Our thoughts on the Government’s new NHS White Paper.
This is not the time nor the sort of reorganisation the NHS needs.
- There should be a full public consultation involving all stakeholders, with implementation delayed till after the worst of the pandemic, as suggested by NHS Providers.
- Councils and primary care should have parity of representation and voting rights on the main ICS NHS board, or at the very least, increased voting representation, not the one each as now.
- Measures need to be in place to ensure that ICSs are fully accountable to local councils, public, and patients, meetings are held in public, papers/minutes etc made public, and ICSs subject to FoIs.
- Independent providers should be excluded from membership on decision-making/resource allocation ICS boards and committees.
- NHS organisations should be the preferred providers
- ICSs should use the provisions in the PSR to continue or directly select existing NHS, and some not-for-profit providers, when contracts come for renewal
- Staff should be maintained on NHS contracts and terms and conditions.
- Records should securely follow patients through care for safety.
- There needs to be increased investment in public health and social care, with wholesale reform of the latter, and restitution of local authority funding cutbacks.
- There appears to be no merit to the proposals on professional (de)regulation and they should be scrapped.
- Face to face consultations and direct spoken contact with appropriate advocacy if needed should be enshrined as essential core features of the service, not as rationed/delayed exception – Patient First not Digital First with the necessary increased investment.
- Crucially, there is an urgent need for greatly increased NHS funding to meet the backlog that existed before the pandemic, and has been exacerbated by it, and restore annual funding increases of 4% or more allowing for staff wage increases and recognising that the rate of NHS cost inflation exceeds the overall national rate, because of complex care and medication needs.
- The remaining elements of the expensive and wasteful private market tendering provisions should be abolished.
Primary care
- The standard GMS contracts and the less common PMS one, should be supported, and APMS contracts should not be used for primary care. (Centene practice already failed CQC).
- Primary care contracts should remain within the NHS, perhaps with GP Federations, PCNs or local Trusts, with salaried general practice options, rather than private APMS ones.
- Primary Care urgently needs to receive a larger percentage of NHS expenditure, but not at the expense of secondary care, which is also struggling.
- The general practice workforce needs to be increased with more GP training places along with formalised practice nurse training schemes.
- Options for increasing support to GP practices, beyond that currently available from the Federations and PCNs should be encouraged and funded.
- Review and resource primary care to give it a central and expanded role to enable it to carry out some of the work now unnecessarily, and less efficiently referred to outpatients and to A&E alternatives so it can provide better, joined up, local, timely healthcare and a more efficient use of resources.
- Every patient should have a named doctor in their practice.
White Paper – Integration and Innovation and Primary Care
The Government plans to put the Bill formally establishing ICSs (‘Integrated Care Systems’) across England before Parliament in the next few days. As this will happen shortly before the end of the Parliamentary Session, there will be no effective scrutiny of the Bill’s provisions.
While the stated goals of the White Paper look laudable, e.g., promoting integration, reducing competitive tendering, partnership, collaboration, and tackling health inequalities, in fact, the Bill erodes the fundamental principles of the NHS, of tax funded universal health care for everyone at their time of need, and undermines local accountability. If the implementation of ICSs, and the context had been different, the proposals could have been very positive. However, as it stands, the White Paper does not address the real keys to improving health outcomes and reducing health inequalities i.e., workforce and funding in the NHS, relative to comparable countries, (e.g. fewer beds, doctors and nurses per capita), investing in social care and public health, and council cuts and reduced responsibilities. This is at a time when life expectancy has dropped during the ongoing pandemic and inequalities increased.
This is not the time nor the sort of reorganisation the NHS needs.
There should be a full public consultation involving all stakeholders, with implementation delayed till after the worst of the pandemic, as suggested by NHS Providers.
Concerns
1.Unequal partnership between the NHS and primary care and local authorities (LAs). The ICS NHS board membership comprises a chief executive, nursing director, medical director, and a minimum of two other ‘independent executive directors’, allowing representation of potential contractors. NHSE also expects that boards will have three additional partner members, including one from the local NHS, one from general practice and one from social care. The ICS NHS board controls plans and budgets for the whole system including the very subordinate ICS Partnership Board. The large geographical areas and populations covered by individual ICSs may worryingly disguise increasing inequalities of service and outcome within them.
There is no mention of representation for patients and public. There is no requirement that ICS boards meet in public, that board papers and minutes are published, nor that they be the subject to FoI requests, which given that private providers can be members of both the ICS NHS as well as Partnership Boards, is unsurprising, but retrograde for a public body.
As an example, the Bath, North East Somerset, Swindon and Wiltshire ICS has a Virgin Care director on their Partnership Board. Virgin Care was not prepared for any information to be shared with the public. In response, the other board members agreed that the ‘open book approach would need to be amended to prot-ect providers’ corporate and commercial interests.
- Councils and primary care should have parity of representation and voting rights on the main ICS NHS board, or at the very least, increased voting representation.
- Measures need to be in place to ensure that ICSs are fully accountable to local councils, public, and patients, meetings are held in public, papers/minutes etc made public, and ICSs subject to FoIs.
- Independent providers should be excluded from membership on decision-making/resource allocation ICS boards and committees.
- The role and remit of JHOSCs should continue if and when ICSs are formally constituted.
- The White Paper will repeal competition law as it applied to procurement, in section 75 of the Health and Social Care Act 2012, and exempt the NHS from the Public Contract Regulations safeguards for compliance with environmental, social, and labour law (ILO). Also, with private independent providers permitted on both ICS boards, there is potential for major conflicts of interest, as highlighted by the BMA, ‘the White Paper takes the first step to abolishing these wasteful rules, but unless it goes further -making the NHS the default option for delivering NHS services -there is a risk that contracts will be awarded without scrutiny to private providers at huge expense to the taxpayer, as was seen with the procurement of PPE and Test & Trace during the pandemic’.
The new Provider Selection Regime (PSR) consultation document permits contracts to be continued, directly selected or tendered – the former creating opportunities for private companies, e.g. Centene to ‘lock in’. There is also a developed, private health care sector of 200 plus, pre-approved companies in NHS England’s Health Support Service Framework.
- NHS organisations should be the preferred providers
- ICSs should use the provisions in the PSR to continue or directly select existing NHS, and some not-for-profit providers, when contracts come for renewal, as these are better value for money, with no funds diverted to profit and contracting costs, and all funds reinvested in the service.
- Quality of professional and lay staff should be maintained, through employment on NHS contracts with training and professional education, continuity of service and benefits from pension to sick pay, and regulation of health and safety.
- Records should securely follow patients through care for safety.
3.Major social care (SC) proposals are deferred again. The Discharge to Assess model will be updated, with assessments taking place after discharge from acute care, with an estimated 80% not receiving an assessment. Councils’ responsibilities for SC have already been eroded by the Care Act Easements 2020, and now the Secretary of State (SoS) will be given powers to make direct payments to SC providers, and the CQC will gain new powers to assess LAs’ delivery of SC. The plans for Public Health (PH) are sparse and mainly relate to restrictions on food advertising and labelling, to tackle obesity.
- There needs to be increased investment in public health and social care, with wholesale reform of the latter, to deliver significant improvement to health outcomes and inequalities, and restitution of local authority funding cutbacks. Without this the NHS will remain in crisis.
- The Secretary of State can remove a profession from regulation and abolish regulators; this opens the way for employment of a less skilled, lower paid workforce with poorer health outcomes for patients.
- There appears to be no merit to the proposals on professional regulation and they should be scrapped.
- Digitalisation and technology are central to ICSs, to reimagine care pathways, with little acknowledgement that the huge and fast shift to virtual and remote consultations has in many cases eroded the ‘doctor patient’ relationship and continuity, which evidence shows is key to better patient outcomes, not least to reducing mortality and inequalities. The use of these technologies needs to be reviewed alongside direct personal face to face care, involving service users, with the goal of better outcomes and reducing inequalities not cutbacks. The emphasis on data driven planning between NHS and LAs, using Population Health Management (PHM), and data sharing, with poor safeguards, and actuarial health targets for the whole population, within a capped budget, are likely to result in further rationing and delays to healthcare.
Face to face consultations and direct spoken contact with appropriate advocacy if needed, between health care staff and patients should be enshrined as essential core features of the service, not as rationed/delayed exception – Patient First not Digital First with the necessary increased investment to ensure a clinically appropriate blend of F2F and digital contact, rather than an over reliance on digital contact, driven by resource pressures
- Introduction of capped budgets to be delayed or preferably scrapped – there has always been the ability to roll over some deficits and seek bailouts – but coming after years of low percentage annual funding increases, the impact of Covid 19, and NHSE’s latest demand for savings, increased productivity and efficiency, and the restoration of ‘normal financial disciplines’, capped budgets will result in even more serious delays and rationing.
6.Funding and competition
- Crucially, there is an urgent need for greatly increased NHS funding to meet the backlog that existed before the pandemic, and has been exacerbated by it, and restore annual funding increases of 4% or more allowing for staff wage increases and recognising that the rate of NHS cost inflation exceeds the overall national rate, because of complex care and medication needs.
- The remaining elements of the expensive and wasteful private market tendering provisions should be abolished.
- Social care needs rebuilding and funding as part of building and adequate service for the nation’s health.
Primary care – post Covid and Centene. Primary care is under severe pressure, described by some as at breaking point. Patient satisfaction has plummeted because of difficulties contacting GP practices, long waits for an appointment, erosion of personal continuity of care, telephone triage, and delayed referrals to secondary care.
Funding and workforce: Primary care provides 90 % of patient contacts but receives only 10 % of NHS funding. There was a 10% vacancy rate in the NHS pre-Covid, now higher, and for many years there have been insufficient GP training places to cope with replacement needs and increased demand. Proper support for training and pay of the primary health care team is needed. Nurses are key to general practice, and provide vital services, but Government withdrawal of training bursaries, and poor levels of pay have affected recruitment, even before the pandemic.
If general practice fails, so will the NHS, with patients diverting to emergency departments (ED) and other unscheduled care provision; but still the workload increases without concomitant funding. A year’s worth of GP care per patient, costs less than two trips to EDs.
Valuable links between primary and secondary care, essential for timely advice on referrals and patient management within primary care, need to be developed further e.g., Consultant Connect, the GP/Consultant calls, and speedy referrals to the Two Week Wait and Ambulatory care clinics. There is still a disconnect between the two sectors, with an over emphasis on symptoms and pathways, rather than the whole patient, and patients often speedily referred to secondary care, tested, and with often negative results, returned to primary care with the same problems, or retuned with a host of new tasks for primary care, for which it is under -resourced to fully deliver.
There needs to be a review of primary care, so it has a more central role with an expanded remit, fully resourced and skilled up, to undertake some of the work now referred to outpatients (tests, initial consultations), and that of some of the services established to relieve pressures on A&E and provide instant access to a GP service, circumventing overworked GP practices. These resources should be (re)invested in primary care to provide a one stop shop or polyclinic model, resulting in local, timely, more joined up healthcare, greater job satisfaction and opportunities to specialise and collaborate for primary care staff, and a better use of resources. This would be a game change, popular with patients and primary care staff, freeing secondary care for more complex cases, genuinely beyond the scope of a well-resourced primary care service.
Pressures: These, and other pressures, have resulted in reduced job satisfaction, heavy workloads, demoralisation, difficulties for partners to buy in, and lack of career structure for salaried GPs. Because of these issues, many GPs, both salaried and partners, are tempted to leave or retire early, giving up practices, which if they had received greater support, e.g. help to merge or partner, collaborate on projects (as with the vaccination programme), gain economies of scale by sharing back office specialists (HR, IT, complaints, compliance and premises management), may well have continued. This has adversely impacted staff stability and commitment.
Contracts: NHSE made clear by 2014, that all new GP practices should be on Alternative Provider Medical Services (APMS) contracts, i.e., those held by private companies or third sector organisations, other than core NHS GP partnerships. This has opened the door to Centene type takeovers and one of the Centene practices has already been judged unsafe by the CQC. One of the difficulties for GP partnerships or even GP Federations when bidding for contracts, is that large corporations have teams for contracting and can put in glossy, deceptively polished tender documents. They also threaten, or actually sue, if they fail to win contracts, facing NHS commissioners with the prospect of hefty legal bills; so tendering is not a level playing field between the NHS and private operators.
There is a Judicial Review pending on the Centene takeover, and in Haringey, Keep Our NHS Public have submitted an FoI requesting dates of forthcoming contracts due for renewal.
- The standard GMS contracts and the less common PMS one, should be supported, and APMS contracts should not be used for primary care.
- Primary care contracts should remain within the NHS, perhaps with GP Federations, PCNs or local Trusts, with salaried general practice options, rather than private APMS ones,
- Primary Care urgently needs to receive a larger percentage of NHS expenditure, but not at the expense of secondary care, which is also struggling.
- The general practice workforce needs to be increased with more GP training places along with formalised practice nurse training schemes
- Options for increasing support to GP practices, beyond that currently available from the Federations and PCNs should be encouraged and funded.
- Review and resource primary care to give it a central and expanded role to enable it to carry out some of the work now unnecessarily, and less efficiently referred to outpatients and to A&E alternatives, so it can provide the range of consultations, diagnostics and interventions associated with the better holistic, polyclinic models. This would be a game changer, popular with patients, offering joined up, local, timely healthcare and primary care staff with opportunities to specialise and provide more continuity of care, and finally be a more efficient use of resources.
- Every patient should have a named doctor in their practice.
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US HEALTH INSURANCE GIANT BUYS
HARINGEY GP SURGERY
In February 2021 49 GP practices across London and South East England were bought by a company called Operose – the UK arm of a giant American health insurance corporation called Centene.
One of these practices is in Haringey. The St Ann’s Practice in St Ann’s Road.
WHY DOES THIS MATTER ? Centene is a private company more interested in profits than patients. It has a record of saving money by prioritising phone/digital GP consultations, while at the same time replacing GPs with less expensive non-GP staff and cutting services. Their hope is that remote and digital consultations will become the new normal.
Two of its London surgeries also house a private service where it’s possible to get a quick appointment, twenty-four-hours a day , seven days a week – if you pay. One service for the rich, one for the poor.
WHAT KIND OF COMPANY IS CENTENE ?Centene is an American company based in St Louis. It’s worth $60 billion, the 42 biggest company in the US. Last year it made operating profits of £2 billion and paid its managing director £19 million.
CENTENE HAS BEEN ACCUSED IN THE US OF POOR PRACTICE. It stands accused in the US courts of inflating costs and overcharging government departments, fleecing taxpayers out of millions of dollars. It has been fined for not providing adequate numbers of doctors, specialists and hospitals to meet contractual. In March this year the State of Ohio filed a lawsuit against Centene accusing it of ‘an elaborate scheme to maximise company profits at the expense of the Ohio Department of Medicaid’ by means of using its web of subsidiary firms and subcontractors to misrepresent pharmacy costs.
HOW DID THE SALE HAPPEN ?The decision to permit the sale of the St Ann’s practice to Centene was taken behind closed doors at a virtual meeting of the local health authority – the North Central London CCG – in February 2021. No members of the public were present and protests from some local councillors were ignored.
PRIVATISATION This is part of a growing pattern of privatisation of NHS services. Centene has ‘significant influence’ over the largest chain of private hospitals in Britain – BMI hospitals. This opens the possibility of Centene GPs referring patients to Centene hospitals for routine medical procedures: a private network within the NHS, funded by public money. It also gives Centene an important voice in shaping local NHS services for Islington and surrounding boroughs.
IT’S TIME TO STOP THE CREEPING PRIVATISATION OF OUR NHS
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Read KONP’s full statement on the Government’s Covid 19 plans
There is no government plan to control Covid
For several weeks, it has been clear that the UK is entering a second wave of Covid-19 infections. Across all relevant measures – estimated and confirmed current infections; hospital admissions; positivity (or ‘percent positive’) rate – it is clear that the virus is once again spreading uncontrollably. The whole of the country, except for Cornwall and the Isle of Wight, now has a higher infection rate than Manchester had when it went into Tier 2-level restrictions several weeks ago. In the most affected regions of England (currently the North East and North West), the situation is as severe as the situation in London at the point in March when the first national lockdown was instigated.
The government’s new three-tier system of restrictions may be simpler to understand in theory than the patchwork of different localised measures that it replaces, but the new system is still unequal to the task of restricting the spread of Covid. So far, the tiered restrictions are being applied with the same haphazardness that characterised previous measures, without consultation or even clear communication with local authorities and public health bodies in the regions most affected, and with a heavy laissez-faire bias overall in favour of allowing businesses and profit-making activities to continue as normal, regardless of the impact on public health and Covid transmission.
Just as troubling is the unsavoury powerplay that the government is now engaging with towards those regions and municipalities which have been instructed to adopt rigorous restrictions. The government’s feud with Greater Manchester Mayor Andy Burnham is a clear example. Regions and cities cannot be expected to suspend their residents’ lives and livelihoods without adequate economic support to bridge the gap during the suspension. Evidence suggests that Covid cases are increasing rapidly in Greater Manchester – but this is all the more reason why the government must provide sufficient financial assistance to allow the city to combat the virus without inflicting huge economic damage on residents.
Circuit breaker needed now with full economic support
The only response which is now capable of arresting the spread of the virus, and preventing a repetition of the catastrophe of the Spring, is a rigorous national lockdown. Work that cannot be done remotely must cease, and full economic support should be provided directly to those whose livelihoods are affected (rather than the limited and conditional support represented by the current furlough scheme which pays 67% of wages to workers at firms that are instructed to shut). Social venues must close – something not envisaged even under the third and highest tier of the government’s new restrictions system, which suggests that pubs, for example, can stay open if they are operating as restaurants.
A lockdown is not an option which anybody should call for lightly, given the severe potential impacts on the mental and physical health of the population; however, the current speed and extent of the virus’ spread leaves no other option in order to avoid further death and severe long-lasting injury from Covid-19 on a massive scale. Second time around, a more strict curtailing of business activity would allow greater leeway for the limited social activity (such as small, socially distanced outdoor gatherings) which is vital to public wellbeing.
Public health-run ‘find, test, trace, isolate with support’ system
However, the crucial point is that a lockdown is not a permanent fix to Covid. Independent SAGE offers a comprehensive plan and urges the government to adopt it. This must finally include investment in a publicly-run ‘Find, Test, Trace and Isolate with Support’ (FTTIS) strategy run by the NHS, local public health and primary care – to get a grip on the spread of Covid for the first time. The national ‘circuit break’ is a short-term strategy which buys time to allow the implementation of a medium-term strategy. The medium-term strategy is to establish the highly effective testing and contact tracing system needed, capable of distributing tests swiftly to anyone who needs them, and of analysing and communicating the results accurately within 24 hours. Basing this system in the NHS, working with local authorities and their public health teams, will build on their systems, already achieving over 90% success rate, to rapidly identify and intervene around geographical clusters of infections within the general population. The Deloitte-Serco system is currently only reaching around 60% of contacts nationally against a minimum target of 80%.
To successfully contain the virus, these test-and-trace systems must also be coupled with a robust set of economic support mechanisms and comprehensive sick pay provision, so that anyone who may be carrying Covid is able to self-isolate for two weeks without suffering financial hardship, and without being penalised for absence at their workplace. For those who cannot self-isolate at home, including those living in crowded homes; this could involve provision of separate accommodation for those who cannot self-isolate at their normal residence.
Failed privatised test and trace has lost time and over 50,000 lives
The reason we now face a resurgence of Covid is that the government has failed to implement these essential steps in the months since a lockdown was first introduced in late March. Rather than deferring to NHS professionals and experts on disease control, the Prime Minister has attempted to build a test-and-trace apparatus by lavishing vast quantities of public money on private-sector consulting firms with no relevant experience in the fields of work concerned. The resulting system has always underperformed when compared to other testing systems around the world, and the problem has become more and more glaring as the number of infections has risen in recent weeks.
In terms of economic support, as well, the government’s measures have fallen far short of what is required. There is still no guarantee of adequate sick pay to all workers who need to self-isolate; even in NHS hospitals, many cleaners and support staff work under out-sourced contracts which do not give them a realistic chance of being able to stay at home for two weeks after showing potential Covid symptoms. Data suggests that the vast majority of those contacted do not self-isolate when asked to do so by NHS Test-and-Trace, even though most respondents do believe in the importance of doing so; the discrepancy suggests that many people cannot access the support that they need to self-isolate, or are unaware of what support exists. Surveys also show widespread confusion and demoralisation after several months of shaky, fragmented and highly contradictory government messaging: a poll in September found that 56% of people believed the government to be handling the pandemic badly, whereas a few months previously, the government had a wide margin of trust.
We are left in a deeply unsatisfactory position: a specific set of measures are required to allow the containment of Covid-19 and the resumption of any life approaching “normality”, but the government seems incapable of implementing them, in sharp contrast to the governments of many comparable countries around the world. More generally, the government also seems incapable of abandoning its overweening orientation towards maximizing private-sector involvement in healthcare and approaching every public health issue through private-sector patronage. With 53,640 Covid-19 deaths registered upto 9 October since the start of the pandemic according to the Office for National Statistics, and thousands more on the way, the Cabinet must either take the steps required, or step aside for another government which will do so.
Listen to scientists, public health specialists – and trade unions
Campaigners must also continue to exert our own pressure on politicians to ensure that they take the steps required. We must continue to seriously challenge the government’s record, and must also support those taking steps at all levels of society to ensure safety. Trade unions and organised employees have an important role to play in workplaces: for example, it is notable that the National Education Union accurately predicted the dangers of a mass reopening of schools without adequate safety measures in place, and University College Union members have been in the forefront of attempts to avert the unsafe reopening of university campuses. The first lockdown in March was brought in partly in response to mass public pressure, with many people intervening to ensure their workplaces, schools and universities closed. We must be collectively engaged in trying to combat the spread of Covid in our own workplaces and communities – and we also need to demand a government response that turns the public’s many sacrifices into a lasting solution.
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Integrated Care Providers
October 2020
The Government is undertaking a last minute consultation on its plans to allow so-called Integrated Care Providers to run large areas of the NHS. They will fundamentally change the organisation of the NHS and open the door to the private Sector.
PLEASE MAKE YOUR VOICE HEARD …. AND OPPOSE THIS DEVELOPMENT.
Below is a brief explanation of what’s involved.
NHS England is consulting on the contract for a new model of health and social care provision that threatens the break-up of the NHS into units run by less accountable ‘Integrated Care Providers’ – or ‘ICPs’. Each of these ‘business units’ would control spend and rationing of healthcare for populations of up to 500,000. These huge contracts will be eminently open to the private sector to compete for.
The ICPs will deliver the dangerous new restructuring plans of government which could see fragments of the NHS managed by non-NHS, non-statutory and therefore less accountable bodies. They are the embodiment of government plans to disperse the NHS and its staff, drive down public funding, promote private contracts and put cost limits and profit before patient safety.
Integrated Care Provider contracts:
- Dis-integrate the NHS
- Give control to non-NHS bodies potentially beyond scrutiny
- Threaten public accountability
- Hand over control to these non-NHS bodies for 10-15 years
- Manage multi-billion-pound contracts for blocks of 500,000 population
- Open the door to private companies winning these contracts
Please watch our video – https://www.youtube.com/watch?v=fANVnISrFpU – and share on social media to help spread the word about the Government’s deliberate and insidious privatisation plans.
You can also visit our website – https://keepournhspublic.com/privatisation/icps-what-are-they/ – for more information, videos and links.
How can you help?
Along with our friends at We Own It and Health Campaigns Together we have created a petition calling on the Government to;
a) Abandon the Integrated Care Provider contract model.
b) Guarantee that any Integrated Care Provider organisations will be statutory organisations i.e. NHS bodies, not private providers.
c) Focus health improvement efforts on pressing the government for:
- Sufficient funding and staffing for health and social care.
- Social care to be brought into public provision, free at point of use
- Legislation to end the failed NHS contracting system and to renationalise the NHS: the only sound basis for service integration.
SIGN THE PETITION https://weownit.org.uk/ICP-petition-NHS
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SUPPORTING THE NHS
A briefing for Haringey’s new councillors.
Current plans to reorganise the NHS and integrate health and social care mean that for the first time local councillors have some influence over NHS provision in Haringey. With this in mind we thought you might be interested in a back-ground briefing on the more immediate threats to the NHS and some suggestions for what you can do – as councillors – to help defend it.
1. FUNDING.
Health services in Haringey are run by Haringey Clinical Commissioning ` Group.(CCG ) In 2016 this was bundled with CCGs in Enfield, Barnet, Camden and Islington into what’s known as the North Central London Sustainability and Transformation Partnership [NCL STP]. There are 44 STPs covering the country.
STPs are designed to improve the co-ordination of local health services and encourage greater co-operation between the NHS and local authority social care services, putting hospitals, GPs, public health and community services under a single “administration.”
The government hopes this arrangement will improve services and save money by taking pressure off expensive hospital provision and increasing ‘cheaper’ social care.
To this end the NCL STP has been told it will be expected to make savings of nearly £700 million over the next four years – roughly a ten percent annual cut in its budget.
Social care however as it currently stands is not cheaper. It’s estimated the NCL STP area will need to invest an extra £247 million by 2020/21 in preventative and early intervention services before savings can be made. With local authority budgets across London facing cuts of 40 percent there’s no sign of this happening.
As a result an internal NHS document leaked to the Guardian in June 2017 admitted the NCL STP was already £183.1 million off its savings target – just for the current financial year, and went on to propose ‘drastic’ and ‘unpopular’ cuts in services including increased waiting times for operations and A&Es and the closure of some maternity units.
NHS officials denied the report but some of these drastic rationalisations are already feeding through.
2. RATIONING SERVICES.
Late last year the NCL STP announced plans to declare a number of common medical practices of ‘questionable clinical benefit’ and proposed GPs should be banned from requesting them on behalf of their patients.
They include early intervention for back pain, postponing a range of knee, hip and shoulder operations, cataract surgery and the treatment of varicose veins and relatively benign skin complaints.
The policy, known as ‘PoLCE’ or ‘Procedures of Limited Clinical Effectiveness’, is expected to take effect later this year. There has been virtually no public consultation.
It means the people of Haringey will be provided with a service that is below the national level recommended by the Government’s own National Institute for Health and Care Excellence (NICE).
We urge candidates and councilors to resist any rationing of health services in Haringey
But Haringey KONP believe 2018 will be dominated by two even bigger concerns.
3. PRIVATISATION
In the second half of last year NHS England announced it would begin trials of so-called Accountable Care Organisations or ACOs in eight areas of the country.
These are essentially STPs designed to encourage the integration of the health and caring services but with one big difference: they do not have to be run by public bodies. Contracts to run ACOs will be put out to competitive tender and private heath companies encouraged to bid for them. The private sector will be brought into the heart of the NHS.
Jeremy Hunt has already extoled the virtues of two multinational health corporations as examples of good practice in integrated health care. They are:
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The Ribera Salud Group in Spain, currently under police investigation in Spain for corruption and overcharging 2.6 million euros in emergency assistance. Ribera Salud have already won a preliminary contract to run an ACO in the Nottingham area.
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California based Keiser Permanente which recently clocked up the highest number of fines for breaches of contract of any company in the State of California. It’s claims to be a not-for-profit organisation but in 2016 Kaiser senior executives were handed five-figure bonuses on top of their $1 million plus salaries.
Our health and social care system has many faults but out-sourcing to private contractors is not a solution.
4. SELLING THE NHS ESTATE or the “ FAMILY SILVER”.
Meanwhile the government has begun to look at another controversial source of extra money. In March 2017 the anodyne sounding Naylor Report into the NHS’s buildings and estate was published. It argues the rapid disposal of ‘surplus’ NHS property could bring in between £20bn and £30bn by 2021/22.
It sounds a sensible move. But Naylor raises several thorny issues:
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It wants to do this in a hurry before there has been a comprehensive appraisal of the long term property needs of the health and caring
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There is no recognition the NHS estate is a public asset built up over decades, even centuries, often with the support of voluntary and/or charitable contributions and should first and foremost be used for the public good not as a short term financial fix.
Naylor is a ‘fire sale’ of public assets for short term gain.
In the Haringey area several sites may be affected :
St Anne’s Hospital, devoted primarily to mental health services, is up for ‘redevelopment’ in the near future. But current outline planning permission includes only fourteen percent ‘affordable housing’, against a Mayor of London manifesto commitment of 50 per cent for all new housing developments. It fact at St Anne’s a well advanced community backed project – the St Ann’s Redevelopment Trust – is calling for 100 per cent affordable housing
Ditto Chase Farm Hospital where only nineteen percent of the land up for grabs has currently been allocated for ‘affordable housing’.
The Whittington has controversially teamed up with the private developer associated with the Grenfell Tower disaster to help redevelop some of the enormously valuable forty nine sites it owns across Haringey, Camden and Islington.
Naylor is good when encouraging NHS Trusts to use at least some of their ‘surplus’ land to house NHS staff, but it goes against principles of public finance , it is not planned and has no proper democratic oversight.
Councillors should oppose any sale of NHS Estates without a long term appraisal of the property needs for Haringey’s health and social care services
5. WHAT YOU CAN DO
A. Scrutinise and Question NHS plans affecting Haringey :
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Join or lobby the Health and Adult Scrutiny Panel which holds the Cabinet and council to account for health issues.
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Lobby or join the Haringey Health and Wellbeing Board. It’s job is to co-ordinate public health and integrate care between the Council and the NHS. It’s a powerful body as it has to approve all health planning in Haringey and so has a close relationship with the CCG, local hospital trusts and NHS England .
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Engage with the STP Advisory Board which has Leader level representation from each borough and is meant to “ensure the perspectives of our local communities are considered”. It should therefore be an arena to discuss Issues such as the STP, cuts and the Naylor report.
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Follow the work of the Joint Health Overview and Scrutiny Committee, set up by the five north London boroughs to scrutinise the work of the NCL STP. Time and again over the last year it has successfully encouraged and cajoled the NHS into discussing, clarifying and occasionally rethinking its plans.
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Lobby Cabinet members responsible for health and for social care and ensure health and social care are high priorities for the council.
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Ensure Haringey uses its planning powers to rigorously vet NHS estate plans and stress that land should be used for affordable social housing key worker housing and NHS staff.
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Ensure the local NHS ie the CCG or the NCL STP make its health plans transparent and make sure there is proper consultation with residents and users on any changes
B. Campaign for improved Social Care Services.
Haringey KONP supports the Social Care Alliance Haringey’s (SCAHs) campaign for better social care in Haringey . Therefore we ask that you:
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Seek restoration of day centres across Haringey for those with autism, learning disabilities and dementia.
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Reconsider the decision to close Osborne Grove Nursing Home
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Campaign to establish an innovatory approach to domiciliary
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Support a much needed review of mental health policy and practice
For details of these and wider proposals see SCAH website http://sca-haringey.org.uk/ and for their briefings click “Election May 2018”
C. Don’t buy the Austerity Agenda.
Cuts to budgets are a political not an economic choice. When the Tories needed support to form a government in June last year, they found £1 billion to buy the backing of the Irish DUP. We believe the NHS should be funded to the same level.
D. Support an increase in the Council Tax
In the long term we believe social care should be funded from general taxation in the same way as the NHS and that “means test” community services should be abolished. In the meantime Haringey Council should be encouraged to raise the social care tax precept by 3% in 2019/20.
E. Support a campaign of public education which emphasises:
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Haringey’s commitment to a publicly funded, publicly delivered and publicly accountable health and social care service.
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That the private sector has no place in health and social care provision and that current PFI [Private Finance Initiative] projects are appalling value for money and should be nationalised.
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NCL STP Watch’s comments on the Naylor Review into selling off NHS land and buildings.
It is important that councillors recognise the powers they have in dealing with proposals for changes in the NHS estates. All the leaders of councils in NCL have expressed their concerns about the Sustainability and Transformation Plans for NCL. They asked Simon Stevens for a number of commitments that included: a long-term transformational change over the STP period working across health and social care as equal partners with local flexibility instead of central control; and full and proper consultation with residents and patients to involve them in any changes in health and social care.
As planning authorities you may review and scrutinise any matter relating to the planning, provision and operation of the health service in your area. You have powers to make reports and recommendations to the local CCGs and the Provider Trusts, and can also ask the Trusts or CCGs to provide you with any information you reasonably require in order for you to carry out the scrutiny process, including attendance of appropriate employees to answer any necessary questions. All this is particularly pertinent given the approach taken by NHSE to the Naylor report. We would ask Local Authorities to use their planning powers accordingly.
A broad response to the Naylor Review (March 2017) should have an approach based on the following.
1. The rushed sale of valuable NHS estate land and buildings. The NHS estate has taken generations to assemble, through purchases by public money and through centuries of charitable donations and legacies of money, land and buildings by public spirited persons. Before any sale of this precious NHS estate, the land that is likely to be required for the future development of the NHS, on a reasonable forward plan of at least 15 years, must be identified and safeguarded, to meet foreseeable patient needs, as part of a long-needed NHS estates strategy which should be open to public consultation and be agreed by Parliament. The NHS should not breach the trust placed in it by previous generations of donors and taxpayers.
2. The offer of extra money to health authorities who sell quickly is a wholly inappropriate and wasteful incentive. It subverts their fiduciary duty of care to ensure that any sale, without undue haste, is able to achieve the full value of the land. NHS managers must not be placed under pressure to sell at an undervalue, causing financial loss to the public, merely to meet the unrealistic funding targets (ie cuts) of their current spending cycle. If this extra ‘incentive’ money is available, then it should now be added, unconditionally, to the budgets of the NHS authorities.
3. NHS land was provided historically as a long-term capital investment. It should not be disinvested by frittering away sales receipts as short-term revenue payments, to the detriment of future generations. Instead, such moneys should be safeguarded as capital investment to be used first; to purchase any other land and buildings needed for patient care and second; to fund other capital projects for the NHS. Such projects should include the provision of affordable rented accommodation for NHS staff in all areas where a shortage or adverse pricing of housing makes the recruitment and retention of NHS staff difficult. In addition, some of the land should be used to provide much needed primary care facilities.
Because of a lack of financial provision to the NHS, a need has been created: STPs must rapidly sell ‘surplus’ assets in order to continue the process of the transformation of health services and so attempt to meet stringent financial requirements. These assets belong to the people and their exploitation should be in our best interest. There is no long-term NHS Estates Strategy, rather a benchmarking exercise has been carried out by Deloitte to enable a powerful NHS Property Board to ensure rapid disposal. Rapid sales may be to the longer-term detriment of the public purse and, indeed, benefit private investors.
Question 1: Rather than allowing the rapid sale of lands and buildings to private developers and investors, would it not be in our best interest to develop a longer-term NHS Estates Strategy, retain the buildings and land and exploit them for the benefit of Health and Social Care in North Central London?
The Review believes that current low rates of return and the low risk profile of NHS investments means that there is likely to be no shortage of private capital finance available to the NHS. Government should borrow now for transformation and exploit our assets to the full in the longer-term.
There is still some concern that a proportion of any capital released by the sale of ‘surplus’ estates may continue to be vired into running costs and disappear that way. Jeremy Hunt has recently made it clear that this practice may continue up to 2020 (interview in Health Services Journal 2017).
Question 2: Do we have any reassurance that money released from the sale of our assets will not be ‘lost’ in running costs but instead will be used for the development of our health service?
Question 3: Do we have the skills required in our NHS Estates teams to make ‘good deals’ with any private investors or purchasers?
There appears to be enormous pressure to strike deals quickly.
Question 4: Do we have assurances that our NHS Estates team will walk away from any deal that is not in our best interest in the longer-term?
Naylor states: ‘Even if the new models to be developed are fully successful, the STPs are likely to need the same level of hospital capacity (e.g. in terms of bed numbers) as at present. The disposal of any estates must therefore not result in a reduction in bed numbers’.
Question 5: Do we have reassurance that hospital capacity (bed numbers) will not be reduced?
There is a temptation, particularly in London, to want to increase the total national amount released from disposals to £5.7bn but this can only happen if the NHS agrees to adopt a “more commercial approach”. This apparently involves changes in the way planning consent is obtained; affordable housing quotas are negotiated; and value is maximised from the highest value sites in London.
Question 6: What exactly does this involve that is different from a “less commercial” approach?
Question 7: Does achieving more Capital mean losing ‘social’ or even ‘affordable’ housing needed for the benefit of NHS staff that is so important especially in London?
The Review suggests that if STPs do not move quickly enough in the Government’s direction with provider plans embedded in STP plans, maximum possible disposals, addressing backlog maintenance, and delivering the 5YFV, then apparently STPs should not be eligible to access public capital funding.
Question 8: If the STP plans do not hit targets and public capital funding is not given to or is reduced for Providers, could this lead to unnecessary risks for the community? If so, then who has responsibility for any harm caused given that the STP has no legal status?
There are plans for a ‘time limited offer, with a fixed funding pot and allocation on a “ first come first served” basis’, to match disposal proceeds with an equivalent amount of state funding. This is intended to encourage STPs and providers to act quickly and discourage them from holding on to any land.
Question 9: Will the offer of extra funding undercut the NHS bargaining position because a fast deal may ensure twice the income, and any purchaser slow to offer more money will put our staff in a bind (i.e. they would have to decide whether to go for the best deal with the purchaser or speed up the process to get a ‘double deal’ from the Property Board)? Could this in effect mean sales on the cheap?
The Naylor Review states that the creation of Accountable Care Organisations (ACOs) with population based ‘capitated’ budgets would be a way to overcome the conflicts of interest that currently exist between the “advisory” role of STPs and the statutory responsibilities of NHS provider trusts. An ACO would incentivise acute providers to invest property assets in primary, community and mental health services, alongside private investors, and so enable more patients to be treated closer to home in line with the 5YFV.
Question 10: As an ACO becomes a stand-alone, standardised, “public-private partnership”, would we not have therefore lost any sense of any National Health Service?
Question 11: If Naylor is supported, then will we not lose a lot of our public assets and public wealth into private pockets?
The review recommends the creation of a powerful new NHS Property Board to address the challenges. In particular, the NHS Property Board should consider if it continues to invest in property or, given the direction of travel for greater local ownership, it divests to Providers the residual assets it has inherited from the abolition of PCTs. But most Providers are now, in effect, private businesses and the Secretary of State has no legal responsibility for the provision of the NHS.
Question 12: Does the divesting of property to Providers mean that our local assets may in effect be handed over to become part of the portfolio of a Provider and that such a Provider may be susceptible to take-over in the future if it “fails”?
The Naylor Review will set up a bargain market of estate sales, healthy opportunities for matched-investments in integrated community services and create the managed-care environment of an ACO that is currently attractive to transnational corporations.
Question 13: Is the Naylor Review the beginning of the end for any form of a National Health Service and therefore, as it presents us with an ACO, does it not also present us with enormous potential losses: the loss of any national pooled-risk, the loss of national equity of care and the loss of the enormous benefits of strategic and national planning?
Question 14: Is the Naylor Review simply a means to bring about a structural change in the system of healthcare in England?
It will also probably hasten the loss of publicly-owned healthcare paid for through taxation. All of this achieved without consultation with the public.
NCL STP Watch’s comments on current plans to limit the range of medical procedures available for GP referral. [So-called POLCE or Procedures of Limited Clinical Effectiveness ]
Enfield CCG Procedures of Limited Clinical Effectiveness (PoLCE) policy aka Adherence to Evidence-Based Medicine (AEBM) JHOSC November 2017
The PoLCE/AEBM paper presented to you at the last JHOSC remains of the utmost importance in determining the type of health care your constituents will receive in the future.
1. The policy has been given high priority by the Director of Recovery (independent consultant appointed on behalf of NHSE attached to Enfield CCG), as it is not simply about improving healthcare but it is about the setting up of a referral management system so that planned care can be rationed- this is a critical part in the development towards a local population-based Accountable Care System.
2. It is presented to you as ‘appropriate actions on certain Procedures of Limited Clinical Evidence’ but for some reason the Policy STILL includes the highly effective and evidenced procedure of knee replacement-joint replacement procedures have a high short-term cost to the local health economy-and the referral threshold on knee replacement has been increased despite no proven clinical evidence base (please see: i) PoLCE/AEBM Policy wording on Knees post consultation, ii) their ‘improvement’ on NICE criteria and iii) the British Orthopaedic Association opinion given to the Enfield consultation on these matters in the attached evidence)
3. The PoLCE/AEBM policy not only affects patients, it also takes clinical judgement, clinical decision-making and professional integrity away from GPs.
4. To have any use clinically, Pain Questionnaires need to be proven to show that they do what they are supposed to do (are validated) for pre-operative screening, and do this in all the different languages and for all the different cultures present in Enfield, or else they may well put non-English speaking and culturally diverse groups, as well as stoical older people, at a distinct disadvantage when seeking surgical intervention.
5. The guidance from NICE states that a delay in receiving surgery beyond six months may cause unnecessary financial costs and physical harm to patients (see evidence). The British Orthopaedic Association states in its response to the consultation that a six-month delay before referral, as suggested in the policy, MAY MEAN A YEAR of waiting before surgery.
6. There is also great concern that in the future, once a referral management service is set up, there may be the addition of clinically effective procedures, with increases in referral thresholds without proper consultation. These actions may push many people with sufficient funds to seek private health care alternatives available through local Providers.
7. This is an issue that demands full and proper consultation across NCL. It should not be forced through in one borough and then simply rolled out across NCL.
APPENDIX: Evidence.
NICE guidelines
Please look at the quotes below from the nationally determined evidence on hip and knee replacements taken from the ‘National Clinical Guideline Centre; Osteoarthritis: Care and management in adults, Clinical guideline CG177, Methods, evidence and recommendations February 2014 Commissioned by the National Institute for Health and Care Excellence:
Quote: ’The use of orthopaedic scores and questionnaire based assessments has become widespread. These usually assess pain, functional impairment and sometimes radiographic damage. The commonest are the New Zealand score and the Oxford Hip or Knee score. Many (such as the Oxford tools) were designed to measure population based changes following surgery, and none have been validated for the assessment of appropriateness of referral’.
Quote: 11.1.8 Recommendations
35.Clinicians with responsibility for referring a person with osteoarthritis for consideration of joint surgery should ensure that the person has been offered at least the core (non-surgical) treatment options (see recommendation 6 and Figure 3 in section 4.1.2). [2008]
36.Base decisions on referral thresholds on discussions between patient representatives, referring clinicians and surgeons, rather than using scoring tools for prioritization. [2008, amended 2014]
37.Consider referral for joint surgery for people with osteoarthritis who experience joint symptoms (pain, stiffness and reduced function) that have a substantial impact on their quality of life and are refractory to non-surgical treatment. [2008, amended 2014]
38.Refer for consideration of joint surgery before there is prolonged and established functional limitation and severe pain. [2008, amended 2014]
39.Patient-specific factors (including age, sex, smoking, obesity and comorbidities) should not be barriers to referral for joint surgery. [2008, amended 2014].
Quote: ‘We looked at studies that conducted economic evaluations involving referral to joint surgery for patients with osteoarthritis. One paper from New Zealand investigating 153 patients on orthopaedic waiting lists was found. The paper investigates the waiting times for patients, and the cost incurred by the patients, as well as considering the health status of patients at different time points before and after surgery. The paper found that the cost is significantly higher for patients who wait longer than 6 months for surgery compared to patients who wait less than 6 months. However, it is interesting to note that this is from a societal perspective. Costs are significantly higher for personal and societal costs for the group that waits over 6 months, but for medical costs alone the cost is higher but not statistically significantly so. The paper also finds that the health of patients generally worsens over time up until their operation, after which health improves, suggesting that the longer a patient waits the more health losses they accrue as opposed to someone who is treated more quickly’.
The British Orthopaedic Association
The British Orthopaedic Association’s submission to the consultation is independently reported as giving views on the proposals relating to knee arthroplasty (replacement) and surgery for hallux valgus (bunion). With respect to the knee replacement proposals, they recognise that while in the main the criteria seem reasonable, they have serious concerns about the use of the New Zealand or Oxford scores as a pre-operative assessment. They also suggest that an initial delay of 6 months is likely to mean that patients will be waiting the best part of a year before treatment and suggest that the 6 months is incorporated within the referral process.[so that patients can be operated on at six months].
They also feel it is inappropriate to consider surgery for bunions, as well as knee replacements, as Procedures of Limited Clinical Evidence (since there is good evidence for benefit with both procedures).
Enfield CCG PoLCE/AEBM Policy
Enfield CCGs will only fund knee replacement for osteoarthritis when conservative measures have failed (listed below) and the following criteria have been met:
Referral Criteria:
1. Referral to Knee Replacement Surgery Pathway:
The patient will require assessment of severity of knee pain (using validated scoring system such as New Zealand or Oxford system, a functional assessment of their mobility, the level of analgesia used and a correlation with severity of x ray changes)
2. Physiotherapy:
Physiotherapy: in early cases may improve muscle strength / stability such that knee replacement is not necessary or in later stages to prepare for rehabilitation following surgery.
3. Smoking:
Patients who smoke should be advised to stop smoking for at least 8 weeks before the surgery to reduce the risk of surgery and the risk of post- surgery complications. Patients should be routinely offered referral to smoking cessation services/stop smoking programme to reduce these surgical risks.
4. BMI:
Patients with a BMI of over 45 must be advised to lose weight to reduce the risk of complications and improve outcomes. Patients should be offered referral (where available) or signposted to local weight management programmes to support weight loss.
Symptoms that have not adequately responded to 6 months of conservative measures, including Intra-articular steroid injections when facility is available in primary care
Enfield CCG Policy following the Consultation:
Knee Replacement
Whilst no new evidence of substance was provided to change the CCG’s view that there was a clinical need to change access criteria for Knee Replacements in some circumstances it was recognised that the supporting services needed by patients to help them lose weight along with access to other treatments such as community physiotherapy required further work on before the changes could be adopted. In addition, the referral pathway for primary care clinicians needed to be both reviewed and clarified. The CCG will therefore not proceed with the proposed changes at this time but will seek to introduce the changes when there is sufficient assurance that patients will be able to access the support they need to make the lifestyle changes necessary and to access appropriate alternative services. This will be subject to a further public paper (BUT NO FURTHER CONSULTATION) at the appropriate time in the future and the Equality Impact Assessment (EIA) will be updated at that time.
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LABOUR PARTY NEWS
This year’s NHS composite motion at the Labour Conference was a landmark achievement for all those trying to shift Labour policy towards a publicly-provided National Health Service.
Great news indeed – if it’s implemented.
A strong NHS composite motion passed unanimously as Labour policy. It demands a clear manifesto commitment to restoring the NHS’ founding pillars, explicitly as embodied in the NHS (Reinstatement) Bill.
In another significant shift, conference demanded Labour oppose current government NHS policy, written by private healthcare multinationals. This policy plan, the 5 Year Forward View is being implemented by former United Health CEO and arch-Blairite Simon Stevens. It dismembers England’s NHS into over 40 separate “Accountable Care” systems and “Sustainability and Transformation Partnerships”. These defeat the NHS’ core purpose of giving us all the care we need. They make profitable denial of care the rule instead.
The fight for the NHS within the Labour Party has won a great success. Let’s cement that and make sure that Labour’s next manifesto commits to the NHS Reinstatement Bill.
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Haringey Keep Our NHS Public 