Sustainability and Transformation Plans

NHS Sustainability & Transformation Plans -STPs:

Sustainability = cuts, Transformation = Privatisation

These STPs will implement the 5 year Forward View for the NHS. They will drastically cut services in order to further privatisation.

The 2012 Health and Social Care Act created a healthcare market. Allyson Pollock describes this as an act of “extraordinary savagery and violence against the public in England, and against common values and widely held beliefs in universal healthcare” (1).

In 2014: Simon Stevens became CEO of NHS England, after 10 years with US transnational UnitedHealth. He is an arch-privatiser of health services (2). In October 2014 he published his Five Year Forward View (3), the 5-year plan for the NHS 2016- 2020 to do three things:
a) Reduce demand for services
b) increase efficiency of services and the workforce
c) Slash funding:

Slash funding:
George Osborne planned to reduce NHS funding to 6.6% of GDP by 2020, down from 8.8% in 2009. (Don Berwick, expert on patient safety, called the severity of this defunding “an experiment”, and said that to try to have “a universal health system, free at the point of care, government-funded, [with] ever-increasing excellence” for about 7% of GDP was “risky”, and “way out on the edge compared with any other Western, developed democracy I know.” (4)

Five Year forward View predicts a £30bn annual funding gap by 2020/21: it envisages the gap can be plugged by £22bn of ‘efficiency savings’ of 2-3% per year by 2020, and selling NHS assets, and by £8bn of extra funding from government. A major report by a panel of experts called this “a heroic assumption” (5).
Stevens has said that since social care funding is being cut, the £8bn may need to be closer to £21bn (6).

Sixty-eight beds have recently been closed (supposedly temporarily)at the Norfolk and Norwich Hospital to cut costs, and 24 beds have been closed permanently at Henderson Ward, a step-down ward to prepare patients to return home after treatment at the NNUH acute hospital.

We are being fed the lie that the NHS is unaffordable, and that the old, fat and mad are to blame. The solutions offered are patient charges, withdrawal of services, and making people with unhealthy lifestyles ineligible for non-emergency treatment.

There are TWO problems with NHS funding: the low total, below OECD average, and the mis-spending of a huge and growing proportion of it on the healthcare market including PFI. The latter is of course not mentioned in FYFV!

Reducing demand:
– Close hospital beds through ‘Care in the Community’ (the second major hospital bed-closure programme). But OECD statistics show we are already underbedded, with 2.73 hospital beds per thousand UK population in 2014, OECD average 4.8 (7).
– Adequate community facilities are not in place, and evidence shows that care in the community does not lower costs or reduce unplanned admissions:
“GP practices that devise care plans for the majority of their most vulnerable patients have higher rates of unplanned admissions”. (8)
– And Lord Carter’s report on acute hospitals asserts £900m a year could be saved if patients were moved out of hospital more quickly (9). But that would need more social care funding (or self-pay), which local authorities haven’t the money to provide.
– ‘Targeted health support’ aims to keep people in work (it complements the Department of Work and Pensions’s ‘Fit to Work’ programme, which gets people back to work after sickness):
– ‘Intensive lifestyle intervention programmes’ – group sessions focussing on diet and exercise to prevent obesity or diabetes; workplace health programmes (10).
The UK has the highest level of obesity in Western Europe, so it needs tackling.
According to Norwich CCG, obesity in Norfolk and Waveney “is costing more than £100 per year”. Norwich CCG proposes the “Healthy Child Programme” involving a health visitor and school nursing service (11).

BUT FYFV ignores the underlying structural causes of ill-health: the UK has the highest level of inequality in western Europe.
– According to Alison Tedstone, Director of Diet and Obesity at Public Health England,“Obesity is closely linked to deprivation levels. The association is especially strong with children. Children in poor communities are far more likely to be obese.” (12)
– And an NHS Health Scotland paper found that (for Scotland) the evidence “suggests that focussing on reducing individual risk and increasing individual assets will ultimately be fruitless in reducing inequalities and may even increase them. Elimination and prevention of inequalities in all-cause mortality will only be achieved if the underlying differences in income, wealth and power across society are reduced.” (13)

– Demand is also to be reduced by making patients responsible for managing their own healthcare, using developments in IT: ‘put a doctor in your pocket’ is a mobile-phone app. This ‘mhealth’ market could be worth $23bn by 2017 (14).
But how will the frail elderly cope?

– 5YFV is also ‘empowering patients’ by massively increasing Personal Health Budgets, especially for patients with long-term conditions e.g. diabetes, and mental health conditions. PHBs transfer financial risk to the patient, and are a key part of the move to an insurance-based healthcare industry – patients may need to top up their PHB with insurance to cover increasing costs not met by the fixed PHB. Worse care is likely for those who can’t afford top-ups. There is also massive scope for fraud, largely the reason that Holland abandoned the use of PHBs (15, 16).

5YFV aims to Increase efficiency of services and the workforce through ‘radical restructuring’:

i) Workforce:
– it will create a ‘modern workforce’ to fit the New Care Models (NCMs), with:
– local pay – breaking the nationally-agreed ‘agenda for Change’ system that assesses jobs and determines the appropriate pay for most NHS staff
– seven-day working (Junior Doctors’ contract; GP weekend opening)
– flexibility (downbanding)
– ability to ‘cross boundaries’ (work in private sector)
– ‘high efficiency’:
– increased productivity, reduced skill-mix – Physician Associates, worse terms and conditions, altered training, a huge new role for volunteers
– regulation of standards is to be loosened by allowing new local standards merely ‘having regard to’ national service standards

This modern workforce fits the requirements of the for-profit healthcare industry: de-skilled, casualised.

ii) Services:
– Devolution, giving stronger ‘health-related powers’ to local government and elected mayors. But Devo-Manc is delegation not devolution – control is centralised, and local authorities are starved of funding.
– New Care Models, entailing ‘complete redesign of whole health and care systems’. There are five of these:

a) One New Care Model is for Urgent and Emergency Care:
In 2013 we had 144 A&Es in England. They will be cut to 40-70 when the Keogh Review is implemented, and the remaining hospitals downgraded to Urgent Care Centres (17). Lincolnshire may have one A&E!

b) ’Acute Care Collaborations’ will form hospital chains, ready for take-over by the private sector.

c) Enhanced care in care homes:
Almost all care homes are in the private sector. Some will have ‘beds with care’, replacing closed community hospitals (Southwold and Halesworth have closed recently).

d and e) The other two are the big ones in FYFV: ‘large out-of-hospital providers’:
These are all about ‘integration’, which has at least two meanings for the NHS:
1. Integration of health and social care (horizontal)
2. integration of primary, secondary and community care (vertical), possibly with commissioning and health insurance (the US Kaiser Permanente model).

What is the evidence that integration saves money? None!
– As the Health Service Journal/Serco Commission reports: “There is a myth that providing more and better care for frail older people in the community, increasing integration between health and social care services and pooling health and care budgets will lead to significant, cashable financial savings in the acute hospital sector and across health economies. The commission found no evidence that these assumptions are true.”

These two NCMs are Integrated Primary and Acute Care Systems (PACs), and Multispecialty Community Providers (MCPs).
An MCP is being established in Norwich.

MCPs and PACs closely correlate to US Accountable Care Organisations (ACOs). 5YFV acknowledges this. But ACOs were devised to tackle a uniquely US problem. Their function in England is to convert the NHS to a US-style insurance-based industry. See below.

These large out-of-hospital providers,(PACs and MCPs) will do integration. They will have fixed capitated budgets (a fixed sum per registered patient), which cannot be overspent. Private companies will be heavily involved – they have been selected and approved by NHSE. They include Optum (formerly UnitedHealthUK). Others lined up for NHS contracts are KPMG, Capita, Mckinsey, EY and PWC (18).

How is FYFV being implemented? In two ways: through ‘Vanguards’, and through ‘Sustainability and Transformation Plans’.

There are 50 around England. But there are two problems:
– their performance is to be measured on how much they keep patients out of hospital, how patients rate their ‘involvement’ in their care (not the care itself) and a vague ‘quality of life’ measure.
– and before the Vanguards were up and running, NHSE produced a new directive ‘Delivering the Forward View’, which imposed a major top-down reorganisation of the NHS nationally, through Sustainability and Transformation Plans (STPs) (19). England has been divided into 44 STP local health systems or ’footprints’, roughly county-based. Ours is Norfolk and Waveney, involving fifteen organisations in total including local authorities. They are not statutory bodies. All the bodies in an STP area pool their funding. Since local authority funding has been cut by 27% over 5 years to 2015 and NHS funding is being savagely cut, they will be presiding over cuts rather than improvements in services.

STPs are a case of ‘Demand the Impossible Now!’

Each footprint has to submit a 5-year STP to NHS England by Autumn 2016. STPs considered inadequate by NHSE will not qualify for extra funding from the £1.8bn Sustainability and Transformation Fund’.
According to ‘Delivering the Forward View’, ‘The best STPs will have strong plans for prevention, self-care and patient empowerment, workforce modernisation, digital NCMs and finance’. Although the document’s sub-title is ‘planning guidance’, it is in fact a set of instructions, with penalties for non-compliance. These instructions include nine ‘must-dos’:

The first ‘must do’ is Balancing the books:
– Each CCG and trust must submit a 1-year plan showing how it will eliminate deficit by April 2017, focussing initially on cost reduction not income growth: workforce productivity is a main priority as a 1% improvement saves £400m
– STPs must show how they will use cheaper staff: associate nurses, physician associates, community paramedics and pharmacists in general practice.
– Providers (hospitals) must “embed a culture of relentless cost containment”:
Hospitals must make the Carter savings.
NHS Improvement is setting a maximum agency spend and hourly rate.
‘Headcount reduction’ means safe staffing levels are abandoned.
CCGs are to use RightCare to help reduce demand. The Norfolk and Waveney STP reckons to save millions through this big-data scheme.

What’s in it for Local Authorities?
LAs are starved of funding (cut by 27% over 5 years to 2015). They can’t run deficits, can charge for services, many of which they outsource. They see a big pot of money they can access. Some health care is reclassifiable as social care, so chargeable.

The other ‘must-dos’ include:

2. ‘Develop and sustain a local plan to address the sustainability and quality of general practice’.
BUT there’s a national recruitment crisis in general practice. Even if all the medical graduates this August were to become GPs, it wouldn’t deliver fully-trained GPs for another 7 or more years.

3. ‘Get back on track with access standards for A&E and ambulance waits’
BUT A&E faces the same problem as above – a shortage of A&E doctors

4. “Non-emergency hospital treatment: over 92% of patients are to wait a maximum of 18 weeks from referral to treatment, and must be offered choice”
BUT hospitals use gaming to meet targets, and what constitutes ‘treatment’?
Choice includes private providers, destabilising NHS hospitals.

5. “Deliver the new mental health access standards” – see the Campaign to Save Mental Health Services in Norfolk and Suffolk website!

6. Dementia diagnosis: ‘Continue the rate of over 67% of the estimated number of people with dementia.’
How, without screening? Why, as no treatment is available? Maybe because dementia is classed as social care and so means-tested, and programme failure will bolster the ‘NHS is ‘unaffordable’ claim.

New Care Models must also conform to six principles which “set out the basis of good person-centred, community-focussed health and care”. They require that:

1. “Care and support is person-centred: personalised, coordinated, and empowering.”
This transfers risk to the individual by treating the patient as a consumer, who is to take responsibility for care (Personal Health Budgets, self-management of conditions using apps)

2. “Services are created in partnership with citizens and communities”: the focus is on preventative care to justify closing hospital beds

3. “Focus on equality and narrowing inequalities”. BUT austerity and the incoming US healthcare industry massively increase inequalities

4. “Carers are identified, supported and involved”: Who are carers – family, friends, neighbours, voluntary organisations? Your bed replaces a hospital bed

5. “Voluntary, community and social enterprise and housing sectors are involved as key partners and enablers”: But this involves the voluntary sector again, this time replacing NHS services instead of just supporting them as they used to (e.g. Mind running the mental health emergency phone line in Norfolk).

6. “Volunteering and social action are recognised as key enablers”: As more cash-strapped Clinical Commissioning Groups and hospitals deny care, a role of the voluntary sector may be to field the excluded (20).

Accountable Care Organisations: New Care Models are ACOs!

ACOs are a key recent development in the US health care industry: originally intended to control runaway costs of insurance and over- treatment in the US industry, they were a threat to health insurers. Insurers responded by adopting the ACO model (ditching fee-for-service for capitated payments) and promising to be good in order to maintain their market dominance.

An ACO is a group of healthcare firms who take responsibility for providing care for a given population for a defined period of time, under a contractual arrangement with a commissioner.

They incentivise companies to lower costs through financial rewards (!!) – any budget savings made are shared between hospitals, doctors and private insurers.- i.e. incentives to deny care – under- treatment is profitable! ACOs must also achieve pre-agreed quality outcomes.
(see Stewart Player article ‘Accountable Care’, Our NHS, 1 March 2016)

In fact:
1 – Medicare ACO programmes have not realised projected massive savings – costs have risen
2 – ACOs have led to consolidation of hospitals and physicians’ practices into giant systems with the market leverage to demand higher prices, driving up costs for the privately insured
3 – Doctors and nurses face growing requirements for ‘mind-numbing electronic documentation’ in this
marketplace
4 – ACOs use risk stratification to deny care to high-risk patients
5 – There is ubiquitous gaming of risk adjustment and quality measures, which distort the data needed for fair payment and real quality improvement.
6 – A single-payer national health programme could solve most of the problems! (21)

In summary:

STPs will make drastic cuts – delisting services, raising access thresholds
The big health insurers and management consultants will get lucrative contracts
The NHS will wither to a skid row service
More health services will be chargeable
LAs and mayors will take the blame
No private company is big enough to buy the whole NHS, but might take on a devolved, deregulated local health and social care system, with means tests and insurance top-ups to cover patients when the Personal Health Budgets run out.

Simon Stevens: the CEO of NHS England is in post to further the interests of private health-care corporations. This is clear from not only his 5YFV but also his CV since the 1990s, which is well worth reading (22).
Sources:

1. Allyson Pollock, “Morality and values in support of universal healthcare must be enshrined in law”, International Journal of Health Policy and Management, June 2015, 4 (6): 399-402
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4450737/

2. http://selloff.org.uk/nhs/CVforSimonStevens260516.pdf

3. NHS England, Five Year Forward View. October 2014.
https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

4. Will Hazell, “Don Berwick warns current level of funding for the NHS is ‘risky’, Health Service Journal, 1 March 2016.
http://www.hsj.co.uk/topics/finance-and-efficiency/exclusive-don-berwick-warns-current-level-of-nhs-funding-is-risky/7002876.article

5. HSJ/Serco Commission on Hospital Care for Frail Older People, Main Report: HSJ, 19 November 2014.
http://www.hsj.co.uk/hsj-knowledge/commissions-and-inquiries/frail-older-people/commission-on-hospital-care-for-frail-older-people-main-report/5076859.fullarticle

6. Denis Campbell, “NHS boss says promise of £8bn in extra funding may be far from enough”, The Guardian, 17 June 2016.
http://www.theguardian.com/politics/2016/jun/17/nhs-boss-says-promise-of-8bn-in-extra-funding-may-be-far-from-enough

7. OECD Health Statistics 2016.
https://data.oecd.org/healtheqt/hospital-beds.htm

8. Jamie Kaffash, “Unplanned Admissions DES is Failing to Reduce Emergency Activity”, Pulse, 4 April 2016
http://www.pulsetoday.co.uk/news/commissioning/commissioning-topics/emergency-admissions/unplanned-admissions-des-is-failing-to-reduce-emergency-activity/20031497.article

9. Jessica Ormerod, “‘Slack Attitudes’ and ‘Bed Blocking’? Lord Carter of Coles is Avoiding the NHS’ Real and Very Urgent Issues”, National Health Action Party News, 5 February 2016.
http://nhap.org/slack-attitudes-and-bed-blocking-lord-carter-of-coles-is-avoiding-the-nhs-real-and-very-urgent-issues/

10. Patients4NHS, The Five Year Plan for the NHS – the proposals.

The five year plan for the NHS – the proposals

11. Norwich Clinical Commissioning Group, Norfolk Waveney STP Checkpoint Submission, May 2016.
http://www.norwichccg.nhs.uk/publications-policies-and-documents/corporate-information/1310-norfolkwaveneystp-checkpointsubmission

12. Health Exchange, ‘Britain: the fat man of Europe’, 20 March 2014.
https://www.healthexchange.org.uk/live-well/britain-the-fat-man-of-europe/

13. NHS Health Scotland, What would it Take to Eradicate Health Inequalities? Testing the fundamental causes of health inequalities in Scotland. NHS Health Scotland, October 2013.
http://www.healthscotland.com/uploads/documents/22292-What%20would%20it%20take%20report_1.pdf

14. Justin Montgomery, “GSMA: mHealth market worth $23b by 2017”, mhealthWatch, 16 February 2012.

GSMA: mHealth Market Worth $23B by 2017

15. Caroline Price, “Personal Health Budget scheme ‘wholly inadequate’ and may worsen care”, Pulse, 1 May 2014.
http://www.pulsetoday.co.uk/commissioning/commissioning-topics/long-term-conditions/personal-health-budget-scheme-wholly-inadequate-and-may-worsen-care/20006586.article#.U-DlwihiHJx

16. Alex Scott-Samuel, “Personal Health Budgets in England: Mood music or death knell the National Health Service?”, International journal of Health Services, vol. 45 no. 1, 73-86, January 2015.

17. Bruce Keogh, Transforming Urgent and Emergency Care Services in England, NHS England, November 2013.
http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.FV.pdf

18. Tamasin Cave, “The Foxes Have Control”, Spinwatch, 3 May 2015.
http://www.spinwatch.org/index.php/issues/lobbying/item/5769-nhs-the-foxes-have-control

19. NHS England, Delivering the Five Year Forward View: NHS planning guidance 2016/17-2020/21, December 2015.
https://www.england.nhs.uk/wp-content/uploads/2015/12/planning-guid-16-17-20-21.pdf

20. The Privatisation of the NHS (blog). https://crackedmirrorsandangelpie.com/2016/05/19/the-privatisation-of-the-nhs/

21. Gaffney, Adam and others, ‘Moving forward from the Affordable Care Act to a single-payer system’, American Journal of Public Health: June 2016, Vol. 106, No. 6, pp.987-988.

22. Sell-off org, CV for Simon Stevens.
http://selloff.org.uk/nhs/CVforSimonStevens260516.pdf

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