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.
NHS ECCG OOH Services, 10 Year, Single Supplier Contract ITT Issued: Contract Value Between £450 Million and £1.2 Billion
On 22 March 2018 the NHS Ealing Clinical Commissioning Group (ECCG) advertised an Invitation to Tender (ITT) for a 10 year, single supplier Out Of Hospital (OOH) services contract for Ealing The deadline for responding to the ITT is 21 June 2018.
The basic value of the contract is £450.2 million and it will run from 1 April 2019 to 31 March 2029. But that isn’t the end of the potential value of the contract. ‘Transitional’ funding of £47.4 million might be available as might the possibility of adding to ‘the contract scope by annual value of £79.9 million’. Add this lot up for 10 years and we arrive at a potential contract value of some £1.2 billion.
Of note is that Dr Mohini Parmar Chair of ECCG wrote on 8 September 2017 that the 2017/18 OOH services spend in Ealing would be £121.794 million. Over 10 years that would cost (excluding inflation) £1.2794 billion. If the basic cost of the contract (£450.2 million) is all that is spent over 10 years then there would have to be massive reductions in the quantity and quality of OOH services managed and delivered. Maybe if potential bidders think this might be the case, they will not bid.
Why No NELs Reduction Target?
ECCG Managing Director Tessa Sandell recently confirmed in public that no cost reductions would be targeted in the future management and delivery of OOH services in Ealing. The cost reductions would be achieved by reductions in Non-Elective hospital admissions (NELs). So, why one might ask is there no NELs reduction target for Ealing specified in the OOH ITT or in the supporting documents? By 2025/26 and beyond annually for Ealing there should be (pro rata) an annual reduction of 12,375 NELs.
If the NHS SaHF IMBC SOC1 Business Case Continues To Be Rejected, Is This OOH Services Single Supplier Contract a Non-Starter?
In 2012 NHS North West London (NWL) launched its ‘Shaping a Healthier Future’ (SaHF) project. Part of the SaHF plan was the closure of Ealing District General Hospital and the enabling of OOH services via the creation of Ealing community health ‘hubs’ and the expansion of some Ealing GP surgeries. The final SaHF business case for these OOH services changes was published in December 2016. In it (IMBC SOC1) was a request for £513 million for OOH services building work. In September 2017 this business case was rejected by NHSE/NHSI (London). Surely without this £513 million capital grant the OOH services contract is a non-starter?
Where are the OOH Social Care Services and the OOH Integrated Healthcare and Social Care Services in this ITT?
I’ve had a good look at the 36 OOH services listed in the OOH Contract Prospectus, and at all of the ITT supporting documents. The phrase ‘social care’ is hardly mentioned at all. The Government launched the programme to integrate health care services and social care services way back in 2010. We now even have a single Healthcare and Social Care Ministry. The 2014 NHSE Five Year Forward View and the 2016 NHS NWL Sustainability and Transformation Plan (STP) require integrated healthcare and social care services. In the supporting documents we have a paper on Clinical Standards, but no equivalent paper on Social Care Standards. This ECCG OOH services ITT is almost exclusively about NHS healthcare services. As such it’s a complete dinosaur.
Multiple Confusions About Accountable Care/Integrated Care Organisations
The ITT describes the OOH Services contract as’…a building block in the development of integrated care systems for Ealing in the support of the NW London Health and Care Partnership ambition for an integrated care system for NWL’. Now this is all over the place. The October 2016 NHS NWL STP makes no reference to integrated care systems (or their progenitor Accountable Care Partnerships (ACPs)) in Ealing. In fact the only ACP reference in the NHS NWL STP is for Delivery Area DA3 ‘Achieving better outcomes and experiences for older people’.
Where is the Evidence that a Single Supplier OOH Service in Ealing Will Be Any Better Than What We Have Now?
I understand that a business case exists to support this outsourcing move, but this is being kept hidden from the public. Surely the contents can’t be commercially sensitive and anyway public money is involved here and how and why it is planned to be spent should be publicly accountable.
NHS North West London (NWL) 2012 ‘Shaping a Healthier Future’ (SaHF) Still in The Doldrums
It’s now six months since NHS England (London) and NHS Improvement (London) said ‘no’ to the NHS NWL SaHF ImBC SOC1 business case, which asked for £513 million for building work. According to the London North West University Healthcare NHS Trust (LNWUHT) Strategy Committee meeting Minutes, the SaHF Programme Management Office team, the NHSI SOC1 Oversight Group, NWL Trusts and NWL CCGs are all attempting to justify the unjustifiable. SaHF predicts that if we do nothing there will be some 250,000 Non-Elective (NEL) annual NWL hospital admissions annually by 2025/26. ImBC SOC1 requires an annual reduction of 99,000 NELs by 2025/26. NHSE/NHSI state that no evidence has been presented by SaHF which justifies such a massive reduction in annual NELs.
But those pesky NELs keep on rising. LNWUHT Deputy Chief Finance Officer Bimar Patel stated recently that NEL activity rose every month between October 2017 and January 2018. It’s no better with social care and mental health bed blockers either. Delayed Transfers of Care (DTOCs) are not reducing significantly, and in fact beds are being opened rather than closed. In March 2018, LNWUHT Chief Financial Officer Jon Bell confirmed the Trust had planned for 40 (extra) beds for April 2018.
And there was no joy for NHS NWL in the 28 March 2018 Government announcement of NHS capital grants. Out of £760 million awarded nationally, NHS NWL will receive just £4.2 million. You have to ask yourself just how realistic is NHS NWL SaHF’s request for a capital grant of £513 million in the context of these recent awards.
NHS NWL Trusts Fighting Each Other or Working with Each Other to Try to Win the Ealing Out Of Hospital 10 Year, Single Provider Contract
LNWUHT, West London Mental Health NHS Trust (WLMHT) and Hillingdon Hospitals NHS Foundation Trust are all seemingly working on bidding for this contract which was advertised on 22 March 2018. WLMHT is seemingly pursuing discussions with Central and North West London NHS Foundation Trust and Central London Community Healthcare NHS Trust.
It seems extraordinary that WLMHT, which last year was found wanting by CQC in 9 of its 11 core areas of operation, should be considering taking on running over 30 primarily physical care services in Ealing. This would be on top of improving its mental health services in Ealing, Hounslow, Hammersmith and Fulham, and at Broadmoor.
I can just about remember a time when we had hospitals which just provided care for patients – and that was all they did.
NHSE/NHSI is Making Impossible Demands on Overworked NHS Hospital Doctors
An NHSE/NHSI letter dated 9 March 2018 to NHS hospital doctors instructs that every patient should be medically assessed each morning and evening by a senior doctor. The letter also tells hospitals to ‘boost essential services such as diagnostics and pharmacy at weekends to maximise Non-Elective (NEL) patient flows’. These orders are all about moving patients out of (expensive) hospital beds as soon as possible.
The 2014 NHS Five Year Forward View (FYFV) and all 2016 44 NHS Sustainability and Transformation Plans (STPs) require the NHS in England to collectively improve care services, achieve annual cost savings of £33 billion and a 3% improvement in efficiency – all by 2020/21.
In January 2018 the BMA reported that seven out of ten hospital doctors said there were gaps in the shift rotas in their departments. NHS Providers in March 2018 stated that 9,600 doctor posts in England were vacant. One does wonder whether pressurising and hectoring clinically under resourced NHS hospitals is an effective approach to help the NHS attain its challenging performance, financial and efficiency goals.
A House of Commons Library Paper Attempts to Describe and Explain the Accountable Care Organisation (ACO) Saga
Just as NHS England (NHSE) decides to ‘retire’ the term ‘Accountable Care’ and replace it with ‘Integrated Care’ the House of Commons (HoC) Library issues a paper entitled ‘Accountable Care Organisations’.
This 5 March 2018, CBP 8190, 16 page paper provides an interesting audit trail of decisions, opinions and facts about ACOs in England. However I find it thin on the ground in identifying ACO challenges. It does not get to grips with the enormity of integrating healthcare services with social care services. It does refer to IT, culture and mindset challenges, but it fails to mention the considerable dichotomies of business models and patient databases in NHS healthcare and Local Authority social care.
ACO Cavalcade Has Been Halted
The whole ACO cavalcade has had to be halted because of Government legislative
‘gaps’ being attacked by Judicial Review (JR) initiatives. On 25 January 2018 we were promised a 12 week public consultation on ACO, but none has been forthcoming. The Government said it wanted to introduce ACO enabling legislation in February 2018 – and this has just not happened. The Department of Health’s (DoH’s) edict that 20% of England’s population should be covered by ACOs/ICOs/MCPs/PACS in 2017/18 has also not been realised. The DoH call for this to be 50% coverage by 2020 is truly risible.
The August 2017 draft ACO contract is alluded to. The contract concepts of ‘full’, ‘partial’, and ‘virtual’ integration are repeated. I can’t help being reminded that it’s hard to be partially or virtually pregnant – and I suggest this also applies to integration.
All the eight grant-aided Accountable Care Systems ACSs (now ICSs) announced in June 2017 have been halted – no reason given, but the two JRs and missing legislation must be clues here. The grant aid for these ACS/ICS experiments is £450 million over four years.
The paper alludes to the riddles of ACSs/ICSs involving CCGs, whilst ACOs/ICOs do not; and ACSs/ICSs broadly relating to STP areas and ACOs/ICOs relating to (smaller) CCG areas.
Will ACOs Be the Death-knell for CCGs?
In ‘2. Role of CCGs’ we enter a surreal world of ‘children’ supposedly supervising their ‘parents’. If an ACO is awarded a 10/15 year, fixed price contract to provide integrated healthcare and social care to a defined population then, for this to make any sense at all, this ACO must be the commissioning body for all the care services. The CCGs and Local Authorities – sitting ‘below’ the ACO – cannot themselves commission these services as well. You can only have one ‘big boss’ and that clearly will be the ACO.
Jeremy Hunt MP is quoted as saying in 2014 that the 211 CCGs would be turned into ACOs. I see this as highly unlikely and what is more likely is that ACOs will make CCGs irrelevant and they will atrophy.
In ‘3. Legal Challenges’ the 999callforNHS JR will be in court on 24 April 2018 and the JR4NHS JR will be in court on 23 and 24 May 2018.
In ‘4.2 Role of GPs’ both ‘GP Online’ and the BMA are quoted raising concerns about the future role and status of GPs. Both worry about GPs losing their independent contractor status. NHSE envisions ‘multiple models of GP participation’ including partial and virtual integration. This sounds like twaddle to me.
‘4.3 Rationing of Service’ gets to the heart of the ACO raison d’etre – cutting costs. From my 21 years of running my own business I have never experienced a cost cutting initiative resulting in improved quality or quantity of service.