The plans may still be fantasy: but NHS cuts are starting to get realSunday 14th August 2016
Theresa May's government is stepping up George Osborne's programme of relentless real-terms reductions to NHS spending, to reverse Labour's decade of expansion. And NHS chiefs are raising the pressure on hospital trusts, GPs and Clinical Commissioning Groups, demanding concrete plans for cuts to tackle monster deficits.
The Health & Social Care Act of 2012 made clear that the Secretary of State has no duty to provide health services: so the cuts and privatisation that are taking shape are being done by 'remote control', through Simon Stevens and NHS England, under the approving eye of Jeremy Hunt.
This is why since Christmas Stevens and NHS England have carved England into 44 "Footprint" areas in which the "local health economy" of NHS trusts, CCGs and local authorities are required to work together rather than compete.
However this is no enlightened reintegration to scrap the competitive market. It's a desperate effort to cut the deficit, balance the books and "transform" services - collaborating in secret, to develop Sustainability and Transformation Plans (STPs), which must all be vetted, and may be changed, by NHS England.
It's NHS England's way to assert central control, to speed the implementation of the policies outlined in Stevens' Five Year Forward View. Alongside the rapid development in each "Footprint" of 5-year plans to bring the NHS back within budget, more tangible, painful cuts are already taking shape.
This very quest for "sustainability" is now threatening services. As a recent report by the King's Fund on trust deficits argues:
"The scale of the aggregate deficit makes it clear that overspending is largely not attributable to mismanagement in individual organisations - instead it signifies a health system buckling under the strain of huge financial and operational pressures. The recent strategy of driving efficiencies by cutting the tariff has placed disproportionate strain on providers and is no longer sustainable."
The same report goes on to warn that: "cuts in staffing and reductions in quality of care are inevitable if the government's priority is to restore financial balance".
Right on cue Stepping Hill Hospital in Stockport, with a deficit of over £40m, is closing 30 beds, cutting 350 staff and selling off part of the site to cut costs and raise short term cash; trust managers argue that this is in line with plans for other similar trusts.
Just down the road East Cheshire NHS Trust, delivering acute and community services, has declared it is not sustainable in its current form.
And in a nasty echo of the bad old Thatcher era of cuts in spending from 1985, the chief executive of the Care Quality Commission has argued that he prefers cash-strapped trusts to let waiting times increase rather than reduce the quality of care. Not long ago long waiting times were themselves a measure of poor quality.
In another blast from the 1980s St Helens CCG has now resorted to a complete 4-month halt to all non-urgent referrals to local hospitals, reducing services to emergencies only.
Across the country trusts are repeatedly missing targets for prompt treatment of A&E patients - with performance often worst for the more serious Type 1 patients, who need admission to a bed.
However the regulator mis-named 'NHS Improvement,' now obsessed with the effort to wipe out deficits, has discarded any pretence of concern for quality of care, and announced that staffing wards at more than the bare minimum of 1 nurse per 8 patients is not affordable, warning that trusts with higher staffing levels may have to cut back as a condition of extra funding.
NHS England, meanwhile, has announced a fresh drive to "reset" the finances. The main components of the "reset" are:
" Pumping in £1.8m of additional cash in a one-off effort to clear deficits;
" Setting tight financial cash limits for every trust and CCG;
" Even tighter controls on use of agency staff;
" national action to implement Lord Carter's recommendations for savings in procurement and "back office" teams;
" Setting up another team within NHS Improvement to promote efficiency improvement
" Programmes in each STP to increase efficiency through "transforming" services.
But big savings require big cuts. Section 4 of NHS England's Reset plan argues that hospitals and services which now depend on locums and agency staff need to be closed and centralised in "nearby" larger units.
"By the end of July STPs should have reviewed services which are unsustainable for financial, quality or other reasons […]. They should have developed plans to re-provide these services in collaboration with other providers to secure clinically and financially sustainable services, both for 2016/17 and for future years."
Despite the fine words about "transformational efficiency" it's plain that NHS England is primarily resorting to old fashioned cuts to balance the books.
Trusts are being squeezed by CCGs, and in turn have to shed staff and squeeze down on prices they pay to suppliers and agencies.
In many areas - Cumbria, Calderdale, Oxfordshire, Lincolnshire, Devon, North West London, Bedfordshire, Essex, and more - the most vulnerable targets are A&E units, or smaller hospitals that are to be sacrificed on the altar of "sustainability."
However little has so far emerged from the 44 "Footprint" areas: the details of the STPs have so far been kept firmly under wraps.
The completed documents may have little more of substance to offer than early sketchy drafts. They could yet be a diversion from the actual cuts at trust and workplace level.
The recent publication of at least the 40th version of the North West London STP Plan announces a renewed determination to drive through the closure of Ealing and Charing Cross Hospitals, based on plans debated since 2012 - now openly seen as a way to save money.
However the rest of the 54 densely-packed, chaotically-presented pages in tiny type, indicates that while the volume of paper consumed has increased, management thinking remains stuck in the realm of fantasy.
The same old assertions that have been around for well over 20 years are again embraced by desperate NHS managers -despite the absence of evidence that they can deliver the promised results. The STP shows a semi-religious belief in the effectiveness of prevention programmes to produce rapid improvement in public health. Trendy new apps and digital devices are expected miraculously to keep frail older people out of hospital, and the answer to any problem is seen as paying management consultants to draft another document, or strategy.
It's a wish-list more than a plan.
However amongst the incantations and pious hopes there is also a commitment in the NW London STP to create "Accountable Care Partnerships" along the lines of the US-style Accountable Care Organisations proposed by the Five Year Forward View.
These would be provider organisations which would work for a fixed budget to cover a defined population. It's a risky business. In the US private health insurers have homed in on with these, but lost money - despite much higher levels of health spending. Similar NHS "lead provider" projects covering older people's services in Cambridgeshire and cancer care in Staffordshire have seen private sector bids withdrawn, and the Cambridgeshire plan collapsed for lack of adequate funding.
Nonetheless NHS Improvement have clearly declared their intention to push for much more private sector "partnership" and involvement in local "transformation" plans. The STPs are vehicles to open up contracts for possible privatisation or outsourcing as well as cuts.
With Labour largely silent on this, the only questions seem to be coming from a few local authorities. Councils are being roped into STPs, bribed by pitifully small additional sums towards their meagre social care budgets, then bullied by threats that this could be withheld.
Council leaders are being pressured to sign up in support of STPs without seeing or studying the full document - and many are doing so.
However one or two are standing firm: Hammersmith and Ealing councils in North West London have bravely refused to sign up for an STP which threatens hospitals in their boroughs, and saddles them with even more under-funded responsibilities.
Northamptonshire's Tory-led county council, facing £60m of cuts, has announced it will cut funding for social care, including support for discharging patients from Northampton and Kettering hospitals.
In Warrington, the chief executive of the Labour-led borough council has spoken out against NHS "naïve" attempts to drive through STP plans without proper consultation, describing them as a "recipe for disaster," and warning that there was little sign of partnership in the relations between NHS and social care.
Whether it's STPs, old-fashioned cuts, or the privatisation offensive that is the greatest concern, every part of the country faces a major test in the autumn and winter as a result of the ruthless spending squeeze.
Health campaigners wanting to understand what's involved, compare their problems and share lessons with others, and reach out to trade unions to build more powerful movements in defence of our NHS are urged to join us at the Health Campaigns Together conference 'The Challenge of STPs', in Birmingham on September 17. More details and registration from www.healthcampaigntogether.com.
The heat is on for NHS cutsThursday 14th July 2016
In the post Brexit political free-for all it's a nightmare scenario for the NHS.
Services were already struggling to cope with rising demand on a budget which falls each year to 2020 in real terms value and as a share of national wealth (GDP).
Nonetheless it seems that - however much rhetoric there may be about the importance of public health - there is no imminent prospect of the extra funding that's needed. Instead there's just huge economic uncertainty ahead.
The financial squeeze on the NHS flows from the decisions of the Cameron government back in 2010: George Osborne chose the path of austerity and cutting all public spending. He opted to cut the NHS covertly through a 10-year virtual freeze, designed to unpick the previous 10 years of increased spending - while claiming NHS spending was "ringfenced" from outright cuts.
There has never been any sign that the new Prime Minister, Theresa May, in any way dissented from this approach. Nor is there any sign that her chosen Chancellor Philip Hammond, who established a brutal reputation when he was a Treasury minister for driving through cuts, will substantially change Osborne's approach.
To make matters worse, the Brexit vote is already undermining the ability of NHS employers to recruit health professionals from the EU, who fear that they may not be welcome or secure in the UK.
Since the referendum May herself has refused to guarantee that EU nationals working here would be able to stay following the Brexit vote: that potentially includes the 55,000 or more already working in the NHS as well as many more in other jobs.
May as Home Secretary was an enthusiastic advocate of tighter limits on immigration: her notion of a 'one nation' approach appears to mean excluding people with origins in other nations.
In the midst of her major reshuffle, Health Secretary Jeremy Hunt appears to be almost unique in holding on to his post - despite, or perhaps because of his stand-off with the junior doctors. May's decision to leave him there signals no retreat from the imposition of a contract which the junior doctors have overwhelmingly rejected.
With continuing fears of recession there had been talk even from Osborne of freeing up infrastructure spending, but no hint of easing spending limits on health or local government, which is responsible for social care. Hammond is likely to be as mean-spirited.
However it's not just the health budget feeling the squeeze: social care has been slashed year by year since 2010. With more people living longer with more complex needs, they need social care - and councils are running out of 'efficiencies'.
The latest survey of all councils in England from the Social Services directors (ADASS) says they have to make further reductions of services of £371m for people needing care - and for their carers. This follows five years of funding reductions totalling £4.6bn, almost one third of real terms net budgets.
The proportion of social care savings expected to be raised from efficiencies has fallen from 75% last year to 55% in 2016/17 whilst outright cuts in services have increased from 18% to 39%.
ADASS argues that there are now "next to no further efficiencies to be made from squeezing provider fees paid, or raising income from fees and charges to customers".
Half the cuts will come from older people and almost 20% from personal budgets - a scheme dear to the heart of NHS England boss Simon Stevens. Only a third of social services chiefs were confident they will even be able to meet their statutory duties this year.
All this is bad news for the NHS service users, because most NHS new models of care and hopes for savings through 'integration' of services depend on social care: but it's even worse news for service users.
But big savings are still very much on the agenda on NHS budgets too.
Since just before last Christmas the new mechanism to drive cuts has been Sustainability and Transformation Plans (STPs), which have to be drawn up in each of 44 'footprint' areas across England .
Each STP is required to seek new cuts & "savings" to bridge improbably huge gaps between projected needs and available resources by 2020.
Each plan has to be checked by NHS England, whose boss Simon Stevens has initiated this latest top down reorganisation, hoping to ride roughshod over the structures put in place by the 2012 Health & Social Care Act to impose much more centralised control.
Stevens was reportedly planning to invoke David Cameron's support in pressing for financial discipline had EU referendum gone against Brexit: but since the vote the central pressure for savings is continuing, made more urgent by the latest revelations that despite extensive "creative accounting" reducing overt deficits by £900 million, the underlying deficit of trusts and foundation trusts last year was £3.7 billion.
Despite hugely ambitious savings targets, the most optimistic forecast for this year is a total trust deficit of £500m. NHS Improvement has responded by demanding trusts implement another £250m cuts.
And as this update is drafted NHS England has called for limits on spending on clinical staff - shocking Royal Colleges. NICE guidelines for safe staffing targets have been effectively discarded, with trusts told they need no longer invest to meet CQC or Royal College guidelines. Struggling trusts which have staffing of more than 1 nurse per 8 patients will be told this can no longer be afforded.
Trusts which appear to be making insufficient savings on "back office" services will be forcibly paired up with other trusts by NHS improvement. The heat is on.
So far there is precious little information on the content of many STP plans. First drafts of all 44 plans - drawn up in secret, with only the blandest generalities published - were apparently submitted to NHS England at the end of June, according to the HSJ, which also reports that it is unclear when - or if - all the plans will be made public. Behind the scenes there are huge efforts to strong-arm and bribe local authorities to sign up to plans that cut local health care, but offer a token handout to social care budgets.
Many STPs have plenty to keep secret about: they centre on significant, controversial service reorganisation. More and more A&E units and other services are again at risk throughout England, threatening local access for communities.
Plans to axe services at Bedford Hospital for example would mean that the nearest hospital would be 19 miles away: patients are being offered the "choice" of providers up to 50 miles away. STPs offer the chance to override local concerns and impose cuts regardless of opposition.
But the cuts will of course run alongside privatisation: an NHS England director has also promised a conference of the right wing Reform think tank that STPs will offer plenty of opportunities for the private sector to get into contracts for estates management and new models of care.
So the Keep Our NHS Public campaigners that have renamed STPs as "Slash, Trash and Plunder" are spot on, and campaigners need to join with trade unions to address the danger of STPs and coordinate a response wherever possible.
That's why Health Campaigns Together has established an STP Watch page on its busy website, and organised a national conference in Birmingham on September 17, which will bring together information and experience and attempt to map out solutions.
We need to get together to weather the new, dangerous period for the NHS. I hope readers and their organisations will support HCT, come to the conference, share info on STP Watch - and help us build the strongest possible resistance.
May the Fourth be with you!Sunday 1st May 2016
EMERGENCY DEMO! NHS BURSARIES: VOTE IN THE HOUSE OF COMMONS on Wednesday 4 May
Labour's shadow health secretary Heidi Alexander has called an "opposition day debate" on the government's plans to scrap NHS bursaries for student nurses and midwives - on Wednesday May 4.
The Bursaries or Bust campaign says:
IF YOU CANNOT ATTEND THE DEMO PLEASE LOBBY YOUR MPs TODAY!
We will be assembling at Parliament Square to show the government that we will continue to fight NHS bursary cuts.
Ask your MP to support on the day
Heidi Alexander has called a debate based on the early day motion 1081 which has been signed by 139 MPs so far.
This is exciting. This means we can win.
JUNIOR DOCTORS, TEACHERS, PUBLIC SECTOR WORKERS AND EVERYONE ELSE - WE NEED YOU. TOGETHER WE CAN WIN THIS.
And don't forget
4th JUNE IS OUR BIG MARCH
We want 10,000 of you there!
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