Issue: 44

January 2017

This occasional newsletter is researched, written and edited by a group of concerned residents in Ealing, West London who want to preserve our NHS. We view the wholesale engagement of private, for-profit healthcare service suppliers as unnecessary, profligate and dangerous. Process improvement is what is needed in our NHS – not revolution.

NHS North West London Wants £827 Million for Building Work

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

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

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

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

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

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

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

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

Broadmead GP Surgery Survives to Fight Another Day

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Issue: 43

December 2016

This occasional newsletter is researched, written and edited by a group of concerned residents in Ealing, West London who want to preserve our NHS. We view the wholesale engagement of private, for-profit healthcare service suppliers as unnecessary, profligate and dangerous. Process improvement is what is needed in our NHS – not revolution.

Former NHS Commissioning Boss Says STPs are a Mess

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

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

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

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

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

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

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

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

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

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

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

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

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

NW London Hospital A&E Units Failing Patients

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

+ Loss of hospital beds

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

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

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

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

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

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

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

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

+ Lack of capital funding

+ Mental health care services will deteriorate

+ Some hospital Maternity units will close

+ Some hospital Cancer units will close

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

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

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

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

+ Little information about social care services ‘transformation’

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

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

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

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

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

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

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

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

Issue: 42

November 2016

This occasional newsletter is researched, written and edited by a group of concerned residents in Ealing, West London who want to preserve our NHS. We view the wholesale engagement of private, for-profit healthcare service suppliers as unnecessary, profligate and dangerous. Process improvement is what is needed in our NHS – not revolution.

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

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

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

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

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

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

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

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

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

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

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

8. How many psychologists and psychiatrists were employed?

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

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

11. How many Registered Carers are there?

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

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

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

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

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

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

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

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

5.No adult Aspergers competence anywhere in the Trust

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Judicial Review anyone?

Young People Seeking Help for Anxiety Up Annually by 35%

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

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

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

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

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

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

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

Health Ombudsman Publishes Damning Report on Unsafe Discharge From Hospital

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

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

+  The wholesale incompatibility between healthcare and social care funding

+  The inadequate funding of social care

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

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

+ Night discharges are potentially dangerous

+ The relationship between early discharge and readmission

+ Variations in discharge procedures across England

+ Problems of delays in discharging older people

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

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

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

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

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

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

Judicial Review anyone?

Issue: 41

October 2016

This occasional newsletter is researched, written and edited by a group of concerned residents in Ealing, West London who want to preserve our NHS. We view the wholesale engagement of private, for-profit healthcare service suppliers as unnecessary, profligate and dangerous. Process improvement is what is needed in our NHS – not revolution.

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

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

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

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

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

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

Readability

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

Understandability

I counted 20 unexplained acronyms, with no supporting glossary.

Viability

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

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

Is It Appropriate?

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

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

Cost Cutting?

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

Ealing Hospital

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

Hospital Beds

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

Mental Health

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

On page 7 this statement appears:

‘Development of local mental health tariffs’

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

Southall and Areas of High Deprivation

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

Social Care

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

On page 7 this statement appears:

‘Joined development of social care market development’.

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

Accountable Care Partnerships (ACPs)

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

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

Seven Day Working

No details on how this will be achieved in Ealing.

Staff Levels Now and Over the Next Five Years

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

‘Strong Public and Partner Engagement’

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

What Might Ealing STP Success or Failure Look Like?

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

Appalling STP Public Meeting in Brent on 26 September 2016

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

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

What was sadly missing in the presentations was detail on:

+ The Brent STP

+ How the Brent STP relates to the NW London STP

+ Five years of cost cutting

+ Loss of 500+ beds

+ Changes to access to GPs

+ How integrating healthcare and social care will be implemented

+ Seven day working

+ Care staffing levels

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

+ Evidence to support the STP.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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