, Oliver Letwin and John Redwood.

The source of this newsletter piece is the excellent Socialist Health Association report ‘The Truth about Sustainability and Transformation Plans’ authored by Stewart Player and published on 25 May 2017. For more information go to www.sochealth.co.uk

UK Government and Microsoft Have No Shame in Blaming the NHS for Ransomware Attacks on NHS Computers

I find it quite pathetic that both the UK Government and Microsoft have been pointing fingers at the NHS for the crippling Ransomware cyber attacks on 12 May 2017 which disabled NHS IT services.

Government Ministers Amber Rudd and Sir Michael Fallon have tried to play down the impact of the cyber attacks. Fallon said that the Government had previously warned the NHS about the dangers of ‘unprotected’ software. 45 NHS Trusts were supposedly affected by the attack. However not all NHS bosses covered themselves with glory either. In my region – North West London – NHS bosses initially stated that the region’s Trusts were not affected. This was spectacularly not true at West Middlesex Hospital.

A bit of history here will help put all this in context. In 2001 Prime Minister Blair met Bill Gates – Microsoft co-founder – and was dazzled by him. Gates persuaded Blair to initiate the largest software project ever attempted in England. It was very grandly christened the ‘National Programme for IT’. One of its goals was for full online medical records to be accessed remotely 24/7. It was all a spectacular failure and cost tax payers over £10 billion. The project however opened the door for Microsoft based Personal Computers (PCs) to flood the NHS. There are still around 500,000 NHS PCs running the now obsolete Microsoft XP Windows operating system. In fact this represents 85% of all NHS PCs.  In July 2010 Tory MPs Andrew Lansley and Francis Maude terminated the national NHS software maintenance contract with Microsoft. In April 2014 Microsoft terminated support for XP globally. Cash strapped NHS Trusts in subsequent years could not afford to replace their obsolete PCs or even shell out for expensive software maintenance contracts.

As for Microsoft with $100+ billion in the bank, its withdrawal of support worldwide for Windows XP in 2014 was cynical and money grabbing. However Microsoft does have form for bad behaviour. In March 2013 the European Commission found Microsoft guilty of maintaining a monopoly and fined the company 561 million Euros.

Bolton NHS Trust Enters into a Huge ‘Scary’ IT Merger

The Holy Grail of a single Patient Administration System (PAS) covering hospital and community patient data is being claimed in Lancashire. 17 million case-note activities, 60,000 patient records and 26 million waiting list entries have all been merged together. Breathtaking stuff.

I took in even sharper intakes of breath when I discovered that the IT supplier carrying out this massive project was none other than CSC. CSC is infamous in NHS and Government circles for having failed disastrously in the so called National Programme for IT. After trying for 10 years CSC failed to deliver software care records to 211 NHS Trusts. In the end just nine NHS Trusts finished up running some version of the promised software.

Unsurprisingly maybe, CSC has now changed its name to DXC…..

It will be more than interesting to see how this enormous data merger actually performs.