The NHS’ Sustainability and Transformation process has surely hit the buffers. Last week three separate events each raised serious and considerable doubts about the viability of continuing the project. The National Audit Office produced a report on the Adult Social Care Workforce in England, the Health Service Journal (HSJ) published a leaked document from NHS England and, finally, the written submissions to the Health Select Committee were published. There was little of the positive in any of it.
At the heart of NHS England’s Five Year Forward View (5YFV) is the idea that the NHS in England will never again be funded to a level that maintains its services in the way they are run now. It puts together a series of proposals for change which are not just cuts but are about a fundamental reshaping of how services are provided. Expensive specialist and emergency care is relocated to centralised hubs and more care is to be delivered in the community via partnerships with local authorities. There is an aspiration for fewer emergency admissions with an improvement to overall health which it argues will lead to less dependency on NHS services.
The scope of this aspiration is far reaching. It not only assumes the NHS can cope with a growing population without corresponding growth in services but that it will do so with a reduced service, albeit differently provided.
The National Audit Office Report
On 8 February the National Audit Office (NAO) published a report on the Adult Social Care Workforce in England. It made for grim reading both in terms of the state of the service as a place to work and its ability to assist in safe transfer of patients out of hospital settings. The report shows a steady increase in turnover since 2012, reaching 27.8% in 2017. That is over 1 in 4 staff members changing every year. This has implications for both continuity of care and stability of the service as well as the cost implications of recruitment. Recruitment to fill the vacancies is not faring much better, with a vacancy rate in 2016-17 of 6.6%, well above the national average of about 2.5%.
Acute hospitals across the country struggle to make timely transfers of patients who need further support and care after discharge from hospital. Close co-operation between the NHS and social care services is essential to ensure that vulnerable patients are not left without support.
The BBC reported that: “the Red Cross said that simply was not happening because of the lack of community services available from councils and the NHS. It meant there were growing numbers of patients being readmitted soon after leaving hospital because they were getting no help.”
But the NAO said that it: “considers the Department of Health & Social Care’s role in overseeing the adult social care workforce and assesses whether the size and structure of the care workforce are adequate to meet users’ needs for care now, and in the future, in the face of financial challenges and a competitive labour market.”
It continued that it: “has not found any evidence that the Department is overseeing workforce planning by local authorities and local health and care partnerships, which commission care, to help with the challenge. Without a national strategy to align to, few local areas have detailed plans for sustaining the care workforce.”
The plan that never was
On 7 February the HSJ exclusively revealed a leaked document from NHS England saying they had abandoned plans to create a ‘strategic framework for community health services’: in other words, a Community Forward View. So the national strategy the NAO believes is necessary will not be forthcoming.
The most significant point in the document, aside from the fact that it leaves STP plans in an unfinished state, is that it says: “the expected efficiency-saving associated with the shift away from acute bed-based services will not be achieved” (our emphasis).
It goes on to list a continuation of unwarranted variation and the risk of not being able to achieve a full service-redesign. It adds that the GP Forward View cannot be delivered without work on community services being improved, which it describes as “fractured and disjointed”.
By NHS England’s own admission, the central aim of the Five Year Forward View – to place more care in the community – cannot be achieved.
Do the written submissions to the Health Select Committee reflect these problems?
The 86 submissions to the HSC ranged from Healthwatch to the personal, from campaign groups to a property company (Naylor was referred to). We offer a snapshot, not a full analysis.
The submissions as a whole are detailed and interesting. They give a cross-section of views. Not all the responses are what might have been expected. Some support for the STPs comes from unexpected quarters, as does some criticism. Professional bodies regard the STPs as bringing about closer working between the NHS and social care which they see as a good thing. They assess the process through that lens.
Campaigners, for the most part, see it as an attack on the fundamental principles of the NHS.
Although close co-operation between health and social care/the NHS and local authorities is seen as positive, there are several main points of concern that emerge from the submissions, regardless of specific areas of interest:
- The ACS/ACO format is questioned – why was it chosen? Is it appropriate? Can it achieve the objectives?
- There is poor use of data, little or no evidence-base in much of what has been published.
- There has been too much secrecy, not enough detail.
- Little or no public debate. What there has been is stage-managed.
- There is not enough money.
- There is little work joined up with local authorities. The focus is all on the NHS.
One response from a councillor in Devon highlighted the lack of impact assessments in STPs especially around rurality. He illustrates the problems in Devon but his submission includes a list of other areas where the rural impact of hospital closures is an issue.
He writes: “East Devon District Council voted unanimously (less one) in December 2017 to ask the Leader of East Devon District Council to request Sarah Wollaston, Chair of the Parliamentary Health Select Committee, to investigate the effects on Rural Communities of the STP actions and to test if Rural Proofing Policies have been correctly applied to these decisions in order to protect these communities.”
The submissions from the Royal College of Emergency Medicine, The Local Government Association(LGA) and Hammersmith and Fulham Council are particularly relevant in respect of the co-operation between the two main elements, A&E and social care.
Emergency medicine and Community Care
The Royal College of Emergency Medicine is critical of the use of data and the evidence-base, including evaluation and the period of time for testing new strategies. In particular the assumptions – which they refer to as ‘heroic’ – around bed reductions are examined.
- They rebut the assumption that sustained reductions in demand at Emergency Departments (EDs) are achievable at the scale proposed: “The Department of Health and the NHS have repeatedly tried to achieve reductions in Emergency Department demand over more than a decade without success. Why these measures might succeed where others have failed remains unclear.”
- They rebut the assumptions behind planned reductions in NHS hospital bed capacity. “Discussing demand reductions in these terms invites the idea that patients in the UK are in some way excessive users of the services of Emergency Departments. In fact, the international evidence indicates that this is not the case.”
- The plans anticipate a reduced patient demand as a result of improvements in patients’ self-care, prevention and public health, place-based care and improvements in primary care. But whilst acknowledging the benefit of all these measures they conclude: “Despite all the rhetoric to the contrary, ED attendances are intrinsically linked to population growth.”
They also address a theme common to many of the submissions – poor consultation. They say they “would echo the views of others in the sector that STPs are still not written in a way that means what is being proposed is clear and comprehensible to patients. As but one good example among many, members of the Healthier Lancashire and Cumbria umbrella group complained that one of the major problems they faced when assessing their local STPs was simply their inability to understand it in the first place.”
Even if assumptions about place-based care were based on evidence the work would have to be done to ensure it is in place. The NAO report casts grave doubts over that, as does the evidence from the LGA:
“In general, there has been little meaningful consideration of adult social care as a vital component of a resilient and sustainable health and care system. For individuals this means that opportunities to strengthen health and well-being, maximise independence, and to support family carers may be overlooked.”
The LGA points out that workforce and capacity issues affect the whole health and care system. In July 2017 they surveyed their members on the STP engagement. The results of their survey support the statement they make in their submission that there is “limited meaningful involvement of local political and community leadership in the development of STPs to date”.
One of the criticisms in the 2017 survey was that where there was engagement, NHS England tended to talk directly to local authority officers rather than councillors, ignoring any democratic decision-making process about service reconfiguration.
“We are concerned about the lack of local democratic accountability for STPs and the extent to which they are truly system-wide plans and partnerships encompassing adult social care, public health, and other key council functions that support improved health outcomes and the sustainability of services.”
In 2015 four local councils in Northwest London organised an independent review into the changes in their area: they were concerned about where the cuts were falling and the impact it was having on communities with high levels of deprivation.
The high level of interest and involvement in this area was shown by the number of submissions it generated to the Health Select Committee, including from Hammersmith and Fulham Council. They echo the concerns found in many submissions about the lack of consultation, but worded it more strongly than most:
“Although there has been attendance by representatives at stage-managed ‘engagement events’ these have in our view been tokenistic with a prepared agenda geared toward achieving a set outcome.”
They go so far as to state that what has been done actually ‘flies in the face’ of evidence and feedback received from social care providers.
“Plans are less a product of the engagement of local communities and more a presentation of a solution pre-determined within the NHS to close down much-needed local acute hospital services.”
The LGA expresses this differently: “in practice the overwhelming focus on financial sustainability of the acute sector in STP plans has led to the preventative, community-based approaches to challenges facing health and social care being neglected.”
Whichever way it is expressed the outcome is the same. Taking the submissions in conjunction with the NAO report and NHS England’s abandonment of its Community Care Forward View, the picture is bleak. There is no planned provision for the care which is supposed to reduce hospital admission rates.
Once you eliminate the impossible, whatever remains, no matter how improbable, must be the truth.
Overall, much of the critique centres on a focus on emergency care at the expense of all other services. This is to be expected since so much of the work is about closing A&Es and centralising specialist services. However, there is a general consensus that:
- There has been too much secrecy and that documents that are published are vague and often incomprehensible. There is also an understanding – where the writers are aware – that local authorities have not been engaged in the plans and that this is a major flaw.
- There are concerns that there are not adequate funds, time or resources being given to a project of this scale for it to work.
- The lack of an evidence base or test pilots is considered worrying.
- Key services such as mental health, cancer care and children’s services do not appear in many STPs.
- Staff, patients and the public have been left in the dark with ‘token’ consultations on decisions that have been very much top down.
The charity and local government submissions tend to focus on this last point. The cancer charity MacMillan says:
“We have sought to incorporate patient involvement as a fundamental element of design and delivery of all of our complex system redesign programmes. We work with people living with cancer and the wider public, and we know that the public is highly influential in changing the culture of care.”
Given the failure to meet so many of the criteria, what are we left with?
The answer is hospital closures, staff downgrades and land sales.
We hope that the Health Select Committee will decide that the submissions highlight sufficient reasons to call on the Secretary of State for Health to halt the implementation of the Sustainability and Transformation Plans and Accountable Care Systems and Organisations.