City and Hackney Clinical Commissioning Group (CHCCG) to Test the Legality of STPs (and ACSs) in The Courts -September 2017

 

Issue: 52

September 2017

 

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. Increased financial funding is what is needed in our NHS – not financial cuts, closure of vital services or privatisation.

 

City and Hackney Clinical Commissioning Group (CHCCG) to Test the Legality of STPs (and ACSs) in The Courts

At last someone is going to law to test the legitimacy of a Sustainability and Transformation Plan (and consequentially its implementation engine an Accountable Care System). CHCCG is asking the Courts to decide whether its Footprint’s STP has any legal status or power to compel CCGs or other ‘partners’ to comply with major decisions. What kicked CHCCG into this action was a cabal of five Footprint CCGs wanting a single ‘Accountable Officer’ for all the seven CCGs in the Footprint.

 

Legal opinion from lawyers Hempsons includes the following:

‘The current health and care legislative framework is a brick wall that STPs and ACSs run into when they try to share decision making and join up services. It is designed for an inherently non-integrated, competitive, quasi-market’.

 

Watch this space!

 

Jonathan Bell, Chief Financial Officer , London North West Healthcare NHS Trust (LNWHNT), Total Remuneration, Financial Year Ending 31 March 2017:

 

£715,000 to £720,000

 

Extract from LNWHNT 2016/2017 Annual Report – page 106.

 

I thought at first that no editorial comment was required – but of course it is. The average annual remuneration in London is around £34,000 – outside London it’s around £22,000. So however hard and long hours worked by Mr Green those fire fighters, ground staff, caretakers, GP receptionists, PCSOs, nurses, teachers, journalists, junior doctors, grave diggers, hospital porters, bus drivers, and mid-wives working either in London or outside London earn at most 20 times less than Mr Green.

 

However, in an initiative the timing of which is almost beyond satire, LNWHNT has announced it is looking for 350 people to work for no remuneration whatsoever. The Trust’s Voluntary  Services Manager Shirley Hunte told the ‘Kilburn Times’ that LNWHNT was looking for people aged between 18 and 96 years old. (96??). They were expected to freely give of their time to welcome patients and visitors, help patients at meal times, and be patient companions providing interaction and guidance.

 

Now LNWHNT already ‘employs’ 200 volunteers in its four hospitals. From my experience some of these volunteers are retired professionals who have altruistic motives to help society. Some are lonely elderly people who enjoy the company. But surely the main point here is that we should be collecting and allocating adequate funding so that we are helped by paid, qualified and ideally experienced professionals. I paid my National Insurance for over 43 years and healthcare should be not only be free for me at the point of delivery, it should be delivered by a professional. What if there is some tragic accident in the hospital involving a volunteer? Could the volunteer be sued? Do volunteers take out insurance to cover this? I doubt it.

 

Notes From the Trenches

I recently visited Ealing Hospital accompanying a homeless, rough sleeper friend who had chest pains. He was weak and had to queue on his feet to be registered for triage at the Urgent Care Centre (UCC). Why is this? Why not a time  stamped, numbered, ticketing system so that patients could sit down and wait to be registered? Four burly Policemen had someone covered in blood and in custody and two of the Policemen also had to queue to have the miscreant registered. Madness.

 

After 5 hours of triage, heart and blood tests and diagnosis we had a happy ending as my friend had an infection and was given antibiotics and a puffer to help him breathe. The staff in the Chest Pain Unit were brilliant. However other experiences at Ealing Hospital on that day included:

 

+ A UCC person (private supplier Greenbrook Healthcare employee I guess) told my friend that subsequent to being treated in the hospital he should not come back but should visit his GP. My friend said he didn’t have one. She then told him that he needed proof of address and a passport to be registered and treated by a GP. This sounded wrong and during the day I checked this out with the NHS online. She was wrong – it’s the right of anyone (homeless or not) to register with a GP in England. The only caveat is if the GP list is full. He was give details of 10 local GP surgeries none of whom stated their list was full. A re-training issue here for Greenbrook

 

+ I picked up a copy of a free, full colour, 16 page tabloid called ‘Our Trust’. It was branded London North West Healthcare NHS Trust (LNWHT) but it did also bang on about the LNWHT Charitable Fund. I did find the pleas to give time and money variously to the Trust and its charity somewhat distasteful. After all I paid National Insurance for all those years for free healthcare from LNWHT and from the other 222 English NHS Trusts

 

Just what is the purpose of this publication? At whom is it aimed? On page 2 we have a bizarre piece penned by a LNWHT Human Resources Director on ‘..our new values..’. This is so offensive as I was reading this tosh standing in a District General Hospital which was given a death knell in 2012, had its Maternity closed in 2015 and its Paediatrics and children’s A&E closed in 2016. This from a key service supplier of an NHS region which promised and failed to save 4% on annual costs – but declined to admit this publicly until forced to by a Freedom of Information request. The phrase ‘..knowing the cost of everything but the value of nothing…’ springs to mind

 

There is some useful information in this publication but I feel I am being ‘sold to’. Surely not everything is as very wonderful as portrayed about Ealing, Northwick Park, Central Middlesex and St Mark’s Hospitals? What about transparency? What happened to honesty? If this is to be a regular quarterly publication we should all question whether this is a good use of public money. The Trust is one of the major service suppliers in the NW London STP Footprint which by 2021 has to reduce annual spending by £1.3 billion.  Just exactly how does spending money on this PR puff publication assist the cost saving mountain to be climbed?

 

+ Triage in the UCC is still in a public area. It’s at a counter a bit like a motorway toll booth or a McDonald’s drive through station. Surely triage must be housed in a personal interview room and not in the reception area? Also the person carrying it out must announce his/her status as someone qualified to carry out triage

 

+ I had a look at the Ealing Hospital UCC service supplier Greenbrook’s web site. It has an NHS web site address – www.greenbrook.nhs.uk  How can that be? Did the NHS purchase Greenbrook? I guess it must have done – although I don’t remember reading any press reports about this

 

+ £2:60/hour for car parking. Only new £1 coins accepted – and of course no change given. The ever wonderful ‘Friends Café’ (staffed by volunteers)  understandably ran out of change as countless non-mobile phone literate patients and loved ones wrestled with finding the right coins to feed the hungry parking machine beasts.

 

Medical Student ‘Drop Out’ Rates and the Number of Students with Untreated Mental Health Problems are Way Too High: 1,200 Drop Out Over  the Last Five Years

‘The Sunday Times’ of 27 August 2017 revealed FOI discovered data about the ‘drop out rate’ of medical undergraduates throughout England. It’s 10% and over the last five years. 1,200 did not complete their degree courses. This comes at a time when there are reports of increased mental health problems amongst medical students.

 

In September 2016 a DoE ten year study revealed that 37% of 14/15 year old girls exhibited three or more symptoms of psychological distress. This percentage was significantly lower for boys. In October 2016 NHS England and NHS Digital reported that self-harm had risen dramatically over the last ten years. The biggest rise was girls under 18 years of age. 13,853 girls poisoned themselves – a rise of 385%. Again the figures were lower for boys.

 

Set these almost epidemic levels of teenage mental health problems against the general chronic shortage of psychologists and the limited psychological support available in universities. What you get is that too many 18+ year old medical students – especially girls – are struggling with mental health problems, receiving inadequate treatment and failing to complete their degree courses.

 

Government Asks the Impossible of Local Authorities re: Social Care ‘Bed Blockers’ in Hospitals.

The Department of Communities & Local Government’s (DCLG’s) own figures reveal that social care funding given to Local Authorities (LAs) fell by 8.4% over the period 2010/11 to 2016/17. The cash loss was £1.3 (from £15.7 billion to £14.4 billion). From 2010 to 2017 the population of England rose by 2.1 million – from 52.6 million to 54.7 million (Office of National Statistics).

 

In August 2017 DCLG and the Department of Health (DoH) wrote to all LAs telling them to get social care ‘bed blockers’ out of hospital beds as soon as possible, otherwise they would be punished. Of the 152 LAs with social care responsibilities, 42 are required to reduce bed blocking by 60% or more. If they fail to reach the targets set they will receive reduced (or no?) extra social care grant funding in 2018/19.

 

No doubt those LAs who fail to meet these targets will be increasingly underfunded in 2018/19 and be unable to have social care bed blockers discharged from hospital – as the LA will have no cash to fund care home beds or care at home. As the government (McKinsey & Co) dogma is the reduce hospital beds by 40% anyway this will create a massive social care crisis. As ever with this Government, the largest number of sufferers, losers and life threatening service users will be the poor, the physically and mentally disabled, the vulnerable and the homeless.

 

The Brilliant 2014 ‘Barker Report’ on the Future for Care Services

Every now and then I stumble onto something which I like and want to support and promote. I was TV channel hopping early evening on 21 August 2017 and landed on the Parliamentary Channel. There, large as life, was Chris Ham boss of the King’s Fund talking about ‘Barker’ this and ‘Barker’ that.

 

I did some research on ‘Barker’ and tracked down the September 2014 report on the ‘Independent Commission on the Future of Health and Social Care in England’, chaired by business economist Kate Barker. It just blew me away.

 

Key Findings:

+  Single, ring-fenced budget for the NHS and social care, with a single Commissioner for local services

+ New care and support allowance – removing the battle lines between the NHS and Local Authorities

+ Much simpler pathway through health and social care which would benefit service users and carers

+ More equal support for equal need, making most social care free at the point of use

+ Rejection of new NHS charges and private insurance options in favour of public funding.

 

Policy Implications:

+ Significant re-engineering of Central and Local Government needed to facilitate a single, ring-fenced budget and a single Commissioner

+ Between 11% and 12% of GDP for care will be needed annually as  soon as possible to facilitate change and meet care needs

+ National Insurance contributions need to be increased to meet the annual £5 billion uplift to improve social care entitlements

+ Wealth taxation must been seriously considered as the means of generating additional resources that will be needed for health and social care services in the future.

 

Why oh why have these sensible recommendations not been implemented or at least investigated further by the Civil Service?

 

Private Hospitals Get £52 Million Tax Break: No Such Luck for NHS Hospitals

One in four private hospitals in this country (123 of them) are registered charities and as such have received rate relief amounting to £52 million. So says $177.5 billion turnover US retail pharmacy and healthcare company CVS Health  (www.cvshealth.com).

 

Nuffield Health, Britain’s third largest healthcare charity by income, will save £12.7 million in non-payment of business rates over the next five years. However in the NHS,  the University Hospitals of Birmingham Hospital Trust, for example, faces an increase of £2 million on its business rate for 2017.

 

US Accountable Care Organisations (ACOs) Have  Squandered Over $100 Billion on Software Investments – With Zero Return On Investment

US healthcare data warehousing products and services specialists Health Catalyst has strongly suggested that over $100 billion has been wasted on developing software to support Capitated Budget driven ACOs.

 

Health Catalyst’s opinions bear some weight as its software currently supports some 65 million patients throughout the USA. The company identifies five critical information system software elements for future ACO success. They are:

 

+ An Electronic Medical Record (EMR) used in a consistent and meaningful way across the Acountable Care (AC) enterprise to document patients’ healthcare status and treatment and support safe, evidence based care

+ A Health Information Exchange (HIE) to enable the sharing of patients’ clinical data across disparate EMRs in the AC enterprise

+ An Activity Based Costing (ABC) system to enable detailed, patient-specific collection of cost data that in turn enables the AC organisation to precisely understand cost of production and revenue margins in Capitated payment models

+ A Patient Reported Outcomes (PRO) system to enable the complete understanding of clinical outcomes and quality, from the patient’s perspective. This is not a patient satisfaction system – it is a critical outcomes assessment system, tailored to the patient and their protocols of treatment

+ An Enterprise Data Warehouse (EDW) system which is central to enabling the analysis of data collected in the information systems described above – and more. Without the EDW, the data collection systems described above are relegated to small or non-existent Return On Investment (ROI). It is the exposure and integration of the data in the EDW that liberates the ROI from those systems. It is common for EDWs to realise ROI as high as 450% in two years.

 

It seems the US market for EDW products is a rich one with over 40 vendors. However none of them, apparently, support ABCs and PROs (see above). In the UK it will be interesting to see whether indigenous software emerges to support ACO/ACS operations. Entering this world of sophisticated critical ACO/ACS information systems will not be for the faint hearted and only for those with deep pockets.

 

Health Catalyst has also developed a ‘Healthcare Analytic Adoption Model’. In this model at the bottom of nine levels (Level 0) are ‘Fragmented Point Solutions’. At the top of the model is Level 8 (Cost per Unit of Health Reimbursement & Prescriptive Analytics). Level 8 is also labeled ‘Contracting and Managing Health’. Level 0 is labeled ‘Inefficient , inconsistent versions of the truth’. One suspects that many NHS grant funded ACO/ACS experiments are currently at Level 0.

See www.healthcatalyst.com for more information

 

Greater Manchester (GM) Integrated Healthcare and Social Care Project is a ‘Work in Progress’

On 9 August 1944 I was born in Fairfield Hospital in Jericho, Bury, Lancashire – now in Greater Manchester. This small hospital may not survive in the progressive new world of CCGs, STP, ‘Healthier Together’, devolution and ACSs. That’s my personal baggage out of the way and now let me summarise what I learnt in Manchester, Salford and north Cheshire in August 2017:

 

+  No-one I met had any confidence that the £7.7 billion projected annual GM healthcare, public health and social care bill would be reduced by £2 billion by 2021.

+  There is little or no talk about Accountable Care Systems (ACSs) or in fact about the STP.

+  There were few words of praise for CCGs and there were clear doubts about their competences or in fact their probity

+  A feeling of ‘us all sort-of being it together’ did come across. The massive Labour Party domination in GM is, on balance, a big plus in trying to get NHS bodies, GPs and Local Authority bodies to work together

+  No surprises though to find deep seated Manchester v Salford wars, and Manchester city’s domination of proceedings

+  NHS bodies clearly have the whip hand in any integration initiatives

+  Social care and mental health did not figure prominently in the early proposals. I struggled to find out what the annual GM social care spend is. Annual Public Health and social care spend is £1.5 billion). There has been some turbulence in one of the mental health Trusts

+  There are pockets of successful healthcare and social care integrations, but none seem to declare any cost saving metrics

+  There are clearly some local successes which include medical records creation, maintenance and creative use of telemedicine in care homes, and Ambulance Service triage. But these are thin on the ground and by no means universally applied across the 493 square miles of GM

+  It’s felt that GM Mayor Andy Burnham genuinely supports the Devo-Manc Health project

+  The three NHS Vanguards in GM (Stockport Together, Salford Together and Salford and Wigan Foundation Chain) seem to be viewed as somewhat inconsequential grant funded ‘experiments’

+  A generally held view is that after-care and community support is inadequate. Following hospital discharge there’s evidence of a lack of co-ordination between primary care and secondary care and a shortfall in District Nurses and Health Visitors

+  There’s clearly an over-reliance on private care providers

+  The ‘normalisation’ of healthcare and social care integrated, cost-saving services across the region seems a long way off. It’s surely going to be over a year before even the beginnings of designing a process to set a C apitated budget for one or more ACSs will be feasible

+  What drives changes is the 2014 NHS ‘Healthier Together’ project. This is not all that different to the 2012 NHS ‘Shaping a Healthier Future’ (SaHF) project inflicted upon North West London. The cost saving plan is to maintain four major hospitals – three of which are confirmed but the fourth has been acrimoniously fought over. Threats and worries about down grading District General Hospitals and hospital A&E closures are all too apparent in press reports

+  It’s intriguing that the quoted GM annual healthcare spend for 2.8 million residents is £6.2 billion. However for NW London’s 2.1 million residents the annual healthcare spend quoted in the 2012 SaHF was £3.6 billion.