This was the theme elaborated by Dr Julia Simon, former NHS high-flyer, when she addressed a packed and lively BPV public meeting last Thursday 1st December at the Learie Constantine Centre, NW10.
BPV Chair, Robin Sharp, explained that big changes to the way in which GPs relate to their patients were hidden away in the recently published NW London NHS Sustainability and Transformation Plan (STP). Essentially the Plan was about cutting £1.4billion from local health and social care service over the 5 years up to 2021, including previously announced proposals to “reconfigure” hospitals and cut beds. What was new was the plan to turn GPs from being a “cottage industry” to the brave new world of “Accountable Care Partnerships”.
Dr Simon told us she was not a medical doctor but had been a philosopher before moving into the healthcare world. For several years up to last September she was a senior leader at NHS England, working on primary care and commissioning issues. She had left to be able to break out of some of the constraints that being at NHSE imposed, not least in relation to the speed at which the STPs were being imposed across the country and the realism of some of the claimed financial figures.
Striding around the room like a university lecturer, Dr Simon captivated her audience with the clarity and honesty of her presentation. She said that in the 90s the idea of a market had been introduced into the NHS to drive up standards. This involved creating a division between “commissioners”, who worked out what was needed and paid for it, and “providers” such as hospitals and GPs who delivered it. The trouble was that under the NHS healthcare was not a market because it could not be allowed to fail.
In 2012 Parliament enacted the Health and Social Care Act, the brainchild of Andrew Lansley, whose wife was a GP. This put local GPs into 209 local Clinical Commissioning Groups to be in charge of designing and paying for about two-thirds of the health care provided by hospitals and in the community. The downside was enormous fragmentation because NHSE became commissioners for specialist services and local authorities for public health. In addition local authorities remained responsible for adult social care, which was means-tested, whereas healthcare was free at the point of delivery.
This was the context into which the new chief of NHSE, Simon Stevens, launched his plan for the future in 2014, the “Five Year Forward View”. As well as accepting that the NHS could make £22billion “efficiency savings” by 2021, this plan called for integration between GPs, hospitals and adult social care. All parties, medical bodies and commentators signed up to it without apparent reservation.
Then in December 2015 the annual Planning Guidance from NHSE to the CCGs and hospital trusts announced that implementation of the Forward View was much too slow and current trust deficits were “unsustainable”. The CCGs and trusts were grouped into 44 areas (Footprints) across England and required, working with local authorities, to produce STPs by 30 June 2016 to eliminate deficits and implement “transformation” over a 5 year period.
Meanwhile various experiments in new forms of integrating services locally had been launched under the brand of “Vanguards”. As Dr Simon explained these are still in progress and there are no evaluations. “The jury is out on the Vanguards”, she said.
The Vanguards include integrated primary and acute care systems, as well as multi-speciality community providers. The first of these embraces Accountable Care Partnerships (ACPs). Dr Simon spelled out some of the features of ACPs. These envisage a fixed budget for each patient (capitated budget), an emphasis on self-care and prevention leading to fewer hospital admissions and merging the boundaries between commissioners and providers. New legislation might be needed and there were some perverse incentives in the present system.
To conclude Julia Simon said that, while she was convinced that new approaches to organising the NHS and delivering care were needed the STPs had been produced in semi-secrecy and much too fast. Moreover the savings being suggested were not really credible. She likened the situation to George Orwell’s “1984” where officials state in public numbers that in private they admit are impossible. However she saw some signs that the top of the NHS would soon announce a delay enabling more serious public consultation.
Julia was congratulated by an audience member on delivering the most informative address he had ever heard from an NHS person. There was general support for this sentiment.
Her presentation was followed up by some 40 minutes of questioning and passionate statements of concern, especially at the unacceptability of the STP for NW London. Noting that Ealing and Hammersmith and Fulham Councils had refused to sign up to the Plan, audience members wanted to know what more could be done to persuade elected councillors in Brent and other boroughs not to endorse it.
Robin Sharp
Chair Brent Patient Voice