MEETING ON STPs AT LONDON CITY HALL Meeting attended 2016-10-31

To the impressive City Hall Building next to Tower Bridge with a beautiful night time view of the latter and the Tower of London looking surprisingly diminutive with the surrounding modern office blocks. The following is a reasonable reflection of what was said by the speakers and from the floor. I have only identified the speakers and what they formerly said all other points from speakers and floor are anonymised.

The meeting was organised by Dr Gary Marlowe Chair of BMA London Regional Council.  The assembled speakers were to give their views on the Sustainability Transformation Plans – STP’s for short. I have previously blogged on this (see blog dated seven months ago and other times). The nuances of STPs were detailed in December 2015 in which 44 footprints covering approximately 1.4 million people in each footprint. Gary detailed the four aims and the fact that the final plans  had to be presented to NHS England by October 21st. Gary pointed out that all STP leads had been appointed though he queried how these appointments had taken place and how the decisions are being made. Would the providers just sign off  the decisions made by the STP ? It has been estimated that the total additional management costs for the 44 STP’s is around £132 million. There is also appears to be a lack of Public Patient participation. Gary mentioned the System Control Total. ( JF- for those interested I refer you to for more details https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/506565/STF_FAQ_-_9_march_FINAL.pdf  )

Funding extra for 2019-2020 is £2.1 billion and for 2020-2021 £3.4 billion is available for transitional funding,  but the Trusts must be in balance for 2016-17 and after it is used for bailing out Trusts only £340 million is likely to be available for transfer. The majority of money is probably going to the deficits of the Trusts. Gary then introduced four speakers

  • MARK EAST

Mark East is Program Director of South East London STP. He has worked for 18 months in South East London and his views were based on SE London only. He identified major challenges as 1) Financial 2) Social Services 3) Workforce issues 4) More care in the community 5) Mental Health. Clinical leadership he said is essential and that there needed to be a plan,  one that is owned by the health and social care system. There had been a shared view of the problems that South East London faces; since 2013 with “Our Health in South East London”. This has involved Clinicians and the public. This view has been imported in their STP. The STP is led by a Provider Lead and Clinical Executive. The STP addresses provider productivity between groups and looking at specialist services by looking at a number of strands, which he expanded on.

Strand I Improve primary and secondary care, making it more accessible. GP booking would be 7/7 from 7 am to 7 pm. Using a GP network system will extend primary care to populations of 50 000

Strand II  There are 8 clinical groups. In Orthopaedics Tim Briggs has shown an up to 10x variability in prosthesis infection rate, and litigation. There is likely to be 2 sites for Orthopaedics rather than 7. Consultation begins next month.

Strand III Specialist services cost £ 850 million per annum in SE London with overlaps and duplication. There is a need to improve quality and inefficiencies.  There will be a consultation at some point, he said.

Strand IV There is need to reduce costs with significant differences in agency costs. Two out of three hospitals have one pathology system.  Six accounts departments and 500 different buildings need to be addressed.

In response to criticism of STP’s being secretive SE London he says has had 2000 citizens contributing over 3 years. The web site gives a summary of what is going on. Reconfiguration is in the public interest and they will adopt coherent accounts. The STP proposal should be passed on Friday for SE London.  Notwithstanding todays Daily Telegraph article he said that all A&E departments will remain in his area, and in 5 years the same number of hospital beds and same number of staff will exist..

  • David Grantham

HR Director Royal Free Hospital Group

North Central London needs £876 million savings over 5 years. He said there are significant challenges to the workforce. The supply and affordability of the workforce is compounded by vacancies. There are 10,000 vacancies across London. For Nurses 8.6% are leaving the profession annually. There is a recruitment of 9.6 % ie just a 1% growth.. The STP can help in collaborations to develop staff . Over the time salaries have gone up 3.8% whilst transport cost have gone up 25%. Rents have gone up 35%. Staff are living further away from their place of work. There are shortages in Emergency Departments, Geriatrics and the turnover of staff in London is 17%. Often staff are trained in London and go to work elsewhere. The workforce needs to be adaptable. The new millennium workforce are different wanting flexible working and good IT. There is a perception of staff not being engaged. There are some equality issues peculiar to London. High quality leadership cannot be thinly spread.  There are Issues of workforce productivity with a need to adopt and spreading best practice. Funding challenges with the workforce and STP may help in collaboration. Trying to help mobility in the workforce includes to standardized transfer of mandatory training. This has saved an estimated £20 million in London. For GP trainees they are now under one Trust in London (RFH). Some are not getting enough training a collaborative training development program has to be developed. Trusts need to share sovereignty. There has to be a change of pace , to be attractive to EU graduates and IMG etc. Organisation and system bureaucracy  – culture change, open and collaborative across separate organisations

  • Colin Leys

Colin Leys is an honorary professor at Goldsmiths University of London. He is the author of Market-Driven Politics: Neoliberal Democracy and the Public Interest  and, with Stewart Player, The Plot Against the NHS. He is a member of the management team of the Centre for Health and the Public Interest

The view if the CHPI can be found in detail at https://chpi.org.uk/wp/wp-content/uploads/2016/07/Sustainability-and-Transformation-Fund-.pdf

And https://chpi.org.uk/wp/wp-content/uploads/2016/05/CHPI-STP-Analysis.pdf

Colin gave a presentation saying the Five year forward plan abandons the principles of the Health and Social Care Act which was causing disintegration by competition. The Act is now being worked around. Integration goes against previous Competition Commission rulings which are not now being mentioned. The law is one thing , practice another. But reorganisation is through “informal channels and the emerged “teams” that have no legal basis. In a written question in the House of Commons  “ what the legal status is of the changes to health and social care proposed in Sustainability and Transformation Plans ?” George Freeman answered on 13th  June 2016 with the following

“The Sustainability and Transformation Plans (STP) has no legal basis. Any plans submitted will be proposals that will form the basis for discussion. Depending on the level of local and national agreement, they may form the basis for further plans and actions that will be subject to the same legal and best practice requirements that govern the National Health Service. The local, statutory architecture for health and care remains, as do the existing accountabilities for Chief Executives of provider organisations and Accountable Officers of clinical commissioning groups. Organisations are still accountable for their individual organisational plans, which should form part of the first year of their footprint’s STP.The June STP submissions will be work-in-progress, and as such we do not anticipate the requirement for formal approval from boards and/or consultation at this early stage. Plans have no status until they are agreed. When plans are ready, normal rules around engagement and public consultation will apply.”    Hansard 2016

See  http://www.parliament.uk/written-questions-answers-statements/written-question/commons/2016-06-07/39771

The planning is informal, Colin continued. The Secretary of state is not now answerable for Health. There is no accountability and the outcomes are likely to be poor policy. To  maintain  services  of  the  same  quality  as  in  the  past,  by  2020/21  the  NHS  in  England  would  need  £30bn  a  year  more  than  the  government  was  planning  to  give  it.  In  November  last  year  Stevens  got  Mr  Osborne  to  agree  to  provide  £8bn  of  the  £30bn  a  year  needed  by  2020/21,  with  some  of  the  increase  coming  early  enough  to  cover  the  cost  of  adopting  the  ‘new  models  of  care’  on  which  the  hoped for  productivity  improvements  depend,  and  which  are  currently  being    trialed  at  50  ‘vanguard’  sites  around  England. The “Models of Care” of the Five Year Forward View have some sensible models but require “knocking heads together. All examples are that, examples with no critical analysis given and some of these models of care are a “leap of faith”. In the end it is all about funding. Each footprint must save at least £450 million by 2021. To earn access the “Transformation” funding (the only additional funds available)  CCGs  and  providers  must cut  their  expenditure  and  stay  within  their  budgets  in  2016/17. . This will allow providers to make  changes  to  service  delivery  while  ‘maintaining  and  improving’  patient  safety  and  quality  over  the  years  2017-21.

Local councils are more jumpy. What are the planning solutions to closing the gap and what does it mean for patients ? In North East London the consultation is not widespread. Are the plans realistic? North East London has had a plan “Transforming Services Together”. Problems include in the area around Barts  a 28% turnover of residents.

See http://www.transformingservices.org.uk/.

In North East London there are planned cuts to the number of GPs from 600 to 400 with an increase in number of pharmacists and nurses. By 2025 there will be an additional 38 physician assistants, 106 pharmacists, 238  more nurses and 130 more administrators. What is at stake is the process.

  • Dr Onkar Sahota

Dr Onkar Sahota is Chair of the Health Committee (see https://www.london.gov.uk/people/assembly/dr-onkar-sahota/more-about for his biography) and elected GLA member for Ealing and Hillingdon. He is also a practicing GP. He said in his area “Shaping a Healthier Future” is the program to reshape hospital and out of hospital health and care services in North West London. North West London has a growing and ageing population, and at present, specialist care is too thinly spread over too many sites and some facilities are said to be inadequate see https://www.england.nhs.uk/london/2015/11/09/healthier-future/. He showed concern in particular for Healthcare in North West London (see interview https://leftfootforward.org/2015/02/hospital-closures-are-an-experiment-with-human-life-interview-with-dr-onkar-sahota/. GP’s are taking early retirement. There is no investment in primary care. There is low morale and staff shortages. We are a profession disconnected from our leadership. His view was the STP’s lacks leadership and there is a democratic deficit. The STP has not been signed off by Ealing. According to the government this is Clinically lead but is it ? There is a need for greater honesty engage with patients, engage with community.

Before asking for questions from the floor LRC Chair informed us of a BMA survey on the lack of understanding or involvement by Consultants and GPs in the London Region. He also pointed out he had tried to get a representative of NHS England to attend to no avail. There were a large number of questions and statemenst from the 80 or so people present. I will avoid attributing.

NB by JF All the points minuted below are up for debate and are not necessarily a statement of fact.

Summary of Points made after the presentations

The Health and Social Care Act is a disaster a mess on top of another. The STPs are an attempt to reverse the workings of the Health and Social Care Act and making the best of an awful situation.

NHSE and DoH say “local decisions are being made locally”. What it amounts to is almost £0.5 billion in cuts per footprint. The STP will shape policy but it would be better to have additional funding up front to implement the changes. Transformation will not take place if there is no capital to make the change.

STP’s can be for challenged. STP’s are “democratically deficient” . NHS Leaders should be honest and admit this will result in unsafe healthcare.

What is the evidence basis for the changes ?  Costings appear non-existent.   Savings estimates come out of the air.  The re-organisation should be done with the best qualified not “cooked up” in six months by someone with an MBA. A view from the floor was that no one in NHS Improvement thought STP would balance the books and it was a façade. The regulatory systems “are aware how bad it is” but the control of health issues is no longer with the Department of Health it is a Treasury issue. There is no point being an Economist at the Department of Health. Buying out PPI will not happen.

There is a need to stop the increase in activity which is very difficult. There is not enough money in the system and a 4.1% financial challenge in primary and secondary care. Hospital usage is to be cut by 20%. There is a risk of hospital and A&E closures. Todays (31/10) Telegraph article suggests 1/3rd of STP plans involve closure of A&Es.

(JF see http://www.telegraph.co.uk/news/2016/10/30/almost-half-of-nhs-authorities-to-cut-hospital-beds-and-third-to/)

North West London has lost 2 emergency department 1 Paediatric and 1 Maternity. There was no accountability for the closures. Souhall, Acton and Harlow are suffering whilst central hospital in Paddington and Chelsea and Westminster expand.

For STPs to work there was need for better Social Care but their budgets are being cut over the next 5 years. Social Care has a 20% challenge.

Alternative names for STP included Sticky Toffee Pudding (?) and Secret Tory Plan (to privatise). Some were vociferous that the latter was the main aim of the 5YF Plan. Contracts with private providers are said to be being signed by December 23rd for two year duration. In North Central London one floor speaker suggested 500 beds would be closed.

Pilots have shown there is not a demand for 8 am to 8pm General practices. There needs to be collaboration at GP level. Work force flexibility should include Junior Doctors rotating around practices.

The Obstetric and Gynaecology workforce is undervalued and “on its knees”. The attrition rate in O&G is the highest it has ever been. It has become a situation of “them and us”. O&G trainees are saying things are wrong from patient care. Because of rota gaps O&G Consultants are having to step in. There was a plea from the floor not to undervalue or destroy the morale of Doctors Midwives and Nurses.

The Royal College of Nurses (it is said) have little positive to say and are hostile to STP’s . There has been nothing from the Royal Colleges which was puzzling to one of the speakers. They appear cowed.

Is it making the best of a bad situation or opposing STP ?

Health services are being dismantled and there should be a campaign to keep our NHS public. Patients and staff will suffer. Patients need to understand and told what is going on.

The meeting concluded that the BMA should present a stronger position and passed the Motion :-

This meeting “Calls on the BMA to advise CCGs not to cooperate with STPs.”

 

For those interested in North Central London details of the North Central London Joint Health Overview and Scrutiny Committee can be found at

http://www.minutes.haringey.gov.uk/mgCommitteeDetails.aspx?ID=697

STP

http://www.camden.gov.uk/ccm/cms-service/stream/asset/?asset_id=3508165&

 

News items on STP

31st October BMA news

https://www.bma.org.uk/news/2016/october/mps-urge-govt-to-boost-nhs-funding

25th October BMA news

https://www.bma.org.uk/news/2016/october/stps-consultation-process-inadequate-conference-told

21st September Dianne Abbott

http://www.dianeabbott.org.uk/news/articles/news.aspx?p=1021263

 

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