NHSI (London) and NHSE (London) Directors of Finance Write to Ealing Save Our NHS (ESON)<\/b><\/p>\n
In November 2017 NHS Improvement (London) and NHS England (London) Directors of Finance wrote to NHS North West London (NWL) rejecting the NHS NWL \u2018Shaping a Healthier Future\u2019 (SaHF) business case ImBC SOC1. This business case requested \u00a3513 million for building work connected with plans to close down Ealing District General Hospital. On 6 February 2018 the ESON Research Team wrote to the NHSI\/NHSE Directors expressing concerns about the lack of evidence to support the SaHF changes. Specifically ESON found no proof to support the theory that annual Non-Elective hospital admissions (so called NELs) across the eight boroughs in North West London could be reduced by 40% (i.e. by 99,000) by 2025\/26.<\/span><\/p>\n <\/p>\n On 21 February 2018 the Directors wrote to ESON noting the contents of the ESON letter and stating:<\/span><\/p>\n <\/p>\n \u2018<\/span>We would like to assure you therefore, that proposals for significant changes to the provision of health services will need to meet a high assurance bar and be deliverable\u2019.<\/b><\/p>\n <\/p>\n Hammersmith & Fulham GP Federation and Four NHS Trusts on Track for \u2018\u00a3200 Million to \u00a3300 Million\u2019 for an \u2018Accountable Care System\u2019 (ACS)<\/b><\/p>\n \u2018Pulse\u2019 has revealed this deal which is shocking in so many ways. Dr John Sanfey, Medical Director of Hammersmith & Fulham GP Federation, is the mouth piece in the article. For starters the federation is not a statutory body. Why the wild variation in the budget? Will the ACS \u2018commission\u2019 physical health, mental health and social care for 212,000 residents? Dr Sanfey is aiming for \u2018partial integration\u2019 in 2019. What does that mean? Where is the NHS CCG in all this? Where is the London Borough of Hammersmith & Fulham in all this? Where is the public engagement in all this? Dr Sanfey says that an \u2018alliance agreement\u2019 will be signed in April 2018.<\/span><\/p>\n <\/p>\n Dr Sanfey MB BA BAO BCh DCCH FRCGP appears to be a freelance GP. He is a member of Pallant Medical Chambers based in Chichester. Pallant appears to be a GP locum agency. Pallant employs 125 people and has offices in Southampton and Twickenham.<\/span><\/p>\n <\/p>\n Hammersmith & Fulham GP Federation is a rather secretive, private limited company (H&FGPF Ltd). It does not have a web site. CQC data reveals that it runs the Brook Green Medical Centre. H&FGPF Ltd\u2019s registered address is 20 Dawes Road, Fulham, SW6 7EN. According to Companies House Dr Sanfey is not an Officer of H&FGPF Ltd.<\/span><\/p>\n <\/p>\n ECCG OOH Services Single Supplier<\/b><\/p>\n A prospectus on this has been published.<\/span><\/p>\n What the document is not is an Invitation to Tender (ITT). It\u2019s more of an \u2018engagement\u2019 document at the formative stage of contract writing. What the prospectus says, in effect, is that the Ealing Clinical Commissioning Group (ECCG) is thinking about outsourcing the delivery and management of 36 care services. However the ECCG reserves the right to vary the range of services and the nature in which it might outsource them. One assumes that the prospectus might stimulate the nine NHS Trusts and the eight private care providers that ECCG variously entertained on 19 September 2017 and 2 October 2017 to some kind of response of continuing interest.<\/span><\/p>\n <\/p>\n The contract will be for 10 years and will be in excess of \u00a31 billion. The scheduled start date is April 2019. The prospectus was briefly presented in public on 28 February 2018. 24 members of the ECCG Governing Body approved it at this briefing. Public questioning revealed that no cost saving were envisioned. Cost savings would accrue, allegedly, from reduced Emergency hospital admissions (so called Non-Elective admissions or NELs). \u00a0<\/span><\/p>\n <\/p>\n The care flavour of the decade (along with privatisation) is integrated healthcare and social care services delivery. If you are looking for lots of this in the prospectus you will be disappointed. The prospectus is clearly written from a healthcare perspective and its integration with social care is never consistently referenced. <\/span><\/p>\n No Simple numeric Performance Metrics<\/b><\/p>\n There are no references to any performance metrics. However adhering to the, as yet unapproved, 2012 NHS NWL \u2018Shaping a Healthier Future\u2019 (SaHF) business case no doubt the single supplier will have to deliver Ealing\u2019s share of reductions in NELs (Non-Elective admissions to hospitals). Out of the regional total of an annual reduction of 99,000 NELs by 2025\/26 Ealing will have to pro rata \u2018deliver\u2019 a total of 12,375 of them. On page 41 under \u2018Non-Elective Requirements\u2019 we have an ominous phrase \u2018Table to be inserted\u2019. At the ECCG meeting in public on 28 February 2018, ECCG said that NELs reduction targets would be inserted on 22 March 2018 in the next public OOH Single Supplier document. <\/span><\/p>\n <\/p>\n There\u2019s also no reference to how the 10 year contract might relate to the OOH component of the NHS NWL Integrated Care System (ICS) – previously called the Accountable Care System \u2013 which no doubt will become a reality before 2029.<\/span><\/p>\n <\/p>\n No Financial Details<\/b><\/p>\n There are no financial details in the prospectus. Trying to find out historic annual OOH service spends in Ealing is far from straightforward. Dr Parmar of ECCG wrote to an Ealing resident on 8 September 2017 and told him that the OOH services spend for Ealing in 2017\/18 would be \u00a3121.794 million. 10 times that results in a \u00a31.2+ billion contract. <\/span><\/p>\n <\/p>\n Now some detailed comments:<\/span><\/p>\n + Page 3: <\/span><\/p>\n It says the underpinning business case is not for public release. I wonder why that is. It can hardly be commercial in confidence.<\/span><\/p>\n <\/p>\n It says that OOH services have been fragmented, complex and difficult to navigate for the service user and health and social care staff. (How it would know this about social care services is hard to fathom as they are commissioned by the London Borough of Ealing (LBE)).<\/span><\/p>\n <\/p>\n Telephone Triage<\/b><\/p>\n The triage for all OOH services will be on the phone via the Single Point of Access (now re-named the Community Single Point of Access). The current SPA for mental health service users is not clinically supported 24\/7. I know this from direct experience and from other carers. For a Community SPA to operate successfully 24\/7 for physical health, mental health, social care and their integration with expert support would be a difficult and expensive service to create and maintain. <\/span><\/p>\n <\/p>\n The sharing of care plans makes an appearance here as does \u2018IT functionality of the Community SPA\u2019. The idea of all 434,000 patients registered at the 76 Ealing GP surgeries all having care plans is hard to imagine. NHS and Local Authorities sharing care plans (the former with healthcare plans, the latter with social care plans) is again quite a leap of faith. \u00a0Of course the social care service users are part of a different database of 349,000 Ealing residents. No explanation or even description of the challenges of the dichotomy and legality of the healthcare and social care database sharing is even entered into.<\/span><\/p>\n <\/p>\n Underestimated Population Growth<\/b><\/p>\n + Page 5: \u00a0<\/span><\/p>\n There is a description of Ealing\u2019s current and future population. The future population figures are understated. Mayor Khan\u2019s new 2018 draft London Plan requires LBE to build 28,000 new homes in Ealing 2019 to 2029. This will add some 84,000 new residents. So the social care database will rise to 433,000 and the healthcare database to 518,000.<\/span><\/p>\n <\/p>\n There is a discussion here about nursing homes, but care homes and domiciliary staff are not mentioned. Yet another integrated healthcare and social care omission.<\/span><\/p>\n <\/p>\n + Page 9: <\/span><\/p>\n SaHF makes an appearance here. Its business case requires the closure of Ealing District General Hospital (EDGH) by 2021. \u00a3513 million for building works is requested to create Ealing healthcare hubs and extend Ealing GP surgeries \u2013 all to enable Ealing OOH services to \u2018replace\u2019 Acute hospital care in Ealing. \u00a0But in November 2017, NHS Improvement (London) and NHS England (London) both rejected the SaHF business case.<\/span><\/p>\n <\/p>\n Although there are explicit sections on \u2018Community Care\u2019 and \u2018Adult Care\u2019 here, there are no explicit sections on \u2018Child Care\u2019, \u2018Mental Health\u2019, \u2018Social Care\u2019 and \u2018Integrated Healthcare and Social Care\u2019. This is worrying. <\/span><\/p>\n <\/p>\n (Social care is described later in the prospectus under \u2018Local Authority\u2019 suggesting that integration of the two care services is not in place).<\/span><\/p>\n <\/p>\n + Page 10:<\/span><\/p>\n Here we find aspirational stuff including the phrases \u2018advance towards\u2019, \u2018decisive steps\u2019, and \u2018a new deal\u2019. They add little value to the prospectus.<\/span><\/p>\n <\/p>\n The Manchester and Dudley Vanguard Multispeciality Providers (MCPs) ICSs are mentioned in a positive light. Surprising this, as all three of these grant funded projects have been halted.<\/span><\/p>\n <\/p>\n \u2018\u2026(Current) improvements to OOH services throughout the borough\u2019. The only measureable, tangible OOH services\u2019 improvement in Ealing mentioned by Dr Parmar in her letter of \u00a08 September 2017 was \u2018(Home Ward) service apparently helping to avoid 1,400 hospital admissions over an eight month period\u2019. This is tiny reduction compared with the hospital admissions reduction goal.<\/span><\/p>\n <\/p>\n Performance Aspirations<\/b><\/p>\n + Page 12:<\/span><\/p>\n A goal for the single supplier approach is \u2018increased consistency and reducing variation in quality (of access to) services\u2019. There\u2019s some shallow thinking here, as there\u2019s no guarantee that such benefits accrue for a single supplier. I might get great service from Thames Water, but a chum down the road might get awful service from them. <\/span><\/p>\n <\/p>\n Waiting times will not magically reduce by hiring a single supplier. Hiring more staff, opening more hospital beds and expanding and opening more treatment centres might just achieve this. <\/span><\/p>\n <\/p>\n Expecting a single supplier provider to be the key to keeping \u2018all parties informed and involved in the tailored care using appropriate clinical IT systems\u2019 is a statement of faith. Notice no mention here of integration with social care IT systems.<\/span><\/p>\n <\/p>\n How a single supplier per se might reduce hospital bed-blocking (Delayed Transfers of Care \u2013 DTOCs) is not explained. Reducing DTOCs on a sustainable basis with a rising and aging population must require more nursing home beds, more care home beds and more mental health beds, along with more staff. <\/span><\/p>\n <\/p>\n + Page 14:<\/span><\/p>\n \u2018Vision for OOH care\u2019. This is about healthcare and not integrated healthcare and social care.<\/span><\/p>\n <\/p>\n \u2018The aim is for the single supplier to be clinically led and co-ordinated through a single point of contact to oversee, clinically triage and book all services in scope\u2019. This presumably means the use of the Community SLA. 1,000s of people will be calling this telephone number. And where is the reference to social care triage and integrated healthcare and social care triage?<\/span><\/p>\n <\/p>\n \u2018High quality care as close to home as possible and where appropriate\u2019. Well, after EDGH closes, none of the 434,000 Ealing residents will find any high quality care in Ealing if they are critically ill or seriously injured.<\/span><\/p>\n <\/p>\n Unreal Expectations<\/b><\/p>\n + Pages 15\/16: <\/span><\/p>\n Some of the expectations of what a single supplier must deliver seem almost certainly to be unachievable:<\/span><\/p>\n <\/p>\n \u2018Joined up care across a person\u2019s life from child to adult in the community responding to patient need, and delivering care to address the changing needs of an individual\u2019.<\/span><\/p>\n <\/p>\n Surely the GP has the primary role here \u2013 not the OOH service single provider?<\/span><\/p>\n <\/p>\n \u2018The provider will deliver seamless proactive planned care\u2019. What? For 518,000 Ealing residents in 2029?<\/span><\/p>\n <\/p>\n \u2018Principles underlying the Clinical Model\u2019<\/span><\/p>\n What about the integrated healthcare\/ social care model?<\/span><\/p>\n <\/p>\n The six principles are exemplary aspirational ones. Adhering to these principles and cutting costs significantly will take a genius of a single supplier. There\u2019s reference here to Multi-Discipline Teams (MDT). Anecdotally employing MDTs has proved a little value in Ealing or throughout NHS NWL.<\/span><\/p>\n <\/p>\n The rest of the document covers NHS healthcare service specifications and separate Local Authority social care specifications.<\/span><\/p>\n <\/p>\n NHS Recruitment Crisis: EU Nurses Registering to Work in the UK Last Year Dropped by 96% – from 1,304 to 46<\/b><\/p>\n These July 2016 to April 2017 figures are very worrying. 34,000 vacancies for nurses and midwives were advertised in January 2018. The January 2018 minimum salary to qualify for a Skilled Work Visa was \u00a346,000\/year. In the Thames Valley only one nurse was recruited for the 400 posts advertised.<\/span><\/p>\n <\/p>\n One in 11 NHS posts are unfilled. The 234 NHS Trusts, who employ 1.1 million \u2018whole-time-equivalent\u2019 staff, have 100,000 vacancies. 12% of mental health doctor roles are unfilled.<\/span><\/p>\n <\/p>\n NHS North West London (NWL) Marks its Own Homework \u2013 October 2016 to February 2018<\/b><\/p>\n In a quite appalling waste of money NHS NWL has produced a coloured 16 pager entitled \u2018The North West London health and care partnership \u2013 Progress update February 2018\u2019. It pats itself on the back on each page. It\u2019s probable that management consultants wrote this \u2013 thereby adding to the \u00a336 million spend by the eight NHS NWL Clinical Commissioning Groups (CCGs) on management consultants since 2013. However you\u2019ve got to give credit to these NHS regional bosses for having the brass neck to churn this stuff out.<\/span><\/p>\n <\/p>\n Acute care performance is consistently amongst the worst in England. NHS NWL\u2019s attempts to reduce beds and emergency hospital admissions (largely so called Non-Elective admissions \u2013 NELs) has been almost totally unsuccessful. Its many and different attempts at providing sustainable and cost effective Out of Hospital (OOH) services are largely unsuccessful. The well publicised dream of reducing annual NELs by 40% (by 99,000) by 2025\/26 and \u2018replacing\u2019 the Acute functionality with OOH services must look like a nightmare to NHS NWL bosses.<\/span><\/p>\n <\/p>\n The older peoples\u2019 service suffers from a chronic shortage of geriatricians. On the mental health front from personal and anecdotal experience there is no \u2018real time\u2019 clinical support at the Single Point of Access. The service is still just a \u2018go to your GP or A&E\u2019 response service \u2013 as it has been for years. Chronically understaffed, the NHS West London Mental Health Trust (WLMHT) still bears the Care Quality Commission 2016 label for 9 of its 11 core services as \u2018Requires Improvement\u2019. Waiting times for psychological therapy programmes are measured in months and years. Also WLMHT apparently continues to consider bidding to gain other contracts e.g. the 10 year Ealing Out of Hospital services single supplier contract. How adding more \/different service responsibilities will help to improve mental health services for our two million residents in quite beyond me.<\/span><\/p>\n <\/p>\n At last some real data on page 12.\u2019Agency staff bill reduced by \u00a369 million\u2019. It\u2019s still in \u00a3millions but this data is not shared. In \u2018Resilience\u2019 \u00a0it\u2019s a bit distasteful to go on about the Westminster Bridge, London Bridge and Grenfell tragedies. In contemporary London there are going to be \u2018unprecedented events\u2019. The NHS NWL Grenfell Tower response metric of \u20184,514 contacts with our outreach team\u2019 tells us very little about successful outcomes and treatment programmes for victims. <\/span><\/p>\n <\/p>\n