Fractured NHS – 26.10.16

Jim McKenna

10% of the health and care budget is spent by Cornwall Council, £126m this year, £134m next year. The council tax levy of 2% raised £4.7m this year, and will raise £5.1m next year. The Council have raised the amount spent by more than the social levy. The Government have reduced funding. Adult and Social Care is the only council budget that has gone up. The wider health and care budget is £1.2b.

1.       Spending more than resources available.

2.       Most is on NHS provision

3.       Commissioning and provision is not sufficiently joined up

4.       Too many organisations

5.       Role of NHSE

He would like to see one commissioning service and pooling budgets is the only way to make changes. NHSE dictates – thinks CC should represent the people of Cornwall, not just do what it is told. Cornwall is different. The STP – CC is involved. It is required by NHSE. Must be clinically and financially sound. Requires substantial savings - £200m over five years. Will require change to level and location of services. Public and stakeholder engagement Dec/Jan OBC, Feb 2017 submit. Detailed consultation, summer 2017. Final STP late 2017.

 Challenges –

Finance. Retaining control within Cornwall, impact of NHSE. Attracting and retaining staff. Demand exceeds available resources (DToC). Reducing public reliance on health and care services. Resources for prevention services. Setting aside organisational boundaries – a single system. CC paying more to care companies than other councils.

 Opportunities –

Greater public and stakeholder engagement – no more Board meetings in private. Accountability and transparency. Simplification of commissioning. Potential for a single NHS provider. A system in Cornwall which is fit for purpose.

 Finally –

Significant change is inevitable. Proper public engagement is essential. Must develop alternative service models before change.

Rik Evans (NHS Action Party candidate and previously Deputy Chairman of RCHT)

 We should be spending more money, we can afford it. Wants integration of health with a national service, not a post code lottery.

 Problems –

Heading towards private care. Ideological shift since 1980s. Internal market, splitting commissioning and providers, created lots of accountants. The internal market costs £10b/year in bureaucracy and increase from 5% to 14% of the budget. The Commonwealth fund (US think tank) puts the UK NHS at number 1 under most criteria.

In 2010 government decided it had to cut the debt, despite being able to borrow cheaply. Now this is being reversed and starting to spend after realising austerity is not the answer, which has caused more problems. Spending money to alleviate poverty improves health.

 Answers –

Invest more in staff. This is 60% of RCHT budget. Totally opposed to privatisation. Bringing in private companies to cut costs eg Mitie who get rid of the highest paid staff and standards drop. People need to stand up and shout, lobby councillors and MPs. Cynical about consultations. Don’t use the Duchy when offered. It is making money out of RCHT which will lead to less staff.

 Andrew George

 Modern NHS is budget driven (STP), deliberately complex, under perpetual change (eg RCHT CEO and Chair 10 in 10 years).

 Themes – Standards, choice, the blame agenda.

 Suggests increasing income tax (2% would raise £7.8b) If resource is not sufficient, can’t do anything.

 Tories 1991 – purchaser/provider split and GP fundholding. Labour 1997 – kept p/p split, abolished GP fundholding but later replaced it with practice based commissioning. Then Independent Treatment centres, alternative providers (giving competition), Foundation Trusts, PFI, Any willing provider, Hinchingbrooke Hospital (failed after 3 years). Coalition 2010 – Health and Social Care Act 2012, led to biggest reorganisation, risk of profit before patient care, choice allowing the private sector to cherry pick.

 Choice – desirable for who? Disadvantages the poorest, children, least assertive, elderly, learning disabled, those without cars. Advantages the higher socio economic group. Risks of choice – remote areas leads to threadbare services and cycle of decline. Choice may work for one off event but not for complex pathways of care.

 Standards, campaigning for safe level of registered nurses on acute wards.

Beware management babble – eg having the right staff with the right skills in the right place at the right time. (Who would have the wrong staff etc)

 Beware the law of perpetual change. Recent examples the STP, EHH beds closure – (using a PR company), showing a video to make a plausible justification. Are the safety standards any better in a care home or personal home? Passing the responsibility.

 Health tourists – Deliberate cost £60m - £80m. Those taking advantage (ex pats) cost £50m - £200m

 Government political objectives –

Keep the NHS out of the news. Co-opt and confuse campaigners.

 Campaigning objectives –

Demystify. Hold to public account.

 Kathy Byrne – CEO RCHT

 Thinks it is an integrated, not fractured NHS.

RCHT last year had 80k ED contacts, 500k out patient appointments, 70k planned procedures, 4.4k births. Challenging geographies – depends what you are used to. (Previous job had 2000 mile area) RCHT does struggle with ED and unplanned attendances. The whole system is under strain. The NHS was designed for a different era, originally set up to deal with episodes. Now people are living longer with ill health and people live with long term ill health. It can’t cope with the demand so things will have to be done differently.

 Integrate – move money around the system – resources are finite, there will be no more money. The Government requires a 5 year plan – it should be 40 years. Doing the STP because thinks it is right, not just because the Government says so. Why do we need an STP. Despite many examples of good practice the system is over stretched, not achieving best outcomes, over spending, out of date hospital bed based care, is reactive not preventative. More money is not the only answer.

 Challenges are –

Older population, deprivation, sparsely settled communities, complex needs, risky behaviours, financial, integration. Want to help people to stay well at home, keeping their independence. This year budget increase of 3.7% for NHS, 17/18 will be 1.7%, 18/19 will be 0.3% and in 20/21 the Government wants to spend per head what it spent in 2010.

 Principles –

Prevention first. Citizen at the centre. Avoid duplication of services. Better use of clinical time. Better support for carers and families. Prevent unnecessary time in care. Use technology. Cost effective care.

 Priority areas –

Prevention and primary care. Community care, transforming, build integrated teams. Urgent and emergency care, OOH and 111. Pathway and provider reform (commissioning). Productivity and efficiency savings.

Relocate funds away from acute into community based services.

Where are we?

Plans developed in outline. Acting on early wins. Starting conversations with the community. Building understanding and support for fundamental reform. Consultation next summer on major service changes.