NHS senior managers and the medical director and clinical staff at Imperial College Healthcare NHS Trust assured the public in November 2017 that Charing Cross Hospital will not be downgraded or closed before 2021 nor "for the foreseeable future" due to the large and rising demand by patients with acute illnesses. But there has been no official retraction of the plans in "Shaping a Healthier Future" (2012) and the "Sustainability and Transformation Plan for NW London" (the "STP" - Oct 2016) to do just that at some time in the future. The NHS has lost over 50% of its beds over the last 30 years and the current national crisis is very largely due to an insufficient supply of hospital beds to meet acute demand from a growing and more elderly population.

The assurances from both NHS senior management (Accountable Officer Clare Parker and NHSI's query about SOC1) and the clinical management at Imperial Trust are as extensive and as solid as it is possible to give about Charing Cross Hospital "for the foreseeable future". They cannot guarantee Charing Cross Hospital beyond a period in which many scientific changes are going on around them. The clinicians are scientists and must evaluate these changes. But that doesn't let them off the hook for their acquiescence to the adverse effects of Accountable Care Organisations. 

There are huge changes going on in the NHS which the Government and the NHS have totally failed to explain to the public: improvements in medical science and in IT, many of which are positive, and changes in funding arrangements, especially the introduction of ACOs. ACOs will usher in regionalisation and privatisation as they implement "new care models" (ways of treating) in the STPs. STPs contain "local" statistics inserted in a Dept of Health national template and the private sector is specifically "encouraged" to bid for contracts for 200,000 patients for 10-15 years for £10Bns. The changes are huge, far greater than any previous NHS reorganisation although they are a further step in the same direction of travel. And they are irreversible because in English law private contract law takes precedence over public law. ACOs are a form of regional (STP "footprint") outsourcing - privatisation - and a step in the financialisation of health services which has already happened in other public services.  At national level the NHS concepts of "risk stratification" and demographic "packages of care" are borrowed from the insurance and finance industries. Medical, IT and funding changes are, of course, interacting.

Medical science and IT - population medicine:

The scientific changes depend on information technology and science applied at population level. The NHS takes a paternalistic approach and thinks that the public mostly distrusts information technology unless it is an "app", and certainly does not understand statistics. These changes are only just becoming visible in health care practice world-wide after years of development in the US. They are only described in specialised journals or, in outline form, in NHS management briefings. For example:

Software is being rolled out to GP surgeries to instigate and maintain "watching briefs" on populations of patients with long-term conditions. Right now the national WSIC "Care Professionals Dashboard" carries the NW London Collaboration of CCGs logo - User Guide v5 - and it contains costed and non-costed versions. In addition there are more specialised Dashboard "Radars", for example the "Diabetes Radar" and "Asthma Radar". This supersedes existing software in a GP surgery.  Eventually all chronic conditions will be managed by such "dashboards", by a federation of all GPs in one STP "footprint" to a single population of about 200,000 patients. This means the dissolution of GP patients lists. It will be "pro-active" medicine for the entire population for the first time ever in history. We can quibble about the standard of that supervision. It will probably not be what the Queen has for her OAP check-ups. And we can worry about the confidentiality of medical records - experience to date shows that if the exchange of data is kept to regional level the dangers of unauthorised disclosure and use, theft and re-assembly of "pseudononymised" data are much lower. GPs themselves are unsure about what their role will be in this new primary care landscape, especially as they will will loose their own lists, their financial independence and they will become employees of a subsidiary company of an ACO - see below.

We are beginning to see on-line "consultations" with GPs or, indeed, with a lengthening list of other specialists like Assistant Physicians, pharmacists, more highly qualified nurses, "life coaches", etc... in a local GP surgery (soon to become a branch of a "new care model hub"). It is hoped that they can deal with specialised requests of a non-urgent nature. The NHS will need to explain to the public the precise nature of each profession's specialisation - and the public will decide whether they trust them in practice.

As the costs of test kits, hardware and software come down patients or their carers will be told to conduct their own monitoring of chronic conditions at home with much, much cheaper diagnostic tests e.g. the bowel cancer screening programme - testing every 4 years; home cholesterol tests, etc... You can buy your own blood-pressure measure for £30 - £130 if you need one! But can patients really understand that they are being given total responsibility for their own long term condition? Do they have the skills of a doctor or nurse?

The NHS assumes that patients will search for websites: NHS and non-NHS patient reference fora. Many are extremely helpful and supportive, and offer avenues for discussion for informed patients, which sometimes interface with research and researchers.

The information is getting out there... but the public has little experience of assessing a scientific problem, taking scientific decisions, taking responsibility for those decisions. And a sizeable proportion doesn't take a responsible attitude to maintaining their own health. Obesity is a recent population-wide condition which only occurs in rich countries.

All these new types of care are only for already identified, non-urgent and/or chronic conditions, what the NHS calls "Long Term Conditions".  Patients and carers will need to learn about the range of their own symptoms and the usual pattern of their LTC in depth in order to identify themselves exceptions requiring a re-evaluation by specialists. But, if used widely and properly, it should be possible, for example, to keep blood sugars of diabetic patients in better balance and avoid most crises and thus hospital admissions. Can this approach be applied to other chronic conditions? Each one differs. Software developers and clinicians want to do so. The modelling gets really complicated when two or more LTCs interact.

And it is mentally depressing to be given this much knowledge as a patient or carer.... Do you want a computer readout to tell you bad news or a real doctor or nurse?? And a lot of patients may well distrust their own readings.

Most of the bodies watching the NHS are adopting a wait-and-see approach to the new science and IT.

 

Accountable Care Organisations - regionalization, privatization and capping of funding:

A long-term regional contract from the Government for an ACO presupposes a fixed budget to provide the services: this is capping. Capping health service provision has not worked in the US and it won't work here. In the past NHS funding has waxed and waned according to political decisions and the UK economy. The conversion of the NHS into a collection of ACOs will be a final and irreversible change with capping for the duration of each contract. It remains to be seen whether the private sector will renege on its promises when predictions fail to materialise and costs exceed expectations, as happened for example on the East Coast mainline railway recently.

Campaigners and many NHS professionals believe that the responsibility for deciding (1) the standards of care and (2) the allocation of funding between different parts of the primary/acute/chronic/social care services should stay with a mostly publicly provided, 100% publicly funded, 100% publicly managed and 100% publicly accountable NHS ("true" NHS), and not be delegated to private outsourcing insurers/providers on huge and long contracts to decide according to their and their shareholders' profit requirements. Fraud is set to become a big new headache - in the US the Dept of Health is suing UnitedHealth for $1bn for overstated claims for Medicare - https://www.nytimes.com/2017/05/19/business/dealbook/unitedhealth-sued-medicare-overbilling.html.

The dangers of ACOs cannot be overstated and we think that campaigners should be concentrating on telling the public about these dangers. All the good developments above could be undone by entrusting health management to private companies and losing public oversight, transparency and accountability. That is why we think that the Labour party should grasp the nettle about keeping the NHS truly public and they should back the NHS Reinstatement Bill at every level (national, regional and local). This is already Labour Party policy - composite motion 8 at the October 2017 party conference.

Public accountability and control of funding are why the two actions for Judicial Review of ACOs are so important. He who controls the purse strings and how the purse strings are pulled wields ultimate power. ACOs will hand enormous power to largely unaccountable private companies.

 

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