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
