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

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

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

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

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

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

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

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

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

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

+  The wholesale incompatibility between healthcare and social care funding

+  The inadequate funding of social care

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

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

+ Night discharges are potentially dangerous

+ The relationship between early discharge and readmission

+ Variations in discharge procedures across England

+ Problems of delays in discharging older people

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

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

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

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

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

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

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

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

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

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

Local Health bosses have paid out millions of pounds to management consultants and professional public relations staff – money that could have gone to front line NHS staff.

Their message is that services will somehow be mysteriously be improved by closing hospital departments, cutting services and putting NHS contracts out to tender on the private market.

But the battle to save Ealing Hospital and our NHS continues and we need your support.

Ealing Save Our NHS just relies on local people giving their time and money.  We have given out hundreds of thousands of leaflets on the streets; we have to pay for posters, meeting rooms and other costs.

Please contribute to our fight to save NHS services, locally and nationally.  It really is appreciated.

We’d like to thank donors here online, but if you want to be anonymous and discreet, let us know.

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Thank you from Ealing Save our NHS

Changes to health care provision, including the latest ‘Sustainability and Transformation Plan’, usually lead to increased demands on the ambulance service. But few if any increased resources are put in. Stuart Crichton, Assistant Director of Operations at Hanwell ambulance station, tells me that demand has increased greatly over the last 20 years. Staff now do not get any waiting time between jobs.

So ‘deficits’ begin to appear. These ‘deficits’ are due to lack of Government funding, not inefficiency on the part of the ambulance service. The London Ambulance Service (LAS) has been placed in ‘special measures’ following an ‘inadequate’ rating by the Care Quality Commission.

There is a Patients Forum for the LAS to put the patients’ side of the case. It is a lay organisation that has monitored the LAS for 10 years.

It organised a meeting on 11th July 2016 to try to address the problems. Its chair, Malcolm Alexander, has produced a useful report dated 18th May 2016 and addressed to London Clinical Commissioning Groups (CCG’s). It contains proposals to get the LAS out of special measures and “it is aware of the current negotiations regarding funding for the LAS”. This in my view is the crux of the matter. It also notes that “urgent and emergency care services will only radically improve to meet the needs of people in London if the weaknesses of primary care, community health and social care are dealt with”…”The LAS is often forced to take the patient to A&E even though we know this may be the worst option for patients whop have dementia or mental health problems”…”This can amount to a wait of 8-10 hours from 999 call to admission for an elderly vulnerable person”.

Stuart Crichton says that the increased pressure has led to staff morale becoming, in his words, “strained”. Qualified paramedics are in great demand. Urgent Care Centres and the 111 service draw staff out of the LAS. It takes three years to train a paramedic and Stuart acknowledges the need to improve the working environment. Staff shortages have led to the use of about 20 private emergency ambulances per day across London. They are staffed by qualified paramedics (trained by the LAS) though Stuart says the LAS is not losing staff to the private providers. Where do they get their staff then? They cover times of peak demand and unsocial hours. On a recent morning visit to Ealing Hospital I counted three private emergency ambulances on the ramp. LAS do plan to end the use of private ambulances but they do not say how or when. Retaining staff is described as “challenging”.

The LAS are “full partners” in ‘Shaping a Healthier Future’ and the STP. They agree with the process of developing ‘specialised pathways’ and are “satisfied” with the changes to the system. They are not “engaged” (their word) with Healthwatch but would be happy to be involved.

Graeme Crawford observes that the LAS Board seem to be ignoring the financial problems highlighted by the ‘special measures’. They are hoping that GP’s will substitute or help out with situations resulting from ambulance deficiencies. They are relying on increased self-help by patients, friends and family. Ambulances queueing for more than an hour at hospitals has become the norm  Graeme says that there is a need to prioritise informed input to Scrutiny Panels and Healthwatch, and to monitor the impact of the closure of the Children’s Ward at Ealing Hospital on ambulances.

Foto: © Copyright Kevin Hale and licensed for reuse under this Creative Commons Licence.
www.patientsforumlas.net

Performance figures are available on the LAS website

Issue: 40

September 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.

NW London’s Draft STP and an STP Engagement Tool Enter the Public Domain

The Sustainability and Transformation Plan (STP) is the Government’s latest initiative to reduce spending on healthcare and social care. Each of 44 regions (so called footprints) in England will have their own STP. Ours here in Ealing is the North West London STP. We also have a NW London STP Engagement Tool.

The draft NW London STP aims to cut the annual care spend by £328.3 million in year 5 of the STP (optimistically set for 2020). On 5 August 2016 the latest draft of our STP was placed into the public domain. On 16 August 2016 the NW London STP Engagement Tool was also put into play.

The 55 page draft STP and the 6 page STP tool can both be viewed at:

https://healthiernwlondon.commonplace.is

The tool is clearly aimed at those with little time to wade through the thousands of words and new acronyms in very small type size in the STP. The STP tool is very, very much shorter with easy to read words and almost no acronyms.

STP Engagement Tool

We are asked to submit our views on improving our health, better long term care, home care for the over 65s, improved mental health care and high quality services. However no explicit references are made to across the board cost cutting, hospital bed reductions, staff numbers and closing Ealing Hospital.

One of the STP goals is integrating healthcare services with social care services. There is no explicit reference in the tool as to how any of this might be achieved. What about Accountable Care Partnerships (ACPs) – the vehicle being trialled around England to do this job?  The tool doesn’t ask our opinion about ACPs – even though some are planned in NW London. Much more on ACPs below.

The tool informs us that the STP will improve ‘housing, employment, schools and the environment that affects health’. This is twaddle. There is absolutely no way that the 31 public sector organizations thrown into a room together and told to cut care costs are going to improve housing, employment, schools and the environment. In a similar vein ‘more focus on preventing ill-health’ is all well and good, but will it achieve anything? Persuading people to adopt healthier life styles costs money and is not always successful. The marketing budgets of drug, alcohol, food and tobacco companies are huge. It took Government action to ban smoking in public places which clearly has reduced the number of people smoking and the amount many smokers smoke. It’s not clear how prevention success might be calculated or measured. So it’s clearly debatable how annual savings of £11.8 million on prevention in five years time might be computed. However the STP tells us that grants of £110 million will be received for ‘investment in prevention and social care’ over five years.

The tool page on improving mental health services opens with ‘We all have mental health’. This is a ludicrous statement. Statistically 50,000 adults in Ealing and 328,000 throughout NW London have mental ill health. ‘Improving mental health services ‘is again a laudable goal, but it’s going to take more money and more staff to achieve this. If you have already been waiting for over six months to see a psychologist only hiring more psychologists is going to improve things. More emailing, more Skyping, more telephoning and new ‘models of care’ just won’t hack it. STP grants expected over five years should total £53.7 million. The annual mental health spend in 2015/16 of £308 million will rise to £358 million in 20120/21. In year 5 annual mental health savings are quoted at £11.8 million.

Old people are asked whether they want care at home as opposed to visiting hospital or residing in a care home. The choice being offered here is an illusion. Hospital care is free, but social care at home is not, it is expensive and is, in effect, unregulated.

I view the NW London STP Engagement Tool as a deflection or displacement exercise. NHS NW London has for four years been cutting hospital beds, cutting staff and closing  local services. Its excuse for this was that these cuts and closures would provide us all with better healthcare services. The jury is still out on that one. The STP carries on this cuts-mean-better-services charade. The decisions on more home care, more technology, fewer beds, fewer staff and Ealing Hospital closure have already been made. How cruel is it to ask citizens for their opinions after the service re-designs have been completed? This is disrespectful and insulting to people like me whose taxes pay the wages of these after-the-event engagers.

Will Accountable Care Partnerships (ACPs) Finally Destroy the NHS?

The national media, thanks to prodding by 38 Degrees, has finally caught up with STPs. But it hasn’t, as yet, cottoned on to Accountable Care Partnerships (ACPs) as the engine of STP change and the harbinger of doom for the NHS. In the NW London STP ACPs are mentioned for delivering ‘end of life’ care for elderly people.

ACPs are/will be networks of organisations which will assume clinical and financial responsibility for providing care for a defined service user audience for a fixed price for at least 10 years. The potential area of operations for ACPs is wide, including community care, out of hospital care, core primary care, social care, Acute/hospital care and mental health care. The patient populations will be aggregations of GP surgery patient lists. Partners’ organisational boundaries will be removed and no doubt the partner brands will by subsumed by the ACP brand.

The key puzzles ACPs will be asked to solve will surely be cost cutting, integrating healthcare services with social care services and shifting much of Acute hospital care into GP surgeries, the ‘community’ and into people’s homes. There is no doubt that achieving these goals will not be easy. However removing clinical and financial responsibility for these tasks from public NHS and Local Authority bodies and handing it to untested, private partnerships seems foolhardy at best.

ACPs are likely to destroy traditional GP practices as federations of GP surgeries are subsumed into ACPs and asked to do more to provide replacement secondary care services for hospitals downsized or eliminated.

There are 50 fledgling ACP pilots in operation throughout England. The smallest will serve 97,000 people and the largest some 6 million. None of these ACPs are NHS bodies. Constituent ACP organizations include Local Authorities (LAs), private healthcare and social care providers, NHS Trusts, GP federations, Clinical Commissioning Groups (CCGs), Healthwatches, charities and voluntary groups.

ACPs drive a coach and horses through the Health & Social Care Act 2012 as the strict division between commissioners e.g. CCGs and LAs and service suppliers e,g, NHS Trusts and private care suppliers is completely trashed. Still, this is no more respectful to the Act than the 44 footprints which corral a similar cast of commissioners and service suppliers together to create the STPs.

The track record in England of ‘real’ ACPs is very limited and not good. There has been only one which became fully operational in 2015. Sadly it lasted just nine months. The Cambridge and Peterborough ACP was a five year, £725 million car crash which failed ostensibly ‘for financial reasons’. There is no convincing evidence around the world (USA and New Zealand ACPs are often quoted) that ACPs actually save any money.

Does Brent’s ‘Referral Optimisation Service’  Spell the End of GPs Clinical Independence?

Brent Patient Voice (BPV) has raised concerns that Brent GP referrals are about to be intercepted and reviewed by a private healthcare provider. Brent CCG (BCCG) has hired Bexley Health Ltd for £1million to second guess GPs. The Brent Optimisation Referral Service (BROS) will never have met the patient and will not have access to the patient’s full medical history.

BPV were about to meet BCCG to discuss BROS on 16 August 2016. However BCCG pulled out of the meeting. BPV wrote to BCCG about its concerns. No content bearing reply has been received by BPV. BROS goes live on 1 September 2016.

BPV further notes the workings of a pilot optimisation service for urology in Devon. 30% of all GP urology referrals to hospital consultants were refused. GPs have had to carry out further investigations themselves, such as ultrasound scans – for which they are not re-imbursed by the NHS. More on this at: www.bpv.org.uk

A surprising postscript to this story is my discovery of the Ealing Referral Facilitation (ERF) service which is surely ‘optimisation’ by another name. ERF has been in operation for at least three years and is run by a group of local GPs. ERF works with your GP ‘to ensure that the service you are referred to best meets your clinical need’. In December 2012 Ealing CCG confirmed that the ERF would be ‘challenging referrals ‘in 2013/14. Ealing CCG Governors Dr Mohammad Alzarrad and Dr Vijah Tailor are two of these ERF ‘optimising’ GPs. The ERF is commissioned by Ealing CCG. But surely healthcare commissioners can’t also be healthcare service suppliers?

One in Three 14/15 Year Old Girls are Suffering From Mental Illness

A ten year Department of Education (DoE) study of 30,000 school pupils has revealed very worrying mental ill health profiles for teenage girls. 37% of girls had three symptoms or more of psychological distress. In teenage boys the mental ill health profile only affected 15%.

Interestingly enough, alcohol consumption, drug taking, truancy and pregnancy rates have all gone down for teenagers in recent years. However, a variety of reasons have been suggested for this virtual mental ill health epidemic amongst teenage girls. ‘Pushy’ higher social status parents have been suggested as a factor as have social media pressures. Former mental health tsar Natasha Devon thinks, however, that social media is just a reflection of what is going on. She blames community breakdown and Michael Gove’s school reforms in reducing school time for sport, music, arts and dance.

The Government has committed £1.4 billion of new money for increased mental health services for children. Let’s hope some of these additional mental health services help the 4,800 or so teenage girls in Ealing suffering (according to the DoE research) from psychological distress.

Judicial Review to Challenge Hunt’s Power to Impose Contract on Junior Doctors: 19 and 20 September 2016

Justice for Health, a social justice movement founded by five Junior Doctors, has secured a Judicial Review (JD) on Hunt’s contract imposition. It’s scheduled for the High Court on 19 and 20 September 2016.

A full, expedited JD was granted in the High Court on 21 July 2016. Hunt’s blustering approach of asking for high ‘Security of Costs’ (what the doctors would pay if the JD failed) was knocked back by the judge. Justice for Health raised the reduced amount of £130,000 in just four days.

The five founding doctors have a combined 37 years’ experience as NHS doctors. Four of them are Registrars. Their excellent web site is clear and concise and puts many commercial sites to shame. More at www.justiceforhealth.co.uk

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

NHS and Local Authority bosses have been meeting in secret for over eight months concocting five year plans for delivering healthcare and social care services. The plans are called Sustainability and Transformation Plans (STPs). STPs have to achieve significant cost savings, integrate healthcare and social care services and implement seven day working. Each region (or footprint) in England is writing an STP. There are 44 footprints and ours is North West London. Approved versions of these plans are expected by October 2016. We expect there will be an STP for my town of Ealing.

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 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 a specific population. 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 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.

At some time in the future all State care services in England will be delivered by ACPs.

In NW London up to five ACPs will sometime in the future deliver all State care services for seven towns – Ealing, Hounslow, Hammersmith, Fulham, Westminster, Kensington and Chelsea. Up to five ACP contracts will be created. No decisions have yet been made as to what each ACP will be delivering. They might be geographic ACPs or there might be perhaps an ACP for end of life care. ACPs will serve populations of between 500,000 and one million. ACP contracts will be for ten years. The first ACP contract is scheduled to begin in April 2018. Full ACP coverage of all care services across all seven towns will be achieved sometime 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. There are also many STP documents in the public domain – including a draft of the NW London STP. However nowhere in all these documents can I find answers to these questions:

+ how free at point of use healthcare services and means tested social care services will be integrated?

+ how seven day healthcare services will be implemented?

+ 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?

+  when and how the shortage of care workers e.g. Doctors, Nurses, Paediatricians, Psychologists, Physiotherapists, District Nurses and Health Visitors – will be made good?  

+ when will the destruction of my local Major Hospital – Ealing Hospital – be completed?

+ 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?

On 30 June 2016 North West London NHS and Local Authority bosses submitted their draft five year plan to NHS England for cutting care costs and changing how care services are provided. After considerable pressure from a number of organizations this plan was placed in the public domain on 5 August 2016. The name of the plan is ‘The Sustainability and Transformation Plan’. You can read the plan here. 

It’s not an easy read and ESONHS members and others have begun meeting, discussing and researching in order to fully understand what these cost cuts and service changes will mean to residents of Ealing. As with the NHS NW London 2012 ‘Shaping a Healthier Future’ plans the survival of Ealing Hospital is at risk.

There are proposals for changing how primary care and community care services are delivered which could threaten the survival of the traditional GP surgery. Services form the seriously mentally ill are seemingly to be improved but the spending on these services will be cut.

Healthcare and social care services are to be integrated but this will clearly be difficult as healthcare is free at the point of use and social care is means tested. Again these service improvements are to be achieved at the same time as spending on them will be reduced.

Foto: By Oxyman (Own work) [GFDL, CC-BY-SA-3.0 or CC BY 2.5], via Wikimedia Commons