Causes for concern in Brent NHS provision

Peter Latham, Chair of Willesden Patient Participation Group and Member of the Steering Group of Brent Patient Voice, has given permission to Nan Tewari for this extract from his November 2015 Newletter to be published on Wembley Matters as a Guest Blog. It gives an interesting, and at times worrying, insight into current developments in local health provision.

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The national NHS news remains worrying.  Today we have news of junior doctors voting on a strike.  A new OECD report says that Britain now comes low in the international league tables for most categories of national healthcare.  Male expectation of life at birth comes 14^th out of 34, and 24^th for women.  Cancer 5 year survival rates are 21 out of 23 nations for cervical cancer, and 20 out of 23 for both breast and bowel cancer.  For surviving a heart attack we come 20^th out of 32 nations, and for surviving a stroke 19^th out of 31 nations. For unnecessary hospital admissions for asthma or lung disease due to poor care at home we are ranked 22 out of 34 nations.   The OECD estimate that to bring the NHS up to just OECD average performance would require an extra 26,500 doctors and 47,700 extra nurses at a cost of an extra £5 billion per year.  Britain currently spends £2,100 per person on healthcare, slightly below the OECD average.  Another report this week suggests that one quarter of all cancer diagnoses are made only when the patient goes to A&E already having symptoms so that their average survival time is poor. 

At our local Brent level there continues to be much paper activity at Brent CCG but not very much to report about actual changes put in place.

At the Brent CCG Governing Body meeting on 4 November 2015 the Deputy Chair Doctor Sarah Basham announced that the Brent CCG Chief Financial Officer Jonathan Wise is leaving.  She did not give any reason and did not announce a replacement.  This is unfortunate at a time when Brent CCG have moved from an annual financial surplus to Mr Wise’s report of an underlying financial deficit of about £1.3 million as at September 2015.  The CCG has filed a financial recovery plan as required by NHS England by 31 October 2015.  This needs to be set in the context of an annual budget of about £375 million.

Brent Community Cardiology Service & other Brent Planned Care projects.

The new Brent Community Cardiology Service provided by Royal Free London NHS Foundation Trust that started in March 2015 at the Willesden and Wembley Centres for Health and Care is improving on many of its early problems.  There are now clinics at both centres each weekday.  More specialist cardiologists have been appointed although not all have started yet.  There was a gap in the contract specification with no provision for diastolic heart failure.  The CCG has now decided to issue a contract variation to cover this when the projected volume of patients and their needs have been clarified.

I have been appointed as a patient representative on the monthly contract review group for this service.  The main continuing concern for patient safety is on the 14 day contract maximum waiting time for urgent cases from GP referral to first offered appointment.  Mr Robin Sharp Interim Chair of Brent Patient Voice has waived doctor/patient confidentiality in the public interest to reveal that when referred by his GP for atrial fibrillation in June 2015 his first offered appointment was with a 62 day wait.  No explanation has been given. At the monthly meeting on 4 November with an agenda item for waiting times as at 30 October no figures were published for current waiting times.  It was said by Brent CCG that the figures will only be published after they have been verified. So patients have no confirmation that all or any patients assessed as urgent are being offered a first appointment within 14 days.  I requested the figures ‘subject to verification’ but this was refused.  Brent Patient Voice will now report this problem to Healthwatch Brent with a view to notification to the Care Quality Commission.

At the Brent CCG Annual General Meetings on 2 September and re-run on 14 October in answers to my questions the chair Doctor Etheldreda Kong confirmed that the 2012 ‘Planned Care’ business case for transferring about 13 specialist adult out-patient services out of hospital in 5 ‘Waves’ into new community clinics under the slogan ‘Better Care Closer to Home’ has been discontinued after the introduction of just the Wave 1 new ophthalmology service provided by the commercial provider BMI (who run the commercial Clementine Churchill Hospital at Sudbury Hill), and the new Brent Community Cardiology Service provided by the Royal Free whose problems are reported above.  

This project has been currently replaced by much less ambitious schemes e.g. just for physiotherapy instead of the major Wave 2 new integrated multi-disciplinary, musculo-skeletal (MSK) service project for which the procurement was discontinued in March 2015 following which  Brent CCG estimated  £713,000 had been spent on it.

Brent CCG A&E Advertising Campaign: “A&E is for life-threatening emergencies only”.

This advertisement has cropped up at bus stops in the borough etc and also carried the Brent Council logo.  Brent Patient Voice has complained that it is false and misleading and made a complaint to the Advertising Standards Authority.  BPV has given examples of non life-threatening emergencies that justify admission to hospital through A&E e.g. a penetrating eye injury.  Brent CCG has not challenged this and it is notable now that the wording on the Brent CCG website headline slide show has now been altered to say ‘A&E is for emergencies only’.

Brent CCG Whole Systems Integrated Care (WSIC) Project with Brent Council

This imposing sounding project has run into difficulties from lack of funding.  It proposes an integrated care plan just for elderly people with one or more long term conditions such as heart failure or asthma. Part of the aim is to reduce the need and cost for unplanned hospital admissions.  A WSIC pilot in part of the borough was planned to make sure the systems would work.  This pilot has now been abandoned for lack of funds.  The current proposal is to start the scheme across the whole borough in April 2016 without this pilot testing.

Brent CCG Commissioning Intentions 2016/17.

At the Governing Body meeting on 4 November the ‘final’ draft Commissioning Intentions (local health services purchasing plan) 2016/17 was approved.  The plans can be found on the Brent CCG website and include feedback from the patient involvement and consultation events including the Health Partners Forum on 7 October 2015.  I have been unable to discover the closing date for the online patient survey.

Notes from the Mansfield Enquiry

Guest blog by Peter Latham

On Saturday 28 March 2015 I went to Hounslow Civic Centre for the morning half of the NW London local authorities' Mansfield enquiry hearings into the impact of the NW London NHS 'Shaping a Healthier Future' project on healthcare for patients in NW London.

 

The main new thing I learnt was that the enquiry secretary Peter Smith told me that all the Clinical Commissioning Group and hospital trust NHS witnesses have declined to attend to give evidence until after all the 5 volumes of written evidence have been disclosed by the enquiry online next week. So any Clinical Commissioning Group or Healthcare Trust witnesses will be only be cross-examined at Brent Civic Centre on 9 May - after the General Election. 
Counsel to the enquiry is the barrister Katy Rensten instructed by a solicitors Birnberg Pierce.  She asked very easy leading questions for all witnesses critical of the Shaping a Healthier Future project.  There was no-one to cross-examine witnesses critical of the 'Shaping a Healthier Future' project.
The chairman of the enquiry Michael Mansfield QC asked a few well focused questions to each witness.   The other panel members are a retired Ealing GP Dr Stephen Hirst MBBS London 1974, and Dr John Lister (non-medical PhD) who is is a journalist academic with strong links to the National Union of Journalists and prominent in the pressure group 'Save Our NHS'.
It was clear from the panel questions that they are very interested in the same topics that the Brent CCG locality Patient Participation Group chairs criticise:

• weaknesses of the evidence for the original case for the 'Shaping a Healthier Future' project; 
• the failure to put in place the proposed community services to take the strain before the acute A/E departments were closed on 10.9.14;
• the lack of clarity for the public as to the demarcation between Urgent Care Centres and acute A/E;
•  the flimsy basis for the attempted implementation of the Shaping a Healthier Future projects with insufficient tendering procedure know-how.

It became clear to me that the panel and even some of the professional witnesses are not fully familiar with the full range of new NHS structures e.g. no-one was able to say where the funding for the Better Care Fund comes from - although it was thought that it involves no new money.  There appeared to be ignorance as to how limited the first tranche of implementation of Whole Systems Integrated Care is to be: in Brent just over 65s with at least one long term condition.

It became clear to me that some of the witnesses are failing to distinguish 2 quite separate issues: the political controversy over privatisation of NHS services, and the separate clinical and financial efficiency issue as to the merits of transferring more NHS out-patient services from the secondary hospitals into a community primary care setting.  This was particularly true of Professor Allyson Pollock of Queen Mary College who made a  very emotive politicised statement about destruction of the NHS by importing US style commercial privatisation.

The witness Hounslow Councillor Melvin Collins chair of NW London Joint Health Overview and Scrutiny Committee (JHOSC) was very critical of the NW London and CCGs long-standing secretiveness towards them with failure to provide requested information which he said made their work ineffective e.g. at a meeting on about 23 March Dr Mark Spencer had made it clear they would only get the business case for Whole Systems Integrated Care after the general election.

The 2 witnesses from Hounslow Council, their leader Steve Curran and cabinet member for Health and Adult Social Care Lily Bath, emphasised the shortcomings of their local CCG over SaHF and WSIC, but understandably had no criticisms of the local authority component of local health and social care other than emphasising their insufficient funding.

Consultant in Emergency Medicine Dr Julian Redhead, Chair of the Royal College of Emergency Medicine London Regional Board and with Imperial College and St Marys emergency trauma unit emphasised the shortage of appropriately qualified and experienced A/E staff as driving the need for centralisation of acute A/E services, and the need for a sufficient patient base to support specialist skills.  He gave rather vague oral evidence about the NHSE/Monitor 2009 patient base A/E funding cap with 30% funding disincentive for excess patients, and suggested that the whole way in which we pay for emergency medicine needs to be reformed: without making any specific suggestion in his oral evidence.

Medical practitioner Professor Allyson Pollock emphasised the transformation resulting from the repeal of sections 1 and 3 of the NHS Act 2006 by the Health and Social Care Act 2012 with the result that the Secretary for State no longer has a statutory duty to 'provide' health care  for the people of England, but only a duty to 'promote' such healthcare.  The duty transferred to the NHS Commissioning Board and local CCGs is only to meet the reasonable requirements of their population.  Public health has been carved out of CCGs and transferred to local authorities.  GP practices no longer have a specific territory.  She contended that we no longer have a National Health Service.  The present government are keen on the prime provider model which encourages sub-contracting so that we are importing US solutions and US problems.  Services are already falling away when specific services are not not specifically includedin contracts.  We are moving to the over-treatment and under-treatment of the over-expensive commercial insurance company US model whose algorithms focus on profitable premium fixing with no local accountability or local link.   She strongly proposed abolishing Foundation Trusts and the NHS internal market.  

The chairman of the enquiry Michael Mansfield QC asked Professor Pollock whether she had researched the vested interests of members of the House of Commons and House of Lords who had spoken in favour of the model of the 2012 Act.  She said that she had not researched this but that many did have such vested interests e.g. Alan Milburn.  She said that the last leader of the NHS had described it as being in 'managed decline'.

Peter Latham,  Chairman Willesden Patient Participation Group.