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Is the new 'collaboration' in the NHS merely a way to make cuts?

It's hard to see how the latest NHS reorganisation now secretively underway does anything other than put the accountants in charge, and balance sheets ahead of patient care.

Image: Flickr/Raysto. Some rights reserved.

We now have a new prime minister, a new government, a completely new political and economic situation – but the same Secretary of State for health, and no indication of any change in the massive, unprecedented squeeze on NHS spending that weighs on local services like a millstone.

And it's not just health that is feeling the pressure. The latest report from the Association of directors of adult social services spells out a grim picture of the situation in social care.

Meanwhile the hospital sector is being increasingly bullied by NHS England and local Clinical Commissioning Groups (CCGs) to take drastic steps to address end of year deficits of £2.5 billion.

The new instrument being used to force through the drastic "efficiency savings" and outright cuts required has been the reorganisation of the NHS since the beginning of the year into 44 "footprint" areas.

In each of these, in a break from the purchaser provider split established by Andrew Lansley's Health and Social Care Act 2012, local commissioners are required to collaborate with providers, who are also required to collaborate with each other – in the quest for cash savings and centralisation of services.

In almost any other context but the current overriding pressure for cash savings this reorganisation, in by-passing the legislation, would be a positive move towards more strategic, area based and collaborative work, breaking down the artificial barriers created by the costly apparatus of competition.

However the current situation makes it difficult to see how – despite the constant rhetoric insisting that proposals are "clinically led" – this latest reorganisation does anything other than put accountants in charge and balance sheets ahead of patient care.

NHS England Chief Executive Simon Stevens has made clear he wants the new “combined authorities” to "pool sovereignty" and make it possible to push through highly contentious cutbacks and closures which impact on specific communities, overriding any "local vetoes". The larger planning areas serve as a device to minimise any local accountability for specific communities, and marginalise those who stand up for them.

NHS Improvement, which is supposed to be a regulator driving up standards and quality of care, has begun issuing a series of increasingly heavy-handed demands that trusts make savings, wherever necessary at the expense of ignoring performance targets for A&E waiting times and cancer treatment, and disregarding guidelines for safe staffing drawn up by NICE. This makes one nurse per eight patients into a maximum permitted level of staffing rather than a minimum level to ensure safety.

Trusts have been given to the end of July to draw up measures for savings in "back office" services – which turn out now to include pathology and other services which might be thought clinical and technical rather than office services, and with obvious impact on "frontline" services.

All 44 Footprints have been required to draw up five-year Sustainability and Transformation Plans (STPs) – at rapid pace, and in almost every case, without any serious consultation or engagement with local communities or regard to their views, needs or wishes.

NHS England has stressed to CCGs that any consultation that may take place on these plans would only come at the end of the year – after the plans have been finalised, vetted by NHS England bureaucrats, and reached the stage of implementation. "Consultations" at such a late stage in the process can at best be a series of token exercises discussing a fait accompli.

So obsessive is the level of secrecy that in North-West London council leaders were called upon to sign a 2-page document which was claimed to be a summary of the local STP – without seeing the full document!

The still confidential and unfinished text was draft 39 – indicating the number of versions already discussed  behind closed doors.  It had changed beyond recognition from earlier skimpy sets of Powerpoint slides with vague diagrams, to 51 densely packed pages containing repeated commitments to hospital closures.

The pressure for savings – to bridge a "gap" between service needs and resources estimated in some STP footprints to exceed £1 billion by 2020 – comes after six years of relentless underfunding of the NHS. Minimal cash increases each year lag far behind costs of caring for an increasing population. Any easy savings have already been made, leaving CCGs to choose – or pick and mix – between cuts and closures, cuts in staffing, increased waiting times, rationing of services, exclusions of certain treatments or certain types of patient from access to treatment – or seeking ways to impose charges.

The available budgets are so limited that the momentum towards contracting out services, and seeking to get the winning bidders to shoulder financial risks in underfunded projects, has ebbed. The high profile collapse of the contract for older people's care in Cambridgeshire – for lack of funding – and the prolonged, constipated silence over the future of the underfunded contract for cancer care in Staffordshire have highlighted the problem.

But now Dudley CCG is tendering for a Multi-specialty Community Provider contract, at a massive £240m-plus per year for 10 to 15 years. This could put the issue of privatisation right at the centre of the new "vanguard" schemes and the "transformation" of the NHS as we know it. NHS England has promised the private sector the STPs would bring it ”enourmous opportunities”.

The Dudley Hospitals Foundation Trust has already warned that the contract could undermine its financial viability, by potentially hiving off work which is currently part of the hospital's budget.

With all of these issues in the melting pot, campaigners, and trade union activists seeking to protect jobs and conditions of their members, need to know the key proposals of their local STPs – and debate the extent to which these proposals are backed up by evidence, and contribute to any positive development patient care.

Where STP's are clearly proposing significant cutbacks in local access to services, and prejudicing the access of deprived sections of the community, we need a discussion on the most effective response.

That's why Health Campaigns Together has established an STP Watch  page on its website www.healthcampaignstogether.com, to pool available information on the detail of STPs and the way in which they are being driven forward.

We have called a national conference in Birmingham on September 17, where we hope campaigners from across the country will share and develop their understanding of the STPs, the plight of their local NHS, and the responses that have worked.

It's not intended to be a conference with a fixed set of demands or conclusions established in advance – but a learning and networking exercise. Details of registration are available at www.healthcampaignstogether.com.

We hope to attract a range of views and experiences from a range of localities – and to emerge with a consensus that to fight an increasingly organised and centralised offensive from NHS England, campaigners need to unite wherever possible in joint action rather than disparate efforts that too often make little impact.

About the author

John Lister of London Health Emergency is a writer and academic who has campaigned against NHS cutbacks and privatisation for almost 30 years. He has taught journalism and health policy at Coventry University, is a founder member of Keep Our NHS Public, and a board member of the International Association of Health Policy.


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