Image: Caroline Molloy
Not a week goes by now without some part of the estalishment warning us that the NHS is ‘unaffordable’ in its current form. This austerity mood music struck up in 2008 when New Labour asked the American management consultants McKinsey for advice on how to run the NHS more cheaply, after the government had spent huge amounts of public money on bailing out the banks.
McKinsey proposed “efficiency savings” including cutting ten per cent of NHS staff and moving care out of hospital into “cost-efficient” settings.
The plans drew heavily on an American system of 'integrated care in the community', as used by the private health care company Kaiser Permanente. New Labour had already been exploring the Kaiser ideas in 'beacons' like Torbay.
The trouble with these proposals was that they required more capital spending to create these new settings.
And the NHS workforce fiercely rejected the proposed staff cuts. Health ministers said they had rejected McKinsey report.
But in 2009 the NHS Chief Executive Sir David Nicholson took on board McKinsey’s cost cutting agenda and ordered “efficiency savings” of between £15bn-£20bn over the three years between 2011 and 2014. These efficiency savings came from cutting staff - mostly nursing and support jobs - and axing services.
In 2010 the Tories came to power on a platform of not reorganising the NHS, and promptly did so, adding huge ongoing bureaucratic costs and profit margins as well as a one-off reorganisational cost of £3 billion.
The Coalition government ramped up the cuts, with a real terms cut each year (a below inflation 0.1% annual increase). It loaded on a pay freeze, cuts to the tariffs hospitals are paid for procedures, and swingeing fines for infringements like 'treating too many patients'. The climate of penury was such that even above these cuts, the NHS handed a further £2bn back to the Treasury.
This is not what the public wants.- a YouGov poll earlier this year found that we want to protect NHS funding above all other areas of public funding.
Integrating health and social care - the right plan at the wrong time?
The Coalition government also told the NHS to transfer £2.1bn to local authorities over the next five years as part of the drive to cut costly hospital services and move patients into supposedly cheaper 'integrated' social or community care, in line with proposals from the pro-privatisation ‘think tanks’.
The government had neither evidence nor mandate to support these 'reforms'. But the Kings Fund national strategy report for “integrated care for patients and populations” said,
“change must be implemented at scale and pace.”
The same think tanks sit on the government’s handpicked consultative body, the NHS Future Forum. In June 2011 it said:
'we need to move beyond arguing for integration to making it happen'.
As is happening across the country, the Calderdale and Huddersfield proposals we've been examining in depth are vague about what integrated care might mean, though they draw heavily on the Nuffield Trust report into the ‘Kaiser Beacons’.
They are connected to a compulsory country-wide plan for what was originally called the Integration Transformation Fund and is now called the Better Care Fund.
This is a national (English) £3.8bn fund that should transfer £1.9bn of (til now ringfenced) NHS hospitals money and pool it with local authority spending on integrated health and social care in the community, starting in 2015. It follows on from the Coalition government’s five year transfer of NHS funding to local authorities that started in 2010.
Each English local authority and their local Clinical Commissioning Group have had to produce a joint plan that shows how they would spend their share of this £3.8bn fund.
Councillor Tim Swift, Leader of Calderdale Council, said,
“There has been an incredibly tight timescale for agreeing a framework to make sure this money is available within Calderdale.”
This may be why the Cabinet Office recently held back the Better Care Fund scheme national launch, scheduled for April 2014, on the grounds that there was no evidence that the policy would deliver the planned savings or work.
Despite the Cabinet Office’s delay, the Health and Local Government Ministries in Whitehall say the funding switch will go ahead as planned on 1 April 2015.
Calderdale Council’s Chief Executive Merran Macrae is still championing the plans, and denies that the Cabinet Office criticism will have any effect on Calderdale’s Better Care Fund plans.
NHS England has told Calderdale Clinical Commissioning Group to tie in their plans in more tightly to the Better Care Fund.
More 'Big Society'?
The theory is that care in the community, including specialist treatment and equipment provided in a patients home, is much cheaper than hospital care.
It is also, of course, far more likely to end up being paid for by the patient - if they can.
And if not? Who will do the work? The Calderdale Strategic Outline Case admits:
“realignment of the current workforce to the revised model will impact on the number of people employed. Given 70% of costs currently relate to pay in order to achieve the level of savings required the overall paybill will need to reduce...”
Questioned about this, the Hospitals Trust Director of Workforce says that most of the anticipated reduction in the wage bill will come from cutting the use of agency staff.
But reading through the proposals, they also note “significant potential shortages in the health and social care workforce” and identify “An expansion and increasing role for an informal workforce of peer support workers and volunteers” as a key principle from a 2013 Kings Fund briefing paper (NHS and Social Care Workforce: Meeting Our Needs Now and in the Future).
The Calderdale report suggests that “Increased self-care will reduce the number of people needing to seek help from a health or social care professional”, and adds that self management and care will be the first option to be considered for patients being cared for in the community. Volunteer health trainers, peer support workers and expert patients will coach at-home patients in how to self-care. “The approach will be to support individuals, families and communities to undertake activities that will enhance their health, prevent disease, limit illness and restore health.
It suggests volunteers and voluntary organisations will be part of the “locality teams” that would deliver community care.
Calderdale’s related Better Care Fund Submission (p9) outlines how at-home patients would rely on social care and support from volunteers from community groups, friends, family, and third sector groups (charities and social enterprises). It proposes that social needs are assessed in a way that “reconnects people to their natural networks of support within their community and avoids the need for statutory health and social care assessment.”
Which sounds like code for throwing people onto relying on family, friends and neighbours - what else are the “natural networks of support”?
Another way in which patients would take more responsibility for their own care would be through self-monitoring their symptoms using digital devices (so-called ‘telehealth’) to measure blood pressure, heartrate, breathing, blood oxygenation and sugar, and so on, depending on the patient’s illness. The outputs of these monitoring machines would be automatically sent to specialist teams and would alert them if anything’s going wrong with the patient’s health. Medical advice would be available via skype or phone (so-called ‘telecare’).
But claims for the efficacy of telehealth and telecare are unsupported by evidence. There is no definitive evidence that there are economic benefits or improvements in outcomes at scale. Established and funded by the Department of Health, the Whole System Demonstrator programme was a randomised control trial involving over 6000 patients and 238 GP practices in three places in England (Cornwall, Kent and Newham).A 2013 BMJ paper found “telecare as implemented in the Whole Systems Demonstrator trial did not lead to significant reductions in service use, at least in terms of results assessed over 12 months”.
The Calderdale CCG contract for introducing telehealth and telecare in care homes was awarded after industry lobbying.
The plans promise that there would still be face-to-face treatment and support in the home and in the neighbourhood - as nursing, physiotherapy, GPs, social workers etc. These health and social services would, we are told, be accessible at short notice in the patient’s home via so-called “locality teams” (groups of 5 to 10 GP practices).
The locality teams would “align seamlessly” with private home care providers, community pharmacies, voluntary organisations and self-help groups, as well as facilitating the use of specialist kit in the home to help with mobility and so on.
Two specialist community hubs could bring together Minor Injuries with community and mental health services, diagnostics, pharmacy and social facilities (though it's not clear if much of this are actually new services).
All this would - it is claimed - help patients to manage their health problems better so they wouldn’t have to go to hospital for acute and emergency care so often, and would be supported when they came home so they could leave hospital sooner.
The Nuffield paper suggested that a Nottingham pilot had shown that home care to support “healthy independent living” and “chronic disease management” - was between £1 and approx £30-40/day. The cost of “locality team” services - speciality pharmacy, community clinic, GP and skilled nursing facility - was between approx £30-40/day and £700/day. The cost of acute hospital care was approximately £700-£5k/day.
There is no question therefore that acute care is expensive, and avoiding it would reduce costs. Whether the current plans would do so, in a way that met patient needs, is more debatable.
Is the NHS listening to its staff?
At the end of 2010, in the face of people’s protests at the McKinsey-inspired cuts, Sir David Nicholson told NHS Employers that,
“There are people in the service who hate all this. My view is that they should go.”
The NHS Constitution pledges:
“ to provide a positive working environment for staff and to promote supportive, open cultures that help staff do their job to the best of their ability”
“to engage staff in decisions that affect them and the services they provide, individually, through representative organisations and through local partnership working arrangements. All staff will be empowered to put forward ways to deliver better and safer services for patients and their families”.
But staff at Calderdale and Huddersfield NHS Foundation Trust say that they don’t feel safe questioning or speaking out against the proposals.
Julie Hull, Director of Workforce, has reassured staff that as part of the “engagement process” for the Strategic Outline Case/Right Care Right Time Right Place proposals, all staff are free to speak their minds without fear of reprisals.
But a Trust employee said,
"We are afraid of losing our jobs if we speak out. Staff feel they need to be careful of what they say in case the Trust takes them down the disciplinary route for bringing the Trust into disrepute. The Trust have not to my knowledge, directly addressed this issue in regards to these changes. We have in the past been told that we must not speak directly to press about Trust issues but direct them to someone in a senior management role. I think that is a General Trust Policy.”
Another Trust employee said that staff want a statement from the Trust management that staff are free to speak their minds honestly about the reconfiguration proposals, without fear that this will put their employment at risk, but so far this is not forthcoming.
Staff are deeply uneasy. It's not at all clear that adequate care in the community will be available to make up for cuts to acute and emergency hospital services.
The proposals say cutting the pay bill is a key way to cut costs but there is no clarity about what will happen.
Asked about jobs, Trust Chief Executive Owen Williams, said,
“...each [NHS] partner is committed to supporting...the continuing employment of its current permanent workforce now and into the foreseeable future...we have a well-established and, in the context of the development of our services, an evolving Saving Jobs Strategy that seeks to engage the workforce in measures to reduce the overall paybill without the need to lose jobs....Any reduction in workforce across the provider organisations will be achieved wherever possible through natural wastage.”
Julie Hull, CHFT Director of Workforce, said that the main measure the CHFT would use to reduce the paybill without cutting jobs would be to reduce non-contracted pay through the use of agency staff - a bill that has rocketed as a result of staff cuts in the first round of 'efficiency savings'.
NHS staff don’t know what is going on. Previous cuts have led to short-staffing and increased stress, they say. One Calderdale Hospital worker told us:
“Due to staff cuts many of us work the odd half hour-hour unpaid here and there otherwise the job would not get done and patients would suffer. It's certainly not unusual for me to eat my lunch in 2 or more shifts.”
With this kind of pressure on staff, and in the absence of a clinical case for the proposed changes, it’s not surprising that staff are worried. Trades Union Convenor Pauline Pilcher told Shadow Health Secretary Andy Burnham when he visited Halifax in April that staff are worried that,
“If no-one’s there to provide care in the community, patients would be readmitted to hospital soon after discharge.”
Tomorrow we publish the final part in our 4-part 'View from the Grassroots' - how are 'social care integration' and 'personal budgets' working out on the ground?
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