Sustainability and Transformation Plans became Sustainability and Transformation Partnerships by dint of a statement in the March 2017 NHS England Five Year Forward View Next Steps document. As both terms reduce to STP acronyms it’s not all that helpful. For the sake of clarity I will use ‘STP’ in its original ‘plan’ definition in this submission. Accountable Care Systems are a flavour of generic Accountable Care Organisations. NHS England has chosen to define and name a range of Accountable Care Organisations which include ACSs, ACPs, MCPs, PACSs and PCHs. If and when these variants are up and running we will discover the unique characteristics of each of them.
The context of the latest changes to healthcare services delivery in England begins with the appearance of a paper written by Oliver Letwin and John Redwood and published in January 1988. Papers written by McKinsey & Co in 2009 and in 2012 for the World Economic Forum in Davos Switzerland, follow on developing ideas for radical reform of the NHS. Reducing the cost of running the NHS and ‘partnering’ with private healthcare suppliers have been on Government agendas now for many years.
One of the key big ideas was that 40% of people who are in NHS residential Acute hospital care should not be there and where they should be is being treated at home and/or in NHS local day care centres. The latter are called, or have been variously called, Out of Hospital services, community care services, and Intermediate Care services. The theory is/was that Out of Hospital services would ‘replace’ 40% of residential acute services and could be provided at a reduced cost.
The 2012 Health and Social Care Act formalised the NHS Commissioner/Service Supplier split and led to the formation of 200+ Clinical Commissioning Groups throughout England. NHS hospitals could sell up to 49% of their services to private clients. In my town (Ealing) and in others the CCG now commissions GP services. Local Authorities retained their commissioning role for purchasing and in some cases delivering social care services. Care/Nursing Homes are now largely privately owned. In Ealing GP surgeries are now commissioned by the CCG to provide Primary Mental Health care services.
The Five Year Forward View published in October 2014 set a target of reducing annual NHS costs by £22 billion by 2021. The ‘Next Steps’ published in March 2017 demolished that cost reduction target and replaced it with achieving ‘financial balance across the health service’.
Hospital beds are such a big issue with regard to care delivery that it’s worth noting here that the Next Steps states that by March 2019 the 100,000 NHS bed population in England will be reduced by between 2,000 and 3,000. In NHS North West London between March 2017 and June 2017 the General and Acute beds in use rose from 3,120 to 3,400. Bed numbers rose by 300 from March 2011 to June 2017. If these trends continue yet another target will be missed.
Sustainability and Transformation Plans
In NHS North West London we were, and still are, taking part in a pre-Sustainability and Transformation Plan project called ‘Shaping a Healthier Future’. Launched in 2012, with a seriously flawed public consultation, this contained ambitious plans for physical healthcare – there was virtually no mention of mental health services and certainly no mention of social care services. (There had been no meaningful previous engagement with the public). The plans included cutting annual costs by 4%, reducing the number of District General Hospitals and hospital A&E units from nine to five. Out of Hospital services would ‘replace’ 40% of residential Acute hospital care – all in ‘at least three years’. Over five years later no cost reductions have apparently been announced or almost certainly achieved, only two of the four District General Hospitals and A&Es were eliminated and various attempts at Out of Hospital services have had only limited success. Ever since the two A&Es were eliminated in September 2014 A&E performance has consistently been amongst the worst in England. The most recent Shaping a Healthier Future ignominy – for what has now apparently has become a 14-year project – is that its request for £513 million for building work was turned down by NHS Improvement and NHS England. In the 7 November 2017 rejection letter NHSI/NHSE could find no compelling evidence to support reducing annual Non-Elective or emergency hospital admissions by 99,000 by 2025/26.
Here in Ealing rumours about Sustainability and Transformation Plans began circulating in Spring 2016. An early draft of Footprint 27: North West London Sustainability and Transformation Plan appeared in April 2016. An NHS England vetted version appeared in public in October 2016. Amongst the ‘new’ ideas in the plans was the integration of social care services with healthcare services. This idea immediately became a car crash locally, as Ealing Council and Hammersmith & Fulham Councils refused to sign up. The Council Leaders stated that they had not been given the plan to review. They were given only a short overview with just hours of review time.
One of the basic reasons for creating Sustainability and Transformation Plans is to admit that CCGs are failing as ‘masters’ to the service supplier ‘slaves’. This is apparent in that CCGs and NHS Trusts come together as peers in the Sustainability and Transformation Plan. The NHS bias is clear when one sees a lack of detail of social care services in many plans and the fact that 43 of the 44 Sustainability and Transformation Plan bosses are NHS executive/NHS ‘alumni’.
It seems to be somewhat absurd that in North West London we have two cost cutting, transformation attempts running in parallel. One, the 2012 ‘Shaping a Healthier Future’, only concerned itself with healthcare initially ‘for over three years’ whilst the other, the October 2016 NWL Sustainability and Transformation Plan, covers healthcare, social care and the integration of the two up to 2021.
On 13 June 2016, I attended a public meeting in Ealing run by NHS Ealing Clinical Commissioning Group on future local NHS plans. The lack of publicity for the meeting meant that out of an adult population of 200,000+ only 20 residents attended. Sustainability and Transformation Plan content was revealed, but under the title of a local care plan. When I was a Director of Healthwatch Ealing we ran an Sustainability and Transformation Plan debriefing in Ealing on 16 November 2016 which was attended by 100 residents.
Accountable Care Organisations
The first reference to Accountable Care Organisations in England I can find is in April 2016. Accountable Care Organisations, conceived in the USA in 2006, are NHS England’s chosen future implementation ‘engines’ for STPs. Shadow Accountable Care Organisations might commence in April 2018, and real ACOs with £1+ billion 10/15 year contracts might commence in April 2019. But not only are NHS date predictions regularly inaccurate, legal action and Parliamentary decisions might delay/prevent this. Dudley Shadow MCP and Manchester Shadow Accountable Care Organisations have both recently ‘paused’ their launches.
In North West London there has been no meaningful engagement with the public with regard to Accountable Care Organisations. As for public awareness, there is so little in the public domain about them and so little in the 44 Sustainability and Transformation Plans that I would guess that 99% of adults in England have no idea about them. As for public consultation, one can hardly consult on topics on which the public has no knowledge.
From what NHS information I have been able to glean about Accountable Care Organisations in England, the cost cutting element (i.e. fixed price contracts) has been largely ignored. Budget setting by Capitated/Population budgets is all well and good. However if no information is forthcoming about how such budgets will be set, there is precious little public scrutiny.
On 5 December 2017 I attended a North West London Joint Health Overview and Scrutiny Committee meeting to which the eight comprising Local Authorities Councillors were invited. At this meeting the two Accountable Officers representing the eight CCGs gave presentations which were minimalist in the extreme. They confirmed that an elderly people Hillingdon Shadow Accountable Care Partnership would start on 1 April 2018 – in less than four months’ time. No details were given about who would run this Accountable Care Partnership, who would be on its board and how and when they might be elected or selected. No clues were given about the Capitated/Population budget or how it might be calculated. No information was disclosed as to how it would clearly usurp the Local Authority in ‘commissioning’ an elderly social care services budget and similarly usurp Hillingdon CCG in ‘commissioning’ an elderly people healthcare services budget. I quote this as an example of how covert the machinations within NHS North West London are around Accountable Care Organisation creation and implementation.
Accountable Care Systems which implement Sustainability and Transformation Plans will effectively assume the role of regional care authorities. Surely for the Accountable Care Systems to be effective they will take on the role of managing the finances (on a fixed price) of healthcare and social care services’ delivery? In this way an Accountable Care System will usurp the roles of CCGs (or CCG collaborations) and Local Authorities in care commissioning. Will this make CCGs and Council social services commissioners redundant? GP surgeries are being lobbied by NHS England to consider suspending their contracts and to prepare to get into bed with an Accountable Care Organisation. The BMA is very concerned about this. It warns of the risk of widespread privatisation of healthcare services. One does wonder as to whom Accountable Care Systems will be accountable. Surely it can’t be the CCGs /LAs ‘below’ them – whose very existence they threaten?
It seems really quite odd for NHS England to state that ‘in some areas, a Sustainability and Transformation Plan will evolve into an Accountable Care System’. If ‘some’ why not all STP Footprints? Surely what is good for the goose is good for the gander?
Integrating Healthcare and Social Care Services
At the NHS England ‘Innovation Expo’ in Manchester on 12 September 2017, NHS England Director of Acute Care Professor Keith Willett delivered a withering public attack on relations between Local Authority staff and NHS staff. He bemoaned the fact that NHS and local authority staff consistently failed to engage with each other. They don’t trust each other or understand each other and each have a different culture and jargon. Often they will not share data, so it often has to be re-keyed. On the financial side they each have different costing and purchasing processes. Neither are willing to open up and share their financial books with each other.
He felt it was ironic that 43 of the 44 STP Footprints were run by NHS/healthcare folks – and just one by an local authority/social care executive. This flies in the face of who is the bigger player. For example the NHS has around 100,000 beds whilst in the social care sector there are between 300,000 and 500,000 beds. In term of staff the NHS employs 1.3 million, but there are 1.5 million working in the social care sector.
The Health and Social Care Act 2012 confers health scrutiny functions on elected local authority Members (i.e. Councillors). With local authorities joining NHS bodies as partners in Sustainability and Transformation Plan and Accountable Care Organisations conflicts of interest and divided loyalties are clearly coming to the fore throughout the country. The rubber is constantly hitting the road when an NHS CCG is proposing to close a hospital and the local local authority, as elected representative of the people, is opposing this. It will surely get even more complicated and messy when Accountable Care Organisation consortia involving a local authority as a partner is on the one hand party to a long term, fixed price cost cutting care contract and on the other hand is holding the local healthcare CCG to task for transformations deemed by the local authority to be degrading local healthcare services.
Out of Hospital Services
Out of Hospital Services according to NHS North West London are all those services provided in community settings such as your home by community nurses, at your GP surgery and in (day care) health centres. Out of Hospital services are such a key component of the rationale for Sustainability and Transformation Plans and Accountable Care Organisations that they need their own spotlight discussion. Out of Hospital services, from way back to McKinsey & Co papers in 2009/2012, are seen as the replacement panacea for reducing (expensive) residential Acute hospital care by 40%. The question must be asked as to whether there is any evidence that this target has ever been met anywhere in England at any time on a sustainable basis?
All attempts in NHS North West London to attain and maintain this Out of Hospital services target have failed from 2013 to date. The 2012 Shaping a Healthier Future – pre-STP – transformation business case postulated an annual reduction in residential Acute emergency admissions of 99,000 by 2025/26. (In NHS jargon these admissions are known as Non-Elective admissions). In November 2017 NHSI/NHSE rejected this business case on the basis of the lack of compelling evidence that Out of Hospital services could annually ‘replace’ 99,000 admissions. In Ealing they remained at a steady rate from August 2013 to February 2017, but then rose sharply throughout the summer of 2017.
After five years of abortively trying to reduce Acute admissions with transformational Out of Hospital services, the CCG has decided to go for broke and sign up a single supplier for Out of Hospital services for 10 years. This initiative is no doubt aiming to make big reductions in local admissions so that Ealing District General Hospital can be closed – as yet an unrealised dream of the 2012 NHS North West London project. This 10-year contract is likely to be for around £1 billion, as Ealing’s Out of Hospital 2016 costs were allegedly £127 million. The question that must be asked is whether there is any evidence to suggest that a new single supplier – other than the incumbent NHS supplier – will have any more success at providing Out of Hospital services to replace Acute services? The answer to this must be a resounding ‘no’.
Sustainability and Transformation Partnerships: Engagement
Taking my own Footprint and my own town as examples, I have noticed very little effective engagement within Sustainability and Transformation Partnerships or in their relationships with third parties. Local Healthwatches, bizarrely, act as the paid handmaidens of local CCGs – bodies they should be holding to account. Healthcare activist groups throughout the region are continually having to resort to Freedom of Information requests in order to discover commissioning information and service performance and purchasing data.
Engagement, in its purest form, is qualitative and should take place during the formative stages of plan making. Our Plan was created in secret behind closed doors. No doubt Accountable Care Organisations will also be created and implemented covertly.
NHS NWL Management Consultants and CCG Costs – Value for Money?
Around £200 million has been spent by North West London CCGs on running costs from 2013/14 to 2016/2017. Over £89 million has been spent on management consultants variously advising on strategy and implementation since 2009. One has to ask the question – what value has been derived from spending this public money? In terms of not meeting the stated goals of the Shaping a Healthier Future and the Sustainability and Transformation Plan, consider the following:
Shaping a Healthier Future will improve care both in hospitals and the community and will save many lives each year’ (page8). ‘Most care that is currently delivered in hospitals will still be delivered locally in a local hospital’ (page 40).’Between 484 and 980 hospital beds will be closed (page 44).
In the October 2016 Sustainability and Transformation Plan (it will) ‘transform general practice…ensuring proactive, co-ordinated and accessible care’ (page 7). ‘..for the first two years ..(it will) ..address the financial challenges (page7). It will ‘offer integrated social care outside an acute hospital setting’ (page7).
- Shaping a Healthier Future has failed to reduce hospital bed numbers. It has not made any announcements about how many lives have been saved because of it (2013 to date).
- Only one of the three local hospitals has been created
- Since June 2013 hospital bed occupancy has consistently exceeded the 85% target
- Since November 2013 five out of the seven surviving District General Hospitals have consistently missed the Type1 A&E 95% 4 hour waiting target
- It’s not unusual now to wait two weeks to see our local GP. I recall this being a two day wait in 2013
- No Shaping a Healthier Future or Sustainability and Transformation Plan cost savings have ever been announced. Shaping a Healthier Future replied on 30 May 2017 to my Freedom Of Information request that ‘the Shaping a Healthier Future programme does not hold information on the savings achieved by individual organisations’.
Recommendations
The Five Year Forward View/STP/ACO bandwagon needs to be halted and a cross-Party review initiated immediately.
The Five Year Forward View planning window of five years is far too short. It would be more appropriate to adopt the 15 year planning window approach used by spatial planners in Local Authority Local Plans.
The integration of healthcare services and social care services is more of an aspiration in Sustainability and Transformation Plans than existing reality on the ground. I can’t see this integration being successful without both services being delivered within a single organisation utilising a single business /organisational model. Accountable Care Organisations will just contractually impose this failing business model dichotomy on local societies for 10/15 years.
In an ideal world a new national care organisation would be created – the National Care Service. This would run healthcare and social care services. All NCS services would be free at the point of use. All the PFI hospitals would be bought out of private ownership and become NCS assets. The marketisation of healthcare services would be stopped and the 200+ CCGs closed down. All the care homes previously state owned would be compulsorily purchased by the NCS. New state owned care homes would be built.
The McKinsey & Co dictum that 40% of Acute patients should not be in hospital and can be treated successfully, less expensively and sustainably in the local community has to be trashed, on the basis that no evidence exists to support it. The closure programme for District General Hospitals and hospital A&Es must be stopped. In areas of high expected population growth (e.g. areas of London) additional hospitals need to be built.
The elephant in the healthcare/social care room is mental health care services. Shaping a Healthier Future incredibly makes no mention of mental health services and Sustainability and Transformation Plans, like the NHS itself, is physical health oriented. Residential mental health centres need to be built in each of the 44 Footprints and thousands more psychologists and psychotherapists need to be trained and deployed.
The NCS would hire a significant number of MBA graduates who would undertake the strategic and implementation research and proposals currently undertaken by third party management consultants. Rather that all each of the 200+ CCGs purchasing this expensive research, the NCS would carry out this work centrally and share it around the country.
Based on a submission to the House of Commons Health Committee Sustainability and Transformation Partnerships Inquiry 2017