NHS blog: Home surgery could spell the end of NHS cuts - this is NOT funny

From: https://www.networks.nhs.uk/editors-blog/home-surgery-could-spell-end-to-nhs-cuts  Julian Patterson 4th November 2016

 

The BBC and Independent last week reported  that a man with a gangrenous foot cut off his own toes after a hospital operation had been cancelled. Doctors said the operation, performed with a pair of surgical pliers had probably saved the man’s foot. It also saved the NHS the cost of putting him under the knife.

The government said the case illustrated the potential to improve NHS outcomes and efficiency without inconveniencing taxpayers or putting further demands on hard-working ministers preoccupied with Brexit plans.

Operating framework

NHS Improvement has started work on a self-care tariff that would reward patients with John Lewis vouchers for cutting out layers of bureaucracy including doctors, nurses and hospitals. The so-called "personal surgery budget" will incentivise people to tackle their own diseased limbs and organs rather than relying on the state to intervene.

The Department of Health dismissed concerns raised by leading doctors about quality and safety. “These will be dealt with by the payments system, which will promote high-quality care by only rewarding good outcomes. It won’t be in patients’ financial interest to make a mess of their operations,” a spokesman said.

Patients in control

The government said that a radical move towards self-care could be the solution to the financial problems facing the NHS, with big potential savings in training alone. 

"No one has the time for formal medical qualifications any more. In the digital age they can just download a tutorial from YouTube and get going," he added.

A further benefit is that patients would no longer need to travel miles to receive treatment, but would get the care they need in the comfort and convenience of their own homes.

“People would also learn useful new skills, such as sewing, which they could apply in other areas of their lives,” the spokesman said.

Surgical spirit

While there are doubts about the ability of individuals to carry out procedures requiring a general anaesthetic (defined by the new NICE home surgery guideline as more than one bottle of brandy), a leading think tank said this is where more community-based approaches would be required.

Neighbours and networks of community “in-reach” workers could be enlisted for complex procedures including heart surgery.

Children could also be useful, particularly in delicate areas such as neurosurgery where their small fingers could be an advantage.

Public Health England warned that children should not be allowed to perform any surgery without adult supervision and reminded parents to take particular care before letting them loose with scalpels or power tools.

“This idea definitely has legs,” said a government spokesman, “for the moment at least.”

Shares in Kingfisher, the parent company of B&Q and Screwfix, rose sharply following news of the initiative.

DIY editor:  Julian Patterson

@jtweeterson
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Julia Simon: "STPs and ACOs: solutions for a 'bankrupt' NHS and social care system"?

Talk given at the Learie Constantine centre, Dudden Hill Lane, on 1st December 2016 at the invitation of Brent Patient Voice to an audience of 50 people.

Dr Julia Simon was until Sept 2016 the head of NHS England's commissioning policy unit and its programme director of co-commissioning of primary care.

She had worked at London and national NHS level since 2012 on CCG and commissioning issues.

 

Dr Simon referred to a small number of presentation slides.

"There has been a split between commissioning and provision for over 25 years. The 2012 Health and Social Care Act aims to create a truly clinically led system with GPs in the driving seat. But the outcome is actually a fragmented commissioning system with three main budget holders across CCGs, NHSE and local authorities (public health), and a bewildering number of other national organisations.

In my view healthcare isn't a market: hospitals do not fail. They are always bailed out in order to give citizens care - which seems obvious. Andrew Lansley, the Secretary of State for Health responsible for the introduction of the HSCS Act, is married to a GP.

CCGs:

There were 212 in 2012 and there are 209 now. They are legally constituted by their members and all practising GPs must be members of one. CCGs have a statutory duty to (1) improve primary care and (2) to engage citizens.

Fragmentation:

The three commissioning bodies have different budgets. NHSE buys centrally for specialist and primary care. The CCGs buy acute care and elective care. The Local Authorities buy Public Health services (prevention and well-being). The trouble is that the incentives are not lined up correctly: the expense of commissioning public health services is born by LAs but they do not see the benefit - the CCGs do instead (eventually!)

To remedy these mismatches, the Five Year Forward View focusses on three gaps, and every one of the bodies involved in the Health system has signed up to this analysis and proposed solutions. The gaps are:

  • Health and Wellbeing gap: evening out and upgrading public health education and prevention measures
  • Care and quality gap:  improving access to care and addressing inequalities in healthcare across the country (resulting in longer life expectancy)
  • Funding and efficiency gap: the funding of the NHS under the present system is "spiraling out of control" and must be changed to prevent the NHS going bankrupt - STPs are a last ditch attempt

 

FYFV:

The gaps must be addressed on a system-wide basis. We need to develop new models of care that break down the traditional boundaries between:

  • mental and physical health
  • primary and acute care
  • healthcare and social care

The aim is to create "integrated care", closer to home, etc....

In order to test out models the NHS has ordered "Vanguards" of "new care models". These are large-scale pilot schemes - but they have only been running just over one year (2015). There are 5 vanguards:

  1. Integrated, Primary and Acute Care System - PACS - bringing together GPs, hospital, community and mental health services
  2. Multi-specialty Community Provider - MCP- bringing specialist care out of the hospital and into the community, for example, continuing specialist care for diabetes, renal, etc.. with some specialised diagnostics
  3. Enhanced health care in care homes
  4. Urgent and emergency care - co-ordination of services
  5. Acute care collaborations: the aim is to improve clinical and financial viability by reducing variation in care and improving efficiency in hospitals. The Royal Free Hospital (CEO David Sloman) is leading a "hospital chain" (like schools) to raise standards and improve efficiency by adopting best practice.

These are all experiments. It is not yet possible to answer the questions: Do they provide better care? Do they save money?

Accountable Care (Accountable Care Partnerships, based on US Accountable Care Organisations):

These involve organisations, systems and "partnerships" with:

  • capitated budgets
  • responsibility (for how long?) for the care of a whole population e.g. the frail elderly, or Musculo-skeletal or diabetes

Dr Simon is going to Valencia next week to see the Accountable Care scheme in place there which is currently deemed successful.

In the USA ACOs are not always successful - there are some failing ACOs which have neither raised the quality of care nor saved money.

The commissioning is about to become even more complex, with some commissioning activity to be transferred onto the provider's books.

The new arrangements in ACOs present challenges including, in Dr Simon's view, the need for new legislation.

It is impossible to avoid perverse incentives in any imaginable system and so the new system will have new ones. The current system rewards hospital episodes (activity) whereas the new one will reward outcomes. But there is such a leap in changing from our familiar system based on national tariffs, the current regulatory and assurance frameworks, an (unhelpful!) national contract, etc...!  She is sure that England needs new legislation to regulate these new arrangements.

Once again, the objective (incentive?) is to catch disease early and minimise acute illness (and high cost).

At Kaiser Permanent there is self-care: the patient becomes the expert (e.g. diabetes and COPD). You look after yourself with support. And the system is not going to pay for episodes of acute care [sic] (????) NHS senior management appears to believe - as Dr Simon tells it! - that hospitals want to secure acute episodes for purely financial reasons (e.g. £4000 for a hospital episode of care vs. £250 for a prevention strategy). [In this case it is not clear why hospital doctors are still practicing since tariffs for procedures have been reduced year on year by 3% for at least 5 years, largely from the salaries of doctors and nurses which comprise 70% of hospitals costs].

This wholesale change of incentives has been introduced far too quickly and with no transparency.

STPs:

In December 2015 the NHS produced "planning guidance" (viz: mandatory instructions) to CCGs to prepare their draft STP by June 2016:

  • prompted by the tacit recognition that CCGs are not able on their own to control costs that are spiraling out of control
  • basic premise: there is one pot of public money in the "health economy", initially just for the health care economy - but the culture is not ready for this change and is not in place
  • The STPs will be multi-year, place-based plans based around the needs of the local population
  • New and energetic leadership: need to build capacity and capability of new leaders to support change

In summary: the NHS is "nearly bankrupt", has "run out of tarmac", "run out of road".....

In social care:  There will be a £2.4Bn underspend next year.

Simon Stevens said: "Two leaky buckets do not make one sound bucket". The implication is that each part of health and social care will have to be "made sound" on its own.

Dr Simon has been supporting 2 or 3 STPs last week. It is not an easy task...

She summarised the situation as a "genuine chaotic mess", a "truncated process", "murky".... (Dr Simon looked stressed!)

She has no idea how the priorities in any given STP have been decided (1) by the CCGs, (2) on behalf of local patients, including in NW London!

"The greatest problem with this process is the lack of transparency". There is a legal requirement to consult for a minimum of 3 months - but we only barely have 3 months after 23rd December and before 31st March. It's not nearly enough time! It's a "twisted time-frame".

Challenges of the STPs:

  • No statutory authority given to the STP lead
  • lack of capacity, resource, capability of leaders
  • challenging time-frame at a time of austerity
  • going from a competition culture in the HSCA 2012 to a culture of "deep, instinctive collaboration" of STPs
  • the existing national regulatory and assurance frameworks do not follow the STPs

 

GPs:

  • GP practices are currently independent organisations with statutory responsibilities.
  • Most GPs are partners on a "for life" contract, or are employed on well-understood employment contracts

 

The ACPs require fundamental changes for GPs:

  • All GPs will be employed on 5 or 10 year contracts
  • Federation will take on "collective responsibility"  for the STP "Control Total", i.e. their year's budget
  • What are the sanctions if things go very wrong?  This is not at all clear

She thought that one of the biggest problems with STPs (and ACOs) will be the in-built Conflicts of Interest. She helped to develop the first guidelines on conflicts of interest in the NHS in 2014. The NHS has published a new consultation document in September 2016 (https://www.england.nhs.uk/wp-content/uploads/2016/05/conflicts-of-interest-consultation.pdf)

 

Dr Simon was thanked for a very succinct presentation!

 

Questions from the audience:

Dr Robert Sale:

Isn't this a "back-door" way of bringing in insurance-based service? They are not bothered about the privatisation of GPs, but they want to shed the larger expenditure?

Dr Simon:

No, Dr Simon is against the "market" in health. She thinks it wasn't the NHS's intention to privatise. For example care homes are all in the private sector. She claimed that the "current climate does not pose particularly greater problems".... The "Vanguards" are all NHS bodies. She is not worried about a "completely commercialised NHS". However, there is a risk of purely commercial ACOs.

 

American lady:

Kaiser is a Health Maintenance Organisation. Are we going to get that? They just throw you out of a hospital when your insurance money runs out?

Dr Simon didn't think so.

Dr Simon said: "Most of the STPs are "pants", "they don't hang together", they have "high-falluting language" but what is the content? "It's not a done deal yet". Jim Mackay, the head of NHSI, expects a "reboot" of the STPs after Christmas because of the lack of consultation.  At that point he may say: "We can't fund what we funded before" and he may be upfront.

Dr Simon agreed that the transaction costs of the "internal market" in the NHS are ~£2BN per year. And the audience told her that the management consultants who prepared SaHF and the STP in NW London were paid £200M to date.

 

A young GP (James, a GP in Ealing):

ACOs will not be private companies (e.g. a Foundation Trust can keep and invest its own surplus), but might it include private organisations in itself? - interjection: "Brent Care Ltd"?

Dr Simon thought not.

Conflicts of interest: Dr Simon had doubts about whether they can be contained. If something goes wrong or is not affordable, what happens? There is a democratic deficit.

Dr Simon thinks that accountability has not been fully thought through. The regulation and accountability issues are so grave that writing an STP without these essential parts is like "building an aeroplane as we fly it!"

The STPs will be published on 31st March 2017.

 

Gaynor Lloyd (Brent Patient Voice):

As a solicitor specialising in commercial property she sees the ACPs as a legal can of worms: they cannot be set up in a proper way except, possibly, with vast armies of lawyers. For example the UnitingCare partnership in Cambridgeshire collapsed after just 8 months in 2015 because of carelessness in an apparently unimportant detail: some of the constituent organisations paid VAT and others didn't. This 20% difference in cost was an important fact which blew the contract up (see National Audit Office report https://www.nao.org.uk/report/investigation-into-the-collapse-of-the-unitingcare-partnership-contract-in-cambridgeshire-and-peterborough/).

Addressing the GP she asked: what legal advice were you and your practice given?  And she mentioned that she had come across a Chair of a CCG who was "black-listing" (!) medications.

James:

"I have not been given any useful advice". He knew next to nothing about ACPs. He asked: "How will GPs be part of ACOs? It seems that CCGs will be forcing GPs to take on new primary care contracts and to be employed by new bodies" [from a position of strength]

Dr Simon replied that there were a lot of legal costs, but GPs were free to opt in or stay out. Finally she conceded: "The answer is not there yet, but expect to see some kind of solution".

 

Robin Sharp (Brent Patient Voice):

(1) The savings proposed in the STP are so enormous that one could conclude that, to date, the system has been wasting enormous amounts of money for years. Why do we not see this waste? The proposals are so dubious that we have to ask: "Do we trust the figures?" His answer: "No, we don't".

(2) PFIs have been used to rebuild hospitals and schools using private sector money to create extremely profitable private contracts. It is profligate spending! If these contracts were bought out we would eliminate the deficit on the NW London STP. We are in a low-interest era: why can't we refinance the PFIs?

What work has been done to buy out PFIs?

Dr Simon replied that she could not answer the question. She agreed that PFIs are unaffordable.

Concluding the meeting Robin Sharp reminded the audience of George Orwell's "double speak": "Those who wrote the words don't believe them" "I don't have confidence in the numbers".

Dr Simon said that she didn't think that the parameters are the right ones. "I was personally not comfortable. There was a 'cognitive dissonance' with our leaders."

The greatest danger for GPs is as follows: "When you have 'market capture' of GP federations it will become impossible to run CCGs without conflicts of interest. That would be completely unmanageable. Therefore the powers of the CCGs would need to be given to another body"

 

 

 

 

 

 

 

 

 

 

 

Ambulance target failures highlight NHS crisis, say health chiefs

NHS England says figures showing only one of UK’s 13 services met eight- minute target is a system-wide problem.

The figures showed that ambulance crews are wasting more than 500,000 hours queueing outside hospitals.

 

Figures showing that every ambulance service in England failed to meet response time targets for the past 16 months are a sign of a system-wide problem, NHS England has admitted.

The figures, released under freedom of information rules, showed that of the UK’s 13 ambulance services, only Wales was reaching emergencies within the target time of eight minutes. They also showed that the number of patients waiting for ambulances for more than an hour had almost tripled in the past two years, and that ambulance crews were wasting more than 500,000 hours queuing outside hospitals.

Health unions and the Labour party seized on the figures as an illustration that funding was failing to keep pace with unprecedented demand.

Jonathan Ashworth, the shadow health secretary, said: “This is yet again more evidence of the huge pressures facing the NHS. “Labour has been warning for weeks now of patients being forced to wait in long ambulance queues outside overcrowded A&E departments across the country. “Under the Tories, our NHS is underfunded and understaffed. The astonishing failure of the chancellor to provide extra funding for the NHS and social care is proven to be more and more misguided every day.”

Alan Lofthouse, Unison’s national officer for ambulance staff, said: “The frustration is really within the whole system. The funding hasn’t matched the increase in call volume.” He claimed accident and emergency departments were struggling to cope and deliberately making ambulance crews wait outside.

NHS England conceded that the problem was getting worse and highlighted broader difficulties across the service. “This is a system-wide problem,” Keith Willett, the director of acute care at NHS England, told BBC Radio 4’s Today programme. He added: “It is about an increase in demand for urgent healthcare need. Of all the parts of the healthcare sector, the ambulance service has seen the largest increase in demand at 7.3% in the last year. “It is also about how we manage the flows through hospitals and back out into community. Many of the handover issues are really a reflection of the pressure on beds and the difficulty we have in that area.”

Willett said the NHS was trialling different ways of handling emergency calls so that ambulances crews could concentrate on life-threatening cases.

But he conceded this would only go some way to tackling the problem. “Clearly, as demand gets greater the amount of reserve in the system goes down … It is not at breaking point, but we are in new territory here. We have never had demand like this and we also have never been better prepared. Yes, there is concern, but we are taking these steps to transform the NHS.”

But Matthew Westhorpe, a former paramedic and now a clinical adviser with the 111 service, said the system was at breaking point. “The ambulance service is essentially the canary in the coal mine of the wider NHS malaise,” he told the BBC’s Victoria Derbyshire programme. “The ambulance service is under increasing pressure because of closed A&Es and under-resourcing and the staff can only be pushed so hard for so long before they become broken.

“The crews on the frontline are now expected to deliver more for less so they are stretched beyond their means.”

Staffordshire £1.2bn cancer contract given green light

  • 26 November 2016
  • From the section Stoke & Staffordshire   - BBC News

A £1.2bn plan to outsource cancer and end-of-life care in Staffordshire has been given the go-ahead by NHS England.

The project, which has attracted considerable opposition, was put on hold in January after a similar contract in Cambridge was scrapped due to financial concerns.

The 10-year contract in Staffordshire is expected to be up and running by April. Bidders are believed to include private companies Virgin Healthcare and Interserve.

The deal includes a £690m contract to run cancer care across four Staffordshire clinical commissioning groups (CCGs) - Stafford and Surrounds, Cannock Chase, Stoke-on-Trent and North Staffordshire. The successful bidder will be asked to co-ordinate cancer care throughout the county - from diagnosis through to treatment and end-of-life care. The CCGs have previously said the aim was to streamline services and "provide the best cancer and end-of-life care for patients".

However, Labour MP for Stoke-on-Trent South Rob Flello, described it as an unpopular and dangerous project that could see a private provider take over NHS care.

In July 2015 a Staffordshire NHS Trust, thought to be University Hospitals North Midlands NHS Trust, pulled out of a complex partnership to bid for this contract.