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.
Has NHS England awarded Six Integrated Care (ACO) Contracts to Five Foreign, Private Companies?
Veteran NHS analyst John Lister and 38 Degrees are both quoting ‘Healthcare Europa’ who apparently stated that Simon Stevens has awarded six Footprint/STP Accountable Care Organisation (ACO) contracts to six private healthcare companies. The only company named in the publication is OptiMedic of Hamburg. OptiMedic describes itself as an Accountable Care development and delivery company with a close working relationship with Imperial College Healthcare Partners (ICHP). Ealing Clinical Commissioning Group is one of the 20 ICHP partners. The other five private ACO companies are apparently American.
I wonder whether one of the five American companies is Centene Corporation of St Louis, Missouri. Via outsourcer Capita, Centene has been awarded a £2.7 million ACO contract in Nottingham. Centene is heavily involved in running Medicaid programmes in 20 American States and has annual revenues of over $40 billion.
A Cabal of NW London CCGs Rushes to ‘Enable’ Regional Bosses to Run Regional Commissioning
A sudden rush of hastily convened local CCG meetings has been set up in Ealing and in other NW London towns in order, seemingly, to ‘bless’ the concept of a single ‘Accountable Officer’ (AO) and a single Chief Financial Officer (CFO) for the region. In Ealing the meeting starts at 8:45am! Ealing’s CCG region seems to be an amalgam of Central London, West London, Hammersmith & Fulham, Hounslow and Ealing.
It’s always amazed me why these cabals of CCGs exist at all. Surely the CCG dream was local GPs purchasing local services armed with their local knowledge. Now we are about to have a single regional AO and CFO for 2.1 million people. Why?
Could it be that this is all under the radar manoeuvring as part of setting up a regional ACO or multiple ACOs across NW London?
Ealing CCG and London Borough of Ealing (LBE) Involved in International Trawling For Interest in Bidding for £Multi-Million Care Contracts
Research into the EU publication ‘European Procurement’ by Oliver New of Ealing Save Our NHS has revealed that Ealing Clinical Commissioning Group (ECCG) and LBE
are touting for private companies across the world to potentially bid for the following:
Date: Contracting Body: Service: Value: Duration
01/2017: H&F CC Telemedicine: £15M Unspecified
12/2016: LBE: Home Care £22M 10 years
09/2017: ECCG Out-Of-Hospital * Unspecified 10 years
09/2017 NWL CCGs Care Home Services ** £130M Unspecified
*Potential suitors pitching to ECCG in Ealing on 19 September and 4 October 2017
**Potential suitors pitched to the NWL CCG cabal on18 July 2017.
Not much of this has been heavily publicised (or publicised at all) by the contracting bodies. Such secrecy fuels the flames of distrust between citizens and those elected to represent us and those appointed by Government to serve us.
NHS England Director Professor Keith Willett Thinks NHS Folks and Social Care Folks Don’t Understand or Trust Each Other
On 12 September 2017 I attended a packed audience in Pop-Up University, PUU5 Stream at the NHSE Innovation extravaganza in Manchester. The topic was ‘Local Government and the NHS: are they serious about working together’. The main speaker was Professor Keith Willet. Professor Willett is an NHS veteran. He is the NHSE Director for Acute Care and leads the transformation of urgent and acute care services across England.
His comments lit up the ‘pop-up’ room.
He kicked off by pointing out that £1 billion had been removed from financing social care services over the last six years. Then he threw in the organisational mismatch between appointed NHS folks and Elected Members’ controlled Local Authority (LA) social care folks. He then said that Local Authorities were a Venn Diagram. People like me in the audience with just ‘O’ Level Maths were confused. In the comfort of my home some days later I asked Google to define a Venn Diagram:
‘A diagram representing mathematical or logical sets pictorially as circles or closed curves within a enclosed rectangle (the universal set), common elements of the sets being represented by intersections of the circles’.
I can only conclude that this mathematical reference was the rather serious Professor’s attempt at humour. What came next was no joke. He stated that the culture, language, attitudes and bureaucratic differences across both care worlds are immense. Tribal concerns dominate. Both care worlds need to mature and build understanding and trust together. Everywhere ‘co-production’ was being attempted.
NHS people don’t understand Social Care people – he claimed. No-one in the audience jumped up to dispute this.
He then threw out some questions about the size and ‘primacy’ of both care sectors:
Who has the most beds, the most staff and the most power? The numbers he then came out with were very revealing:
+ NHS – 100,000 beds: Social Care – anywhere between 300,000 and 500,000 beds
+ NHS staff – 1.3 million: LA Social Care staff – 1.5 million
+ 7,500 independent GPs: 8,500 Social Care domiciliary staff
+ NHS STP bosses – NHS 44: LA Social Care – 1.
As for Delayed Transfer of Care, 10 days in hospital for an elderly person results, on average, in a 10 year reduction in life expectancy. (Wow!)
Then came his pleas:
+ Why can’t we (healthcare and social care) share information? Why are we continuously and continually re-keying the data?
+ Why do we have too many different financial/costing/purchasing approaches – some per head, some as block contracts , some as activity based costings etc, etc?
+ NHS and Local Authorities can only work together if they trust each other – but do they?
+ Everybody needs to open up their financial books and openly share the data – but do they….will they?
The NHSE Innovation Expo held at Manchester Centre on 11/12 September 2017 must have cost someone (us?) a fortune. 170 exhibitors, 264 free-to-attend conference presentations across 16 streams.
Will South Yorkshire and Bassettlaw’s Accountable Care System and its Five
Accountable Care Partnerships be Ready to Launch For Real on 1 April 2018?
STP Footprint no:9 is South Yorkshire and Bassettlaw (SYB). Its Sustainability and Transformation Plan (STP) is scheduled to be implemented with an Accountable Care System (ACS) and five Accountable Care Partnerships (ACPs) on 1 April 2018. Operating now is a Shadow ACS and (possibly) five Shadow ACPs, which are variously described in a 30 page ‘Memorandum of Understanding: Agreement’ (MOU) dated June 2017.
The MOU tells quite a lot, but a lot is also missing. These first thoughts on omissions and observations include:
- The goals and aspirations contained within the MOU are indeed worthy ones. However from my perspective it is the mechanics and details on how these aspirations will be met which are suspect or indeed missing from the MOU.
- When and how will the Capitated Budgets (‘population budgets’ in SYB-speak) be set for the SYB ACS and the five SYB ACPs?
- What are the annual 2021 cost saving targets for the SYB ACS and the five SYB ACPs. (On a pro rata basis, SYB’s annual share of the NHSE FYFV national annual £22 billion savings would be some £600 million).
- What sophisticated software will SYB deploy to run the SYB ACS and the five SYB ACPs?
- Who will be the CEO of the SYB ACS business and the five SYB ACP businesses?
- Who will choose and appoint the six Accountable Care CEOs?
- Will the six Accountable Care contracts operating from 1 April 2018 be for 10 or 15 years?
- To whom will the SYB ACS CEO report?
- How can any rational person have any confidence in this MOU which admits not to be a plan or a legal contract or to have any statutory basis. The SYB MOU throws around the words ’partner’ and ‘partnership’ like a drunk chucking confetti around at a wedding party. My business background reminds me that partnerships are all about sharing profit, loss and risk. I am astonished at the possibility that 28 public bodies would enter into formal business relationships with each other to share profits, losses and risk – especially given that the MOU content consistently trashes some of the strictures of the Health and Social Care Act 2012.
- It’s a sobering thought that if SYB is viewed as a thought leader/pioneer of ACSs in England it still needs capital and revenue grants to support it until 31 March 2019
- There is plenty of motherhood and apple pie in the MOU. For example on page 6 it states ‘…to enable safe, sustainable and equitable hospital services across SYB..’. Surely such a platitude is outside the gift of the SYB ACS? For starters, with national NHS staff vacancies running at 85,000, on a pro rata basis SYB has staff vacancies of 1,913. The National Care Homes Association estimates we will soon need 71,000 more care places. On a pro rata basis that means SYB is short of 1,613 care places. Hospital bed blocker monitors please note. On the mental health hospital bed blocking front, 17,509 bed days were lost nationally in October 2016. Annualise that and you get to 211,100 bed days lost. Pro rata that for SYB and you get to 4,797 hospital bed days lost annually owing to the inability to discharge mentally ill patients.
- At 1.12 we read about ‘…an altruistic approach to each other as partners working as one’. This all very inspiring but it surely cannot be the basis for an operational and organisational strategy. ‘…putting the needs of individuals, patients and the public before organisations…’ is clearly a recipe for organisational chaos.
- The MOU is remarkably ‘light’ on including and defining Local Authority (LA) and social care roles and responsibilities. At 1.17 there is a reference to ‘separate and specific agreements with …local statutory organisations’. One of the big national goals of STPs is the integration of (NHS) healthcare services and (LA) social care services. These NHS/LA agreements will be complicated and contentious to draft, agree and implement. No wonder the MOU steers clear of them!
- At the end of Section 6. is an extraordinary ‘Overarching Principle’ – ‘All organisations will retain their current statutory responsibilities’. How that sits with the ‘altrusitic approach’ set out in 1.12 beggars belief. Imagine you are a cricket club groundsman. Because, through an ‘altruistic approach’ by club management, you help the coaching staff, help with making the players sandwiches and spend time looking for a lost cricket ball, you fail to apply the heavy roller to the pitch by 6pm – and you end up being fired.
- At 7.03 the MOU drives a coach and horses through the Health and Social Care Act 2012 by replacing the commissioner/service supplier split with ‘…collaboration and integration’.
- At 8.2 we at last have some substance on cost savings with references to reducing system demand (cancelling some GP referrals) and efficiency improvements. At 8.4 reference is made to ‘…reduce demand on A&E and acute beds’.
- At 8.3 GPs get another mention. Expanding ‘multidisciplinary care’ is emphasised – although when it came to specifics about numbers of (additional perhaps) clinical pharmacists, mental health therapists, physicians associates and GP nurses – it was a ‘TBA’.
- At 8.5 mental health is featured. ‘Alternative Commissioning’ and ‘System Commissioning’ are referred to. The latest (August 2017) issue of ‘NHS Care Models: ACOs and the NHS Commissioning Systems’ makes no reference to either of these terms. One can only suspect that alternative commissioning might mean involving the private sector. System commissioning may refer to ACS commissioning I suppose.
- Mental health provision in SYB is strange. There are no NHS Mental Health Trusts providing Secondary mental health services for 1.5 million residents. Consequently there is no mental health partner on the SYB ACS ‘board’.
- At 7.4 ‘Financial’ one might reasonably expect some figures here – maybe grant income, maybe Shadow ACS/ACPs actual or projected cost savings for 2017/18. but… no such luck. However there is a reference to a ‘..basket of efficiency indicators’ but there is no MOU commitment to adopt one……
- Why is there not even one care home group partner in the SYB ACS?
- Why is there no GP Federation partner in the SYB ACS partnership?
- Where does this organisational distinction between an ACS and an ACP come from? ACSs seemingly are single supplier-run whereas ACPs are run by consortia.
- I see no clues as to how the five ACPs relate to (report to?) the Footprint/STP ACS
- The MOU keeps referring to itself as a ‘framework’ without defining what it means by this. Dictionaries are not much help here and ‘outline of anything’ can mean anything you want it to mean I guess.
- To give you some idea as to how complex and unwieldy the SYB/Footrprint/STP/ACS/ACPs management is and will be, there are 55 members on the Collaboration Partnership Board.
NHSE Tries to Position Accountable Care Organisations Within the Context of Clinical Commissioning Groups
NHSE in August 2017 published ‘ACOs in the NHS Commissioning System: Accountable Care Organisation (ACO) Contract Package – Supporting Information’. It is quite an extraordinary 25 page document. Right up front it states that ACOs will not change Clinical Commissioning Group (CCG) statutory functions – and then spends over 20 pages effectively refuting this.
In defining CCGs role in the ACO world, NHSE excludes the key word ‘purchaser’ completely! The document talks about working with grant-aided NHSE Vanguards which suggests to me that it’s a make-do document with a short life.
‘Pooled Budgets’ are discussed, under the aegis of the NHS Act 2006. An opportunity exists in the Act for NHS (healthcare) and Local Authority (social care) budgets to be ‘pooled’. However the document does point out that changes to Section 75 of the Act are needed for full ACO operational flexibility.
Now to the meat of the story. The bulk of the document is made up of two Annexes. In Annex A are listed and described a whole host of historic CCG responsibilities and how ACOs will ‘relate’ to them. In short ACOs will have a major role in ……subcontracting services, allocating CCG-level resources (through ‘Capitated Budgets’), configuring and providing services, implementing patient-centred strategies, addressing health inequalities, managing supply chains, creating and managing demand management, re-designing services, improving service quality, decision making relating to funding routes, pathway planning, ensuring patient choice, enabling personal health budgets, managing subcontractor contracts, sub-contractor quality management and responding to patient complaints.
Annex B maps out how ACOs can jump statutory CCG fences, crawl through regulatory NHSE tunnels and negotiate around the Act of Parliament Local Authority bollards.
Various ACO healthcare and social care flight formations are listed along with the tortuous list of potentially adverse Primary legislation weather patterns which need to be avoided when filing ACO Flight Plans.