NW London STP: 'Change is needed - but not like this'

From Brent Patient Voice LINK

This was the theme elaborated by Dr Julia Simon, former NHS high-flyer, when she addressed a packed and lively BPV public meeting last Thursday 1^st December at the Learie Constantine Centre, NW10.

BPV Chair, Robin Sharp, explained that big changes to the way in which GPs relate to their patients were hidden away in the recently published NW London NHS Sustainability and Transformation Plan (STP). Essentially the Plan was about cutting £1.4billion from local health and social care service over the 5 years up to 2021, including previously announced proposals to “reconfigure” hospitals and cut beds. What was new was the plan to turn GPs from being a “cottage industry” to the brave new world of “Accountable Care Partnerships”.

Dr Simon told us she was not a medical doctor but had been a philosopher before moving into the healthcare world. For several years up to last September she was a senior leader at NHS England, working on primary care and commissioning issues. She had left to be able to break out of some of the constraints that being at NHSE imposed, not least in relation to the speed at which the STPs were being imposed across the country and the realism of some of the claimed financial figures.

Striding around the room like a university lecturer, Dr Simon captivated her audience with the clarity and honesty of her presentation. She said that in the 90s the idea of a market had been introduced into the NHS to drive up standards. This involved creating a division between “commissioners”, who worked out what was needed and paid for it, and “providers” such as hospitals and GPs who delivered it. The trouble was that under the NHS healthcare was not a market because it could not be allowed to fail.

In 2012 Parliament enacted the Health and Social Care Act, the brainchild of Andrew Lansley, whose wife was a GP. This put local GPs into 209 local Clinical Commissioning Groups to be in charge of designing and paying for about two-thirds of the health care provided by hospitals and in the community. The downside was enormous fragmentation because NHSE became commissioners for specialist services and local authorities for public health. In addition local authorities remained responsible for adult social care, which was means-tested, whereas healthcare was free at the point of delivery.

This was the context into which the new chief of NHSE, Simon Stevens, launched his plan for the future in 2014, the “Five Year Forward View”. As well as accepting that the NHS could make £22billion “efficiency savings” by 2021, this plan called for integration between GPs, hospitals and adult social care. All parties, medical bodies and commentators signed up to it without apparent reservation.

Then in December 2015 the annual Planning Guidance from NHSE to the CCGs and hospital trusts announced that implementation of the Forward View was much too slow and current trust deficits were “unsustainable”. The CCGs and trusts were grouped into 44 areas (Footprints) across England and required, working with local authorities, to produce STPs by 30 June 2016 to eliminate deficits and implement “transformation” over a 5 year period.

Meanwhile various experiments in new forms of integrating services locally had been launched under the brand of “Vanguards”. As Dr Simon explained these are still in progress and there are no evaluations. “The jury is out on the Vanguards”, she said.

The Vanguards include integrated primary and acute care systems, as well as multi-speciality community providers. The first of these embraces Accountable Care Partnerships (ACPs). Dr Simon spelled out some of the features of ACPs. These envisage a fixed budget for each patient (capitated budget), an emphasis on self-care and prevention leading to fewer hospital admissions and merging the boundaries between commissioners and providers. New legislation might be needed and there were some perverse incentives in the present system.

To conclude Julia Simon said that, while she was convinced that new approaches to organising the NHS and delivering care were needed the STPs had been produced in semi-secrecy and much too fast. Moreover the savings being suggested were not really credible. She likened the situation to George Orwell’s “1984” where officials state in public numbers that in private they admit are impossible. However she saw some signs that the top of the NHS would soon announce a delay enabling more serious public consultation.

Julia was congratulated by an audience member on delivering the most informative address he had ever heard from an NHS person. There was general support for this sentiment.

Her presentation was followed up by some 40 minutes of questioning and passionate statements of concern, especially at the unacceptability of the STP for NW London. Noting that Ealing and Hammersmith and Fulham Councils had refused to sign up to the Plan, audience members wanted to know what more could be done to persuade elected councillors in Brent and other boroughs not to endorse it.

Robin Sharp

Chair Brent Patient Voice

NHS Kill or Cure? STP knowns and unknowns - some key questions

So much creeps up on NHS 'reform'  and realisation of its true repercussions known only to a few who can penetrate the jargon, that I am pleased to publish this early warningby Robin Sharp and Peter Latham  taken from the website of Brent Patients Voice


 Sustainability & Transformation Plans (STPs) being prepared across the country on the orders of NHS chief Simon Stevens. There is a plausible view that they present the greatest threat to the NHS since the 1948 settlement. Although there is much that we don’t know, veils are removed almost every day.

This is a brief account of what we have so far gleaned. We don’t think we should delay further sharing it with our readers. What follows is based on a note we sent to Brent’s Chief Executive, Carolyn Downs, for a meeting she kindly offered us on 1st June about the process for preparing these plans. She is the local government lead for the 8 NW London boroughs.
Overall the national STP process as well as its local iteration appears to be radical and internally self-contradictory, but moving forward in semi-secrecy at an unacceptable speed. If it was clear that clinicians and other professionals who deliver care, as well as the wider public, were going to have a proper input before STPs were finalised and implemented we would be content to wait for our turn. However this does not seem to be the case.

By virtue of the NHSE National Planning Guidance for 2016/2017 NHS CCGs and Trusts are required to produce and submit STPs in outline (checkpoint) form by mid-April and in full by the end of June, with implementation beginning in October. Local authorities, though not subject to NHSE jurisdiction, are to be engaged in the process of production. Clinicians and patients are to be involved, presumably after the full STP has been submitted. STPs cover newly-created areas called “footprints”. In the case of our area the footprint consists of the 8 boroughs already grouped together for the purpose of 'Shaping a Healthier Future', 'Whole Systems Integrated Care' and 'Transforming Primary Care'.

The main purposes of STPs are 
to speed up implementation of the changes in ways of working between hospitals, GPs and community services outlined in The Five Year Forward View and;
to eliminate financial deficits, i.e. spending above budgets, in short order.

The Guidance makes no reference to current NHS shortcomings, pressures, staff shortages or population growth but strongly asserts that in the short term better services can be delivered with fewer resources. It has a list of questions to be answered which seem likely to provoke cynicism among front line staff.

The NHSE publication: General Practice: the Five Year Forward View issued on 21 April 2016 with Introduction by Simon Stevens describes a major transformation of NHS GP practices that Sarah McDonnell for Brent CCG recently described at the Brent Health and Wellbeing Board as a 'cottage industry', and Dr Sarah Basham characterised as 'getting more corporate'. This is set out in Chapter 5 at page 49.

The vehicle proposed for this transformation is the new 'Multispeciality Community Provider'(MCP) contract:

"Today the range of services funded within general practice owes much to history rather than optimal working arrangements for GPs or patients. The MCP model is about creating a new clinical model and a new business model for the integrated provision of primary and community services, based on the GP registered list, but fully integrating a wider range of services and including relevant specialists wherever that is the best thing to do, irrespective of current institutional arrangements. At the heart of the MCP model the provider ultimately holds a single whole population budget for the full breadth of services it provides, including primary medical and community services."

So-called Accountable Care Partnerships, including GP federations with patient lists averaging 170,000, would be formed to provide these services in place of the old model of care with the individual GP practice at the centre, going back to the 1948 origins of the NHS. These would still need to address the long-standing problem as to who pays when long-term residential care is needed for individuals who should not be in hospital but cannot care for themselves at home. The current shortfall in social care funding, even when supplemented by the Better Care Fund, only exacerbates this dilemma. These deep issues are not going to be solved by a series of hastily written and implemented STPs.

Moreover this is the point at which the STP process becomes self-contradictory. The major change in primary care, the “new model of care”, has not begun to be sold to GPs and the public, far less designed and accepted. It will need time and a good deal of money to be tested and to demonstrate its advantages. This is completely inconsistent with a requirement to eliminate NHS deficits in a couple of years or even less.

The trend in NHS Trust deficits is moving sharply downwards from a surplus 4 years ago to £800m in 2015 and £2.45bn this year (though experts say the true figure is closer to £3bn). Rising demand, higher costs of agency staff because permanent staff are not available and over-use of management consultants are factors. There is no evidence that this trend can be significantly reversed over the five-year planning period without reductions in the care delivered. Most key care outcome indicators are already on a downward trend.

Some questions and issues:

Is not a candid analysis of the current situation and immediate prospects the essential basis for realistic STP planning?

Can such planning be done without full involvement of medical and social care professionals?

Does not the recent dispute with junior hospital doctors just highlight the deterioration in relations between core staff and political leadership, whereas trust between these two elements in the system is essential for successful reform?

Why has the national political leadership made no effort to justify to Parliament and the public the major changes in GP/patient relationship envisaged by the Five Year Forward View proposals for transforming primary care?

Is not the structure of the footprints (and regional leaders above the footprints) where official representatives are meant to have delegated powers to commit their organisations an attempt to sidestep the legislation of the Health and Social Care Act 2012 with its devolved and GP-led commissioning by a centralised top-down planning system without any recourse to fresh legislation?

How can the secretive and rushed process for STPs ordained by Simon Stevens end up securing any measure of public consent? When is serious public and clinical engagement going to begin?

Is it not the case that projects to group GPs into federations working with other providers to deliver packages of care in the community or “out of hospital” will not deliver savings in the short term – even if GPs manage to understand and approve of them – with the consequence that closing acute hospital beds and A&E departments (in NW London 500 beds and two more A&E's) becomes once again the preferred method of acceding to HM Treasury demands?

Bearing in mind that outline STPs already submitted are not in the public domain and that local authorities are party to them, have elected Brent councillors seen and approved them or authorised officials to proceed without reference to them? Will the final STP submissions be considered in public before submission at the end of June?

Should we not recognise that the health and social care workforce is going flat out and that there are no more large “efficiency savings” to extract under the present financial settlement? Is not the underlying question here how much the UK taxpayer wishes to spend on health and social care as a proportion of GDP if the NHS 'free at the point of delivery model” is to be preserved? Or is the intention of this Government initiative to facilitate an extension of commercial provision of NHS medical and local authority social care?

Robin Sharp and Peter Latham
Brent Patient Voice
31st May 2016
 

Brent NHS CCG takes its toys away

Guest blog by Nan Tewari

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In the most extraordinary spectacle I have ever witnessed in over 40 years of attending public meetings and meetings of public bodies (two different things) on Wednesday evening, Brent NHS Clinical Commissioning Group (CCG) fell out spectacularly with its patient representatives. In short, the CCG refused a perfectly reasonable, unanimous patient request to change the order of the agenda items of the patient engagement meeting and in the face of patient disapproval, decided to close the meeting with no business having been transacted. The badly run meetings (by a CCG public appointee) had failed consistently to run on accepted lines, namely, apologies, approval of minutes. matters arising etc. and as a result, minutes of meetings held in November 2013, March 2014 and May 2014 have never been approved and therefore cannot be put onto the CCG website for the benefit of the public at large.

The law requires CCGs to consult with patients and the public on proposed changes to the delivery of health services.   Failure to comply with the requirement can be serious with the CCG being challenged by providers as well as by individual patients and groups of patients who perceive changes as being detrimental.  Even if the CCG is confident that it is making the best decision, it still needs to go through a proper and proportionate public engagement process.

In order to meets these legal obligations, the CCG set up a committee of its Governing Body called the Equality, Diversity and Engagement (EDEN) Committee to provide itself with assurance that its public involvement activity in the multiplicity of proposed service changes was as robust as it should be.

My fellow patient reps and I (some, appointed by the CCG and others, elected by fellow patients) worked really hard to help the CCG and pointed out where it could be open to challenge.  We take the view that we are neither a rubber stamp nor nodding donkeys, and it is our duty to withhold the desired assurances if patient involvement is unsatisfactory.  The CCG did not appreciate this one little bit and started a smear campaign against patient reps saying that we were failing in our duties.

The CCG is effectively rewriting the rules to tell patient reps how they must act. In the course of doing so, they are also breaching all of the accepted rules of public body committee procedure and have stated that their particular public body (the CCG) does not have to act in accordance with these norms.

I have taken up this guest blog spot, courtesy of Martin Francis, because there is nowhere officially in Brent CCG for patients to air their views on matters of public involvement in proposed changes to local health services as is required by s14Z2 of the NHS Act 2006 as amended by the Health and Social Care Act 2012. It would be interesting to hear what others patients and members of the public have to say.