Are plans to move the NHS 'into the community', a wolf in sheep's clothing?

Plans to close swathes of Yorkshire hospital services will 'improve care', say local NHS bosses. Campaigners are unconvinced. In the first of a four-part series Jenny Shepherd asks who - and what - is really behind similar claims being made across the country.

Jenny Shepherd
10 June 2014

long grass.jpg

The view from the grassroots / Flickr 

Yorkshire hospital Calderdale Royal is to lose all its acute and emergency beds, under plans put forward by local health bosses. Along with neighbouring Huddersfield Royal, the two hospitals would lose 100 beds in total.

Calderdale Royal - funded by an expensive Private Finance Initiative Scheme - now faces an uncertain future. It could be downgraded to a small, planned care clinic with a minor injuries unit. Campaigners have asked the Trust if there's a risk the remaining three quarters of the hospital could be turned over for the use of private patients. The Trust has refused to publicly comment.

As for NHS patients, those who already have long journeys from the other side of Calderdale would have to travel still further distances to Huddersfield, relying on an already over-stretched ambulance service.

At marches and rallies in recent weeks, people have voiced alarm that lives will be lost.

Ken Roe, Chair of Band Together for our NHS, said,

“If they close Calderdale A&E and people have to travel the extra distance to Huddersfield, that’s going to mean several deaths each year. Calderdale A&E saved my life twice, once when I was bleeding internally. If I’d had to go to Huddersfield, I would’ve died.”

Roe points to academic research showing a 10km straight line increase in the journey distance to hospital is associated with around a 1% absolute increase in mortality.

At a public meeting in Todmorden, at the far end of Calder Valley from Halifax, dialysis patient Amanda Kirwan said that she relied on access to the A&E in Halifax, and that the prospect of having to travel further to A&E in Huddersfield or Leeds made her fearful. She explained,

“Time for me is very important. I am in the high-risk category for stroke and heart attack.”

Local NHS bosses point to four new planned Minor Injuries Units in the area. But these are able to treat far fewer conditions than a full A&E. 

 Local NHS bosses say that this avowedly cost-cutting exercise will improve patient safety, through centralising acute and emergency care in one hospital with 24/7 consultant presence. The plans are in line with last year's Keogh report which recommended the introduction of different tiers of hospital emergency department. Smaller centres would triage patients and transfer them where necessary to a small number of large Major Emergency Centres with 7 day a week consultant cover.

Calderdale and Huddersfield NHS bosses also say the loss of acute and emergency hospital services will be made good by replacing costly hospital services with cheaper integrated NHS and social care in the community. This care will be “closer to people’s homes”, supported by “virtual wards”, “locality teams” and “community hubs”.

There is an inter-locking set of proposals  to deliver this new vision of integrated care in the community. The plans will - we are told - keep people with chronic and multiple health problems out of hospital, particularly the elderly. Patient data will be interrogated to identify those who might be statistically at risk of developing serious or acute illness. Patients will be ‘empowered’ to use technological devices to ‘self-manage’ their own monitoring and prompt diagnosis. And will be given personal health budgets to ‘self-manage’ their own care, ‘creating a responsive  market’ in health & social care.

There are just two problems.

There seems to be no reliable evidence that this model of ‘integrating care’ will reduce costs or improve patients’ health.

And there seems to be little faith - from town halls all the way up to Whitehall - that it can actually be delivered on the ground.

So what is driving these ideas? And what are they really designed to achieve?

Clues leak out in Calderdale and Greater Huddersfield’s “Right Care Right Place Right Time” (RCRPRT) documents and the Better Care Fund Submission from Calderdale Council and Calderdale Clinical Commissioning Group.

These proposals will ‘create a responsive local market’ for health and social care They will also ‘reduce the pay bill’ and make increased use of voluntary sector organisations  and self-management.

Government (trying to wash its hands of unpopular closures) likes to say it’s all about 'local decisions' now. But funnily enough Calderdale’s 'local decisions' look a lot like 'local decisions' everywhere else.

Calderdale and Greater Huddersfield NHS bureaucrats say that their proposed changes are the result of the clinical judgments of local health professionals, and that they also give the public what they have said they wanted in extensive consultations.

Across England, NHS Trusts and Clinical Commissioning Groups are “reconfiguring” and “transforming” NHS and social care in very similar ways.

In South West London, the proposed changes - which the CCGs have withdrawn following widespread public protest - go by the Asda-sounding title Better Service, Better Value.

In Calderdale and Greater Huddersfield, they are called Right Care, Right Time, Right Place (apparently plagiarising the 1980s Martini ads “Anytime, anyplace, anywhere”).

These proposals are top-down changes, heavily influenced by management consultants and pro-privatisation think tanks.like The Kings Fund and the Nuffield Trust.

During the “listening pause” for the Health and Social Care Bill, these two think tanks produced the national strategy for “integrated care for patients and populations”, which now informs NHS reconfiguration proposals across England.

Such proposals are a close fit with a new business model promoted by global management consultancy companies like Ernst and Young and the Coalition government’s new Office for Life Sciences.

They are being replicated across the country.

Dodgy Evidence

The Calderdale NHS proposals, like others across the country, rely on evidence that comes from the pro-privatisation think thanks and management consultants that the Department of Health and NHS England have effectively outsourced policy making to. Their suggestions are built on sand.

There seems to be no reliable evidence that integrated health and social care in the community cuts costs or improves patients’ health.

Hidden in the models is an over-reliance on lowering staff costs through cuts, replacing them with volunteers, or with telehealth technology. 

Claims that an aging population is overloading the NHS in its current form appear to be unfounded, despite Jeremy Hunt’s statement that this is

“a challenge more serious than the economic crisis...potentially even as serious as global warming”

A review of studies of the effects of an aging population on healthcare costs concludes otherwise:

“On the whole, there is... a small positive effect of aging on per-capita health expenditure, which several studies estimate to be in the order of an annual growth rate of 1.5%.” (Friedrich Breyer, Stefan Felder, Joan Costa-i-Font, 14 May 2011)

This is because people aren’t just living longer, they stay healthier for longer. And although there is a small increase in health care spending because of them, older people contribute a massive amount to the economy, in terms of both waged and unwaged labour.

Ignoring this evidence, the rhetoric of apocalyptic demography serves a neoliberal agenda of cuts to public services.

Where the NHS is under pressure is not from an aging population as such - but as the result of austerity politics in the shape of cuts to social care funding since the recession.

Research carried out by the LSE found that social care funding cuts have left half a million older and disabled people, who would have received social care five years ago, without support. The number of people receiving social care has plummeted for five years in a row – by a total of 347,000 since 2008. This has put huge pressure on the NHS.

Never let a good crisis go to waste

But management consultants and think tanks can’t turn a profit from simply saying ‘stop the cuts and fragmentation’. They thrive on organisational upheaval - it’s their raison d’etre.

PA Consulting’s involvement in the Calderdale and Greater Huddersfield NHS reconfiguration is typical of the outsourcing of NHS policy making, both locally and nationally.

Calderdale and Greater Huddersfield Clinical Commissioning Groups paid the management consultancy company PA Consulting nearly £1m for support with Strategic Review Development during 2012.

PA Consulting’s Future of Healthcare Report trumpets the need for “innovation in business models” and “entirely new commercial arrangements”, saying,

“The infrastructure, institutions and culture in healthcare can exert powerful forces

to maintain the status quo and, unlike almost any other industry, healthcare professionals – and the institutions in which they serve – hold a special place in the general public’s heart. All this is set to change; all of this has to change.”

PA Consulting has a direct interest in the kind of "innovation" it's reports for Calderdale NHS promote. It is working on the kind of centralised digital patient data systems which will underpin such plans.

This is the same company whose misuse of pseudonymised patient data, bought from the Health and Social Care Information Service, sparked the still-unresolved furore over the Government’s care.data plans.

Turning pseudonymised patient data into identifiable patient data would allow drug companies and private healthcare providers to target patients directly. This is the basis for Big Pharma’s new business model, as we will explore further tomorrow.

Meanwhile new NHS boss Simon Stevens’ recent announcement that the NHS must stop closing cottage-style hospitals and return to treating more patients in their local communities was billed in the Daily Telegraph as a “reversal of policy”.

But in fact it seems to endorse “Right Care” policies for redesigning care in the community with the aim of reducing acute and emergency hospital admissions.

The Right Care proposals for  “redesigned” care in the community are based on a system imported from the American private healthcare company Kaiser Permanente.

In an interview with the Health Service Journal, Simon Stevens advocated that hospitals should adopt a more recent American version of this system, called the accountable care organisation.

An accountable care organisation is a single “provider” eg a hospital, or a group of providers, that is given a single budget to serve a specified population.According to Stevens,

“In some cases it’s going to mean we’re going to have to completely reinvent what we mean by a hospital, by a local hospital.

“We’re going to have to say that the division between what consultants do in hospitals [and] what GPs do in community settings, that is going to be dissolved.”

Lining up hospitals or a group of providers to deliver pretty much all health and social care in and out of hospitals, along the American Kaiser Permanente/accountable care organisation system would open up the NHS nicely to US healthcare companies to take over. 

Tomorrow we continue our series with a look in more detail at the companies and industries standing to benefit from this dramatic remodelling of NHS care.

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