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.
Time to Abandon the Failing NHS NW London SaHF Healthcare Project
In the Summer of 2012 NHS North West London published proposals which were aimed at both improving healthcare services and cutting healthcare costs. These proposals were called ‘Shaping a Healthier Future’ (SaHF). The proposals noted that changes were already underway and that it would take ‘over three years’ to complete the changes. The SaHF proposals involved reducing the number of Major Hospitals from nine to five, closing four hospital A&E units, reducing the number of Acute hospital beds and replacing 30% of Acute hospital care with care outside hospitals.
Four and a half years later we have to ask these questions: have the proposals been implemented and have service improvements and cost cutting aims been met? This paper attempts to answer both questions.
+ SaHF Has Not Cut Costs
SaHF planned to cut costs by 4% each year. NHS NW London spent £3.4 billion in 2011/12. So three years of cost cutting should have cut costs by £408 million. However there have been no SaHF announcements or press release about cost saving. No doubt if any cost savings had been achieved SaHF would have proudly and loudly trumpeted them. On 22 February 2017, Ms Tessa Sandall, NHS NW London CCGs’ Managing Director was asked in a public meeting what the SaHF cost savings amounted to. She replied that she did not know. When asked for a ‘rough estimate’ she declined to answer.
Clearly SaHF implementation has resulted in zero cost savings.
+ Healthcare Services Have Not Improved During the SaHF Project
The healthcare services that are key to a seriously ill patient’s survival are Accident & Emergency (A&E) services. The 2012 plan specified closing four hospital A&E units. Only two however have been closed. They were closed in September 2014. Immediately after these closures, hospital A&E performance throughout NW London plummeted and has never recovered. North West London hospital A&E units are regularly some of the worst performing in England with Hillingdon Hospital often featuring as having the worst performing hospital A&E unit in the country.
+ Out–of-Hospital Care: When and Where?
SaHF promised seven day a week out-of-hospital care. This has not been delivered for either physical health or mental health. So called ‘Health Centres’ were to be provided to provide ‘networked’ GP services such as therapy, rehabilitation, diagnostics or specialist imaging. Where are these ‘Health Centres? They don’t seem to exist. SaHF promised improved access to GPs. Locally, regionally and nationally we are all having to wait longer to see our GPs. SaHF told us that our GP will co-ordinate care across all services and will have overall responsibility for our health. This is clearly not the case. In many parts of NW London so called Referral Facilitation Services determine whether your GP referral for you to see a specialist/consultant/hospital department is granted or not.
+ Mental Health Services Have Not Improved
The largest mental health NHS Trust in North West London is the West London Mental Health Trust (WLMHT). In 2015 and 2016 CQC carried out full inspections of WLMHT. Both inspections rated the WLMHT poorly. In fact the December 2016 inspection report rated 9 of the 11 mental health services as ‘Requiring Improvement’.With one in five adults suffering from mental health problems at any point in time this casts WLMHT and SaHF in a poor light. Incredibly the 2012 SaHF proposals made no explicit mention whatsoever about improving mental health services. For this reason alone the SaHF project was completely flawed from day one and should never have been begun.
+ The SaHF Business Case: Four Years Late, Incomplete and Unrealistic
In 2012 residents searched in vain for a detailed SaHF business case. It could not be found. It was only in December 2016 that a partial, detailed SaHF business case emerged. Amazingly the SaHF ‘over three years’ project was now a ten year project. I really can’t recall being consulted on that massive project extension!
Entitled ‘Strategic NHS NW London Outline Case Part 1’ the document contained a request for money for NHS building work in ‘outer’ North West London. Apparently SaHF wants H.M. Treasury to hand over £513 million for this building work. (Sometime in the future an additional £377 will be requested for ‘inner’ North West London NHS (Part 2) building work). To give some impression of just how unrealistic this request for capital funding actually is one only has to study Chancellor Hammond’s Budget proposals in March 2017. For NHS building work over the next three years across the whole of England the Chancellor has allocated just £325 million. Of this only £130 million will be spent this year.
+ Surely the NW London Sustainability and Transformation Plan (STP) and the SaHF Can’t Co-exist?
In December 2014 NHS England announced a Five Year Forward View on healthcare and social services. This required all regions to produce a five year plan to improve services and cut £22 billion off annual care costs by 2020/21. These regions were designated ‘footprints’ and there are 44 of them. NW London’s footprint published its STP in October 2016. The cost savings target was annual cost savings of £1.4 billion in 2020/21. Integrating healthcare and social care services, improving mental health services and illness prevention are key elements of STPs. The future delivery vehicle for the cuts and the changes for care delivery improvement will be Accountable Care Organisations (ACOs). ACO’s in NW London will be private consortia of Local Authorities, NHS CCGs, NHS Trusts and federations of GP surgeries. These ACOs will enter into 10 year, fixed price care delivery contracts to deliver specific services to specific populations.
The NHS SaHF project – unlike the STP – completely ignores social care, integrating healthcare and social care, mental health services and illness prevention. SaHF makes no reference to ACOs, which in future will be the sole care delivery vehicle. SaHF is run by CCGs with no formal management roles for Local Authorities, NHS Trusts and GP surgery federations. In fact SaHF follows the commissioner/supplier split laid down in the 2012 Health & Social Care Act. The STP requires Local Authorities, CCGs, Trusts, GP federations and other public and private bodies to all work together. In the STP all these bodies are peers in private ACO consortia and the commissioner/supplier requirements of the 2012 Health and Social Care Act are completely ignored.
It is perverse, utterly confusing and unproductive for NHS NW London management to attempt to run SaHF and the STP in parallel. STP is part of a 2016 national initiative and hasn’t had a chance to succeed or fail as yet. However the SaHF is a 2012 regional initiative which has been failing for over four years.
ACO Progress is Slow
Accountable Care Organisations (ACOs) are, apparently, the future delivery vehicles for all State funded care services. All 44 Sustainability and Transformation Plans (STPs) have ACO intentions ‘hidden’ inside them. ACOs will be private consortia of Local Authorities, NHS CCGs, NHS Trusts and federations of GP surgeries who will ‘enjoy’ long term, fixed price contracts to deliver specific care services to a well defined population. In North West London the contracts will be for ten years and the first ACO is likely to be for the care of the elderly.
On 31 March 2017, NHS England published a 75 page report entitled ‘Next Steps on the NHS Five Year Forward View’. In the May 2017 issue of this newsletter we’ll examine the GP and mental health aspects of this report. On the ACO front, new jargon appears in the report. It tells us that some STPs will become Accountable Care Systems (ACSs) in years 2017/18 and 2018/19. It’s clear that ACSs are just transition bodies prior to fully blown ACOs.
However there are no STPs identified as certainties for ACS status. Eight STPs are listed as ‘likely candidates’. None of them are in London. Overall these ACS intentions are somewhat lack lustre. Where is the brave new world of 10/15 year fixed price ACO contracts? Management consultants and then NHE executives have been beavering away on STPs and ACOs now for at least two years. The ACO Vanguards were announced just over two years ago. Just how long do these experts need to create the brave new ACO world? Realism however is alive and well in the report as terms like ‘complex transition’, ‘staged implementation’ and ‘working towards the ACS goal’ reveal the authors’ sensitivity about the scale of the ACO dream.
But all is not sweetness and light in the ACO firmament. Two recent stories catch the eye:
+ Torbay and South Devon Integrated Care Organisation Collapses
The Torbay and South Devon Integrated Care Organisation was set up in October 2015 as a Multi-Speciality Community Provider (MCP) flavour of an ACO. It used a system provided by US healthcare company Kaiser Permanente. Torbay and South Devon NHS Foundation Trust has pulled out of the MCP claiming its dislike of the ‘risk sharing’ element of the contract. Torbay Council has revealed a £12 million overspend by the MCP and has warned of substantial financial risk to the Council.
+ Northumbria Healthcare Falls At First Financial Hurdle
Due to go live on 1 April 2017, the launch of this ACO has now been postponed indefinitely. Northumberland CCG claims it is broke with a projected annual debt of £41 million. NHS England has also been caught telling the NCCG to refer only to an earlier estimated debt of just £5 million.
Only time will tell if the ACO will follow join the Rogues Gallery of NHS failures. At some future time will we add it to polyclinics, NPfIT, Mid-Staffordshire, care.data, Shaping a Healthier Future, the Better Care Fund and perhaps STPs themselves?
Lancashire County Council Planning to Annex 8 CCGs
Democratic accountability may well be alive and well in Lancashire where regional government is planning to run all care services in the future. According to Local Government Chronicle (23 February 2017) Lancashire County Council (LCC) commissioned PricewaterhouseCoopers (PwC) to propose a way forward for running care services. PwC proposed the creation of five integrated care providers, with LCC being the ultimate boss. The eight Lancashire CCGs would effectively be annexed. LCC seems keen on the proposals but NHS bosses are seemingly not impressed.
30,000 Excess Deaths in 2015: Researchers Conclude Cuts in Care Costs is the Main Cause
There was a significant increase in mortality across England and Wales in 2015. At 30,000 excess deaths this was the largest recorded increase in mortality since 1945. These deaths have been analysed by the London School of Hygiene and Tropical Medicine, the University of Oxford and Blackburn and Darwen Borough Council. The analysis was published in the ‘Journal of the Royal Society of Medicine.’
The excess deaths were largely in the older population who are the most dependent on health and social care services. The researchers found that NHS data revealed clear evidence of health systems failures. Almost all targets were missed including ambulance call-out times and A&E waiting times, despite unexceptional A&E attendances compared to previous years. Staff absence rates rose and more posts remained empty as staff had not been appointed.
The researchers say that there are already worrying signs of an increase in mortality in 2016. Without urgent intervention, they say, there must be a concern that this trend will continue.
It’s hard not to conclude that implementing STPs to cut £22 billion off the annual healthcare services bill by 2020/21 will lead to much greater increases in annual excess deaths.