The area around Calderdale spends about £1.7billion a year on health and social care.
There is a huge reorganisation propopsed, including most of Calderdale Royal’s beds as covered here.
Quite how much money it would save - or needs to save - is unclear. Different figures are batted around - a £303million "combined savings challenge" across 7 organisations. A "case for change" based on the need to cut £160million over five years, with commissioning alone having to save £124m a year.
In February the various local health bosses “agreed the commissioners’ figure of £124m would be talked about”, their minutes state.
But whatever the true “savings challenge”, the “case for change” focuses not on how to meet the health needs of the population or how the proposed closures affect people - but on the needs and costs of the providers.
According to a regulatory lawyer’s guidelines on NHS reconfiguration, published in Guardian Healthcare, such an approach may not even be lawful.
Planning has been underway for 2 years, but there is still no clinical evidence to support the proposed ‘reconfiguration’. Instead the “case for change” is one-sided, cherry picking often questionable benefits and ignoring possible costs, risks and impacts on local people, campaigners feel.
The model underpinning these proposals can be better understood as being about maximising profit opportunities for new hybrid business interests, that combine BigPharma with digital and data technologies and companies.
Big Health's quest for new business model
Calderdale and Huddersfield’s “Right Care” proposals copy the model used by an American private health care company, Kaiser Permanente. This model aims to cut costly hospital services and replace them with a new, low-cost system of integrated health and social care in the community that’s intended to keep people out of hospital. It’s known as “demand management”.
Patients with long term health problems would be required to monitor their own symptoms at home using interactive digital technology that will send data about their bodily processes - eg heart rate, oxygen levels in blood, or blood sugar levels - to specialist nurses and/or GPs.
The aim is to target care before symptoms become acute, without relying on expensive personal contact between doctors/nurses and patients as a way of checking on patients’ health.
Using so-called risk stratification data, derived from computer models based on patient records, the system would direct behaviour change incentives and messages to people statistically at risk of developing various illnesses. This aims to reduce the the likelihood that they will become ill.
But there's little evidence that behaviour change initiatives - whether directed to patients via digital ‘apps’ or otherwise - actually work.
Big Pharma is playing a key role in developing the model, sure that they can make money out of mining the huge amount of data on symptoms and behaviours that it creates. They see big profit opportunities in creating lifelong relationships between patients and drug companies without the need for GP, hospital and health centre intermediaries.
Big Pharma is seeking a new business model as patents on many of its most profitable drugs are due to expire soon. It is driving a global transformation of health and social care that aims to replace costly hospital care with cheaper healthcare in a “third place”.
It is looking to the aging “superconsumer” Baby Boom generation to be the early adopters of this model.
“Virtual wards” and patient data
Calderdale and Huddersfield plan to use digitised data from patients’ GP and secondary care medical records to identify the patients most at risk of emergency hospital admissions . Using “risk stratification” and “predictive modelling”, someone in a GP practice selects patients and admits them to a “virtual ward” - ie one that exists on the computer, not a real hospital ward.
In theory, staff intensively assess the health of patients in this “virtual ward” and co-ordinate their home-based care, provided by various members of the multi-disciplinary team. Once patients’ health has stabilised they would be discharged from the virtual world.
There is however so far no evidence about whether this model of integrated health and social care is a cost-effective way to reduce rates of emergency bed use or length of stay. A Kings Fund study says that evaluation for several years is needed to see what impact it has.
Such schemes have been trialled in a few areas, including South Devon and Torbay.
The pilots were jointly funded by NHS England and Devon County Council. Some good results are tempered by the heavily increased workload (not fully matched by extra staff and funding) meaning not all the co-operation and meetings could take place. The pilot also ran into problems with data sharing, which has become a political hot potato as the NHS becomes increasingly commercialised.
In Torbay, changes brought in by the Caldicott review meant GP practices had to rely on local intelligence to identify patients to include in the virtual ward. Whilst care.data is in limbo, beset by fears of inappropriate commercial exploitation, risk stratification of identifiable patients remains impossible. Its centrality to the model means care.data is unlikely to be readily abandoned.
But the virtual ward idea appears to be expanding nonetheless. In April 2014, NHS England announced a new, one year Enhanced Scheme that will pay participating GPs up to £2.87/patient to introduce the “risk stratification” model, identifying at least 2 percent of their patients as being at risk of an unplanned hospital admission and putting them on a pro-active risk management register.
A GP poll in January found that only 51% of GPs were planning to sign up for the new Direct Enhanced System because of fears that it will consume huge amounts of practice time.
GP Online reports the GPC deputy chairman Dr Richard Vautrey as saying:
“I think it is disappointing that this information has been issued at the 11th hour, or after the 11th hour. Practices wanted more preparation time, but there is now very little respite.”
Dr Vautrey said he hoped the process would not become a bureaucratic burden.
What will the expansion of ‘virtual wards’ mean?
Will GPs overloaded with admin really be likely to run “virtual wards” themselves for next to no money? If not, will we see case management increasingly being handled by a ‘case co-ordinator’? Will they ever see patients on the virtual ward? Or will they just have patients’ data? Will they have any medical training.
Behind the well-worn rhetoric of prevention - is this a way of shifting care away from a GP (inconveniently wedded to professional ethics, from the free marketeers viewpoint) to a non medically qualified administrator at the end of a phone line, much like in the US style insurance model?
Prevention and public health? Or a bonanza for Big Pharma?
Calderdale and Greater Huddersfield's NHS plans also claim to focus on the prevention of ill health.
They include targeting behaviour change initiatives at people whose demographic profile suggests they are statistically likely to develop chronic illnesses. This could be because of their age, for example, or because they live in a deprived area with high incidences of ill health related to poverty.
Behaviour change schemes would try to incentivise people to adopt a lifestyle that involves eating healthy food, exercising more and smoking and drinking less.
But such schemes do not address the wider social and economic structures and conditions that create deprivation and poverty.
As Calderdale’s own Public Health Officer Paul Butcher said,
“Individualistic approaches to improve health without addressing the systems and structures which shape health are ineffective in improving population health. Furthermore the evidence would indicate that a focus on individual behaviour change increases health inequalities.”
As elsewhere, the think-tank influenced Calderdale NHS proposals ignore underlying causes of ill health including:
• growing inequality, leading to poverty-related illness
• regulatory capture of government by junk food companies and alcohol companies
• market incentives for medical overtreatment
Their version of “preventative medicine” focuses on the “behaviour” of the individual healthcare “consumer” and not at a collective level.
Written out of the causes of illhealth is Big Pharma itself. Dr Jonathan Tomlinson points out:
“The numbers of prescriptions issued are rising dramatically...on average people over 60 received more than 42 prescription items per head in 2007 compared to an average only just over 22 in 1997. Hospital admissions for adverse drug reactions (ADR) are increasing substantially and particularly so in the elderly . Between 1999 and 2008 the annual number of ADRs increased by 76.8%.”
The use of risk stratification will lead to attempts to get people to undergo diagnostic tests (and preventative prescribing) for health problems they are deemed statistically likely to develop, even if they are quite healthy and symptom-free.
Commenting on the use of diagnostic testing for dementia, where people have no symptoms of dementia, Dr Shibley Rahman, author of “Living Well With Dementia, says
“The case for dementia screening is...more to do with the economic, social and political power of vested interests rather than in the hands of experts who know about this field.”
Earlier this year NHS England commissioned a lobbying company working for some of the world’s biggest drugs and medical equipment companies to write a draft report which could help shape NHS policy.
Big pharma and digital technology companies are key players in this transformation of medicine and healthcare. The business opportunities it opens up for Life Sciences are extolled in business documents that range from Ernst and Young’s 2012 Global Life Sciences Report, Progressions - the third place: health care everywhere to the government’s Office for Life Sciences/Department for Business, Innovation and Skills ‘Strategy for UK Life Science’.
It is advocated by new business alliances between English universities, NHS hospitals and life sciences companies - promoted by both government and management consultants like Ernst and Young - the agenda is being set by the think tank Reform. Keep Our NHS Public describes Reform as
“one of the new breed of parliamentary/corporate hybrid lobby groups, backed by the chief executives of major corporations, with ready access to the corridors of power...the membership of Reform’s Advisory Board points to its funding: chief executives, chairmen and directors of major corporations, with ready access to the corridors of power...the membership of Reform’s Advisory Board points to its funding: chief executives, chairmen and directors of major pharmaceutical companies, global investment banks, and accountancy firms.”
It’s all a long way from healthcare driven by patient needs…
Tomorrow we look at what’s happening to the funding - and to the staff - and ask whether the pressures are making real ‘integration’ impossible.