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:
Here follow my initial comments and observations on this ten page, but 5,500 word, document:
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?
I counted 20 unexplained acronyms, with no supporting glossary.
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.
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?
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?
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?
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.
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?