crackedmirrors and angelpie

I watched this film soon after it was publicised and having just watched it again am horrified that the privatisation tank is rolling on with virtually no resistance. It is eighteen months since the film was made, and the latest steps towards full privatisation are currently proceeding in near secrecy.

STP – Sustainability and Transformation Footprints are an integral part of Simon Stevens’ and the government’s Five Year Forward View. The blurb about them basically states that STPs are a major reorganisation in healthcare starting this year, 2016, and carrying on over the next five years.

STPs are a huge reorganisation – the government’s own statement says that they will “transform the way that health and care is planned and delivered for their populations.” If “transforming” isn’t a major change then I’m not sure what is.

We the public, and indeed most healthcare professionals, have heard very little about STPs – I wonder why?

Alarmingly, local health and care organisations were given just over a month – between a few days before Christmas and the end of January this year – to agree the 44 STP footprints, nearly all of which now has a leader. Each footprint is responsible for the well being of an average population of over 1 million, and encompasses as many as 12 CCGs. These important changes are happening well below the radar:

STPs footprints are not statutory bodies, but collective discussion forums which aim to bring together health and care leaders to support the delivery of improved health and care based on the needs of local populations. They do not replace existing local bodies, or change local accountabilities. STPs will be submitted in June, with a view to implementation starting in Autumn 2016.     (https://www.england.nhs.uk/ourwork/futurenhs/deliver-forward-view/stp/)

The obfuscating gobbledy-gook is quite unbelievable:

What does success look like?

If we get this right, together we will engage patients, staff and communities from the start, allowing us to develop services that reflect the needs of patients and improve outcomes by 2020/21, closing all three gaps. We will mobilise energy and enthusiasm around place-based systems of health and care, develop the ownership, relationships and governance necessary to deliver, providing a coherent platform for future investment from the Sustainability and Transformation Fund.

This will require a different type of planning process – one that releases energy and ambition and builds greater trust ownership. It will require the NHS at both local and national level to work in partnership across organisational boundaries and sectors, and will require changes not just in process, but in culture and behaviour.

In reality STP and the 5 year forward plan will devolve all budgetary control away from the Secretary of State and the Department of Health to the STPs (who of course have no statutory powers). Having abrogated all financial responsibility for the NHS by

1. having made nearly all hospital trusts independently run foundation trusts, and
2. having devolved all commissioning of healthcare to the STP footprints and the CCGs within them

the government has laid down nine ‘must do’targets for each STP to deliver in 2016/17. Of course they aren’t really targets as they are mandatory requirements. These must dos have not only got to be delivered, they have got to be delivered at the same time as abolishing the financial deficit. “Deficit reduction in providers will require a forensic examination of every pound spent on delivering healthcare and embedding a culture of relentless cost containment. Trusts need to focus on cost reduction not income growth.”

• Return the system to aggregate financial balance. This includes secondary care providers delivering efficiency savings through actively engaging with the Lord Carter provider productivity work programme and complying with the maximum total agency spend and hourly rates set out by NHS Improvement. CCGs will additionally be expected to deliver savings by tackling unwarranted variation in demand through implementing the RightCare programme in every locality.
• Develop and implement a local plan to address the sustainability and quality of general practice, including workforce and workload issues. How are STPs meant to do this? There is a national recruitment crisis in General Practice, not only about recruiting existing suitably trained doctors into vacant GP posts, but even more importantly about recruiting junior doctors into GP training schemes. Even if all the medical graduates coming out of medical school this August were persuaded to become GPs this would not deliver fully trained GPs for another 7+ years.
• Get back on track with access standards for A&E and ambulance waits, ensuring more than 95 percent of patients wait no more than four hours in A&E, and that all ambulance trusts respond to 75 percent of Category A calls within eight minutes. Much the same arguments obtain as for general practice. There are insufficient A&E doctors at all levels. Improvements in access standards could only be made in the short term by using nurses to do the work of doctors (ie. reducing standards of care) or by using non-specialist or agency doctors – an expensive and unsatisfactory solution.
• Improvement against and maintenance of the NHS Constitution standards that more than 92 percent of patients on non-emergency pathways wait no more than 18 weeks from referral to treatment, including offering patient choice. Most clinicians are aware that an enormous amount of ‘fudging’ goes on to meet 18 week targets. What constitutes ‘treatment’ is a distinctly variable feast; 18 week waits are an absolute fantasy in mental health care, as is patient choice.
•  Deliver the NHS Constitution 62 day cancer waiting standard, including by securing adequate diagnostic capacity; continue to deliver the constitutional two week and 31 day cancer standards and make progress in improving one-year survival rates by delivering a year-on-year improvement in the proportion of cancers diagnosed at stage one and stage two; and reducing the proportion of cancers diagnosed following an emergency admission. This is frankly bizarre. Are the STPs going to force patients to attend their GP practices? Have these targets taken into account lead time bias? Why choose one year survival rather than five year survival?
• Achieve and maintain the two new mental health access standards: more than 50 percent of people experiencing a first episode of psychosis will commence treatment with a NICE approved care package within two weeks of referral; 75 percent of people with common mental health conditions referred to the Improved Access to Psychological Therapies (IAPT) programme will be treated within six weeks of referral, with 95 percent treated within 18 weeks. These targets are sprinkled with fairy dust! The current mental health services across my part of southern England can barely provide crisis care. There are insufficient inpatient beds for people sectioned under the Mental Health Act. There is an acute shortage of community psychiatric nurses. There are few appropriately trained psychotherapists and counsellors available to staff IAPT programmes, so accelerated training courses for trained nurses are increasingly common. These people are limited in the type and amount of therapy that they can deliver, and I know of cases where a patient has had six sessions of counselling and been recommended for referral to more intensive therapy from a more experienced practitioner. There are no time limits for onward referral which may take years to enact, if indeed it happens at all. It is difficult to envisage any way in which the STPs will be able to conjure up trained psychiatrists, CPNs and psychotherapists from the ether.
• Continue to meet a dementia diagnosis rate of at least two-thirds of the estimated number of people with dementia. This is alarming. Increasing the rate of dementia diagnosis to this extent seems unlikely without resorting to screening tools. The use of screening for dementia is controversial, and many people would be reluctant to undergo it. It would be deeply unethical to pressurise older people to submit to screening especially as the benefits are still unclear.
• Deliver actions set out in local plans to transform care for people with learning disabilities, including implementing enhanced community provision, reducing inpatient capacity, and rolling out care and treatment reviews in line with published policy. I know little about learning disabilities, but the emphasis on reduced inpatient care rings alarm bells. This mirrors the previous policies in mental health and it is now recognised amongst many patients and practitioners that the wholesale closure of beds was not a good thing. There needs to be considerable investment in community facilities and provision before bed closures are planned, and a recognition that there will always be a need for inpatient beds for respite and emergency care.
• Develop and implement an affordable plan to make improvements in quality particularly for organisations in special measures. In addition, providers are required to participate in the annual publication of avoidable mortality rates by individual trusts.

Full details of all this can be found at https://www.england.nhs.uk/wp-content/uploads/2015/12/planning-guid-16-17-20-21.pdf

Call me a cynic, but this is only the beginning:

 

 

 

 

 

 

 

No wonder it is all happening without us knowing much about it.