What, When and Where is Out Of Hospital (OOH) Care? – October 2017


Issue: 53

17 October 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.


What, When and Where is Out Of Hospital (OOH) Care?

According to the 2012 NHS North West London ‘Shaping a Healthier Future’ (SaHF) programme OOH is:


‘All those services provided in community settings such as in your home by community nurses, at your GP surgery and in health centres. It also includes all the ways that you can ‘look after yourself better’. According to SaHF it could include services in a ‘Local Hospital’. Apparently GPs will be at the heart of delivering OOH.


OOH seems to be pretty much the same as ‘community based services’, ‘community services’ and ‘Whole Systems Integrated Care (WSIC)’. All four terms are seemingly used interchangeably throughout ECCG/NHS NW London publications.


After five years of trying to deliver SaHF OOH, NHS Ealing Clinical Commissioning Group (ECCG) has decided to ‘throw in the towel’ and outsource OOH for 10 years to some as yet to be appointed ‘single lead supplier’. ECCG wants a single point of access for the 76 different service providers involved. A 35 page ‘Prospectus’ about community services has been published. Private briefings were delivered by ECCG to interested parties in late September and early October 2017.


On the subject of SaHF health centres, we might usefully review where SaHF is with healthcare ‘hubs’. There were going to be five in Ealing originally but this then went down to three. Clearly one new hub will be in Greenford at some point by 2023 using developer taxes from the Greystar mixed use development on the old GSK/J. Lyons site. (This hub will be shared with Hillingdon’s residents). One of the others will be what’s left (by 2021) of Ealing General District Hospital after all its life saving services and facilities have been closed down. The other will be a new build (or re-purposed) facility somewhere in East Ealing.


Some questions and observations which come to mind include:


+ Why a 10 year contract? Surely the typical NHS ‘tenure’ contact period is five years. It’s five years for CCGs, STPs and NHSE’s Forward View.


+ If this single lead supplier approach to OOH/Community Services is so right for Ealing, why will it not apply across the whole of the NHS NW London/NWL CCGs’ cabal domain?


+ If this single lead supplier approach is so right why was it not part of the five year NHS NW London STP?  None of the five STP Delivery Areas is for OOH services.


+ If the single lead supplier who is chosen is a private company then some of the money that would have been spent on OOH services will be creamed off as profit.


+ Why the continued secrecy about the location of the East Ealing hub?


+ Surely the current flavours of the month for business models are the Accountable Care Organisations (ACOs). There are plenty of them, including ACS, ACP, MCP and PACS. Why isn’t the ECCG OOH business model one of the flavours of ACO?


+ How will the contract value be calculated? Again, the current ACO approach is using a  ‘Capitated Budget’. Using this approach you take the GP list population of 426,000 and multiply that with a cost/head/year (e.g. £1,000) and you then multiply that by 10 (years) and arrive at eg £4.26 billion.


+ On 16 December 2016 NHS NW London SaHF announced it was asking H.M. Treasury for £513 million for building work in ‘Outer NW London’. Some of this cash would be used to build/re-purpose/extend hubs and selected GP surgeries throughout Ealing. It’s 10 months later and no response has been forthcoming from H.M. Treasury. Presumably without these new/expanded facilities the new NW London OOH single lead supplier will not be able to actually deliver what’s needed come contract start date of 1 April 2018.


UCC Outsourcer Vocare Ltd Suffers the Indignity of its St Mary’s Hospital UCC Going into CQC ‘Special Measures’ and Being Sold For a Song to Totally PLC

In July 2017 St Mary’s Hospital Urgent Care Centre UCC) in Paddington was rated ‘inadequate’ by the Care Quality Commission (CQC). Up until April 2016 the UCC had been run by hospital staff. But Central London Clinical Commissioning Group (CLCCG) took the contract away from the NHS and gave it to Newcastle based Vocare Ltd. CQC has now placed the UCC in ‘Special Measures’.


Vocare is a supplier of UCC, 111 NHS telephone and GP out-of-hours services. No stranger to controversy, Vocare caused public concern when confidential documents became public in 2012 revealing it was experiencing ‘issues’ with its 111 NHS North East telephone service. It was also fined £141,281 for failing to meet NHS Tees contract conditions for a GP out-of-hours service.


Almost co-incidentally (or possibly not) London based Totally PLC has purchased Vocare Ltd in October 2017 for £11 million. In 2015/16 Vocare had a turnover of £77 million. These two figures only stack up if Vocare was making only small profits or worse it was in all kinds of trouble. Mere speculation, of course, on my part as a retired businessman.


Totally is a small AIM listed company. It missed the deadline for filing its 2015/16 accounts at Companies House. Totally’s web site lists Declan Gilhooly as Head of Finance but Companies House, again, show that he left the company in March  2017, having been in post for just five months.


One does wonder what kinds of due diligence was undertaken for CLCCG to hire Vocare in the first place. In the Tot–ally acquisition of Vocare we see just one of the liabilities of the NHS awarding a contract to a private company. That a company can be bought by another company and the NHS and citizens have absolutely no say or oversight on the suitability and financial probity of the new service supplier.


Thanks to Anne Drinkell, Tony Brewer and Colin Standfield for information and research on CQC, Vocare and Totally.


The National Mental Health Crisis

+ Health Secretary Jeremy Hunt MP has promised that sometime over the next four years an additional £1.3 billion will be invested annually in mental health services. This money is needed now. Also there is no commitment for extra money after 2021. It is just not credible to run a national mental healthcare service using such a short planning window as five years.


+  One in six adults in the UK are currently suffering from mental health problems. That adds up to 8 million adults (Mind, Mental Health Foundation (MHF)). To put the scale of this into context, in 2015 it was estimated that 2.5 million people were living with cancer in the UK (Macmillan).


+ 1.2 million people each month use the NHS mental health services. (NHS Providers, 2017). This suggest that many suffers are not presenting themselves to GPs.


+ 50% of adults aged 55 or over have experienced mental health problems. 7.7 million suffered with depression and 7.3 million suffered with anxiety. (YouGov research for Age UK, October, 2017)


+ One in ten children currently have mental health problems. (MHF). There are one million children with diagnosable mental health problems. (Centre for Economic Performance (CEP)).


+ 80% of young homeless people have a mental health condition. (National Audit Office, 2017)


+ In 2014/15, 1,180 students left university early because of mental health problems. In 2009/10 the number was 380.


+  Mental health problems are the largest burden of disease in the UK. They are 28% of the total. Cancer and heart disease are each 16% of the burden. (MHF, 2015).


+  In 2015/16, the NHS plan was to spend £11.7 billion on mental health services. No-one is quite certain whether all this money was actually spent on mental health commissioning. (NHS England). However assuming this was the mental health spend, this represents just 10% of the total annual NHS spend.


+ Of the 3,500 ‘locked rehab’ mental health patient beds, 2,500 are in the very expensive, ‘unscrutinisable’,  private sector. (The Guardian, 16 October, 2017)


+ Only 15% of adults with depression and anxiety disorders are offered National Institute for Health and Care Excellence (NICE)-recommended psychological therapies. (CEP).


+ The number of people detained under The Mental Heath Act 1983 has increased every year since 2007. (The Guardian, 11 October 2017).


+ Mental health patients having to travel miles – sometimes 100s of miles – for ‘out-of-area placements’, because no beds are available locally, have increased by 40% in two years. (NHS Providers).


+ Only 25% of children with mental health disorders receive NICE-recommended treatment. (CEP).


+ There are just 1,440 NHS mental health hospital beds for children in England. (NHS England, 2017). In 2014/15, 10,132 children were admitted to hospital for a mental health illness. (Public Health England).


+ 37% of girls aged 13 and 14 years old had three or more symptoms of psychological distress. (Department of Education, September 2016).


+ Mental health research receives 5.5% (£115 million) of the total health research budget (MHF). Cancer Research UK (CRU) alone spent £666 million on research in 2016/17. (CRU).


+ 10,000 mental health jobs have been axed since 2010. (The Guardian, November, 2016)


+ 70 million days are lost from work each year due to mental illness. (MHF, 2015).


+ Bad mental health costs our economy £10 billion each year in extra physical healthcare due to mental illness. (CEP).


+ Nationally Police receive half a day’s training in mental health.


+ In 2015/16 the Met Police handled 115,000 telephone calls relating to mental health. This volume of calls is up by a third since 2011/12. (Labour Party FOI response, August 2017)


Ealing’s Mental Health Crisis

+ There are 420,000 patients registered with Ealing’s 76 GP surgeries. (Ealing GP Federation). Ealing GPs now provide mental health Primary Care. (Ealing Clinical Commissioning Group). 78% of Ealing’s population (327,600) are adults. (London Borough of Ealing). This means that 54,600 Ealing adults are currently suffering from mental health problems. If they were all to present themselves to an Ealing GP surgery, each surgery on average would/could be swamped with 718 mentally ill adults. If we do the same calculation with children, each surgery would have 92 mentally ill children potentially presenting themselves.  


+ There are just 33 Acute mental health beds in Ealing at St Bernard’s Hospital.


+ Ealing Police have been complaining about the lack of available Ealing Hospital beds for patients Sectioned under the Mental Health Act.


+ By 2021, Ealing Hospital will have no A&E services so there will be nowhere in Ealing for mental health patients to be referred/assessed or be medically cleared before they could be admitted to St Bernard’s Hospital 136 suite (for those sectioned under the Mental Health Act).


+ There is no NHS Mental Health Mother and Baby Unit in Ealing.


+ West London Mental Health NHS Trust (WLMHT) provides Secondary mental health services to Ealing residents. For each of the last two years it has received a poor CQC inspection report. In 2017 nine of its eleven core services were rated ‘Requires Improvement’ (CQC).


+ Staff numbers at WLMHT have still not recovered to their 2014 level of 4,000. In 2017 they are 3,325 (WLMHT Annual Reports).


+ A WLMHT Director’s total remuneration in 2016/17 was between £455,000 and 460.000. Her pension pot at 30 March 20917 stood at £1.619 million (WLMHT 2016/17 Annual Report).


ECCG Signs Up With 7 Other CCGs As Regional Healthcare  Purchasing ‘Partner’ With Seemingly No Parliamentary Legitimacy for Joint Commissioning

Starting at 8:45am in Ealing Town Hall on Wednesday 27 September 2017, I sat through 90 minutes of a public Ealing Clinical Commissioning Group (ECCG) meeting in which – unusually – some difficult questions were asked by members of the ECCG Governing Body.


Under discussion was a 12,000 word CWHHE paper on regional CCGs working together. CWHHE is a cabal of north west London CCGs – Central London, West London, Hammersmith & Fulham, Hounslow and Ealing. Ever since the Health and Social Care Act 2012 created CCGs, ECCG has been quite obsessed about working with other CCGs. Various CCG cabal flight formations have been attempted over the last five years. I’ve have often wondered why they were doing this and whether these CCG ‘super groups’ had any statutory legitimacy.  


Now, apparently, these CCGs want to organise more formally so they can collectively purchase healthcare services across their various geographies in NHS NW London. This is all very confusing  For 4.5 years I have sat in public ECCG meetings and been preached to about how local GP led CCGs made of local GPs with local healthcare knowledge were purchasing local services. Now these local GPs will gang up together to purchase regional healthcare services.


The CWHHE paper tells the reader that the reasons for acquiring this regional purchasing role are responding to patients, improving patient care, increased collaboration benefits, supporting Primary Care purchasing, sharing capacity and capability, and enhanced clinical leadership. To this end CWHHE wants to create two new posts – an Accountable Officer for the region and a Chief Financial Officer for the region. I suspect with a healthcare purchasing budget of £100s of millions these posts will command huge salaries.


CWHHE CCG’s Chief Officer Clare Parker’s take on this was that it’s all about the patient perspective, an ageing population, challenges for GPs and money. Dr Mohini Parmar, the local CCG boss and regional STP boss, chipped in with reasons of patient flows, finance and effective work.


The regional purchasing ‘function’ is to be run by a CCG representative committee of 17 or maybe 24. An independent chair would be appointed for at most the first 12 months.


Over a period of an hour there were a torrent of questions – many of them ineffectively answered – covering finance, organisation, legal issues, conflicts of interest, balancing local concerns with regional concerns, duplication, accountability, public access and regional purchasing policies. Clear answers to some of these questions were thin on the ground. Dr Parmar’s and Ms Walker’s favourite response was ‘…that’s a really interesting/challenging governance issue…’.


One persistent questioner (whose identity is not revealed on the ECCG web site) kept asking ‘where’s the glue that will make all this happen?’ She never got her answer.


Lay member Philip Young made some seven points, most of which seriously questioned the viability, accountability and effectiveness of the CCG/regional board dichotomy. His most impassioned plea was along the lines of ’..how do we stop CCGs imploding if regional decisions go against them’.


I observed that what was being created was some kind of regional health board. Oh no said Parmar/Parker. I then said in my experience when businesses merged the new merged entity had to make decisions which at times would not benefit one or more of the merge businesses. But, said Parmar/Parker, we are not merging businesses. I pointed out that I was not aware of any primary Government legislation which supported what was being proposed in this meeting. No response from anyone to that one. My final comment was that I had recently studied the South Yorkshire and Bassettlaw (SYB) STP Proposals to create a regional Accountable Care System with each of the constituent  CCG towns forming Accountable Care Partnerships. If what was being proposed by ECCG for the region was on similar lines to SYB why not be honest enough to admit this. Oh no – this is not anything to do with Accountable Care Parmar/Parker said. This final comment had a hollow ring to it as sitting in the public space with an anonymous presence was David Freeman. In 2016 he was billed as NHS NW London’s Accountable Care expert and is now billed as NHS NWL’s ‘Director of Development’.


Missing from the deliberations was any mention of social care. The STP and ‘Shaping a Healthier Future’ were each mentioned once. Mental health was mentioned just twice and attracted Dr Parmar’s possibly massive understatement of ‘..needs some more working through…’.


Finally Dr Parmar strongly hinted that CWHHE was regarded as a national ‘thought leader’ in CCG collaboration and the move towards joint commissioning. Make of that what you will.


Under Pressure Ealing GPs Now Have a New 107 Page Contract To Wrestle With

When I last worked for someone else – in the early 1980s – my

‘contract’ was two pages of paper on which my role was defined and the terms and conditions of my employment were spelt out. In my own business (1983 to 2004) the longest client contract we signed was 10 pages long. How things have changed.


The 76 Ealing GP surgeries historically signed a ‘contract of employment’ with NHS England (NHSE). But they don’t all ‘enjoy’ the same contract. There are three contract types and they are General Medical Services (GMS), Personal Medical Services (PMS) and Alternative Provider Medical Services (APMS). Not simple eh? To further complicate things, in 2017 Ealing Clinical Commissioning Group (ECCG) ‘acquired’ these contracts from NHSE.


Now these surgeries have another contract to deal with, as well as their GMS/PMS/APMS contract. This new ECCG contract is an 107 page long work-in-progress and is (bizarrely) called ‘The Ealing Standard’ (TES). In implementing this contract (sorry standard) ECCG says that patients can expect improved access, better health outcomes, a more resilient General Practice, consistency, and long term sustainability. (The last expectation makes me wonder just what ‘short term sustainability’ might actually look like).


NHSE has grant funded Ealing GPs with an additional 11.8 million from March 2018 to 2021. There are other bits of cash also – £1.7 million extra up to 1 April 2017 and £11.4 million from then to 30 March 2019. If I understand the figures (possibly unlikely) on a pro rata basis each GP surgery will receive an additional £80,000 of funding each year for the next four years.


Some features of this TES contract and the machinations around it include:


+ Immediate opening hours and appointments available to see a doctor or a nurse from 8am to 8pm at just three of the 76 GP surgeries in Ealing. This only applies to the 430,000 patients registered at the 76 GP surgeries.


+  The whole raft of extra work demanded (except improved access at three surgeries) will have to start on 1 April 2018.


+ By April 2020, all Ealing GP surgeries will be operational 8:00am to 6:30pm Monday to Friday.


+ Half Day closing is abolished


+ There is an ECCG Steering Group charged with making all these changes come about. At 21 strong it would appear to be too large.


+ The Local Medical Committee (LMC) has submitted 84 written queries about the standard. (LMCs are the statutory bodies which represent the interests of GPs and GP surgeries)


+ Future payments to GP surgeries will be based on the Thatcherite principle of meeting targets. Keeping it complicated there are three different payment regimes:

  • Capitation-based
  • Activity-based
  • Prevalence-based


+ The NHS jargon for targets is KPIs (Key Performance Indicators). Some of the KPI weightings are mind-bogglingly vague and esoteric. They include effective care, difficulty to implement, patient experience, clinical impact elsewhere, financial impact elsewhere and collaborative working.


+ There are 23 care ‘standards’and 51 KPIs related variously to them. ‘25% of capitated activity is subject to a KPI payment’ (whatever that actually means). There are KPIs for ‘access’ and also the threats of ‘mystery shoppers’ There are pages and pages on payment distribution, schedules, monitoring and disputes. The level of complexity is surely not helpful, sensible or justifiable.


+ ‘Standard1: Adult mental health: serious long term mental illness & complex common mental illness.’

There are 3.5 pages of detailed ‘standard’ expectations of GP performance which, after 20 years of my wrestling with Primary and Secondary mental health services in Ealing, I find to be totally unrealistic. Anecdotal evidence reveals that many Ealing GPs are not trained to diagnose and treat serious, complex mental health conditions. The evidence also suggests that a significant number are not disposed to want to attempt to deal with the mentally ill. This is all very dangerous ‘pie in the sky’.


+ There is a ’Homeless Standard’. This is aspirational and in places unrealistic. It’s expected a GP will discuss the person’s housing status, financial issues, legal issues, reconnection, educational and employment support. I find this hard to accept as a professional healthcare role for a GP. Surely these are social care issues which should be handled by a trained social care specialist. Would a GP have time to do this anyway? BTW the published TES tariff for ‘care for homeless is £16:25p for 10 minutes of consultation’…..


+ There are long prescriptive ‘standards’ on medicines, safety, optimisation, drug monitoring, patient experience, diabetes, respiratory disease, cardiovascular disease, musculoskeletal health, Ring pessary, care planning and co-ordination, end of life care, wound care, phlebotomy, Dementia, cancer screening, immunisation and vaccination, health improvement in children, self care and learning disabilities.  


+ ‘Standard 22: Demand Management’.This is jargon for refusing NHS healthcare to a patient. TES states ‘The NHS is not obliged to provide every treatment that a patient, or group of patients, may demand’. What a fatuous red herring this is. The Hounslow CCG web site, apparently, explains the rationale and mechanics of treatment refusal. And of course we have the well established Ealing Referral Facilitation Service by which a GP can overrule your GP’s referral to a consultant or to a hospital.


+ There are education and training requirements


+ There are numerous ‘capacity’ targets.


+ Omissions from the TES list include requirements for maternity, HIV/AIDS, liver disease, sexually transmitted diseases, Tuberculosis and mental health carers.


My overall feelings about the contents of the 107 page TES include:


+ Will they inspire, depress or put off existing Ealing GPs and potential future Ealing GPs?


+ How did Ealing GPs manage without these requirements in the past?


+ How much extra clinical and administrative work will TES demand?


+ Anecdotal evidence suggests the Ealing GP Practice Managers are fully extended as it is. Will Ealing GP surgeries have to pay for additional administrative resources?


+ Is TES more about saving money than improving services? Or is it, like the failed NHS NW London Shaping a Healthier Future’ and the stuttering NHS NW London STP initiative, an amateur attempt likely to fail on both counts.