NHS
Our pressure has led to Devon NHS joining a national retreat from privatising Accountable Care Organisations. However the Devon Integrated Care System will still cap care, with weak democratic control – we need time to rethink
Regular readers will be aware that Devon has been following NHS England’s plan to get Sustainability and Transformation Plans or Partnerships (STPs: Devon’s is the successor to the ‘Success Regime’ which cut our community hospital beds) to ‘evolve’ into Accountable Care Systems (ACSs) which in turn will prepare to establish Accountable Care Organisations (ACOs).
Under ACOs, single organisations could be contracted to provide all services in an area for 10 years or more, and these organisations could – Jeremy Hunt has confirmed this to Sarah Wollaston – just as well be private companies as NHS bodies. So all of Devon’s NHS could have ended up being run by Virgin Care – or a US care conglomerate under Theresa May’s desired trade agreement with Donald Trump.
As recently as December 2017, Dr Tim Burke, Chair of Northern, Eastern and Western (NEW) Devon Clinical Commissioning Group (CCG), endorsed a ‘route map‘ for Devon’s ACS which said that in the ACS, ‘The Accountable Care Delivery System will hold the capitated budget for the population covered’, and that the aim is ‘through bringing budgets together on a whole population and/or model of care basis, [to] provide signals to providers on how to organise. This will signal the number, shape and scope of accountable care organisations and how they will need to work together to deliver.’
Devon backs off ACOs
Devon’s CCGs still want to set up an ACS – now rebranded an Integrated Care System (ICS). However in February they said: ‘A few areas in England are on their way to establishing an Accountable Care Organisation (ACO), where a single organisation is responsible for planning and delivering services to the whole population. This is not being considered in Devon.’
They are not the only ones to back off ACOs – indeed this week Kernow CCG went further and rejected the option of setting up an ICS under the overall control of the Cornwall Council CEO. Instead they voted for S75 partnership agreements for integration of NHS and social care, which have the advantage of being lawful as they’re mandated by the NHS 2006 Act. (Devon County Council already has a partnership agreement with the CCGs.)
Last Wednesday, the CCGs told Devon’s Health and Wellbeing Board that a ‘shadow’ ICS which will operate from 1st April, which they hope to be part of the next wave of formal ICSs to be recognised by NHS England. Within this, they aim to set up one Devon-wide ‘care partnership’ for mental health and four ‘local care partnerships‘ for Northern, Eastern, Southern and Western Devon. These will have boards with local government representatives (district and county councillors) as well as representatives of acute, primary care and mental health providers, and will engage with wider stakeholders such as the voluntary sector.
A victory for legal action and local pressure
It appears the retreat is genuine – and national. A Northumberland County Council Cabinet paper says ‘it now seems clear that no ACOs will be created nationally in the near future, as a result in a shift of national policy.’ It also says, ‘The original plans for the ACO are not now proceeding. Discussions are ongoing with NHS England, NHS Improvement and local system leaders about how organisational relationships might now develop to support the integration of services, however the timetable for and nature of any new arrangements remains unclear.’
I am authoritatively informed that this shift results from the impossibility of new legislation to allow ACOs to be created (a result of the hung parliament!). This is very interesting: it implies that while currently NHS England is still defending the crowdfunded judicial review of its draft ACO contract, it is already recognising that ACOs cannot be introduced in England under present legislation. It seems likely that full ACOs may only happen if the Tories regain a parliamentary majority. We shall have to see how precisely the legal challenge develops, but the retreat is already a significant victory for the legal action – and for the local pressure which I, other councillors and Save Our Hospital Services campaigners have mounted in Devon.
Lack of democracy in the development of the ICS
This leaves us with the proposed Devon ICS – and the undemocratic process of its introduction. A proposal is finally being put to DCC’s Cabinet this Wednesday, but since the Council itself will not meet until after 1st April, the CCGs will introduce the ICS without the approval of DCC, whose logo they have been using to advertise the idea since September. The Health and Adult Care Scrutiny Committee, which is supposed to examine important developments in the local NHS, is only discussing it on 22nd March, nine days before the ICS starts, its chair having disregarded the agreement that a special meeting should be held if the ICS was going ahead on 1st April!
This is the result of the lamentable failure of the Council’s Conservative leadership to bring the proposals to Council over the last 6 months. Would they even have been discussing it now, if I – a backbench councillor from the smallest opposition group – had not put it on the agenda of Health Scrutiny on 25th January? Or would they just have joined it without direct authority, as they did with the STP – after the Council rejected the Success Regime in December 2016, DCC officers (presumably with informal Cabinet authorisation) simply participated in the STP following the general duty of the Council to cooperate with the CCGs as statutory NHS organisations?
Problems with the proposed ICS
- The ICS will be based on capitated funding, which means that Devon NHS patients will be entitled only to the services which the CCGs decide they can have within their financial envelope. This is embedding the existing postcode lottery in the NHS, and another major step away from a universal national service.
- In the current situation, capitated funding is capitated underfunding, and threatens to further embed current dire shortfalls in service – as I pointed out at the last Health Scrutiny, all Devon’s four acute trusts were further away from meeting official targets for A&E, cancer care and routine operations in January 2018 than 12 months previously. Better-off patients will continue to be pushed towards private practice leaving the rest with a second-class NHS.
- The CCGs intend to apply capitation to each of Devon’s four areas, calling it ‘fair funding’ which is really equality of misery. Since Eastern Devon is ‘overfunded’ compared to Western Devon, watch out for a sharper deterioration in the east.
- Since the CCGs intend to apply for formal recognition as an ICS, which will bring them greater local financial flexibility, we need to know how they will use this.
- Commissioning power for all Devon’s NHS will be concentrated in the hands of a single Strategic Commissioner, who will be responsible only to the combined boards of the two CCGs. The CCGs say they don’t want to set up an ‘undemocratic organisation’ – but they are undemocratic organisations, with power concentrated in the hands of a few professional managers and selected doctors, and a single commissioner will concentrate undemocratic power further.
- There is no clarity on how NHS and DCC funding will be combined. There is a danger that adult social care, which is currently run by DCC, will increasingly be taken over by the CCGs, diminishing democratic control.
- Local care partnerships have been a fundamental part of the new system since it was first agreed by the CCGs in September, but despite this no paper has yet been published to elaborate this element, so we are being asked to approve a vague idea.
What needs to happen now
- DCC’s Cabinet cannot approve these proposals at this stage.
- Full proposals – including proper details of the Local Care Partnerships – should go to Health Scrutiny first, and then back to Cabinet at its next meeting, and finally to Council later in the summer.
- We need an explanation of how Devon patients can regain national standards of care while introducing this system.
- Proposals for strengthening democratic control, including the role of DCC and other councils, in the ICS should be brought forward first.
- Meanwhile, DCC officers can cooperate under their existing S75 partnership with the NHS.
- Nothing will be lost by a delay in bringing these proposals to Council, but that will not only enable proper scrutiny by Council, but will also allow the public to join the discussion.
- After Scrutiny and Cabinet have further considered the proposals, DCC and the CCGs should produce a document explaining these developments to the public and invite public debate on them.
As NHS relies more on volunteers, new report shows community car schemes in Devon under severe pressure
The CCGs and hospital trusts like the RD&E are increasingly relying on voluntary community activity to support the NHS. However some existing voluntary services are under severe pressure.
A new report by Tim Lamerton and Jo McDonald for NDVS, Community Car Schemes in Devon: State of the Sector 2018, documents the huge volunteer effort that goes into keeping people without their own cars moving throughout the County – especially to access healthcare. It also underlines a real crisis in this activity, which it estimates saves the NHS some £6.7m per year. These are quotes from the report:
- What had been a valuable and pleasurable activity has become, at times, a stressful, highly skilled environment in which to volunteer, relied upon by passengers who have no other transport choices
- The profile of their passengers is changing. They are older and increasingly frail, often living with multiple conditions. For example, they have reduced mobility and/or memory loss, often causing considerable concern to drivers.
- The drivers are themselves also becoming older and more frail. They report finding the stress and effort involved with helping passengers attend medical appointments, often at busy main hospitals, is increasing to almost intolerable levels.
- Job satisfaction managing schemes is reducing due to increased work-related stress.
- Some schemes are also finding it increasingly difficult and time consuming to recruit volunteers; removing the sense of personal fulfilment and fun from being a driver is making this much more difficult.
- Funding to a number of schemes across Devon has been reduced or cut by the CCGs with little or no notice. At least one surgery based scheme has been forced to close, putting immediate pressure on other providers on the area. Managers of schemes are finding such lack of consultation, and of investment, increasingly frustrating.
- Schemes are also reporting a rising expectation amongst hospital staff that they can provide an increasing range of services at very little notice. They report that many NHS staff appear to have no knowledge of the role, purpose or motivations of car schemes and do not understand that they are not there to provide an immediate, on demand, taxi service.
Important community conversation on health and wellbeing in Seaton and area to begin on 23rd March
Sarah Reeves of Action East Devon is coordinating this event, which follows Honiton’s Health Matters which launched last month (the follow-up meeting in Honiton is on 6th March). I am happy to provide further information if you contact me.
Seaton and Area Health Matters – Going Forward Together
Friday 23rd March 2018 – Seaton Town Hall
9.00 for 9.30 am start – 1.00pm
Book here: https://goo.gl/forms/7laMUjhByt8F0w053 (right click on link to open booking form)
You are invited to participate in this community led event with key stakeholders around the future health and wellbeing of all the people in our communities, in response to the new landscape affecting Seaton and surrounding area as a result of NHS and Government policies advocating Place-Based Care in health provision and cross-sector collaborative working with community groups
The aim: To discuss what we know, where there are gaps/challenges and how, as a community we will address these to ensure collaborative approaches to co-design and co-produce local health services/activities that meet the needs of all the people in our communities.
Invitees: Management and senior level employees and volunteers / trustees from community, voluntary and social enterprise sector as well as public and private organisations.
Area to include: Seaton, Colyford & Colyton, Beer, Axmouth, Branscombe
PROGRAMME:
Welcome: Mayor of Seaton – Cllr Jack Rowland
Community Context:
- Dr Mark Welland – Chairman of Seaton & District Hospital League of Friends
- Roger Trapani – Community Representative, Devon Health and Care Forum
- Charlotte Hanson – Chief Officer, Action East Devon
Strategic and Services Overview – Place Based Care:
- Laura Waterton – Royal Devon and Exeter NHS Foundation Trust
- Richard Anderson – Health and Social Care Community Services Manager
- Dr Jennie Button – Social Prescribing Lead – Ways 2 Wellbeing project in Seaton
Workshop, Networking and Discussion will form the main part of this event:
- Workshop 1 – What is working well and what are the challenges for Seaton and surrounding area?
- Workshop 2 – Working together to improve health and wellbeing outcomes? What support do we need?
County Council Cabinet member says of NHS changes, ‘What we’re not going for in Devon is an Accountable Care Organisation’ – but can we take this assurance at face value?
At Devon County Council yesterday, I asked Cllr Andrew Leadbetter, Cabinet Member for Adult Care and Health, whether the Devon Accountable Care System (ACS) (which is being renamed the Integrated Care System!) is still due to start on April 1st. He replied that ‘What we’re not going for in Devon is an Accountable Care Organisation’ – only an Accountable Care System.
He said that the 1st April date was the one ‘on which the two CCGs [NEW Devon and South Devon & Torbay] are going to merge’ and that the ACS already existed in all but name. ‘It’s their plans, they don’t actually need our permission to go ahead with it’, he added – although DCC is ‘in partnership with them’. He didn’t answer Cllr Brian Greenslade’s point that DCC had glossed over it in a recent spotlight review.
You can WATCH THE EXCHANGES BY CLICKING HERE AND FORWARDING TO 2:57.
However I think there’s a confusion in Cllr Leadbetter’s response and in the joint statement with the CCGs which he issued as a written report at the meeting and previously emailed to councillors:
- No one has said that the Devon CCGs, through the Sustainability and Transformation Plan (STP), are currently introducing an Accountable Organisation (ACO), the new form of long-term NHS provider contract which has been developed by NHS England, could hand over large chunks of the NHS to private including American companies – and will shortly be judicially reviewed.
- However according to the CCGs, Phase 1 of the Accountable Care System in 2018-19 will develop an ‘integrated delivery system for Devon’ with a ‘single strategic commissioner’.
- And according to the report Designing the commissioning system in an accountable care environment: A route map for Sustainability and Transformation Partnerships which describes how the Devon STP has been working – and which Dr Tim Burke, Chair of NEW Devon CCG says is the ‘route map’ for the accountable care system – this integrated system is designed to lay the basis for Accountable Care Organisations.
- On page 18, the report says that the integrated delivery system, ‘Through bringing budgets together on a whole population and/or model of care basis, [will] provide signals to providers on how to organise. This will signal the number, shape and scope of accountable care organisations and how they will need to work together to deliver.’
SO – Cllr Leadbetter is right, the emerging ACS is not an ACO. But the ACS is designed to lead to the setting up of ACOs.
Unless, of course, they have changed their mind. Is the route map still the route map – or not? This is the question that the CCGs and Cllr Leadbetter need to answer, before his ‘assurances’ can be considered meaningful. As he mentioned yesterday, I and other councillors will be meeting with him and the CCGs to discuss these issues further.
(Other noteworthy point:
NOTE FOR BAFFLED READERS: I know this is an incredibly complicated subject, not helped by their tendency to change the name of what we’re talking about as soon as objections are raised – as though that makes it better! If you’re confused – you’re not alone. However it MATTERS A LOT to the future of the NHS. Read this report explaining the issues, which I submitted to the Health Scrutiny Committee last month.
FORCE cancer charity funds chemotherapy first in Okehampton – this is exactly the kind of service we need in Seaton
Encouraging news – the RD&E and FORCE have agreed that the cancer charity will deliver chemotherapy to patients in Okehampton Community Hospital.
The RD&E press release also says ‘It is hoped that the service will also be offered at a third location in East Devon later this year.’
We have an active local fund-raising group for FORCE – I was at a well-attended coffee morning in Colyton Town Hall three months ago – and this is exactly the kind of service that we would benefit from in the wider Seaton area, with our elderly population. This is the kind of thing we need to discuss in the community conversation on health matters which will take place in March, and I very much hope FORCE will be able to come.
The press release adds:
The charity began funding a pilot outreach chemotherapy project at Tiverton Hospital in July. The feedback from patients and nursing staff has been so positive that it is being rolled out as quickly as possible in Okehampton.
The benefits to patients include:
- Treatment closer to home so less travelling time and expense
- Easier parking
- Quieter location and treatment area
- Reduced waiting time for treatment, both in Okehampton and Exeter
- Experienced oncology staff from the hospital to deliver treatment
- Access to additional FORCE services to support you and your family
Devon looking for care and support workers – new campaign
Go to http://www.devonlive.com/special-features/devon-looking-care-support-workers-1115792
Care at home – ‘When GPs ring the single point of access number asking for rapid response or night sitting, the carers are not available. This is partly due to lack of resources and partly due to difficulty with recruitment.’
Claire Wright’s blog gives the speech made by Dr Mike Slot at Health Scrutiny: “If community hospital beds was intended to be offset by increasing the capacity of community care so that patients could be cared for in their own homes. This may or may not have been realistic since many of the patients in the hospital system cannot be managed in the community even with excellent community services.
However, with or without community hospital beds it is an excellent idea to expand community services so that all those patients who can be cared for out of hospital can remain at home. Unfortunately there is not sufficient capacity in the home care services to do this job.
When GPs ring the single point of access number asking for rapid response or night sitting, the carers are not available. This is partly due to lack of resources and partly due to difficulty with recruitment. I suspect that part of the difficulty with recruitment may be due to the terms and conditions. If the carers only get paid if they are required then this may not be particularly attractive.
We understand that a hospital only functions well with a maximum of 85% bed occupancy, and similarly with the home care service we need to accept that there will be some unused capacity otherwise the service is never able to accept unexpected cases. Thus we need to allocate enough resource so that we can offer both an attractive rate of pay and attractive terms and conditions.
This is in fact an essential part of the answer to the problem the entire NHS is experiencing. If the level of water in a reservoir is steadily rising and then overflows, you can either try and build the banks higher in which case it will just overflow a bit later, or you can look at the streams going in and going out of it.
Similarly when you see an overflowing A&E or hospital you can buy more A&E or acute beds (very expensive) or you can increase community capacity to prevent people going in and facilitate people coming out (relatively much cheaper but you still have to pay a proper rate for it).”
Health Scrutiny hears there will be no precipitate decisions on community hospitals – local conversations with CCG and RD&E offer chance to shape ‘place-based health systems’ around towns
In my third and final report from yesterday’s Health Scrutiny, I come to the report on the future of the hospitals by NEW Devon CCG and NHS Property Services, in response to the Committee’s request for clarification. (This arose from my presentations at the September and November meetings). While NHS PS stressed that in principle they will eventually have to charge market rents, Claire Wright elicited the useful information that currently NHS England are still paying for the buildings, and the company said they are ‘always happy to work with local communities to consider local services’. Scrutiny’s resolution requested that NHS PS ‘uphold this undertaking’ and keeps the Committee informed on the timeline for changes in the status of the hospitals.
The CCG’s Sonja Manton confirmed that the community conversations the CCG and RD&E are now promoting to develop ‘place-based systems‘ around ‘market towns’ – which have already begun in Honiton and Okehampton – can certainly include the services people want to have delivered locally in the hospitals. While there are cost constraints and not everything which people want will necessarily be delivered, local communities can certainly discuss these services with the NHS organisations, as well as how voluntary organisations can help the NHS and adult social care. Okehampton’s Conservative county councillor, Kevin Ball (below front left, with Non-Aligned Group leader Frank Biederman behind), stressed the progress his community had made in the recent meeting in the town. He and Okehampton’s mayor, Jan Goffey, mentioned that FORCE Chemotherapy will soon be opening a service in the hospital.
In my speech (1:34:20) I welcomed the new ‘place-based’ focus and stressed the importance for towns like Seaton – which is 45 minutes to an hour from acute hospitals – of using the free space in the community hospital to deliver routine treatments and operations for which people currently have to go to Exeter. I pointed out that constituents complain to me all the time about the stress, strain and cost of repeated travelling, often when unwell, without parking, park-and-ride space or bus services – while Exeter complains of congestion!
I mentioned the request of the RD&E’s Em Wilkinson-Bryce, in Honiton last week, for the community to trust the NHS organisations, and said that a serious conversation about local services – in which the NHS takes on board what people want – would be the best way to create this. We wanted to keep the beds, but now they are gone proper ‘place-based’ strategies for each of our towns offer the prospect of working together with the NHS. Preparations are underway for a meeting similar to ‘Honiton’s Health Matters’ in Seaton in March, and I will give more information as soon as the date is fixed.
Devon’s health system’s declining performance over last 12 months – and Health Scrutiny still waiting for winter crisis evidence
At yesterday’s Health Scrutiny Committee, I presented evidence (at 2:10:45) of an across-the-board decline in performance by Devon’s four NHS trusts against 3 key national targets, over the last 12 months.
Devon’s A&E departments are slipping back against the target of 95 per cent of patients to be seen within 4 hours (as we were meeting the average waiting time in Wonford according to the ironically named NHS Quicker app was 5 hours 13 minutes). The hospitals are slipping back against the target of treating 85 per cent of cancer patients within 62 days of urgent referral by a GP – our trusts average between 75 and 80 per cent and one trust, Northern Devon, is seeing 17 per cent fewer within the target than a year ago . And they are further from meeting the target of carrying out 92 per cent of routine operations within 18 weeks – and this was before ‘elective admissions’ were ‘deprioritised’ (in the language of the report) in January. Similarly, it appeared that the SW Ambulance Service was getting to a smaller proportion of the most urgent calls within target.
My comments were a corrective to an over-optimistic report by the CCGs and the County Councils’ social care team, which stressed the halving of Delayed Transfers of Care from hospital (bed-blocking). While this is very welcome, it is less important to most patients’ experiences than the 3 main indicators which the NHS itself has chosen to measure its performance against. The delays in cancer treatment (which the report didn’t even mention) are particularly scandalous – they will cost lives.
Elsewhere on this item, Claire Wright made a valiant attempt to get information about the winter crisis in Devon from the CCG (and earlier from the Ambulance Service). She was promised that evidence would shortly be provided to the committee.
| PERFORMANCE AGAINST KEY TARGETS OVER LAST 12 MONTHS | ROYAL DEVON & EXETER | TORBAY & SOUTH DEVON | N DEVON | PLYMOUTH | England average |
| A&E Target: 95% treated or admitted in 4 hours. | 87.2% (-5) | 88.3 (-1.7) | 88.5 (-6.1) | 79.3 (-4.8) |
85.1 |
| CANCER CARE Target: 85% begin treatment within 62 days of urgent GP referral | 80.4 (-2.9) | 77.3 (-16.9) | 75.3 (-12.9) | 78.5 (+1.7) |
82.5 |
| PLANNED OPS Target: 92% waiting less than 18 weeks | 88.4 (-3.2) | 83.7 (-5.3) | N/A | 82.4 (-2.6) |
89.5 |
Seaton & Colyton MATTERS 