NAO report on health and social care integration 8th Feb 2017
Published: Wednesday, 22 February 2017 17:20
Written by Una
For the last two years (since April 2014) NHS England has run a number of experiments (called "Pioneer" programmes), including in NW London, to try to integrate health (hospital) and social care, which is essential for reducing demand for hospital services and is a central part of "Sustainability and Transformation Plans" for the 44 "footprints" of England.
The National Audit Office published its findings on Wednesday 8th Feb. It said: "Integrating the health and social care sectors is a significant challenge in normal times, let alone times when both sectors are under such severe pressure. So far, benefits have fallen far short of plans, despite much effort." "Nearly 20 years of initiatives to join up health and social care by successive governments has not led to system-wide integrated services" "The Departments [of Health and Local Government] have not yet established a robust evidence base to show that integration leads to better outcomes for patients" and finally "There is no compelling evidence to show that integration in England leads to sustainable financial savings or reduced hospital activity".
Trying to mix health and social care is like trying to mix oil and water, due to the different funding and cultures.
When NHSE, an executive body of the Dept of Health, publishes information, especially as a result of a Freedom of Information request, the public has a right to be able to rely on its contents.
But in the question and answer session Christian Cubbitt, Director of Communications for NHS NW London Collaboration of CCGs, publicly retracted the figures. He said that they were "incorrect" and that there would not be nearly 8,000 job losses. He said that the "correct" figures would be produced, but did not give any deadline.
Given that the objective of the STP is to find £1.3Bn of savings and that the template of the STP is set by the Dept of Health, it is impossible that the final numbers will be very different from the ones just published, using the same categories. SOH and its advisers have looked closely at all the pages in the workbook, including the "solutions" which are the balancing figures between the "Do Nothing" and the "Do Something" scenarios. Most of the solutions include words like "these costs have not been finalised". For Solution 4 (NHSE Specialised Commissioning) it says: "We have not yet developed the "solution" for closing the gap, however it is assumed that this gap will be closed. This is a placeholder".
The Delivery Plan is obviously nearly right too.
The denial by NW London CCGs is a clumsy attempt to limit the harm after the release of highly damaging information which should not have been disclosed on the grounds that its release would prejudice incomplete development of the plans. But then the FOI request would probably have been forwarded to the Information Commissioner and SOH would have made a big fuss about the refusal and about the fact that the figures were still being worked on three months after submission to NHSE on 21st October as a "final" version.
That is why the current dispute about the status of the information produced by the NHS's NW London Collaboration of Clinical Commissioning Groups reveals even more than the figures themselves.
Response by Dr Christopher Wood to article by Prof Chris Ham The King's Fund 12th Sept 2016
Published: Monday, 28 November 2016 20:45
Written by Una
Consultant HIV Physician
North Middlesex University Hospital
19 Sep 2016
Professor Ham, thank you for your detailed, but much understated piece - notwithstanding the statement about STPs that..... 'they are attempting to undertake synchronised swimming against a rip tide'!
The reality is that the current plans and timescales being imposed on STPs are reckless and dangerous. There should be an IMMEDIATE MORATORIUM called on STPs and other similar major re-organisations of the NHS that are in the pipeline.
STPs may well be fine in theory - and that is debatable - but as you clearly state they are not a short-term answer to austerity and quickly delivered savings. In their current incarnation - with the expectation of immediate savings and transformation occurring in a fraction of a financial year they are a reckless and dangerous absurdity. The only sane solution is a moratorium. The NHS and its funding need a proper overall review with some bridging funding made available to meet the immediate needs of the NHS deficit and a proper cross-party/stakeholder consultation to decide its future.
The need for the Acute sector cannot be 'wished away' as you make clear in your piece. I suspect that a lot of recent health policy has been made by fantasists in denial that acute illness really exists. The acute sector has been mistakenly marginalized since - at least - the introduction of the fatal Lansley 'Health and Social Care Act' and the Darzi report.
It will take years of coordinated planning and investment to get prevention and social care to the point where they can make a real impact on hospital activity and the more acute and severe manifestations of ill-health. This certainly will not happen while the current mania for major uncoordinated and unfunded interventions is indulged by the detached and unaccountable elites currently making health policy.
The leadership and vision that the NHS needs is completely lacking from the Secretary of State for Health, the DoH and NHS England - otherwise why would any serious health policy makers be endorsing the unsightly haste with which STPs are being pushed forward? It is a dangerous collective delusion in the context of an engineered funding crisis, collapse of workforce morale, years of austerity cuts and an arrogant policy-making elite who have no interest or respect for 'evidence', 'piloting' or consultation. I have to try and hope that many of them are likely to be well meaning, but many others seem to have serious problems with the original 'mission' and aims of the NHS and are impatient and opportunist in their desire to re-fashion it into something that I believe the great majority of the population that the NHS serves would find very disturbing.
In summary, I believe that there needs to be an immediate moratorium on STPs and other major NHS re-organization, including the increasing role of the private sector. Bridging funds need to be made available to consolidate safe healthcare in the short-term while these issues are being sorted out to mitigate the impact of the current chaos.
The debate will need to start with a public debate about the amount spent on health in the UK as a proportion of GDP, in order to ensure that 'affordability' for the NHS is decided by the population at large with a clear view of the wider political and other factors and choices that help to define 'affordability' and the 'limited' funding for the NHS.
The King's Fund and the Nuffield Trust have already provided sufficient dispassionate and well-researched data and analysis to inform many of these issues and help start the process. However, unless the brakes are put on the current inchoate jumble of proposals and policies, the impact on the NHS and the nation's health will take years to unravel and will be the cause of much unnecessary human suffering.
Dr Christopher Wood (with over 30 years service in the NHS, nearly 20 of those as a Hospital Consultant)
Overview of patient and public understanding of the NHS "Five Year Forward View" and the NW London STP
Published: Sunday, 27 November 2016 23:09
Written by Una
By His Honour Judge Peter Latham (retired)
13 September 2016
His Honour Peter Latham is Chair of Willesden Locality PPG and a member of the CCG EDEN Committee. He is a retired barrister with a specialist medico/legal practice and a retired Circuit Judge who sat at central and north London county courts including Willesden. He has lived in and been an NHS GP patient in Willesden for over 45 years.
1. Patients and public cannot reach conclusions about the overall merits of the NHSE Five Year Forward View NW London STP because the draft dated 30 June 2016 appears to be deliberately obscure and incomplete about key details: either because they have not yet been formulated, or to make public opposition difficult during the transformation. The main NHS Project Initiation Document (PID), the Business Case, Management Consultants' reports and other key documents have not been disclosed even to the small number of 'lay partner' patient representatives hand-picked to attend some NW London Collaboration of CCGs meetings.
2. From a patient perspective from the time the NHS Act 1946 came into force on 5 July 1948 the model has changed remarkably little. Most NHS medical care is still obtained by visiting your GP who will refer you to hospital for specialist investigation and treatment when required. Most of the GP practices remain the same, and the hospitals mostly remain the same. Social care has been provided separately by the local council. The multiple NHS administrative shake-ups of Health Authorities etc. have barely been noticed by patients including the Health and Social Care 2012 Act's introduction of CCGs. The STP proposes the most radical changes to this structure since 1948 that appear to introduce a model that most GP's and almost all patients still do not understand and are mostly unaware of.
3. The NHS Five Year Forward View and STP projects are major 'top down' policies that are clearly mostly focussed on reducing NHS costs to keep within a Government cost cap fixed by HM Treasury. It is an old joke that is funny because of its element of truth that the NHS is the last great Stalinist institution in Europe. The UK allocates about 9% of its GDP on the NHS where other developed counties obtain better outcomes as measured by survival rates for serious conditions on allocating about 11 % of GDP to healthcare. It is arguable that this is really the main problem.
4. In seeking to transfer so much healthcare out of hospital into community services the NHSE Five Year Forward View and the STPs are swimming against the international tide of healthcare improvements obtained with new sophisticated investigations and treatments provided by increased hospital doctor specialisation. In 1948 hospital Consultants were mostly general surgeons and general physicians. Initially antibiotics delivered the great improvement in medical care. All over the world the secondary hospital landscape has changed out all recognition since 1948 with increased medical and surgical specialisation and sub-specialisation for both investigations and treatment. Granted, many special investigations such as resting ECG can now be carried out by the new generation of hospital trained GPs with machines that have become much smaller and cheaper. Many routine low-tech mass numbers hospital services such as diabetic clinics can be transferred out of of hospital to be provided in the community. It remains to be seen whether they will prove to be cheaper and more efficient. But it appears that the STP attempts to swing the pendulum too far.
5. It is not clear what will happen to the traditional GP family doctor practice model under the STP. It has become fashionable amongst NHE executives and their business consultants to decry them as a 'cottage industry'. The core of structural change is the new Multi-speciality Community Provider (MCP) contract for over-arching primary care with 'intermediate' out-of hospital and new primary services provided at 'hubs' leading on to full Accountable Care Partnerships (ACP) by 2021. It is said that primary care will be delivered through networks, federations of practices, or super-practices working with partners. The NHS England publication 'Multi-specialty community provider (MCP) emerging care model and contract framework' published July 2016 at page 30 says:
”New models of accountable care provision will move the boundary between what is commissioning and what is provision. We are working with a number of MCP vanguards to establish which activities must always remain with the CCG (or other commissioners), and which activities an MCP would perform under contract.”
6. No detail is provided of how MCPs and ACPs will work - or how they will affect the traditional NHS GP practice delivered by SMS and APMS contracts. No experience from any existing whole population state-funded model is identified. The King's Fund March 2014 paper on Accountable Care Organisations in the US and England pointed out that the US models on which this concept is based are all much smaller and with different sources of funding. It is arguable that the STP disregards the excellent value for that we obtain from our traditional GP practices - for all their faults – for about 9% of the total NHS budget. It appears that in these new over-arching structures the traditional SMS GP contract may be left to wither on the vine by re-allocating funding to make them unviable. It is arguable that a better, more achievable, and more cost effective solution could be obtained by simply putting more resources into the existing GP network. If the current STP is implemented in full it seems likely that in 10 years time the pendulum will swing again back on a new slogan 'Small is beautiful'.
7. The STP integrated medical and social care proposals depend heavily on the individual patient information sharing duties in the Health and Social Care (Safety and Quality) Act 2015. NW London and Brent CCG posters have have already been put up in Brent GP practices. No date is stated for the start of the sharing, nor exactly what will be shared, nor with whom. The section on Integrated Care Record says:
"The Integrated Care Record (ICR) will display a range of test results, medication, allergies and social or mental health information relevant to the care of that person. Information around people's cost of care may also be included as part of the ICR. It is expected that this will be a key enabler in improving decision making when determining people's care needs."
The last sentence is disingenuous. When it speaks of 'care needs' it clearly does not mean investigation and treatment 'needs': it means cost-controlled investigation and treatment 'allocation'. Under the heading Service User Consent the poster says that "people are able to opt out of their information being shared at any point ...." and goes on to claim that if you decide to opt out later the ICR will be re-created. We can find nothing in legislation that authorises this 'opt-out' model of purported implied consent by default. This appears to be an attempt to re-introduce the opt-out model on which the 'Care.data' failed. Doctors' misgivings about this 'opt-out' model are revealed by Brent CCG providing them with an indemnity against claims for breach of their doctor-patient duty of confidentiality, and penalties under the Data Protection Act 1998. But the indemnity will not protect them against strengthened criminal responsibility under this Act. Nor will it protect them on misconduct complaints to the GMC disciplinary committee for breach of their common law duty of patient confidentiality.
8. An important under-pinning for the financial viability of the STP's ACP and MCP model is the choke being introduced on GP clinical independence on hospital referrals and patient choice. The new Brent Referrals Optimisation Service that started on 1 September 2016 attempts to impose a CCG-supervised clinical triage service through its provider Bexley Health Limited on all NHS GP patient referrals designed to steer all patients into cheaper relevant out-of-hospital community healthcare services where available. The patient information letters produced for this service do not inform patients about their NHS statutory and NHS contractual patient choice rights, and Brent CCG have rejected public consultation proposals that they be inserted. Without this under-pinning the CCG will not be able to assure providers that they will reliably deliver enough patients for their services to be viable financially.
9. There are very big risks with pushing ahead so fast with such a big programme of new models that are as yet untried and untested, since the few Vanguard pilots have only recently started. It is arguably reckless to put so much into new models that have foreseeable but unquantifiable risks of financial insolvency and bankruptcy liquidations when all the responsibility would fall back onto the NHS for expensive crisis management. It appears unrealistic to think that the whole NW London Collaboration STP project can be delivered by 2020/21. Its parallel Shaping a Healthier Future programme (SaHF) became stalled when the capital costs of about £1 billion required to deliver it became clear. When Brent CCG, on commencing in 2014, tried to develop an ambitious Planned Care project for about 13 medical speciality 'out of hospital' community services this project also stalled on attempting to introduce an integrated multi-disciplinary MSK (musculo-skeletal) service as the third of the new services. Both these big projects have remained stalled.
10. The STP proposes to transfer a large part of hospital care into community services commissioned by the CCGs through the new vehicle of one of the variants of the new Accountable Care Provider (ACP) models by the new Multi-speciality Community Provider (MCP) contract model. This appears to seriously weaken the statutory CCG governance model of the Health and Social Care Act 2016 just by administrative action without fresh statutory approval. The 2012 Act created major conflict of interest problems with GP members of the local CCG involved in providers tendering for contracts from the CCG. This conflict of interest is likely to be greatly increased with GPs encouraged by the STP to form large ACP-variant healthcare providers to tender for £multi-million community healthcare contracts from themselves wearing their CCG hats. Large public money scandals are predictable.
11. It appears that there are major financial implications of the STP move to ACP and MCP that have not been disclosed. Why go to all the trouble of setting up the Accountable Care Partnership (ACP) and Multi-speciality Community Provider (MCP) structures ? It now appears that again this may be largely about an attempt to get big future financial liabilities for pensions and clinical negligence off the NHS books. All large employers are desperately seeking advice from lawyers and management consultants on how to do these things. It seems that the NHS now wants to do hat Sir Philip Green did for BHS pensions. Similarly with clinical negligence liability. The NHS clinical negligence compensation bill in 2015 was about £4 billion - up £1 billion on the previous year. It is very difficult to investigate these queries through the obscure finance sections of the NW London Collaboration draft STP dated 30 June 2016. It was the same story with the ill-fated PFI initiatives. When such liabilities are transferred to new contractors they inevitably have to increase their tender figure and add a safety margin. It is foreseeable that commercial professional liability insurers will quote very high premiums to cover such alarge and fast growing contingent liabilities.
12. A great deal of the projected cost savings of the STP are highly suspect as unreliable and unrealistic. Many of the cost savings are projected from progammes to reduce long-lasting and increasing obstinately intractable conditions such as obesity and Type ll diabetes, and from preventive medicine projects. The results of the NHS accounting formulae for booking such projected savings are highly speculative. You can insert almost any figure you wish.
13. The problems of rushing through such large structural changes are likely to be aggravated by the increasing loss of confidence of the clinical workforce: as evidenced by the current industrial action by the junior doctors. For 68 years the NHS has traded on exploiting the vocational commitment of its doctors. The NHS appears to be losing much of this goodwill.
14. On 12 September 2016 the King's Fund Chief Executive Chris Ham published a commentary with muted criticism of what has been published to date about the STPs including his analysis that the ACP and MCP model is swimming against the statutory set-up tide of the Health and Social Care Act 2012 with CCGs of local GPs made responsible for promoting competition within the NHS healthcare economy - http://www.kingsfund.org.uk/blog/2016/09/stp-leaders-challenges-care-budgets?utm_source=linkedin&utm_medium=social&utm_term=thekingsfund.
15. It is very unfortunate that there is so little informed public scrutiny of the STP. Because the changes are being introduced entirely by administrative action there have been none of the automatic debates in Parliament and committee scrutiny that would accompany primary legislation. The BMA and doctors' Royal Colleges have remained strangely silent about the STP. There is just no equivalent of academic and expert peer-review scrutiny. It is being left to a very few concerned individuals to provide devil's advocate scrutiny of the proposals from the limited and late information released, and to identify weaknesses and to voice public concern. In the fable it was only the naive little boy who dared contradict the court conspiracy of silence and speak out saying that the Emperor had no clothes.
16. A major criticism of the NW London STP process is the failure to publish enough of the plans to enable the public to understand the radical changes afoot for delivery of NHS primary care. In the last analysis the default to be criticised is that by the local Clinical Commissioning Groups. Under section 14Z2 of the National Health Service Act 2006 (as amended by section 26 of the Health and Social Care Act 2012) the statutory duty remains with the CCG to involve and consult its patients and public in the planning of its commissioning arrangements and in the development and consideration of its proposals for changes in its commissioning arrangements where they would have an impact on the manner or in the range of health services available to them.
Thatcher pushed for breakup of welfare state despite NHS pledge
Published: Friday, 25 November 2016 11:04
Written by Una
PM declared the health service was ‘safe with us’ but secretly pressed on with radical proposals, archives reveal
The plan commissioned by Margaret Thatcher and her chancellor, Sir Geoffrey Howe, included proposals to charge for state schooling.
Margaret Thatcher secretly tried to press ahead with a politically toxic plan to dismantle the welfare state even after a “cabinet riot” and her famous declaration that the “NHS is safe with us”, newly released Treasury documents show.
Some of her cabinet ministers believed they had buried the plan, drawn up by a seconded Treasury official, Alan Bailey, from the Central Policy Review Staff (CPRS), at a special cabinet meeting on 9 September 1982.
Nigel Lawson in his memoirs said the paper of “long-term public spending options” had been buried after what he described as “the nearest thing to a cabinet riot in the history of the Thatcher administration”. In her own memoirs, Thatcher claimed to have been “horrified” by the CPRS paper and insisted that she and her ministers had never seriously considered it.
The CPRS paper had been partially leaked and she was only able to quell the subsequent furore by famously pledging the “NHS is safe with us” at the October 1982 Tory party conference. Downing Street briefed that the toxic plan had been “shelved”.
But Howe’s Treasury private office papers released by the National Archives on Friday confirm that not only had that special cabinet meeting taken place to discuss the plan but that two months later, far from being buried, Thatcher was still secretly trying to press ahead with it.
The Treasury papers show that once a clutch of tricky byelections were out of the way she was keen to keep pushing the plan and held a series of meetings in December to “to soften up the big three spenders” under her chairmanship “to resolve any immediate political anxieties”.
The papers also show after the 9 September cabinet showdown Howe rejected an approach from the Adam Smith Institute, the rightwing libertarian thinktank, to back their “slightly oddly-named Omega Project” despite it being personally endorsed by Thatcher’s own economic adviser, Sir Alan Walters.
The Omega Project papers said the plans were modelled on research by a rightwing US thinktank for the incoming Ronald Reagan administration. It also argued for many state services to be replaced by “more efficient alternatives from the private sector”.
Photo: HM Treasury
Howe rejected the approach in a note on 29 September 1982 not because he objected to their proposals to dismantle the welfare state but because he feared its “ill-researched proposals, which will be portrayed as strongly resembling our own, might prove an embarrassment”. The then chancellor added: “Every proposal will be seized on and hung (round) our necks. Cf CPRS Report. I see v. (underlined twice) great harm.”
The Treasury papers show that “no real action” was taken on the CPRS “radical right manifesto” until November 1982. “The prime minister (we understand privately) did not want to stir this up before the cabinet discussions on the 1982 survey, nor risk any adverse publicity while the last two by-elections were pending. The leaks of the CPRS report did not help,” a senior Treasury official, Peter Mountfield, told Howe in a confidential note entitled “Follow-up of cabinet discussion on long-term public expenditure”.
“The prime minister has arranged a series of meetings with the main spending ministers to discuss the follow-up to the discussion in cabinet on 9 September. The ministers involved are Sir Keith Joseph (7 Dec, 11 am), Mr Fowler and Mr Nott (14 Dec, 9.30 and 15 Dec 5.30.). You and the chief secretary will be invited to each meeting.”
Joseph was education secretary, Norman Fowler was health secretary and John Nott was defence secretary. The CPRS paper proposed to cancel Trident and halt the growth in defence spending.
“The only paper formally before the meetings will be the original interdepartmental report on long-term trends in public expenditure ... The CPRS paper on options is technically a non-paper, but will be in everyone’s minds (and no doubt in their briefing folders too),” Mountfield told Howe.
The chancellor was told the objective of the meetings was “designed to soften up the three big spenders. Without their support the operation will not work. Your main aim, I suggest, should be to ensure that no sacred cows are prematurely identified. Given the prime minister’s concern about the NHS, this may be difficult. But we want to make sure that the ministers concerned do not close off any options at this stage, and, if possible, put their personal weight behind the exercise.’’
Photo: HM Treasury
These papers flatly contradict Thatcher’s claim that the CPRS proposals were never seriously considered by ministers. The Treasury files released on Friday 25th November 2016 do not record what happened at the meetings with the big three spenders.
But a Treasury official’s note on 28 October 1982 to the then chief secretary to the Treasury, Leon Brittan, gave an indication of the depth of internal opposition Howe and Thatcher faced. “DHSS (health and social security) officials say there is no chance that Mr Fowler would agree to a further study of this idea. I imagine in the circumstances, and especially given the prime minister’s speech at Brighton it is difficult to press them.”
In his memoirs, Howe reflects that although the row had postponed the “fundamental debate” he had hoped to start, until after the 1983 general election, “nothing from the Treasury’s point of view is ever as quite as bad as it seems”.
He reported that the impact of what he called the “CPRS furore” had ensured ministers made no new spending pledges and had “set the pace for our forthcoming 1983 manifesto”.
Save Our Hospitals note:
Please see a paper published six years later by the Centre for Policy Studies in January 1988: Oliver Letwin and John Redwood: "Britain's Biggest Enterprise: Ideas for radical reform of the NHS":
The current STP is the Oct 2016 version. In January 2017 the finance spreadsheets and the Delivery Plan were obtained by FOI. They reveal job cuts of 8,000, outpatients cuts of 222K, planned admissions cuts of 50K and A&E admissions cuts of 64K cumulatively by 2020/21. 500-600 beds will be cut by end March 2021.
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