Category Archives: Health

Health policy in the UK at lynwhitfield.com

The NHS’ own plan 2.0

Jeremy Hunt on protest poster

Jeremy Hunt on an NHS protest poster (picture: Rohin Francis on Flikr: https://www.flickr.com/photos/rohinfrancis/22277630191/in/photostream)

I’m going to a health conference on Thursday that has been organised by the think-tank Reform. Health secretary Jeremy Hunt is the keynote speaker.

If we find ourselves playing conference bingo, we can expect to hear him say that “we gave the NHS £10 billion” (depends how you count), “that was more than the NHS asked for” (nope, it definitely wasn’t), and “we’re funding the NHS’ own plan” (erm…)

If he has something more substantial to say, then there’s a lot for him to talk about; most of it stemming from the progress or otherwise of ‘the NHS’ own plan’.

The NHS’ own plan

This is the ‘Five Year Forward View’ project, drawn up by NHS England’s chief executive, Simon Stevens, to close a gap between flat NHS funding and rising demand and costs that could reach £30 billion by 2020-21.

It worked on the basis that, if the government put in £8 billion, and social care and public health funding was maintained, and the NHS was able to keep on top of its efficiency agenda, and it used some cash to ‘pump prime’ new ways of doing things… it should be able to find the other £22 billion.

The Forward View only came out in October 2014, but a fair bit of this is already off track (see posts below). The government did announce £8 billion for the NHS in its 2014 budget (and then back-counted another £2 billion, to get to the £10 billion figure).

But as Stevens has told several Parliamentary enquiries now, the money is not going in smoothly (it doesn’t feel like it, but this year is a relative ‘year of plenty’ – there will be virtually no funding increases in the next two years). To make things worse, the acute sector has fallen over a cliff.

The King’s Fund, another think-tank that tracks NHS finances closely, reported in February that hospitals will miss their £580 million deficit target this year, and are likely to overspend by £820-920 million.

Director of policy Richard Murray argued that, at best, this will wipe out the ‘sustainability and transformation fund’ money that would otherwise be available to ‘kick-start’ change. At worst, it could eat up reserves and even push the NHS overall into the red.

Meanwhile, investment in public health by a Conservative government always sounded like a non-starter and, as major news outlets have been pointing out, social care faces a crisis all its own.

In fact, it’s so bad that the King’s Fund’s pre-budget statement reckons that if Chancellor Philip Hammond has any money that he doesn’t need for his Brexit fund, it should go into social care.

STPs: neither sustainable nor transformative?

So, the mood music against which the Forward View has to be taken forward isn’t promising. But what about the plan itself? Ideas for turning the Forward View into reality have been put forward in 44 ‘sustainability and transformation plans’.

These got off to a bad start. NHS England tried to hold them back so its comms teams could vet them for ‘positive messages’, but councils went ahead and published them anyway.

This led to accusations that the plans had been drawn up “in secret” that have proved hard to shake off. Not least because papers and activists have picked over them looking for hospital closures and job losses – and these are easy to find.

Just this week, the BMA put out a blog post arguing that without more money, the plans were not only “doomed” but “a way to dress up cuts to public services.” Saying that plans that have yet to start have already “failed” seems a bit much. But there are reasons to worry about the STPs.

Reorganisation by stealth

For a start, there are signs that NHS managers are doing what comes most naturally, which is to focus on management.

Stevens told his most recent appearance at the Public Accounts Committee that the STP ‘footprints’, which are rapidly acquiring the accoutrements of administrative areas, such as leaders and key performance indicators, would in due course become ‘accountable care organisations.’

In other words, bodies that take responsibility for the health (treatment or long term care) of a local community, and get paid according to the size and health profile of that community (rather than services run or treatments delivered).

Stevens admitted this would end the purchaser/provider split for the first time since the internal market was introduced by the Tories in the 1990s; which is a big thing in health policy circles.

All of this is happening without the centrally-dictated reorganisation that has been repeatedly inflicted on the NHS, most recently by former health secretary Andrew Lansley.

Most people in the NHS would say “and thank goodness for that.” However, the fact that the latest reorganisation of the health service is less visible than most doesn’t mean that managers are not being distracted by it.

Fuelling public anxiety?

Also, the lack of public clarity on what is happening seems to be adding to public concern. Just this weekend, there was a huge march in support of the NHS at which there were many cheers for speakers who claimed that it was being ‘privatised.’

Yet the STP changes are, if anything, moving in the opposite direction (unless the conspiracy theorists are correct, and the ultimate ambition is to create ACOs that can be taken over by US corporations – which is frankly unlikely, given the margins and more likely losses on offer).

Be bolder, people

More substantively, the STPs are big and complex; and yet it’s hard to escape the feeling that they are nothing like bold enough. As I live in the county, take Hampshire’s STP.

It talks about the need to: resolve long-standing issues with care on the Isle of Wight, sort out Portsmouth’s struggling A&E, resolve the very public crisis at Southern Health and Care NHS Trust (which suffered another blow this week when the CQC announced it was going to prosecute), and work out what to do with the small district general hospitals in Winchester and Basingstoke.

Also, about the need to: keep these organisations on top of their efficiency savings agendas, while introducing new, more integrated ways of working underpinned by a big expansion of its existing shared care record / IT platform.

Delivering on any one of these imperatives would be a major achievement in five years, but there is neither time nor money to treat them as sequential issues. And what the STP lacks is a sense of how its different elements can be done at once, to support each other.

Never mind a vision of what a safe, modern service, with a digital front-end and highly trained staff in expensive buildings only where they are really needed, might look like – for the available money.

IT’s just not happening…

Just to stress, Hampshire’s STP is not alone in this. Kingsley Manning, the former chair of NHS Digital, wrote a column for HSJ recently in which he argued that the STPs generally fail to engage properly with productivity, and with how IT might drive that.

Instead, he noted, they tend to tick off analytics, shared care records, and digital services as nice things to have, rather than as programmes that will deliver the kinds of improvement in workforce productivity that have been seen in other service industries.

Mind you, when it comes to IT, it’s not just the STPs that are struggling. Last week, my former employer, digitalhealth.net reported that one of the biggest trusts in the country, University Hospitals of Leicester NHS Foundation Trust, had been unable to get its electronic patient record plans past NHS Improvement.

It wanted to spend around £25 million on a US system called Cerner Millennium and, while that’s a lot, it seems incredible that neither the company, nor the trust’s IT department, nor its general management, could get together a business case for it in an organisation spending £860 million a year, and employing 14,000 people.

(Of course, NHS England might have helped, but it seems to have become hopelessly distracted by trying to get a handful of ‘global digital exemplars’ up to snuff with £100 million that, HSJ reported this week, the Treasury probably wants back).

The NHS’ own plan 2.0

As commentator Roy Lilley noted in his newsletter this week, this kind of thing does not tend to worry the activists and medical staff who joined last weekend’s NHS march. They just want more money for the NHS and for their local services to be ‘saved’.

It would be unreasonable to expect otherwise. But Lilley is right; even if this government was going to find more money for the NHS (and all the pre-budget briefing is that it won’t – although social care might, might just get something) it needs to be spent effectively – and that means differently.

Stevens is working on a big reboot of the Forward View. So, if Hunt is going to do more than play conference bingo on Thursday, he’ll need to say something about what ‘the NHS own plan 2.0’ looks like.

Also, how the NHS’ regulatory structures are going to get behind it and start getting managers to think like, well, managers; and how politicians are going to sell all this to a hostile staff body and a very worried public. What’s the betting?

Briefing against the NHS boss: Maybe time to rethink that, Prime Minister?

Simon Stevens at the PAC; FT picture

The FT’s take on Simon Stevens’ appearance at the public accounts committee; where he made cheeky use of a story in the Daily Mail, which briefed against him in November.

Well, that was lively. NHS England’s chief executive, Simon Stevens, was up in front of the Commons’ public accounts committee yesterday (watch here on Parliamentlive.tv).

As he headed into London, he would no doubt have seen an “exclusive” in the Times, claiming that “aides” to Prime Minister Theresa May had “privately criticised” him for being both “insufficiently enthusiastic” in carrying out his job and unduly “political” in flagging up some of its challenges (story, paywall).

May is starting to get a reputation for this kind of thing; the Times story came just a few days after the very public departure of Sir Ivan Rogers, Britain’s EU ambassador, who was duly briefed against for being insufficiently enthusiastic about leave.

But if there are risks in her government starting to look like the kind of thin-skinned and petty-minded administration that lashes out whenever a public servant presents it with inconvenient facts, her “aides” seem to be unworried by them.

The Times story was hardly accidental. Indeed, it was hardly an “exclusive” as the Daily Mail was given pretty much exactly the same thing back in November.

Instead, it looked like an attempt to use the PAC hearing to re-run a hare that had failed to get running (but which I blogged about at the time).

Doing the math (again)

 If the “leaks” were an attempt to bring Stevens to heel, they not only failed, but directed huge amounts of press attention onto fine details of NHS finances that are, in fact, well known; but which are now being presented as new and worrying.

The PAC hearing was part of a short series of hearings on the financial sustainability of the NHS, prompted by a National Audit Office report. The NAO (a financial watchdog that reports to the PAC and gives it unusual clout for a select committee) has been running yearly reports on the financial sustainability of the NHS for some years.

This year, for the third year running, it concluded that the NHS finances were not sustainable. In doing so, it went into exactly how much money the government has promised to give the health service over the next five years.

In what turned out to be his last autumn statement, in 2014, then-Chancellor George Osborne said this was £10 billion. He also claimed this would “fully fund” the NHS’ “own plan” for sorting out its financial woes, the ‘Five Year Forward View’.

This is a plan that Stevens wrote, which says the health service can find £22 billion by 2020-21 from further “efficiency” and bringing in new models of working.

Since then, the NAO – and many other bodies – have shown the £10 billion includes £2 billion that had already been announced for 2014-15 and £3.5 billion shifted from running bits of the Department of Health and public health.

Despite this, May has repeatedly used the £10 billion figure in speeches about the NHS. She did it back in October, and was told off for it by the opposition and by the UK Statistics Authority. And she did it again this week, in her much-heralded speech on mental health, adding that it was “more” than the NHS had asked for, for good measure.

It’s baffling that May continues to use the £10 billion figure, when it’s been disproved so often, and it wasn’t her government that came up with it. But she does, and then her supporters get antsy when experts do the math in public.

The November briefing against Stevens seems to have been prompted by his appearance at the Commons health select committee, which is running its own inquiry into NHS finances, covering more or less exactly the same ground as the PAC (and which I also blogged about).

At the hearing, he was careful to hedge around the question of whether he had, in fact, got what he asked for from the spending review.

However, he did have to agree that the money is not being distributed in the way that the Forward View asked for – most is going in this year; there will be barely any increase next year or the year after, when spending per head of population will, in fact, fall.

And at an earlier PAC hearing, he noted that some of the other assumptions made by the Forward View are not bearing up in real-life.

Most obviously, the plan assumes that if the NHS is to close its funding gap by 2020-21, money will need to be spent on public health – to start cutting demand – and on social care – to help keep the ageing population out of hospital. Yet public health spending is being cut, and social care has a crisis all of its own.

Coming out fighting

So, when Stevens got to Parliament yesterday, he didn’t really say anything new to generate headlines. He just went further than he’s done previously in spelling out what the government has done on NHS funding; and seemed to enjoy himself doing it.

In response to an opening question from PAC chair Meg Hillier, he said it would be “stretching it” to say the NHS had got “more money than it had asked for”.

He contradicted the DH’s permanent secretary, Chris Wormald, when he said an OECD report had shown the UK spends about what most countries spend on health; pointing out that comparable, rich, European countries spend much more per head of population.

He cheekily held up a story from the Daily Mail, the paper that took the bait on the November briefing against him, and said he agreed with it that the NHS “trails the rest of the EU for medics, beds and scanners”; implying that more of all will be needed.

And he had a neat little swipe at the Time story, saying he had been “running a little campaign” to stop cuts on social care and doing so “very enthusiastically, I might add.”

What does the boss think?

 It would be very interesting to know what health secretary Jeremy Hunt thinks of all this. He is now England’s longest serving health secretary, after being re-appointed to the job by May in aftermath of the Brexit debacle.

But his career has been associated with that of Osborne, who May publicly dumped as Chancellor in the same reshuffle. There were rumours on the day that he was off as well – he arrived very late at Downing Street without his NHS badge on, and there were reports in the BBC and papers that he had been sacked before he reappeared with it back in place.

It’s not inconceivable, then, that he might welcome Stevens’ digs at a Prime Minister unlikely to feel warmly towards him, and unlikely to promote him; he told the NHS Confederation’s annual conference last year that health would be his last political job.

Also, Hunt has shown remarkable commitment to the NHS, and might see the headlines about a “winter crisis” and hospitals on “black alert” that have been constant since Christmas as evidence of a crisis too good to waste when it comes to putting pressure on Downing Street for more money.

After all, most spending departments rebel against Treasury constraints at some point, and May has hardly shown herself to be an adept at keeping ministers or officials in line.

Never mind the £10 billion, what about the £22 billion?

 Still, the bigger question is whether the NHS can use the money it has got – never mind any new cash – effectively to address the long-term pressures on it.

The NAO has cast doubt on this, pointing out that the Forward View is not a strategy and does not come with worked through delivery plans with budgets attached. Local health economies have been asked to draw up ‘sustainability and transformation plans’ to put it into action.

But these are only just being published, and are of variable quality (post). The PAC got to this point late in what turned out to be long hearing, after Twitter had lost interest and the papers had gone off to write their stories.

Its MPs were told, by Jim Mackey, the chief executive of NHS Improvement (the regulator that decides whether trusts can operate), that a consolidated and more detailed plan would be available by March or April.

He also said there would be new ‘key performance indicators’ for the STP footprints to meet, with financial control targets for their commissioners, trusts and other organisations to meet together to follow in a year or so.

The centre needs to get a grip on money and targets, if it is to impress on the NHS that STPs are the only game in town, because hospitals overspent to the tune of £2.4 billion last year, and hospitals are publicly saying they are no longer meeting key targets, such as the four hour see, treat or admit target for A&E.

But even if Stevens and Mackey can get back on top of things, there is, as one MP pointed out, a timing issue. It’s simply not clear how the NHS can get from where it is to where the Forward View says it could be, given the huge shift in finances, structures, mangement thinking, and public support that would be required to get it there.

Yesterday’s politics and right-wing press twitting were fun; that question is deadly serious.

 

Reading between the lines, the PM and the Daily Mail have it in for NHS boss Simon Stevens

mail-front-page-on-stevens-snip-for-blog

The Mail Online, 20 November

There’s an astonishing story in the Daily Mail today. It says Downing Street is “gunning” for Simon Stevens, the chief executive of NHS England.

The paper says Theresa May is furious for “telling MPs that the Prime Minister had exaggerated the amount of extra money promised for the NHS” while appearing at a health select committee hearing.

Specifically, it claims Stevens annoyed the PM by telling the committee she was wrong to say the NHS would get “an extra £10 billion a year between now and 2020-21 – up from the £8 billion promised by former Chancellor George Osborne.”

Also, that he’s seen as stepping out of line by making a bid for more money, ahead of this week’s Autumn Statement on Wednesday.

The story may be true

There doesn’t seem to be any reason to think this story is not true. The paper likes May much more than her predecessor, David Cameron, and she has gone out of her way to support its line on, say, Brexit.

So the remarks as reported are likely to have been made. What’s astonishing is that Stevens didn’t say what the paper/Downing Street claims that he said.

NHS finances are complex, and set out in the blog post directly below this one. The basics, however, are that Stevens drew up a plan in 2014 that said the NHS was facing a gap between funding, demand and costs of £30 billion.

He reckoned it could make £22 billion of efficiency savings, with a lot of change, and a following wind, leaving the government to come up with £8 billion. Osborne duly obliged, claiming in last year’s budget that he was “fully funding” what he was quick to call “the NHS’ own plan.”

Things then get complicated because various ministers have claimed the government is in fact putting in £10 billion; counting an additional £2 billion Osborne had already announced for 2014-15.

The health committee reckons it is actually putting in £4.5 billion, because £3 billion is being transferred from the budget for things like running the Department of Health and public health. And one think tank reckons it should be as little as £800,000, because the Treasury has done some creative accounting on inflation and dating.

The health committee went into all this; and Stevens had to confirm the £10 billion to £8 billion and £8 billion to £4.5 billion figures.  He didn’t make the claim attributed to him today. At most could be accused of being forced to do maths in public.

Certainly, journalists have since asked May to do the same kind of maths, and she’s found that embarrassing. But that’s another issue.

The ‘facts’ are not

Stevens did tell an earlier public accounts committee hearing that the money was not being phased in as he asked, and that public health and social care spending had not held up as his modelling demanded. Which raised eyebrows among mandarins and policy wonks.

But he has absolutely not made a public bid for more money. In fact, he almost certainly wants to avoid any suggestion that there may be a bail-out on the way for the acute sector (hospitals), which overspent by £2.4 billion last year, and have been told to accept swinging ‘control targets’ to avoid a repeat this year.

Any hint of a bail-out would make hospitals and their commissioners less inclined to get into the difficult business of change that is being proposed by the sustainability and transformation plans that are supposed to turn Stevens’ ‘Five Year Forward View’ into local action.

As set out directly below, there are plenty of indications this project is not going well, but Stevens does not want it being derailed from the start. Also, when asked a direct question at the health committee, he said that if there was any money going this autumn it should go into social care, which has a financial crisis all of its own.

Ok, what’s the alternative?

The other reason that the Mail’s story is astonishing is that it’s hard to imagine who May thinks is going to take over from Stevens if he goes. Stevens was a Labour advisor at the turn of the century, but when he was recruited to take over from Sir David Nicholson he was working at United Health in the US.

It’s safe to assume that he took a massive pay cut to come back to England. In doing that, he also took on a job that amounts to trying to persuade the NHS to sort out a financial crisis that Nicholson warned it about in 2008 and that it largely failed to tackle.

Stevens isn’t as well-loved as Nicholson, and he can address conferences like he’s read too many management consultant text books in airport lounges, but he must really believe in the health service to have taken on the challenge.

If May and her advisors think there are loads of candidates willing to step into Stevens’ shoes, they are likely to find they are wrong. Indeed, before this morning’s intervention, the general assumption was that the government would be only too keen to keep Stevens in place.

Trotting out Osborne’s “NHS’ own plan” line gives ministers cover whenever there is a suggestion that the health service might fall over this winter, prove to be financially unsustainable in the long-term, or need to get rid of a lot of ageing, clinically unsafe, but much loved local hospitals.

Indeed, MPs on the health select committee have tended to express a cack-handed kind of sympathy with Stevens; asking if he is being set up as the “fall guy” for when the Forward View fails to deliver, as some unhelpful voices are starting to say it will.

Meantime, Labour moans that Stevens is covering for the Tories’ failure to spend adequately on the NHS, that he really wants to make cuts or that he wants to privatise large chunks of it (and yes, the last two are contradictory).

Worrying… on so many levels

We have to hope that May and her advisors know the facts, and were simplifying for effect in their comments to the Mail. If that’s the case, what are we to make of the story?

One interpretation would be that we have a Prime Minister who is so thin-skinned that she is prepared to lash out at a civil servant for answering Parliamentary questions, if this in turn makes journalists ask her difficult questions. This would not be good.

Another is that Downing Street realises the NHS is in deep trouble, that the government is going to have to find more cash for it or face protests on the streets (or both), and that it’s getting its retaliation in early by setting the press pack against the man in charge.

This would be worse. Any check on the Forward View and its STP process will make it less likely to succeed, when the odds are turning against it anway. And one thing we can be sure of is that the government has no alternative plan; and no capacity thanks to Brexit to develop one.

STPs: the NHS’ sustainbility and transformation plans are branded ‘secret’ and look like they’re in trouble

guardian-front-page-stps-for-blog-post

The Guardian leads with a sustainability and transformation plans ‘cuts’ story

The NHS is well and truly back in the news, thanks – if that’s the word – to the sustainability and transformation plan process.

The STPs are supposed to address the NHS’ immediate financial woes and implement locally the big ideas in the ‘Five Year Forward View’. This, in turn, is the big plan that was published two years ago [my blog post] to try and close a gap between funding, demand and costs that could otherwise reach £30 billion by 2020-21.

There are 44 STPs being drawn up [HSJ map] by NHS commissioners (the clinical commissioning groups that plan and purchase care locally), trusts (which run hospitals and mental health services) and local authorities (which are responsible for social care, which has a funding crisis all of its own).

So far, you would have to say that the process is not going terribly well. To put it mildly.

When is £10 billion for the NHS not £10 billion for the NHS?

Firstly, there are two increasingly public rows about the financial background against which the STPs are being drawn up.

The first concerns whether the government is funding the Forward View, as it claims. In its best case scenario, the plan assumed the NHS could find £22 billion of efficiency savings; leaving the government to find the remaining £8 billion.

In last year’s budget, then-chancellor George Osborne claimed he’d done a bit better, and that he would “fully fund” what he was quick to call “the NHS’ own plan” with £10 billion.

However, a succession of Parliamentary health select and public accounts committee hearings [my blog post] have established that it’s only possible to get that figure by counting in £2 billion for 2014-15, which had already been announced.

In addition, as Prime Minister Theresa May has been forced to admit [Guardian] in the past couple of weeks, the remaining £8 billion includes £3 billion that would previously have gone on things like running the Department of Health and paying for public health programmes.

May has said this is because the government is focusing on the ‘frontline’ NHS – but that in itself that sort-of admits it has diverted, rather than found new, money for the service.

Meantime, the £8 billion figure is also generous because the government has, unusually, counted the ‘extra’ in 2019-20 prices (rather than base year prices) and only factored in general inflation (rather than NHS inflation, which is always much higher, because of the high cost of new drugs and treatments).

Also, the way the money is being phased means most of the cash is going in this year (2016-17), when it will get a real terms funding increase of 3.7%. It will only get 1.3% next year (2017-18), 0.3% the year after (2018-19) and 0.7% the year after that (2019-20).

In Parliament, Stevens came close to saying this was not, in fact, what he asked for. He also pointed out that his plan relied on funding for public health and social care being maintained.

Don’t panic, Mr Hopson:

This brings up the second row. Despite repeated questions from MPs, Stevens was not ready to say that the logic of his comments is that the plan cannot be delivered.

Indeed, he told MPs that questions about what would happen if the STPs ‘failed’ made no sense, because the NHS will be bigger in 2019-20, whatever happens, and those areas will be delivering something.

Naturally, he didn’t spell out that ‘something’ might be a service in which there is more rationing, longer waiting lists, a bigger backlog of maintenance, and perhaps lower quality care.

This would be political suicide. Also, the whole point of the STPs is to avoid this scenario and Stevens is determined not to let the NHS itself think there is any alternative to restoring financial control and delivering on the plans.

However, others are happy to oblige. Chris Hopson, the chief executive of NHS Providers, reminded the health select committee that the acute sector (hospitals) finished last year £2.4 billion in the red – or a billion more than that, without some creative accounting.

This forced NHS England to throw most of its planned sustainability and transformation fund into the acute sector black hole this year, dramatically reducing the amount of money available for investment on projects that might save money in the long-run.

Despite this, and 2016-17 being the NHS’s “year of plenty”, Hopson said the “NHS was struggling”. Worse, he argued demand, NHS constitution commitments, targets, and funding could no longer be squared and something would have to give.

Worse, he argued areas were drawing up STPs in which they simply did not believe. Hopson was out this week making similar points ahead of next week’s Autumn Statement.

He told the Guardian, Today programme, and other outlets that May would have to “rip up” the government’s plans for the NHS and either find more money or “risk it becoming unable to function properly.”

So far, Hopson’s a lone voice. The country’s big three think-tanks have come together with their own statement for the present chancellor [Nuffield Trust website], Philip Hammond.

However, they are calling for more money to go into social care, on the grounds that it’s in an even worse state, and improving things would help hospitals discharge elderly people stuck on acute wards for lack of anywhere else to go.

Not live from Leeds:

While all this has been going on, NHS England (the body that runs the NHS’ planning and purchasing set-up from Leeds), has been trying to keep a tight grip on the STP process.

Working with NHS Improvement (the body that decides whether trusts are financially fit to operate) and the Care Quality Commission (a quality inspectorate), it managed to keep the first cut out of the public eye.

These had to be submitted in June, just as everybody was off on holiday – and then, of course, mightily distracted by Brexit. But it signally failed to keep the second cut quiet. Since the plans were finalised at the end of October, a bunch of councils have broken ranks and put them on their websites.

NHS England didn’t want the plans published until its communications teams had made sure they contained “positive” messages. It didn’t seem to stop and think that councils are not beholden to NHS’ PR-wallahs.

Or that elected councillors wouldn’t be able to live with any suggestion that they were ‘hiding’ or tacitly supporting the closure of local hospitals, which the early STPs tend to propose – or, more accurately, revive, since many have been under ‘threat’ for years.

So, in North West London, the STP has been published with a rider from local councils saying, flat out, that they just don’t agree with hospital rationalisation plans.

Secret – a tag that’s going to stick

The way the plans have come out is unfortunate, because it has established the idea that the STPs have been drawn up in ‘secret’; an idea reinforced this week by the King’s Fund think-tank.

It sent a couple of junior analyst to follow the development of four STPs, and issued a short report full of the kind of wonk-speak that these reports tend to contain about the difficulties of working across organisational boundaries and the need for leadership.

In noting that the fast pace of STP development had left little room for staff or public involvement, however, it left open a gap for a slew of headlines about how “NHS bosses are ‘trying to keep cuts secret’” (BBC) or “NHS cost-cutting plans are ‘kept secret from public and media’” (ITV).

Chief executive Chris Ham must be kicking himself; and has indeed been out and about trying to say that while the process is tough, it’s the NHS’ only hope [Public Finance magazine].

Too late. The ‘secret’ tag will now follow the STPs into every local paper, focus attention on the ‘cuts’ and ‘closures’ elements, and ensure the NHS is firmly on the back-foot when it comes to making the case for them.

This morning, the Guardian duly led its Saturday paper with a story analysing 24 STPs that was headlined “A&E, cancer and maternity units to close in major NHS overhaul.”

“Thousands of hospital beds are set to disappear, pregnant women will face long trips to give birth, and a string of A&E units will be downgraded or even closed altogether, as part of controversial NHS plans to reorganise healthcare in England,” it said; before quoting campaigners on how this would be untenable locally.

Back to the politics of the 1990s

This is an absolute gift to Labour and campaign groups such as 38 Degrees. The first has a ‘national day of action’ on the NHS today, and the second has a big “Save our NHS” petition on its website that claims “the NHS isn’t getting the cash it needs” while  “the government is letting money-hungry private companies carve out profits from treating the sick.”

Expect future reports from Oxfordshire, where former Prime Minister David Cameron’s presence as a constituency MP probably saved the Horton Hospital from an almost inevitable downgrade that is now refloated in its STP proposals.

Also, from South London, where a lot of journalists live close to the Epsom and St Helier hospitals that have been under ‘threat’ for years and are now up for review again as part of an STP plan that says it can afford only three or four of its five hospital sites.

Good in parts; if not enough parts

Whether this kind of coverage really informs the public about what is happening and what is at stake is another question. Because the STPs are about a lot more than ‘cuts’. All of those published so far certainly make heroic assumptions about the level of ‘efficiency’ their local services can come up with in the next four years.

But they also propose to focus on prevention, so fewer people get sick in the first place, and on focusing support on the elderly and those with long-term conditions, so they need fewer trips to hospital.

Some talk about introducing long-overdue digital services to take pressure off GPs and reduce pointless trips to outpatients, and some certainly want to create specialist centres for maternity, A&E or cancer, on the grounds that these will do a better job than the local DGH can manage to do.

At the same time, the growing furore may encourage some trusts to resist their local STP plans. An awful lot are still behaving like there is going to be a hospital bailout – although why is anybody’s guess, since the government has said repeatedly that there won’t be, and it has bigger global issues on its plate.

It will make it harder for those managers that do want to be bold to execute change. And, finally, it will distract aattention from the multi-billion pound question. Will implementing the STPs, if it can be done [my blog post], save the kind of money that the NHS needs to save? And what on earth will happen if not?

The NHS: in an awful place

simon-stevens-at-pac-2-september-2016

It was a shock to switch on Parliament TV the other week to watch Simon Stevens at the public accounts committee, and to see him sporting a substantial beard.

The Health Service Journal says the chief executive of NHS England has been on holiday to the Arctic. If so, it’s tempting to think he’s channelling Captain Scott: “My god, this is an awful place!”

Hard sledding

 NHS finances are certainly in an awful state. As detailed in blog posts below, the health service in England has known that it is facing a growing gap between funding and demand since 2008.

It has been asked to tackle via Sir David Nicholson’s ‘quality, innovation, productivity and prevention’ agenda and, more recently, Stevens’ ‘Five Year Forward View’. This called for more effort on public health and the introduction of new ways of working to help bridge a funding gap now projected to reach £30 billion by 2020-21.

Unfortunately, acute finances went over a cliff last year, with the sector finishing 2015-16 some £2.4 billion in deficit, and the NHS as a whole only making it through in balance by the skin of its teeth (and, ahem, forgetting to mention that it was going to get £750 million than it expected out of National Insurance).

In a financial ‘reset’ in July, trusts were asked to accept ‘control targets’ to try and get the acute deficit down to £250 million this year; but some are holding out, and there’s widespread scepticism about whether the rest can deliver.

Meantime, the ‘Sustainability and Transformation Plans’ that are supposed to help local organisations deliver £15 billion of savings over the next five years are yet to emerge from central vetting.

(The rest of the £30 billion is being closed by £8 billion from the government, most of which will arrive towards the end of this Parliament, and £7 million from cuts to the budgets of the various bodies that oversee and regulate healthcare).

Unhelpful questions

 Unsurprisingly, reputable think-tanks are starting to post blogs asking whether the STP agenda can deliver, and if not whether the NHS is financially ‘sustainable.’ Stevens probably finds these unhelpful.

He certainly didn’t react well to a succession of PAC members asking what would happen if the STPs didn’t deliver, or whether he had a Plan B for that. After all, he won’t want trusts thinking there is an alternative (like a bail out) on the way; because they won’t get into the change agenda if they do.

And he doesn’t want policy makers or the public thinking seriously about failure ; because the local results will be awful, and the national results could include a new ‘debate’ about the future of the NHS as a taxpayer-funded, universal service.

Cancel Christmas

 So, no failure and no plan B. This message was backed up by the NHS ‘to do’ list that Stevens told the PAC would be out some three months earlier than normal, on 22 September, rather than Christmas Eve.

This document, officially the ‘NHS operational planning and contracting guidance 2017-19’ says commissioners and trusts will be expected to get into balance and hit key targets, and that if they miss in the next financial year they will simply have to catch up the year after that.

Oh yes, and there’s to be no moaning about contracting being difficult. And if there is, or if healthcare communities miss their targets, or if they fail to sign up in the first place, they won’t get any of the very small carrot that NHS England has available in the form of a £1.8 billion ‘Sustainability and Transformation Fund’.

Cancel the internal market?

There are lots of interesting aspects to the guidance. It tries to tell trusts that they won’t be able to play off one central body (NHS England, with its control targets) against another (NHS Improvement/Monitor with its operational requirements, or NICE and the CQC, with their expensive treatment and staffing rules).

All these bodies are united, it says, in “supporting” the NHS to deliver the STPs. This is sensible, but suggests the NHS in England is no longer trying to operate anything like the internal market introduced during the Thatcher era.

In its latest incarnation, trusts (regulated by NHS Improvement/Monitor) are supposed to compete for business from clinical commissioning groups and patients (acting on CQC information).

But the guidance not only says these bodies will work to bring some central rigour to the situation, but that in future less attention will be to commissioners and trusts than to STPs. These are starting to emerge as administrative areas and ones in which “co-operation” rather than competition is the order of the day.

To support this, the guidance says that STP areas will be given their own control targets. Subsequently, Stevens said that he would not be adverse to them applying to suspend ‘payment by results’ in order to meet them.

The end of PbR would definitely mean the end of the attempt to get money to ‘follow the patient’ that was at the heart of the internal market. This will cheer many, including the BMA, which has been arguing for some years that the NHS can simply not afford the plethora of organisations required to run it, or the transaction costs.

But the STP areas would be very convenient vehicles for the kind of ‘accountable care organisations’ that some left-wing commentators believe that Stevens, who spent a chunk of his career in the US, wants to introduce to England, in order to “privatise” the NHS.

There is no alternative (well there is…)

It’s worth saying that even if the NHS did move towards and ACO model, it would not have to be operated by insurers. It could be run by the NHS itself, to reward the kind of integrated and preventative care that the STPs are being told to develop.

A shift to insurance would be a political decision, and not one it’s easy to see health secretary Jeremy Hunt signing up for.

Just in case, though, the NHS should really try and make it back to base camp. On which front, Stevens’ message is that the sled dogs are not on the way with more provisions. And there ain’t no map out there except the Forward View.

Analysis: I have been writing analysis pieces on financial and policy issues for the research arm of Digital Health Intelligence (picking up the implications for the healthcare technology market). There’s more on the reset here and the planning guidance here.

Stealth plans to steal records: is care.data back?

 

 

Care.data returns snip for blog post

You can tell when a story is really ‘hot’; lots of media outlets rush to claim it as their own.

Last week, the NHS managers’ magazine, the Health Service Journal, claimed a big ‘exclusive’ on a story that a programme very like care.data was heading for Treasury approval, a few days after the political website, Politico, ran a story about a “stealth plan” to “sell UK patient health data.”

Any moment now, one of the papers will run something similar – keep an eye on The Guardian. Even so, this story was definitely broken by the website I work for, digitalhealth.net; which featured it in its Thursday newsletter on 4 August.

What was care.data?

The story is explosive because care.data was explosive. This was a plan, drawn up by NHS England’s gung-ho national director of patients and information, Tim Kelsey, to expand a dataset known as the Hospital Episode Statistics, and to add more information from other healthcare providers.

All this data was to be ported into a little known body called the Health and Care Information Centre, which would hang onto identifiable patient information, but also prepare it for publication.

The HSCIC was to remove identifiers (such as a patient’s name), from some information and then make this ‘pseudonymised’ data available to researchers and others. Completely anonymised information would be published.

The project went awry when GPs realised they were first up to start supplying identifiable patient information to the new service; and started asking how patients would know this was happening.

In theory, patients can opt-out from having their identifiable data used for anything except ‘direct patient care’, but it was not clear what arrangements would be made for them to opt-out of the new GP dataset.

Then, privacy advocates pointed out that it is possible to reverse the de-identification process; so it might be possible to identify patients from their pseudonymised data, especially if they lived in a remote area, or suffered from a rare condition.

Kelsey and Prime Minister David Cameron made things worse, by suggesting that the pseudonymised data sets might be used by insurers, to adjust premiums, and big pharma to make “every patient a research patient” and boost the UK economy in the process [BBC].

As a media campaign finally got going about the proposal [feature by me], the HSCIC embarked on a cack-handed patient information programme that consisted of a junk-mail leaflet that failed to mention the programme by name or include an opt-out form.

Eventually, the outcry became so much that it was forced to stop the programme. Four ‘pathfinder’ areas were lined up to try out new publicity ideas, but these were halted when health secretary Jeremy Hunt announced that National Data Guardian Dame Fiona Caldicott was going to conduct a review of data security and patient consent.

What has happened now?

Care.data finally seemed to have been killed off when Dame Fiona put out her report. After all, the then-life sciences minister George Freeman announced that the programme would be “closed”.

Digitalhealth.net reported this [news story by me], and so did the limited number of other news organisations that covered Caldicott 3 (most being busy with the final report of the Chilcot Inquiry into the Iraq war that was issued on the same day). However, when we got around to digging a bit deeper, it became obvious that things were less clear-cut.

For a start, we established that the collection of the GP dataset will go ahead. Then, we worked out that the HSCIC, which has since renamed itself NHS Digital, wants to set up something called the Data Services Platform to collect information, hold it securely, de-identify and anonymise it, and release or publish it.

That all sounded very much like care.data [feature by digitalhealth.net]. Admittedly, FAQs on the NHS Digital website talk about the DSP collecting and issuing information for ‘commissioning’ (the planning and purchasing of NHS services, undertaken by NHS management bodies) rather than for researchers or pharma companies.

But there seems nothing to stop the recipients of de-identified data being extended in the future. And there’s another wrinkle.

One of the oddest things about the care.data row was that it managed to make the deeply dull Hospital Episode Statistics controversial; and (because more than a million people did register strong objections to their data being shared for anything other direct care) less complete than they used to be.

In the course of her review, Dame Fiona appears to have been persuaded that this is a bad thing; so bad that data destined for the NHS Digital ‘safe haven’ should not be subject to patient opt-out.

So, if everything goes ahead, people won’t be able to object to their information being included; even though the most eye-catching feature of Dame Fiona’s report was a/two new patient ‘opt-out/s’ from data being used to regulate health services and/or for research.

Are medical records going to be sold by stealth?

When people read headlines about ‘records’ or ‘patient health data’ being sprayed around by the government, they probably imagine that the stories underneath deal with the kind of intimate information held in the ‘Lloyd George’ envelopes of their youth.

That is not, and has never been, what care.data or the DSP have been about. Both are dealing with ‘data items’ or pieces of information extracted from such a record, that can be used to answer questions such as: ‘what kind of person goes to A&E on Saturday’ or ‘is treatment x in hospital more or less effective than treatment y by a GP for people with condition z’.

The ‘pseudonymised’ data to be pushed out of NHS Digital would look even less like a medical record. The idea that this information is going to be ‘sold’ is also over-selling.

The proponents of care.data talked about recovering the costs of data processing; there’s no suggestion that NHS Digital will charge commissioners for the information processed by the DSP.

Even so, it’s a basic principle of data protection that data should only be used for the reason it is collected. Where that data is put to other uses, people should know what those uses are, and have the chance to opt-out if they want.

The NHS seems to think it should be different; it’s not entirely clear why. At the same time, the establishment of the DSP looks set to kill off attempts to de-identify data at source (or to remove patient identifiers before the information destined for the DSP leaves the GP surgery).

This is a shame; as the concerns about the recipients of data being able to reverse engineer it to identify individuals haven’t gone away; even if the government looks set to legislate to increase the current penalties for doing it.

And even if data is not ‘sold’ this does not mean it won’t end up in the hands of private companies. Commissioners already use commercial ‘business intelligence’ services; so it will go to the providers of those services, even if usage is not widened beyond commissioners in future.

So: medical records, no. Sold, not exactly, But stealth, definitely. When digitalhealth.net called NHS Digital about HSJ’s story last week, its press office tried to claim the magazine was confused, that care.data has not been revived and that, indeed, nothing new is happening.

No new data has been collected, it said. NHS Digital already processes information for commissioning. There’s a consultation underway on Dame Fiona’s proposals.

That’s true; but also weaselling. George Freeman claimed care.data was being closed and yet all of its elements are to go ahead; this time without an opt-out for patients. That consultation was launched on the day that Chilcot reported and closes on 7 September, just as the schools go back.

You’d be hard pushed to read it and know what is at stake. Even so, as I argued in our editorial at the start of August, the government was trying to pull a fast one, and it’s been caught out. Which is stupid; because it was a lack of clarity and honesty that got it into so much trouble the last time.

 

 

The perils of the pioneers: or, more reasons to worry as the NHS financial climate gets colder

 

William Hahn - Going Home (Pioneers Braving a Storm)

William Hahn – Going Home (Pioneers Braving a Storm)

So, it’s official. As audit bodies and think-tanks have been predicting for months, hospitals in England have run up a £2.45 billion deficit; the biggest overspend in their history.

And that’s after they sucked up an additional £1 billion of money meant for capital spending, and resorted to what the IPPR think-tank described as “crisis driven” “accounting tricks” to stop the figure going any higher.

It remains to be confirmed whether the Department of Health bust its budget as a whole last year. A recent House of Commons health committee hearing was told that it might have done; but there’s a chance it has managed to squeeze enough money out of central and commissioning bodies to get in under the wire.

In a way, it doesn’t matter. The acute sector has gone over a cliff, with horrible implications for the NHS’ big plans to sort out its finances by doing things in new ways.

Ever more heroic plans  

As set out in several blog posts below, these plans were set out in the ‘Five Year Forward View’ in October 2014.

This called for investment in public health (to try and reduce demand), an efficiency drive, and new ways of working (to make the NHS more efficient at dealing with the demand coming towards it, as the result of an ageing population, more chronic disease, and new treatments).

Together, these were supposed to generate £22 billion of savings; with the government chipping in £8 billion to close a funding gap that might otherwise reach £30 billion by 2020-21.

A briefing for the health committee hearing added some useful detail to these headline figures. It said the Treasury spending review settlement assumed that £7 billion of the £22 billion will be “delivered nationally”; presumably by cutting the budget for the DH and organisations such as NHS England.

That leaves £15 billion to be “delivered locally”, of which £9 billion is supposed to come from “conventional provider productivity”; or from hospitals becoming more ‘efficient’ by squeezing wages, maintenance and supplies and generally “doing more with less.”

To reach this figure, hospitals would have to become 2% more efficient every year. The health committee’s note says the NHS regulator, Monitor [now NHS Improvement] believes this is “stretching but achievable.”

However, as also noted below, most watchdogs and think-tanks believe it is “heroic” at best and la-la land at worst; if only because hospitals have been trying to make these kinds of savings since 2008, when the former chief executive of the NHS, Sir David Nicholson, first sounded the finance alarm.

The fact that hospitals overspent by £2.45 billion in the 12 months running up to the first year of the Forward View suggests that the latter view may be more realistic.

Perils of the pioneers

Meanwhile, after a lot of semi-public haggling with NHS chief executive Simon Stevens, the Treasury agreed to front-load a chunk of its £8 billion to create a ‘Transformation Fund’ to pump-prime the bigger reform ideas.

One of the consequences of the hospital overspend is that almost all of the money in the fund for this year will now go on bailing out the acute sector. Another think-tank, the Nuffield Trust, has estimated that all but £339 million of a £1.8 billion pot will vanish this way.

So there isn’t going to be much cash about to try out all the new ideas that the plethora of ‘vanguards’ and ‘test beds’ are supposed to be setting up. This would be worrying if they were guaranteed to work. But they’re not.

As newspapers and broadcasters focused on the hospital deficit figures, they largely ignored a report that slipped out from the London School of Tropical Medicine’s policy innovation research unit on the ‘integrated care and support pioneers programme.’

The integrated care pioneers were set up by the Lib Dem social care minister, Norman Lamb, in the last Parliament, to test out one of the big ideas in the Forward View.

Specifically, they are testing out the idea that creating health and social care organisations that actually talk to each other and try to provide more ‘seamless’ care for patients will save a lot of money; not least by keeping them out of expensive hospitals by treating them at home or even keeping them well.

Some 14 pioneers were announced in November 2013 and another 11 in January 2015; and the PIU asked them how they were getting along in spring 2014 and summer 2015. Not all that well, was the short answer.

The researchers found their staff really wanted to bring about change, but that they were battling to overcome organisational intertia, IT problems, and the bigger financial situation, which gives hospitals an incentive to suck in patients, because they get paid for treating them.

Indeed, it found a lot of pioneers had already scaled back their ambitions, and were focusing on a much more limited agenda of ‘risk managing’ populations (to try and find the elderly, chronically sick patients who are constantly admitted to A&E because other services are so chaotic) and to ‘case manage’ them (to try and make services a bit more coherent, by putting one person in charge of co-ordinating them).

In a bind, with no easy way out

Taken together, these threads suggest the NHS is in a bind. The acute deficit figures suggest it is just not making the kind of “conventional provider productivity” savings it needs to stay in budget, never mind generate efficiencies of 2% a year.

And the integrated care pioneer report suggests that it’s not managing to change the way it does things in order to make more fundamental savings; even when it’s trying pretty hard to do that (although Norman Lamb thinks the pioneers have been left to wither since the Lib Dems left the coalition).

So where next? The response of most commentators is to say the NHS just needs more money. The amount being spent on the service, as a proportion of GDP, is falling; and it needs to rise again.

Faced with similar deficits, in tattier hospitals, ground down by years of cash releasing efficiency savings, governments have cracked and found more money in the past. So the acute sector may tacitly be assuming that this will happen again.

But with a Conservative government in power that appears to have public support for its austerity agenda, it doesn’t feel wise to bet on it. The Treasury and the DH are certainly sticking to the line that the government has agreed to fund “the NHS’ own plan” and that’s that.

A less common response is to say that the NHS’ traditional attempt to first stabilise the acute sector and then get into the reform agenda is wrong.

Things are so bad that the NHS just needs to get on with the kind of shifts that other service sectors have made (introducing IT to streamline operations, finding cheaper ways to deliver activity, and passing work off to new providers or to users where possible) and to pay for this from real – if very painful – personnel and cash shifts.

The experience of the pioneers is not promising; but it’s possible to argue that if they weren’t separately funded they wouldn’t be able to segue into another form of activity, as the rest of the system desperately tries to prop itself up around them.

All eyes will be on the vanguards, to see if they can manage to pull of this kind of trick. Because the third response put forward by commentators is to give up/introduce insurance/privatise it; and we don’t want to get there.