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.
The consultants’ report to go to EDDC is now available here. It’s extremely long, informative and thorough, and my first reaction is that we need to press EDDC to adopt the recommendations and – where necessary – look hard for funding so that more of this agenda can be carried out, to top up the relatively modest statutory funding. There are some ‘wish list’ items which are not included – like the extension of the West Walk to Seaton Hole, which was costed at £4m – but all the items in the list below are things which really must be addressed.
Upgrade concrete encased revetment at Seaton Hole.
Maintain ‘old and new’ revetment at Seaton Hole / Old Beer Road
Extend ‘new’ revetment at ‘The Pillar’.
Upgrade Check House wall.
Maintain West Walk Promenade including concrete / stone blockwork.
Do Nothing: Seaton spit, and consult with SMP (Shoreline Management Plan) group to guide future management of the landward side of the spit
New defences west bank Axe Estuary.
Consider whether to undertake beach recycling, guided by ongoing monitoring, consultation with SMP group and new study
Cliff drainage measures. EDDC to investigate suitable options for cliff‐top drainage (that are agreeable environmentally and affordable), and for EDDC to identify a funding stream for this erosion risk management activity. A study into surface water flows on the cliff‐top would also be required in support.
Works to address undermining of Seaton Hole outfall.
Assessment of pathway along concrete encased revetment at Seaton Hole.
Address issue of pollution of beach at Old Beer Road. To be informed by an investigation and if relevant, development of suitable options.
More monitoring, extended to Beer
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
Welcome: Mayor of Seaton – Cllr Jack Rowland
- 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?
Pay more and more council tax for fewer and fewer services – Devon Conservatives’ inspiring record of managing the County Council’s decline reaches a new low
My last post but not least on yesterdays County Council meeting – it approved the budget and set an increase in Council Tax of 4.99 per cent.
As my Independent colleague Cllr Claire Wright explained in her speech, health visitors, funding for foster care, the schools counselling service, among others are to be cut, cut, cut – while an extra £5m is stashed away in reserves (because of the unreliability of the Government’s new wheeze of letting councils keep business rates as a partial substitute for central funding).
I pointed out that – while we all want to protect spending on the young, elderly and disabled – another year of huge rises in Council Tax (making 14 per cent in the last 3 years) will hit hard those managing on modest incomes.
As a colleague pointed out, Council Tax is an unfair tax and the way in which the Government is loading social care costs on to it is a disgrace.
I said you’d have thought that it would be good for Devon to have the same party running its council which runs the national government. Actually it’s the opposite – the Tory Government takes advantage of the Devon Tories’ slavish loyalty, and the Devon Tories let them get away with it.
YOU CAN WATCH MY SPEECH BY CLICKING HERE AND FAST-FORWARDING TO 1:56.
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.
Devon’s Conservative leader blocks pro-Europe rally being held in County Hall grounds – Tory councillor says protest is not the way to do things
Whether or not you agree with Devon for Europe (D4E) it is worrying that Devon County Council leader, Cllr John Hart, refused a request for the campaign group to hold a rally in the County Hall grounds because he didn’t think it was appropriate for a political rally to be held there.
County officers had told the D4E there were all sorts of practical reasons why the rally would cause difficulties for the Council. D4E had approached me to help and I was surprised that the Council hadn’t discussed the reasons with them – I thought the issues should be possible to negotiate.
However at yesterday’s Council, after I put the decision on the agenda, Cllr Hart gave the game away, and fellow-Conservative Cllr Christine Channon backed him up by saying protest wasn’t the way do things. Cllr Channon – who voted Remain but thinks now that we should let the Government get on with its negotiations without making our views known to them – may not want to protest, but many do and it is their right to do so. WATCH THE DEBATE – FORWARD TO 2:45 FOR THIS EXCHANGE.
Councils control most of the public space where a fairly large number of people could assemble. So they should go out of their way to facilitate peaceful protest even at the cost of a bit of inconvenience. It is essential for democracy that peaceful protest and assembly – including by people we disagree with – should be able to take place!