Local managers are being forced to slash NHS budgets and replace existing hospital and community services with unproven ‘new models of care’ (inspired by, and attractive to, the corporates.).
And local managers are effectively being forced to lie to the public that this will improve care.
They will have to do so in new ‘Sustainability and Transformation Plans’, demanded by NHS England’s annual and innocuous-sounding 2016-17 NHS Planning Guidance (1). In fact, it signals a complete and total reorganisation of the NHS.
The NHS is reorganised into 44 ‘footprints’ (each covering a number of CCGs and an average of 1.2million people).
We’re told the project is about ‘strengthening local relationships’ and building on ‘local energy and enthusiasm’ to achieve ‘genuine and sustainable transformation in patient experience and health outcomes’.
But in fact, the Guidance contains some very specific requirements that will test these new collaborations to the limits and usher in a new wave of privatisations and huge cuts.
Each footprint area must agree a five-year plan locally (2)- by the end of June 2016 – which MUST include proposals to bring their area into financial balance within 2016-17. For England as a whole, this means cuts amounting to £2.3billion. The plan must achieve this by implementing new models of care as set out in the NHSE Five Year Forward View (3). Oh – and it must explain how all of this will improve clinical outcomes and patient satisfaction .
That’s clearly a nonsense. Existing deep cuts mean that nearly one in 10 patients waited longer than four hours in A&E last year – the worst performance since 2003/4 – according to shocking new figures revealed yesterday by the Kings Fund (4).
The number of patients waiting for hospital treatment is up nearly half a million to 3.7 million over the year.
Only 2 per cent of Trust finance directors think patient care has improved over the past 12 months. And 7 out of 10 NHS providers ended 2015/16 in deficit (including 9 out of 10 acute trusts).
Eliminating the NHS deficit
So the government is looking to local partners to help it cut the NHS further at the frontline. Local authorities have extensive experience of cutting services: they slashed spending on social care by 26% between 2011-2014 (5) resulting in 400,000 fewer people getting care services than in 2009-10 and many more receiving fewer hours of care(6). This has led to concerns about the near collapse of social care, and despite frequent boasts from both Tory and Labour councilors that ‘front-line services have been protected’.
The Government is looking for similar performance with the NHS. The STPs must deliver balanced budgets for 2016-17 and beyond.
If they don’t, they’ll be denied access to a vital share of £1.8bn from other funding streams.. Local health bosses are seriously worried.
Of course the NHS could save money by ending the market in healthcare and stripping out the costs of lawyers, accountants and others whose job is simply to run the market. This would save an estimated between £4.5bn to £10bn a year if not more. But that’s something central government - both Labour and Tory – has repeatedly refused to look at.
As part of the plan to reduce deficits, existing hospital estates must be sold off for housing development, though it’s not even clear if the money thus raised is ringfenced.
Meanwhile the NHS Partners Network (a trade association for independent sector providers of NHS services) is gearing up to assist Transformation areas to ‘supplement publicly available capital funding with external investment’ (in other word, more extortionate PFI).
New models for NHS provision
The major STPs are expected to cut spending is through implementing ‘new models’ of care that are set out by Simon Stevens in NHS England’s Five Year Forward View(7) (5YFV). When campaigners ask for the research or clinical evidence to back these models, they are pointed to the existence of ‘Vanguard’ pilots of these new models of care – even though these were only agreed in April 2015 and have barely begun their work, let alone been evaluated.
One ‘new model’ talked up by Simon Stevens and Jeremy Hunt involves reducing demand for hospital beds by substituting digital monitoring and healthcare visits at home. Never mind that England has fewer beds than any comparable economy: Germany has 9 hospital beds per 1,000 population compared with 3 per 1,000 in England. Never mind the absence of any valid clinical evidence for this model, or that it means thousands of carers – predominantly women – having to care for sick family members at home. This model offers a quick win on all fronts for STP planners: implement the model set out in the 5YFV, ‘delete’ a few local hospitals and ‘replace’ the beds with ‘hospital at home’ services from a valued private ‘partner’.
STPs are also expected to develop urgent care services. What this actually means is the downgrade of full Accident and Emergency services at many hospitals. When hospitals lose their A&Es, they lose equipment, skills , training opportunities, and other services vital to the long-term survival of our local hospitals in any form we would recognise. Increasingly, patients will have to travel much further to access services.
Stevens’ new model for GP services includes retraining reception staff for new roles, including triage, gatekeeping access to GPs and referring many patients on to other staff or services. It’s expected that GP assistants -who are not qualified doctors – will also see many of the patients.
The NHS market continues to flourish
Private providers are flourishing. For the time being, the main emphasis is likely to be on corporates involved as ‘NHS Partners’ in providing consultancy to develop the STPs, preparing the new ‘surplus’ NHS property portfolio for sale and providing ‘back-office’ services for a range of services in the area. Once the STPs have been agreed, corporates will be in a strong position to provide ‘commissioning support’ for the new, cost-cutting models of care.
Moving services out of hospital and integration with social care creates huge opportunities for providers to deliver services with cheaper non-clinical staff, and to relabel these services as - chargeable - social care. There are huge opportunities too, to sell us home-based digital monitoring products as substitutes for hospital care.
Already, the private providers trade group NHS Partners boasts they are: ‘delivering mobile capacity across diagnostic and treatment areas’, ‘providing clinical home healthcare and care home capacity to support patient discharge and avoid unnecessary hospital admissions’, and ‘offering management and strategic capacity, as well as procurement and planning skills needed to develop STPs’(8).
CCGs who don’t produce STPs which will balance the budget within 2016-17 risk having their ‘purchasing’ responsibilities handed over to a provider.
In other words, at a stroke, and without the bother of legislative change, public consultation or media attention, the 2016-17 Planning Guidance has abolished the sharp purchaser-provider split. But not in a way that brings it back under proper public control. Instead, we’ll see new purchasing and sub-contracting arrangements developing that are ever more opaque and less constrained by any public accountability.
Private providers will be keen to provide back-office functions for the new Transformation for other reasons, too. Especially if all the ‘risk stratification’ and ‘case management’ they are promising to do for the NHS, gives them access to patient data that is useful for those who want to sell us pharma, lifestyle apps or insurance.
The changes will also open up opportunities for a single provider to deliver the entire complex of health and social care services in one locality, a model that is particularly attractive to giant US Healthcare corporations which already deliver these models in the US.
Starry-eyed or dazed CCGs, local authorities, NHS managers, Health and Wellbeing Boards, clinicians, patients and public health analysts will look on as the five-year plans are developed with ‘NHS Partners’ and delivered to NHSE in time for the end of June deadline. These STPs will contain plans for completely transformed services that have no evidence base and budgets that have been pared beyond recognition. The corporate vultures will await the new tenders.
And unless campaigners can really get our act together, the public won’t have a clue that any of this is happening.
We need to do everything in our power to oppose the ‘Footprints’ and demand that NHS England and Government withdraw requirements for STPs pending further public debate.
We need to demand too, proper NHS funding levels (up to levels of EU average, reversing the decline since 2010). And that all changes to local services must be based on clinical need and evidence-based research. And that rather than forcing local areas to impose cuts that will kill the NHS as we know it, whilst calling it cure, that government ends the costly NHS market by bringing its services fully back into public ownership and control, run for patients not for profit, and saving billions of pounds annually that are wasted on managing the market.
Many campaigners have united around the NHS Reinstatement Bill , putting forward motions to support it to their trade unions and local party branches and other organisations.
Ironically, some MPs refused to back to the bill on the basis that it required another reorganisation. Now it’s clear there’s already a dangerous and undemocratic reorganisation underway.
The Reinstatement Bill will ensure proper local accountability, and put a complete end to the rush of privatisation and cuts, rather than permit it whilst blaming local areas.
Next week, MPs will be balloted for the new private members bill. Any MP who cares about the NHS should work with campaigners to re-introduce the Bill, and ensure that it achieves it stated aims, and restores the NHS as we know it.
If we want an NHS for the future, we must demand urgent action from our politicians NOW before the NHS is finally transformed out of all recognition.
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