Bid for £513m for NW London CCGs to be submitted to implement STP

Just after the Kilburn Times LINK published a story about the potential impact of the Sustainability and Transformation Plan (STP) on Brent, the NHS Brent Clinical Commissioning Group held an extraordinary Governing Body meeting at lunchtime today. The Times story pointed to a difference in emphasis on the STP from Cllr Krupesh Hirani, lead member for community wellbeing who said he would sign up to the STP, and Carolyn Downs, Brent CEO who has led on the STP, who repeated the caveats made at Brent's October Cabinet meeting*. The STP got very little detailed mention at today's meeting.  Ealing and Hammersmith and Fulham boroughs have refused to sign the STP at present.

The chair said that in seeking £513m investment the area CCGs were following through the controversial Shaping a Healthier Future  (SaHF) and the Sustainability and Transformation Plan . The investment was necessary to deliver these plans and the meeting considered the Strategic Outline Case (Soc 1) for the investment. 

The majority of the funding (£304)  would go to acute hospitals, most of it to Ealing Hospital. £69m to improving GP practices, and £141m to out of hospital hubs.

 

The £304m hospital share would:

• support Ealing's changes to become an excellent local hospital
• expand A& E and provide more beds at West Middlesex Hospital
• expand A & E and maternity at Hillingdon Hospital
• provide more primary and community care services at Central Middlesex Hospital
• provide more post-op recovery and critical care beds at Northwick Park Hospital and improve some existing buildings

The £69m GP practices share would:

• make it easier for patients to physically get in and out of practices
• make better waiting rooms and more consulting rooms across all 8 boroughs

The £141m allocated to Out of Hospital Hubs would:

• modernise 11 existing community hubs
• build 7 new ones
• increase capacity and enable people who have multiple health and care needs to have those dealt with in one place 

The overall aim was better health care and preventing unnecessary hospitalisation.

At the public question time Robin Sharp speaking for Brent Patient Voice said:

I thank the Governing Body for making 30 minutes available for public comments or questions during this session. I am afraid that the rest of what I have to say will be more critical.

Sadly we are presented with yet another example of flawed procedure and a flawed case for change on the part of our NHS.

To begin with procedures, it is farcical that the Governing Body are set to approve a complex 250-page submission only 8 days after it was put into the public domain. Doctors on the Governing Body are very busy people with important clinical jobs. How can they have had time to read and understand these proposals?

It is also disgraceful that 7 out of the 8 NW London Healthwatches which make up the PPRG (Patient and Public Representative Group) for SaHF have offered quasi-endorsement for the document even though they admit that the public they are supposed to represent have not seen it.

We are told there will be public engagement in future, but is not this the wrong way round? Engagement should have been before the document goes to the Treasury.

Turning to the clinical case for change, it has been over 3 years since the “Better Care Closer to Home” strategy set out in SaHF was launched. It was supposed to be all in place by 2015. Where is the assessment to show that more care in the community has stopped people being admitted to hospital and reduced the need for acute beds?  It is certainly not in the NW London STP (Sustainability and Transformation Plan). “If Better Care Closer to Home” works why are our A&Es among the most challenged in England. Why are Referral to Treatment (RTT) times on a downward trend?

We were told in the slide presentation that 27 Hubs across NW London are at the heart of this Business Case and that St Charles off Ladbroke Grove is an example of a fully functioning “Hub”. Can we please see a paper giving details of how this is working? As a patient of a nearby Brent practice who uses the Urgent Care Centre at St Charles I have to say that the existence of a Hub is a well kept secret. No-one has told me or my Practice PPG about it.

Maurice Hoffman asked if only a limited amount of the monies claimed was available how would it be distributed?  He asked if  a 'local A & E' would meet London standards. He was told that the CCG had made it clear to the NHS that all the proposals were inter-connected and they were pitching for the full amount.  He was told that a Charing Cross A & E would not take 'blue light' case and NW London CCGs were looking at what services for the frail and elderly could be best placed there.  He was assured that 'until we have the capacity we will not change anything.'

As the presentation had mentioned voluntary organisations as providing services in the hubs, I asked how this would work when NHS England and NHS Estates were saying that market rents had to be paid. There was a momentary silence while the governing body members looked at each other and then Sarah Mansurali replied that they were looking at giving grants to voluntary sector organisations so they could afford the rent, offering sessional space or try to integrate voluntary organisations into new models of care.

The Governing Body noted the scope of the SOC and approved Part 1 for submission to NHSE and NHSI for approval and asked for the following points to be considered prior to approving subsequent related Outline Business cases (OBCs):

• further public involvement is undertaken where appropriate
• the OBCs continue to justify the capital requirement set out in SOC part 1
• opportunities to accelerate the delivery of the benefits are explored
• opportunities to further improve the income and expenditure position of proposals are explored

It is worth noting that this meeting took place during the day on a weekday so opportunities for the public to attend were clearly limited.  

*Cabinet Minutes October 24th 2016:

1.     Cabinet noted the STP submission for North West London. 


2.     Cabinet welcomed the principles adopted within the STP of prevention, out  of hospital care, dealing with the social care funding gap and the need to work across the public sector to maximise benefits from changes to the NHS and other public sector estate. 


3.     Cabinet noted that the STP will need formal sign off by the end of December and that between October and December the following issues need to be clarified both within the submission and through other NHS processes, in 
 order for the council to give full support for the plan:

a.     That the IMBC on which delivery area 5 is based is released, debated and understood; 


b.     That the flow of monies from acute to out of hospital settings are clarified; 


c.      That the specification for out of hospital settings, in particular social care, are clarified
based on an agreed model of out of hospital care; 


d.     That a full risk assessment for the plan and relevant mitigations are included.

Extraordinary Brent CCG meeting on Wednesday to further controversial health plans

There is an Extraordinary Meeting of the Governing Body of the Brent Clinical Commissioning Group at noon-1.30pm on Wednesday 14^th December at the Boardroom Wembley Centre for  Health and Care.  The meeting is open to the public and 30 minutes has been allocated to questions from the public.

The meeting is about the business case for Shaping a Healthier Future and the CCG consider this essential for ‘delivering’  the controversial NW London Sustainability and Transformation Plan. Cllr Krupesh Hirani confirmed in the Brent and Kilburn Times today that Brent Council intends to sign the STP despite the fact that neighbouring Ealing and Hammersmith and Fulham councils have refused to do so.

As usual the documents are massive, jargon ridden and with enough acronyms to fill Wembley Stadium.

Anyone who manages to plough through them AND understand them deserves an honorary degree.

Those who think that the STP, though argued on the  basis of benefits to patients, is really a cover for cuts may be interested in the Strategic Outline Case for investment to eventually save money: 

For trusts under the ‘comparator’ scenario, where no commissioner QIPP is assumed to be delivered and with business-as-usual CIP delivery, all our provider trusts will be in financial deficit, with a combined deficit of £114m at 2024/25. However, if commissioner QIPP were delivered, trusts’ I&E would improve to a combined deficit of £18m as additional CIPs can be achieved (termed the ‘SaHF scenario before reconfiguration). The CCG QIPP delivery is dependent in part on the building of the hubs, which is why it is not included in the ‘comparator’. If we receive the capital funding we are requesting, the trusts’ financial projections demonstrate that all trusts will have a sustainable I&E surplus position of £27.6m at 2024/25, with the reconfiguration contributing a c£50m benefit (termed the ‘SaHF scenario after reconfiguration’). 

Currently the trusts are running in-year deficits which would require an estimated cash support of £1.1bn over the next 10 years (and continue thereafter), which would reduce to £0.5bn under the ‘SaHF scenario before reconfiguration’ (where additional CIPs are delivered, partly due to hub investment to enable QIPP delivery). Under the SOC part 1 option (‘SaHF scenario after reconfiguration’), the cash deficit support in the 10-year period would reduce further to £0.4bn and are eliminated post reconfiguration. 

If the capital investment were funded by loans, two of the trusts would have a below target Financial Sustainability Risk Rating (FSRR) and be unable to meet the loan repayments. As the loan funding scenario is unaffordable from a liquidity perspective, we have explored two further scenarios and have concluded that our preferred option is for Public Dividend Capital (PDC) funding, and an accelerated timeline. 

We have also demonstrated that the case is affordable under a range of scenarios by conducting sensitivity analyses.

Documents

BrentCCG SaHF SOC Part 1 cover sheet 14122016

Shaping a Healthier Future SOC Part 1 Covering Report

14 December GB Agenda

Shaping a Healthier Future - Strategic Outline Case Part 1

This is the Brent Cabinet decision as recorded in the minutes of the October 24th Cabinet meeting:

1.     Cabinet noted the STP submission for North West London. 


2.     Cabinet welcomed the principles adopted within the STP of prevention, out  of hospital care, dealing with the social care funding gap and the need to work across the public sector to maximise benefits from changes to the NHS and other public sector estate. 


3.     Cabinet noted that the STP will need formal sign off by the end of December and that between October and December the following issues need to be clarified both within the submission and through other NHS processes, in 
 order for the council to give full support for the plan:

a.     That the IMBC on which delivery area 5 is based is released, debated and understood; 


b.     That the flow of monies from acute to out of hospital settings are clarified; 


c.      That the specification for out of hospital settings, in particular social care, are clarified
based on an agreed model of out of hospital care; 


d.     That a full risk assessment for the plan and relevant mitigations are included. 


Now Brent CCG gets into NHS estate management and development to further the STP

Last week Chris Hopson, Chief Executive of NHS Providers, warned that poor consultation over the NHS  Sustainability and Transformation plans could cause mass opposition on the streets that would scupper the plans LINK while Diane Abbott has referred to the STPs, quotuing that for NW London, as a 'dagger pointed at the heart of the NHS LINK.

One area that has not received much press coverage or comment is the management of the sites and buildings belonging to various parts of the NHS (see table above).

A report LINK going before the Community and Wellbeing Scrutiny Committee on Wednesday from the Brent Clinical Commissioing Group and NHS Propery Services, entitled the NHS Estate in Brent,  puts forward plans for various parts of the estate. They see the management of property as an 'enabler' to 'delivering' the STP and Shaping a Healthier Future. In particular they look at increasing the use of void space in the Willesden Centre and Monks Park Centre but also have far reaching plans elsewhere:

The CCG estates strategy identifies three site locations to be developed to support the local hospital and hub strategy. In order to maximise the use of the existing estate the CCG estates plans focus on creating out of hospital Hubs at Wembley Centre for Health and Care, Willesden Centre for Health and Care and Central Middlesex Hospital.

The three Hub locations were identified following an assessment of the main areas of deprivation and service demand across the borough. The CCG also took into account the forecast population growth.

The map below shows the forecast population growth in Brent to 2025.

Brent Population Growth 2015-25

This indicates the greatest population growth density to be forecast in the south west of the borough, suggesting the greatest health care demand in the areas are around the intended Hub locations at Wembley Centre for Health and Care and Central Middlesex Hospital

Wembley is the area with the second biggest capacity for new homes within North West London (11,500 new homes).

The Park Royal development on the border with Ealing has the potential for 1,500 new homes and new development proposals in Alperton will impact on south Brent and north Ealing, creating an increased need for primary care provision around Central Middlesex Hospital.

The majority of out of hospital services will be delivered from the Central Middlesex Hospital site which will become a Hub+. The Hub+ will offer specialist services commissioned for the whole borough alongside standard Hub services such as primary care, community services, one stop assessments and treatments and access to more complex diagnostics for the local population.

The Hubs at Wembley Centre for Health and Care and Willesden Centre for Health and Care will offer the standard Hub services for the local population.

The CCG is working with London North West Hospital Trust to develop a business case for the future configuration of Central Middlesex Hospital which will include the provision of a GP practice. The business case is due to be completed in summer 2017 and will then be submitted to NHS England for approval. It is anticipated that the GP practice (subject to commercial arrangements being in place) will be in occupation late 2017.

The business cases for Willesden Centre for Health and Care and Wembley Centre for Health and Care will follow after Central Middlesex Hospital. The aim is to maximise utilisation of both sites to deliver local services to the population in the area.

The CCG is working in collaboration with Brent Council to commission a property consultant to further their plans:  

  The One Public Estate (OPE) initiative is being delivered in partnership by the Cabinet Office Government Property Unit and the Local Government Association. The initiative provides practical and technical support and funding to Councils to deliver ambitious property-focused programmes in collaboration with central government and other public sector partners.

Brent Council, in partnership with the CCG, has made an application for funding towards the co-ordination of a data capture exercise and to undertake the public sector and health review. In working together to deliver a common local public sector estates vision, Brent Council officers working with the CCG have developed a project brief to be used for the purposes of commissioning a professional property consultant if the application is successful.

The projects identified are:

1.     Northwick Park Hospital Brent in partnership with the London North West Hospitals Trust, the University of Westminster and Network Homes, aims to rationalise services and resource and unlock development land to facilitate hospital redevelopment, new homes and improved services for the community. 


2.     Church End Growth Area Brent’s bid aims to enable the creation of a community hub that will attract public services and businesses to the local area, the key emphasis is ensuring that the public services and businesses provide positive services that will build capacity and benefit the local community. 


3.     Wembley The reduction in staff numbers and more efficient use of office space in Brent’s Civic Centre in Wembley Park, provides an opportunity to look more closely at how local public services may better work together, including a review of the area surround the Wembley Centre for Health and Care. 


Vale Farm area

4.     Vale Farm, Brent’s aim is to deliver a new multi-purpose leisure centre, new homes and possibly a new secondary school in an area that is primarily public open space and metropolitan open land, a feasibility study is proposed to identify opportunities for integration between local public sector services, particularly the Metropolitan Police, Brent CCG and the Council. 


A further bid will be brought forward for:

Brondesbury Road (including the Kilburn Square Clinic). These premises comprise 11-15 Brondesbury Road; which provides a home for community mental health teams. The site is Brent owned, but subject to shared usage with Central and North West London NHS Foundation Trust, (CNWL), (although current occupation circa 90% CNWL, 10% Brent). The model for the delivery of such services is under review, and is likely to result in a relocation of staff from the building.

The report states:

The CCG will build on the plans already in place to increase patient, user and carer engagement, which is essential for success as it makes the changes outlined in this paper. The CCG will do this in conjunction with the Council where this is appropriate.

Given widespread dissatisfaction with consultation on Shaping a Healthier Future and the NW London Sustainability Transformation Plan the Brent public may need quite a lot of persuading that these plans are in their interest.

Mansfield recommends abolition/suspension of Shaping A Healthier Future in a damning critique

The Mansfield Commission's Interim Report into the Shaping A Healthier Future consultation states of the programme that would rsult in the closure of four of the nine acute hospital sites in the North West London area and the loss of Central Middlesex A&E:  

The SaHF programme in our view was a preconceived solution that was imposed on the North West London health system without there being any clear problem that it was designed to solve. 

In particular there was no proper assessment of the needs of the whole area to which the health and social care system would respond.

 The following recommendations are made:

1.     We recommend that the SaHF programme is abolished / suspended, thereby saving a considerable sum at one fell swoop. 


2.     We recommend that an independent review of the North West London health system is undertaken under the auspices of a joint health and local authority initiative that builds its case on a thorough assessment of the needs for health and social care of local populations, at local levels. 


3.     There must be no presumption that so-called ‘reconfiguration’ of acute services is the solution to what may not be a problem at all. 


4.     In addition there must be no presumption that the solution will involve a top-down approach across the whole area as SaHF assumed; there should be an openness to consideration of local solutions possibly at the borough level where these can be shown to work. 


5.     The NHS and local authorities must agree to work together to achieve a joint aim to provide good accessible health and social care to all local populations within a sustainable financial model. 


6.     We recommend that the attempt to close Ealing and Charing Cross hospitals is immediately stopped; that a guarantee is given to sustain acute health services on these sites – with no more double talk from NHS leaders – until the above review is complete and any associated business cases are taken through to Full Business Case level, which is likely to be at least five years. 


7.     We recommend that in the light of current failures in the system in North West London there is an independent review of the emergency system under the auspices of the above joint health and local authority initiative; and that this as a matter of urgency examines the closure of Hammersmith and Central Middlesex A&E departments with a view to opening these, if that is what the review suggests is needed, and what local people want. Local people must be given honest and genuine choices; the opportunity cost of retaining these sites as A&Es must be made apparent. 


8.     We recommend that there is a review of primary care services in the region, and that following this review, immediate steps are taken to rectify any issues. However any investment must be based on a clear business case that relates costs and benefits to changes across the whole system. 


9.     Likewise we recommend that there is a review of OOH services in the region, to establish a clear case if it exists for OOH acting as a way of reducing demand for acute services, and also as a way of reducing total system costs. Following this review, any investment in OOH services must be based on a clear business case that relates costs and benefits to changes across the whole system. 


10.  In the case of changes that take place in primary care and OOH services as a result of the reviews outlined above, there must be a clear business case presented that makes a clear case for system- wide improvement arising out of these changes, and this should be consulted on with the relevant local populations; there should be no assumption that this is the population of the whole of North West London. 

The full report can be read here: 

The commission's final public session will be held at the Brent Civic Centre on Saturday 9 May 9am-5pm. Brent Trades Council and Brent Fightback are among those who have submitted evidence. It would be good to have as many health campaigners as possible at this session. More evidence will be heard

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.