The NHS Is Not In Debt – But In Surplus – July 2016


Issue: 38

July 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 NHS Is Not In Debt – But In Surplus: Nationally To The Tune of £600 Million and £72 Million in NW London

Roger Steer is a healthcare audit consultant who has been studying NHS financial data for ten years. On 9 June 2016 he published a bombshell paper which analysed NHS commissioning financial reports for 2015/16. He revealed the following surpluses (what one might call profits) for 2015/16:


+ NHS England – £600 million

+ NHS London – £26.5 million

+ NHS North West London – £72 million


In fact the NHS in England has been in surplus at the end of the last five financial years – in 2013/14 as low as £1 million and in 2010/11 as high as £1.1 billion.


These figures make a nonsense of the scary reports of NHS 2015/16 losses of £2.4 billion. They make no sense in the context of the blanket requirement of the Stevens /NHSE Five Year View/Sustainability and Transitional Plan (STP) imperative of clearing NHS debts – if in fact at a gross level no such debts exist.


One wonders whether the Government’s seemingly erroneous debt message is simply scare mongering to somehow justify the STP cost cutting without Parliamentary scrutiny or any public consultation.


North West London’s Sustainability and Transformation Plan (STP) Finally Enters the Public Domain on 16 June 2016

NW London’s 15 April 2016 initial draft STP submission can be viewed at:


STPs are the latest device being foisted on us by Government in an attempt to eliminate alleged historic NHS debts, reduce future healthcare and social care costs and extend healthcare and social care services. Simon Stevens, boss of NHS England, published a national Five Year View care strategy in late 2015. In it he created 44 care regions (weirdly called ‘Footprints’). Each Footprint threw together all the Local Authorities, NHS CCGs and NHS Trusts in that region. Each of these footprints has this year to produce a first year STP and submit it to NHS England for review. All STPs have to indicate how current NHS ‘debts’ would be paid off, 7 day working would be implemented, hospital A&Es would be replaced by Urgent Care Centres, Acute hospital care reduced and replaced by care at home or in the community, and healthcare integrated with social care. The STP must also supply details of the sale of surplus land and buildings.


Our footprint is North West London with over 2 million people and a Government estimate of over £4 billion spent last year on NHS healthcare and Local Authority social care.


Before I make any comments on the 18 page NW London draft STP I think it’s worth exploring the attempts in recent years to cut healthcare and social care costs nationally and regionally. This exploration will help to answer the question (or question the question): why STP?


Healthcare Cost Cutting

+  In 2010 the Government announced that annual NHS costs would be reduced by $20 billion by 2015. However annual healthcare expenditure (according to Roger Steer – see above) rose over five years from £97.5 billion to £101 billion in 2015/16.


+  The Health and Social Act 2012 created a market for healthcare which separated healthcare professionals into buyers and service providers. Profit and loss accounts were created for hospitals. However mystery and confusion surrounds the NHS accounts for 2015/16. All but seven of the 138 NHS Hospital Trusts supposedly made a loss in 2015/16. NHS England says the NHS losses for the year were at least £2.4 billion. However the recent Roger Steer report (see above) has added up the NHS figures and he states that in 2015/16 the NHS in England made a profit/surplus of £600 million.


+  In 2012 NHS NW London launched its ‘Shaping a Healthier Future’ (SaHF) strategy. NHS expenditure in NW London was then stated to be £3.6 billion. The target for annual cost savings was 4%. By now over £400 million should have been saved. As SaHF has not trumpeted details of any savings one can presume that none have accrued from SaHF. However Roger Steer has analysed all eight NW London CCG accounts and calculates a £72 million profit (or surplus in NHS speak) was achieved in 2015/16.


+  In June 2013 the Government’s Better Care Fund (BCF) was introduced to oil the wheels of reducing costs by integrating NHS healthcare and Local Authority social care services. £3.8 billion was to be invested with the target of saving £1 billion by 2015/16. In November 2014 the Government’s National Audit Office produced a report stating that in its first year BCF savings of just £55 million were realised. Since that announcement we’ve heard little more about BCF.


Social Care Cost Cutting

+  What is social care? It’s the provision of social work, personal care, protection or social support services to children or adults in need or at risk or adults with needs arising from illness, old age or poverty.


+  Since 2010/11 annual social care expenditure in England has decreased by over 10% to £13.3 billion. The expenditure on children in care in England in 2013/14 was £2.5 billion. Try as I might I can’t find any other meaningful historic or current expenditure details on children’s social care in England, London or NW London.


NW London STP 15 April 2016 Submission

So against a backdrop of austerity, population increase and people living longer 31 regional public bodies were thrown together and told to come up with a plan to both cut costs and improve healthcare and social care services across North West London. There clearly is some logic in trying to integrate the service supply of physical health, mental health and social health. To make this work would almost certainly involve the creation of a single business model and a single organisation to provide all these services. But we have the NHS, Local Authorities and private care homes each with different mission statements and different reporting structures.


I can only sympathise with the plan makers as what they are being asked to do is impossible. They must surely know this.


There are very few relevant, understandable numbers in the plan. Two are:


+ Over £1 billion annual savings by year 5 (2021/22?)


+ Lose 500 Acute beds.  


There are seven ‘Emerging Priorities’, which bizarrely are not the Stevens/NHE Five Year View goals. They are really seven aspirations as opposed to priorities. There are no real, tangible clues as to how these aspirations will be met. Quite simply these aspirations might be summarised as wanting better healthcare and social care services for everyone in NW London. As such they represent what citizens have thought the NHS and Local Authorities have aspired to deliver for decades.


On the financial side on page 11 there is an impenetrable table of financial numbers and unexplained acronyms. The table doesn’t even has a title –  which if it existed might help the reader to gain some understanding. However what stands out like a sore thumb are the entries associated with ‘NW London social care’ financial figures. The entries state ‘not available’.


Returning to the Stevens/NHE Five Year View goals the STP gives very little detail on how they might be met. For example there is little explicit detail on how 7 day working will be achieved or how healthcare and social care will be integrated.


Apparently there is some kind of risk register. Number 1 risk is ‘Access to capital for estates and IT investment’. SaHF (which is included in the STP) has wanted up to £1billion for capital projects for quite some time now. However there are no signs or hints anywhere that the Treasury will stump up the cash.


What’s missing from the STP?

There very little in it concerning GP services, social care services generally and care homes specifically. There is nothing on the sale of surplus land and buildings. None of the statutory Healthwatch organisations have been given a role in the formulation or implementation of the plan. And of course there is nothing in the STP about residents and patients being involved in the plan making process.


Finally the North West London Footprint wants a ‘Devolution Deal’. This  would mean that the self appointed healthcare and social care bosses would have direct control of over £4 billion annually to spend as they thought fit. A scary prospect.


Ealing CCG Hosts Vacuous STP Public Meeting on 13 June 2016: Announces STP Deadline Slip to October/November 2016


Ealing Clinical Commissioning Group (ECCG) announced at a rare public STP meeting on 13 June 2016 that NHS England had cancelled its 30 June 2016 deadline for submitting draft STPs. Now the deadline date is a vague October/November 2016.


Fewer than 20 residents attended this poorly advertised Ealing STP public meeting. I asked why the meetings of the 31 public bodies over the last four months concocting our STP were held in secret and why we couldn’t see a copy of the latest STP for North West London. ECCG said that NHS England had told them to exclude the public from involvement in the plan making exercise.


So, how do you run a public meeting on a plan the details of which can’t be revealed to the public? What you do is split the audience up into little groups and ask them to discuss huge societal and political issues like ‘how do we reduce social isolation’ and ‘how do we improve children’s mental and physical health and well-being’? I’m surprised in a way we weren’t asked how to reverse climate change and eliminate world poverty. This is so unbelievably patronising and belittling to citizens. Some people got angry and raged about the UK’s low % of GDP spent on care, the impossibility of improving care services when hospital and care home beds were being lost and how is it that healthcare in Cuba is better than it is in England. The thorny issue of STP legitimacy was raised, as no Act of Parliament supports STPs’ existence.


I lobbied hard with a senior ECCG person on the need for NHS staff and Ealing Council officers to work in tandem with informed volunteers to provide, for example, mental health caring services. NHS England’s approach of shutting out and antagonising volunteers was very unhelpful. I told her I thought it was unlikely that more paid staff would enter the fray and deploying significant numbers of well managed volunteers integrated with paid staff offered some hope of ‘doing more with less’. Her elliptical response was ‘we are working with partners’.


No details emerged from the meeting about how the alleged enormous NHS debts would be paid off, how 7 day working would be implemented, how Acute hospital care would be reduced (rumours of 500 bed losses) and replaced by care at home/in the local community and how healthcare and social care would be integrated.


Apart from losing 90 minutes of my life I will never get back, my overriding impression was that the STP project is doomed. The no doubt well paid public servants in the room tried hard to show enthusiasm for the STP project but this was not entirely convincing as they shut down responses to difficult questions. No Ealing GPs, Ealing Hospital staff or anyone working for an Ealing care home bothered to attend the meeting. No-one mentioned SaHF and the usual SaHF cheer leaders were absent. Ealing Council’s presence was minimal and very low key.


The reality is that if NHS England do not like submitted plans they will send them back to footprints who will have to re-do them. And Thatcher-like, if NHS England finally does not like the re-worked STP the threat is that no new money will be sent to that footprint.


Opposition to Inadequate Funding and Resourcing for Care Grows Locally, Regionally and Nationally

Locally here in Ealing the Ealing Save Our NHS (ESONHS) group remains strong and new blood and new leadership is maybe coming onto the Board of Healthwatch Ealing (HE). HE so far has been largely ineffective. A Judicial Review on the paediatric closures in Ealing is being mounted by a local parent.


Regionally there has been a first meeting of North West London Health Matters. The organisation was inspired and organised by activists in Hammersmith and Fulham. It aims to co-ordinate opposition to closures and cuts throughout NW London.


Nationally, Keep our NHS Public (KONP) seems to have stopped arguing with itself so much and its newish, knowledgeable leaders John Lister and Tony O’Sullivan are making their mark. Health Campaigns Together offers the prospect of an entity supporting and representing all healthcare activist groups nationally.


Inspiration for all care activists has come from Shropshire where a CCG voted against the closure of a hospital A&E department. Rumour has it that the CCG and the Local Authority in Bedford are at loggerheads over reviewing services. News came, initially from Yorkshire, that the deadline for creating Sustainability and Transformation Plans (STPs) has been/will be extended. We now know from Ealing CCG that the submission deadline has been delayed. Sometimes delays in state programmes are precursors to programme change or programme deletion. One suspects that the competing goals of Local Authorities and NHS CCGs and Trusts have resulted in acrimonious and protracted rows about how big financial cuts should be ‘shared’ across  social care and healthcare.