Chance to Publicly Scrutinise NHS North West London Healthcare Purchasers is Wasted.<\/b><\/p>\n
One of the few \u2018in public\u2019 NHS NW London-wide meetings at which elected Members (i.e. Local Councillors) examine NHS healthcare performance and plans took place on Tuesday 5 December 2017. It was a meeting of the NHS North West London Joint Health Overview and Scrutiny Committee (JHOSC). This is a fairly rare event taking place perhaps only twice each year.<\/span><\/p>\n <\/p>\n 16 Councillors from the eight NHS North West London (NWL) Local Authorities were invited to attend this JHOSC meeting but only four of them turned up. None from Ealing and none from Brent for example. More members of the public attended than elected Councillors in NWL. The strange location of the meeting did not help. It took place in Twickenham, Richmond at 9:30am. Richmond isn\u2019t an NHS NWL borough, but some of its Councillors did turn up.<\/span><\/p>\n <\/p>\n The NWL Collaborations of CCGs bombarded the attendees with 90 pages of seven papers. The two Accountable Officers for NHS NWL CCGs Ms Clare Parker and Mr Rob Larkman were in attendance. Juliet Brown also attended. She is Local Services Transformation Director. Clinical support was provided by Dr Le Brooy, the new NHS NWL \u2018Shaping a Healthier Future\u2019 (SaHF) Medical Director. (Her predecessor Dr Mark Spencer has moved out of SaHF into healthcare management consultancy).<\/span><\/p>\n <\/p>\n Many of the Councillors\u2019 questions were \u2018thin\u2019 on content. This was possibly because they had not had time to study the 90 pages and\/or they had insufficiently followed and researched the five year SaHF cost cutting \/service transformation to-ings and fro-ings. One Councillor never spoke at all during the 2.5 hour meeting.<\/span><\/p>\n <\/p>\n Getting Elderly Patients Out of Hospital<\/b><\/p>\n Dr Le Brooy, a senior geriatrician, led the NHS attack here under the banner of \u2018Front End Frailty Services\u2019. The plan is to admit as few as possible elderly people into hospital. Evidence from Sheffield, Leicester and Poole was quoted. The whole approach can clearly only work if significantly expanded home-based and community-based healthcare and social care support services are in place. \u00a0\u00a0<\/span><\/p>\n <\/p>\n The nirvana quoted was multi-disciplinary teams working together to assess old peoples\u2019 needs and to offer an alternative to hospital admission. These team members include mental health practitioners, geriatricians, pharmacists, dieticians, speech and language specialists, frailty nurses, social care decision makers and therapists. One does wonder whether this is happening now? Will it happen consistently in the future given the continuing shortage of staff across the board? Is this just pie in the sky?<\/span><\/p>\n <\/p>\n Dr Le Brooy admitted that there was a shortage of geriatricians . The Chair expressed concern of anecdotes about elderly people being discharged from hospital over night and delivered to empty homes.<\/span><\/p>\n <\/p>\n Accountable Care Organisations (ACOs)<\/b><\/p>\n Mr Larkman and Ms Parker delivered inadequate presentations on ACOs. They ran through some of the usual ACO mantras of fragmentation, misaligned incentives, access, population needs and joined up health and social care services. They mysteriously failed to mention that ACOs will be fixed price, long term contract beasts which will force through massive cost cutting. <\/span><\/p>\n <\/p>\n They provided sketchy details about the Hillingdon elderly peoples\u2019 Accountable Care Partnership (ACP) which is apparently the most advanced regional ACO. This will apparently feature the Hillingdon CCG and the London Borough of Hillingdon (LBH) working together. Rumour has it that LBH is not co-operating with the CCG on the NHS NWL Sustainability and Transformation Plan (STP) for which ACOs\/ACPs are supposedly the STP implementation \u2018engines\u2019. What Parker\/Larkman failed to tell us all (and none of the Councillors asked) was:<\/span><\/p>\n <\/p>\n + What is a Capitated Budget? This is not defined in the NHS NWL ACO Glossary provided \u2013 which is the world\u2019s smallest glossary defining just three terms. A Capitated Budget (sometimes called a Population Budget ) is where an annual budget is set by assigning a cost\/head for a defined patient population (eg \u00a32,500 per elderly person) and multiplying that by the number of \u00a065+ people within that defined population (eg 40,000 in Hillingdon). In this example the annual Capitated Budget would be \u00a3100 million. Over 10 years that would be a \u00a31 billion contract.<\/span><\/p>\n + What is the Capitated Budget set for 2018\/19 ( i.e. how much annual cash per elderly head has been allocated?)<\/span><\/p>\n + How will the Capitated Budget be calculated \u00a0for 2020\/21? My guess will be it will be the 2019\/20 annual cost, less say 20%, divided by the number of older people<\/span><\/p>\n + Who will run the Hillingdon ACP? (Has he or she been appointed already?)<\/span><\/p>\n + How will the ACP Board be elected\/selected?<\/span><\/p>\n + How long will the ACP contract \u00a0run for? Ten years probably.<\/span><\/p>\n + To whom will the ACP be accountable?<\/span><\/p>\n <\/p>\n Will ACOs Deliver Integrated Care or Just Massive Cost Cutting?<\/b><\/p>\n What they did say was that ACOs will result in better integrated care and help in the areas of education and housing. Helping with education is a bit of a stretch \u2013 but helping with housing is just beyond belief. NHS NWL ACO priorities are elderly people, adult long-term mental health conditions and Diabetes. The Trojan Horse for ACOs is apparently the Whole Systems Integration Care (WSIC) programme \u2018which for four years has been integrating healthcare and social care teams\u2019. Has it really one wonders? Will ACOs deliver the \u00a31.4 billion savings across NHS NWL by 2021? And it they do to what extent might healthcare and service care levels fall through the floor?<\/span><\/p>\n <\/p>\n Grant funded ACO Vanguards\u2019 performance is quoted as evidence. \u00a0This is a bit thin as none of them have reduced admissions to A&E, but some have reduced the growth in A&E admissions.<\/span><\/p>\n <\/p>\n There\u2019s also mention in passing, of a \u2018Multi-speciality \u00a0Community Provider\u2019 (MCP) ACO being put together in Hammersmith & Fulham (H&F). Again this seems somewhat doomed as H&F Council is very publicly not supporting the NHS NWL STP.<\/span><\/p>\n <\/p>\n The printed ACO paper did reveal a lot more information. Apparently the ACO contracts will be at least 10 years long. None of them will commence in ernest before 2019.<\/span><\/p>\n <\/p>\n There are seven CCG ACOs in various stages of creation:<\/span><\/p>\n + Brent<\/span><\/p>\n An MCP ACO is being developed to deliver the WSIC model of care planning.<\/span><\/p>\n + Central London<\/span><\/p>\n Working with Westminster City Council and partners a Primary Care Homes ACO is in development which will morph at some point into an MCP ACO <\/span><\/p>\n + Ealing<\/span><\/p>\n \u2018The Ealing Standard\u2019 Out of Hospital (OOH)\/ GP services, single supplier 10 year ACO <\/span><\/p>\n + Hammersmith & Fulham<\/span><\/p>\n An MCP\/Primary & Acute Care System (PACS) is being created to start in 2019. It covers OOH and Primary Medical Services (PMS) <\/span><\/p>\n + Harrow<\/span><\/p>\n An ACO for WSIC is being developed for a segment of the 65+ population<\/span><\/p>\n + Hillingdon<\/span><\/p>\n An ACP for 65+ integrated care<\/span><\/p>\n + Hounslow<\/span><\/p>\n OOH\/PMS ACO leading to an MCP ACO.<\/span><\/p>\n The final ACO slide contains the killer phrase \u2018(ACO) providers take control, commissioners become much more strategic\u2026\u2019. The former is worrying and the latter is meaningless.<\/span><\/p>\n <\/p>\n Community Hubs<\/b><\/p>\n The target is 27 Hubs. 18 of them need \u00a3141 million of funding. In Ealing two of these will need \u00a321.1 million (Ealing East) to open in 2019 and \u00a314.6 million (Ealing North) to open in 2021. Both will be funded by the Local Improvement Finance Trust (LIFT). LIFT is seven years old and is the NHS PFI\/PPP model (60% private cash and 40% public cash). Acton Health Centre is to close and the site to be sold for \u00a32 million.<\/span><\/p>\n <\/p>\n Out-Of-Hospital Hub Productivity<\/b><\/p>\n 22,000 Non-Elective (NEL) hospital admissions will, apparently, be avoided by the use of Hubs. However the NEL annual admissions reduction target is 99,106. Evidence to support this target includes data from ChenMed in the USA. This was one of the sites visited on the McKinsey & Co organised NHS NWL fact finding trip a couple of years ago. This case study features a fleet of 60 vans\/courtesy shuttles and 36 specially built Primary Care \u2018hubs\u2019. Practioner list sizes are up to 450 – unlike NWL General Practioners\u2019 average list size of 1,700. So the efficacy of this evidence is debatable. Evidence is also presented from Canada.<\/span><\/p>\n <\/p>\n Local Services Update<\/b><\/p>\n + <\/span>Access to GPs<\/span><\/p>\n In November 2017 21,000 additional appointments were offered, 60% of these were used by patients<\/span><\/p>\n + <\/span>Diabetes<\/span><\/p>\n 30% of all hospital beds have patients suffering with Diabetes in them. Diabetes, allegedly, accounts for 30% of all emergency admissions<\/span><\/p>\n + <\/span>London Ambulance Service (LAS) Prevention of Admission<\/span><\/p>\n This is about ambulances taking patients anywhere but to a hospital<\/span><\/p>\n + <\/span>Home First for Elderly People<\/span><\/p>\n One in three hospital patients is medically fit to leave hospital. \u2018Home First\u2019 is a multi-discipline team approach to getting the medically fit out of hospital In the first six months of operation (since May 2017), Home First, allegedly, removed 600 patients from NHS NWL hospitals to somewhere else.<\/span><\/p>\n <\/p>\n Ealing District General Hospital Closure<\/b><\/p>\n This transformation will apparently follow the same process as was used to close Maternity and Paediatrics. Key transformation metrics will be:<\/span><\/p>\n + Reduction in occupied bed days<\/span><\/p>\n + NEL admissions<\/span><\/p>\n + Length of stay<\/span><\/p>\n + Capacity of A&E to manage attendances<\/span><\/p>\n + Capacity to manage admissions, including critical care capacity.<\/span><\/p>\n <\/p>\n No closure date was given. The silence from the non-attending Ealing Councillors was deafening.<\/span><\/p>\n <\/p>\n Care of the Elderly: STP DA3 Paper<\/b><\/p>\n The NHS NWL CCG cabal is clearly working with the West London Alliance (WLA) \u2013 a cabal itself of West London Local Authorities. This is probably some kind of work-around given the intransigence of Ealing, Hammersmith & Fulham and Hillingdon Local Authorities. Ealing CCG and WLA both operate out of the same building in Ealing! Lots of data on A&E, hospital mortality, and bed days in here.<\/span><\/p>\n <\/p>\n Royal College of Nursing: STP Concerns<\/b><\/p>\n The JOHSC had received a letter from RCN and wanted to discuss it with NHS bosses. The RCN went into some detail about its concerns, which included lack of evidence, poor engagement, planning behind closed doors, funding, workforce strategy and job security. The NHS bosses seemed largely unconcerned and tried to point out it had engaged with nurses.<\/span><\/p>\n <\/p>\n MENTAL HEALTH<\/b><\/p>\n <\/p>\n The CQC \u2018Review of Children\u2019s and Young People\u2019s Mental Health Services: Phase One Report\u2019 is a Major Disappointment<\/b><\/p>\n This 42 page document was published in October 2017 \u2013 10 pages of it are a list of references. In many ways this is a useful document, but it contains some startling statements and some glaring omissions. I am encouraged but unbelieving that \u2018most mental health services for children are \u2018good\u2019 or \u2018outstanding. This is in the face of:<\/span><\/p>\n <\/p>\n + NSPCC Childline: 11,706 young people counselled for anxiety in 2015\/16. Up 35% from 2014\/15<\/span><\/p>\n October 2016<\/span><\/p>\n + NHS England\/ NHS Digital: Children self-harming annually up 385% over 10 years. Girls under 18 years of age poisoning themselves is up 42% at 13,853 girls.<\/span><\/p>\n October 2016 <\/span><\/p>\n + Department of Education: One in three 14\/15 year old girls suffering from mental illnesses. A ten year study of 30,000 girls.<\/span><\/p>\n August 2016<\/span><\/p>\n