What’s wrong with NHS Devolution?

Briefing: NHS Devolution – Merseyside

Devolution is one of the latest big plans threatening the founding principles of the NHS: a comprehensive, universal health service, funded by taxation, free at the point of need, publicly provided and accountable. NHS Devo will transfer huge cuts from central to local government, promote care models without clinical evidence, and weaken standards, opening the door to further privatisation. It’s an experiment, on us, without our consent.

What is NHS Devolution?

Transferring some NHS budgets, commissioning and legal responsibility from central government to local authorities or a “combined authority” made up of several local authorities. Devolution is being driven by the Treasury.

What’s the context?

Austerity, a deliberate Gov’t policy, means the NHS faces a £2.5bn deficit now and is ordered to find £22bn in “efficiency savings” by 2020 – impossible. It means cuts.

Isn’t local control a good idea?

Not if it means handing huge budget shortfalls to local authorities; deregulation (weakening standards); without clinical evidence for the plans; treatments withdrawn; a postcode lottery replacing the “National” NHS; threats to national pay, terms & conditions of NHS staff.

What’s happening on Merseyside?

Although the Gov’t has said “there is nothing … that requires an authority to take on a national health service function,” Councillors are ploughing ahead.

Last September, the Liverpool City Region Combined

Authority (CA) made 6 health proposals to Chancellor George Osborne’s Comprehensive Spending Review.

Local Enterprise Partnership Chair Robert Hough told business leaders “a devolution deal will only succeed if it is materially shaped by the views of the private sector.” In November the Mayor, 5 Borough Council leaders and Robert Hough signed the Devolution Agreement. It promised further dialogue including on health and social care integration.

In December the CA appointed Knowsley leader Cllr A Moorhead as Cabinet lead for Health & Wellbeing.

In January Liverpool City Council agreed a Joint Commissioning Team; pooling future health and social care resources as part of an expanded Better Care Fund, which uses NHS monies to fund integrated care.

In March an updated Devolution Agreement mentioned health and social care integration; an interim report on the case for change across a number of priority health conditions; a review of children’s services. Sefton Council ran a Soft Market Test for a 0-19 Healthy Child Programme, a dry run before procurement.

Cllr Moorhead denies any negotiations with the Government at this stage on health and social care, as “we are conducting a scoping exercise… our intention is to consult with the public and all interested parties”. But LCC admits their officers have been conducting ongoing dialogue with the Government re health & social care.

Why didn’t you know?

There was no consultation with the public on any of this.

Where else is it happening?

All over England, led by Manchester. Out of 34 Devolution bids, 19 involve Health and Social Care.

Why Integrated Care and Devolution?

The government wants devolution and integration of health and social care, a seven-day NHS, financial “stability” (cuts) and new models of care to “reduce reliance on hospitals” (hospital closures). New models can include “case management”, personal health and social care budgets, self-care, pooling budgets between means-tested social care and the NHS, public-private partnerships, with the private sector involved in developing the new models.

Any medical evidence for Devolution? No.

Any medical evidence for Integrated Care?

Not really. At least 6 big studies failed to confirm that integrated care reduces demand for hospital care. A Health Service Journal commission concluded there is a “myth” that providing more and better care for frail older people in the community, increasing integration … and pooling health and social care budgets will lead to significant, cashable financial savings in the acute hospital sector and across health economies. The commission found no evidence that these assumptions are true.

What’s happening in Parliament?

Deregulation of healthcare – weakening standards – was concealed in the Devolution Act through careful phrasing.

Any other Gov’t plans for the NHS?

The man with the big plan is Simon Stevens, former advisor to Tony Blair, then European head of the US health giant UnitedHealth, now Chief Exec of NHS England. His “Five Year Forward View” suggests that integrated care and “prevention” will plug the £22bn hole in NHS budgets. The hole is Government policy. The latest tactic is to divide England into 44 “footprints”, in which Clinical Commissioning Groups and NHS Trusts must balance the books with a 12 month plan in place by the summer, and then move on to transformation using new models of care to implement FYFV, with or without the local authorities.

Where is NHS Devo heading?

No firm is big enough to buy the whole NHS. But something the size of a Devolution pilot might be an attractive proposition, once healthcare is deregulated, patients have grown accustomed to personal budgets, health insurance schemes proliferate, staff are forced into 7 day working without proper pay rates for nights and weekends, national agreements covering pay, terms & conditions are replaced by local arrangements.

No-one asked us. Why should we fall for it?

Many decisions are being taken over our heads about the future of the National Health Service, whose fundamental principles were – and should be – that healthcare is free, comprehensive (all the required health care that has been available on the NHS), universal (available to everyone who needs it), funded by general taxation, publicly provided and publicly accountable. Devolution is one of the latest big plans threatening these principles. We need to understand it in order to resist.

1. What is NHS Devolution?

2. What’s the context?

The Gov’t has reduced spending on the NHS from 8.8% of GDP in 2009 to a planned 6.6% in 2020.[1] The NHS faces a £2.5bn deficit right now and is supposed to find £22bn in “efficiency savings” by 2020, an impossible task.[2] It means cuts. NHS Trusts have been instructed to

prioritise financial targets over safe staffing levels.[3] As

Chris Ham of the Kings Fund commented,[4] “A major risk is that the failures that occurred at Mid Staffordshire will be repeated in other parts of the NHS. These failures resulted from decisions by hospital leaders to improve financial performance by cutting staff in order to achieve foundation trust status. Patient care took a back seat with predictable but tragic consequences.”

The “Five Year Forward View” (FYFV) for the NHS intends “New Models of Care” to include integration of health and social care by 2020, gambling that this will plug the hole in NHS finances by shifting care into the community and preventing ill health.[5]

3. Isn’t local control a good idea?

Not if it means any of these:

• dumping a huge budget shortfall on local authorities

• deregulation, weakening standards governing the NHS

• lacking clinical evidence that plans improve the service • letting local commissioners decide which treatments are no longer available on the NHS

• abandoning local areas to their own resources rather than pooling risks over the whole country, taking the “National” out of the National Health Service

• without ever asking the public or NHS staff whether they wanted NHS devolution – or any other devolution.

4. What’s happening on Merseyside?

Plenty, without much publicity.

a) on 3 Sept 2015, the Liverpool City Region Combined Authority (CA) submitted proposals to Chancellor

George Osborne’s Comprehensive Spending Review.[6] On health, wellbeing and social care the CA proposed to explore in detail the opportunities and risks covering:

• Specialist health services currently commissioned by NHS England including military and prison health; • Emergency and non-emergency transport including ambulances;

• Primary health care where it is currently commissioned

by NHSE;

• Public Health responsibilities and budgets from Public Health England / NHSE and removal of the Public Health

Grant ring-fence;

• A local leadership role in the performance oversight of the health and social care community, in close partnership with Monitor, the Trust Development Authority (TDA) and Care Quality Commission (CQC), and • Emergency planning responsibilities within PHE’s health protection responsibilities and the NHSE emergency planning responsibilities

b) On 17 Sept 2015, a non-Executive Director of Peel Holdings and Chair of the Liverpool City Region Local Enterprise Partnership, Robert Hough, told a packed meeting of business leaders in the Titanic Hotel[7] “I know I speak for everybody in the room when I say that a devolution deal will only succeed if it is materially shaped by the views of the private sector. Private sector input is vital. Collectively, we – the private sector – understand what the opportunities are; and we understand the barriers to achieving them.”

c) on 18 Nov 2015 the Liverpool City Region Devolution Agreement was signed[8] by the Mayor of Liverpool, leaders of the 5 Borough Councils and Robert Hough. While focused on transport and economic development, the Agreement had two references to health:

“The Liverpool City Region will continue to have further devolution dialogue with the government in the future, including on health and social care integration.”

“Liverpool City Region Combined Authority will set out how they will join up local public services in order to improve outcomes for [harder-to-help claimants], particularly how they will work with the Clinical Commissioning Groups/third sector and NHS England / the Work and Health Unit nationally to enable timely health-based support.”

d) The CA meeting on 20 Nov 2015[9] made no mention of health, but referred to “continuing with phase two of the negotiations which would provide the opportunity to secure further benefits”.

e) on 18 Dec 2015[10] the CA appointed Knowsley leader Cllr A Moorhead as Cabinet lead for Health & Wellbeing. A member of the public asked “Would devolution mean the privatisation of the National Health Service?” The response is not recorded in the minutes.

f) on 8 Jan 2016[11] Liverpool City Council Cabinet agreed:

“(i) the establishment of a Joint Commissioning Team for Health and Social Care within existing resources; (ii) delegated authority to the Director – Adult Services &

Health in consultation with the Director – Finance &

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Resources to develop a business case for the integration of Health and Social Care Provision across Primary Care and Community Services; and

(iii) the pooling of future adult social care resources as part of an expanded Better Care Fund (BCF) under the existing Agreement made in accordance with Section 75 of the National Health Service Act 2006 with Liverpool Clinical Commissioning Group”.

The Better Care Fund[12] uses monies transferred out of the NHS to fund integrated care.

g) Coinciding with the Budget on 16 March 2016 the LCR Devolution Agreement was updated.[13] It includes:

“Liverpool City Region Combined Authority and NHS partners have been in ongoing dialogue around greater health and social care integration including the prevention agenda”

“The city region, with the full engagement of health partners, will shortly publish an interim report on the case for change across a number of priority health conditions” “The government will support Liverpool City Region to undertake a fundamental review of the way that children’s services are delivered.”

h) Sefton Council is currently conducting a Soft Market Test for a 0-19 Healthy Child Programme (HCP), to

“inform any subsequent procurement process”.[14]

i) according to Cllr Moorhead on 23 Feb 2016, there are no negotiations with the Government at this stage concerning health and social care,[15] as “we are conducting a scoping exercise into all aspects of health and social care. When this is completed our intention is to consult with the public and all interested parties”.

j) according to a Freedom of Information response on 18 Mar 2016,[16] Liverpool City Council Chief Executive and Assistant Chief Executive have been conducting ongoing dialogue with the Government re health & social care.

5. Why didn’t you know?

There was no consultation with the public on any of these points, from the 6 “asks” in Sept 2015 to the Updated Devolution Agreement published with the Budget on 16 March 2016. Although Devolution has been reported, the health aspects have kept a low profile.

6. Where else is it happening?

Manchester,[17] London,[18] Cornwall,[19] North-East,[20]

Gloucestershire[21] … But not in Scotland or Wales. Out of 34 Devolution bids identified by the Local Government Association[22], 19 involve Health and Social Care.

7. Why Integrated Care and Devolution?

Devolution plans for Liverpool, Manchester, Cornwall, the North-East and probably all others stress integrated health and social care. The London agreement mentions

the government’s priorities on devolution and the integration of health and social care, on creating a seven-day NHS and on transforming the health system to secure a sustainable financial future for the NHS… London aims to reduce hospitalisation through proactive, coordinated

and personalised care that is effectively linked up with wider services to help people maintain their independence, dignity and wellbeing. This will require:

integration of health and care budgets in a place to

maximise potential for new models of care and reduce reliance on hospitals

building on examples from local and sub-regional

integration pilots to provide early intervention and re-ablement services rather than a crisis-based system enabling investment in partnership working

What does this mean? “Proactive” may refer to case management, a strategy of focusing resources on patients at high risk of hospitalisation. The Greater Manchester Strategic Plan (Dec 2015) says “Key features will be targeted case management of the population most in need delivered by upskilled multi-disciplinary teams, together with streamlined discharge planning in order to reduce the demand placed on acute hospitals.”

“Personalised care” may mean personal budgets, like the

£3000 ‘birth budgets’ recommended by the National Maternity Review[23]. A Freedom of Information request revealed “Liverpool City Council and the CCG propose to review their current arrangements for personal social care budgets and personal healthcare budgets to see how they can be improved for the end user; this would include exploring the option to merge.”[24] It may also mean “self-care”, a theme of Devo Manc.

“Integration of health and care budgets” means plans like Joint Commissioning using the Better Care Fund, as agreed in January by Liverpool City Council. It could lead to means-tests for health as well as social care. “in a place” means locally, rather than nationally.

“reduce reliance on hospitals” means less demand for hospital care, so hospitals can close. As Liverpool CCG Deputy Chair Dr Simon Bowers told BBC Panorama,“The new model is funded by moving money around the system, so that inevitably means taking money out of hospitals to spend in the community. We will have less hospitals in Liverpool at the end of the Healthy Liverpool

programme.”[25]

“investment in partnership working” means public-private partnerships, as for example in Devo Manc where “An overarching Provider Forum will bring together NHS and non-NHS providers (domiciliary providers, private sector health providers, voluntary and hospices) to be part of the development of new models of care”.

8. Any medical evidence for Devolution?

No. There are some pilot projects in London which are just starting, have not been evaluated, peer-reviewed, or published. The Greater Manchester “Devo Manc” plan starts on 1 April 2016. It will be several years before anyone knows if any NHS Devolutions have improved patient care or made it worse – although there could be some clues when hospital depts or whole hospitals close.

9. Medical evidence for Integrated Care?

Not really. Major reviews of IC pilots failed to confirm that integrated care reduces demand for hospital care.

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In 2012 RAND Europe reviewed 16 IC pilots for the Dept of Health.[26] While staff thought care had improved, patients did not. Further, the review “found no evidence of a general reduction in emergency admissions” and “no overall significant changes in the costs of secondary care utilisation”. Any savings would not be apparent in the short term and were not inevitable. However there was evidence that case management could lead to an overall reduction in secondary care costs.

The Nuffield Trust, involved in the review, commented[27] “although in general the integrated care sites had lower than expected outpatient and elective care, there was no evidence that these sites were reducing the level of emergency hospital care. Overall, secondary hospital care costs for patients were not any lower than expected.”

The Kings Fund commented[28] “Perhaps the most unexpected result from the pilots was a significant increase in emergency admissions (9% in the six sites that focused on case management)”. The Kings Fund explained this as “an increase in emergency admissions as patients are appropriately admitted for specialist care” because they were getting more attention.

Research published in the BMJ in 2012[29] examined case-management of high risk patients. “Most admissions come from low risk patients, and the greatest effect on admissions will be made by reducing risk factors in the whole population rather than in a small group of high risk people… To manage this [high-risk] caseload would require a huge investment of NHS resources in an intervention for which there is no strong evidence that it reduces emergency admissions.” Three trials of interventions had to be abandoned because of increased deaths among the patients involved.

Research at the University of Manchester published in 2015 [30] involved a systematic review and meta-analysis of case management for ‘at-risk’ patients in primary care. It concluded “Current results do not support case management as an effective model, especially concerning reduction of secondary care use or total costs”.

In 2014, researchers at the Centre for Health Economics at the University of York examined the impact of pooling funds across health and social care services.[31] They reviewed 38 projects in 8 European countries, including 13 in England, and found that “compared with usual funding arrangements, schemes that pooled funds and resources to support integrated care seldom led to improved health outcomes. Although some schemes succeeded in shifting care closer to home, and some achieved short term reductions in acute care utilisation, no scheme demonstrated a sustained and long term reduction in hospital use.”

As reported in the HSJ in Sept 2015,[32] the Foundation Trust regulator Monitor sees potential in bringing care closer to home, but states: “Our findings caution against expecting too much from a shift away from hospital settings; this is no panacea.” Monitor concluded that although schemes to move care out of hospital will be important in addressing longer term needs, they may not be able to address more immediate operational and financial challenges.

In 2014 a Commission on Hospital Care for Frail Older People,[33] established by the Health Service Journal and Serco, began its Executive Summary bluntly:

“There is a myth that providing more and better care for frail older people in the community, increasing integration between health and social care services and pooling health and social care budgets will lead to significant, cashable financial savings in the acute hospital sector and across health economies. The commission found no evidence that these assumptions are true.”

Keep Our NHS Public asked Liverpool City Council for the clinical evidence in favour of integrated care. They replied[34] by listing the FYFV Vanguard sites designated in Sept 2015, as if the fact that a pilot project has been selected for funding proves that it will turn out to be clinically effective, safe, and cost-effective, when it has been evaluated and the results published.

10. So what if there’s no evidence, why not just experiment?

On us, without our consent?

What’s the point to medical school, if doctors were to ignore evidence when recommending a treatment for their patients or improving services? And just imagine if someone got funding to conduct a 2 year drug trial, and his mates told the hospital to sell their stocks of antibiotics because they were “very confident” they wouldn’t need them in future, and anyway their friend needed the money wasted on antibiotics right now to launch his business…

11. What’s happening in Parliament?

During the debate on the Cities and Local Government

Devolution Bill (now the Act[35]), Health Minister Alistair

Burt declared:[36]

“proposals for reconfiguration must currently meet the Government’s four tests for service change: support from local GP commissioners, clarity on the clinical evidence base, robust patient and public engagement, and support for patient choice.”

Deregulation of healthcare was concealed in the Act through careful phrasing. Although Clause 18 appears to safeguard the core duties of the Sec of State and regulatory functions of national bodies, there is a loophole.

When responsibility for healthcare is devolved to a local authority or combined authority, the Act requires (Clause 18 (1) (c)) “provision about the standards and duties to be placed on that authority having regard to the national service standards and the national information and accountability obligations”.[37] But “having regard to” does not mean “implementing” or “ensuring adherence to”. As the Act explains (18 (5)) , “standards are “placed on” a body if the body is required to have regard to or comply with them”. The word “or” means the local authority need not actually comply with whatever new duties are drawn up “having regard to” current national standards.

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The Act provides for several models of devolution, for healthcare or other services. The local authority can

• have the function instead of the public authority,

• exercise the function alongside the public authority

• exercise the function jointly with the public authority,

[which may or may not continue its own function]

• property, rights and liabilities can be transferred from the public authority to the local authority

• the public authority can be abolished where it will no longer have any functions

12. Must the CA accept NHS Devolution?

We don’t know what Chancellor George Osborne told

Council Leaders when they negotiated the Devolution

Agreement behind closed doors. But according to the Cities and Local Government Devolution Act, the transfer of powers requires the consent of the local authority. During the debate, Health Minister Alistair Burt stated “There is nothing in the Bill that requires an authority to take on a national health service function.”[38]

13. Any other Gov’t plans for the NHS?

Plenty, but that’s another story, even involving the Chief Exec of Manchester City Council.[39] [40] [41] [42]

14. Where is NHS Devo heading?

The Devo Manc plans are currently described as delegation rather than devolution, because NHS England will retain direct control through the appointment and employment of a Greater Manchester Chief Officer.[43] Devo Manc faces a projected £2bn shortfall by 2020, which they hope to tackle with new payment methods to “incentivise cost reductions from efficiency improvements and effective demand management”. They will turn to the private sector to fund capital projects.[44] The Strategic Plan is not explicit that NHS care will remain free at the point of need, or comprehensive (all the required health care that has been available on the NHS), or universal (available to all) – except for child health and antenatal care, or that general taxation will fund NHS care. A Provider Forum developing New Models of Care will include the private sector.

The new models are based on systems, such as Accountable Care Organisations, developed by US healthcare firms.[45] As announced in December, “Barking & Dagenham, Havering and Redbridge aim to develop an Accountable Care Organisation, where primary and secondary care are more closely integrated and patient pathways are redesigned with a focus on intervening early and managing the chronically ill.” [46]

The Dept of Health and NHS England must know there is little or no clinical evidence that their devolution and integrated care plans will improve healthcare for patients. But perhaps they are ploughing ahead for very different reasons: to create the conditions for wider and deeper privatisation of the NHS.

No firm is big enough to buy the NHS as a whole, with an annual budget of over £100bn. But something the size of a Devolution pilot might be an attractive proposition, once healthcare is deregulated, patients have grown accustomed to personal budgets, health insurance schemes

proliferate, “productivity savings” mean staff are forced into 7 day working without proper pay rates for nights and weekends, national agreements covering pay, terms & conditions are replaced by local arrangements…

It could happen, but why should we fall for it?

KONP Merseyside c/o News From Nowhere, 96 Bold St L1 4HY
Notes

1 John Lister, Morning Star 4 Apr 2016 http://goo.gl/g1cUnm

2 Guardian 18 Mar 2016 http://goo.gl/kwBrsq 3 Guardian 29 Jan 2016 http://goo.gl/cMch9H

4 Times 5 Feb 2016 http://goo.gl/HVk6E7

5 NHS England Oct 2014 https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

6 Liverpool City Region Sep 2015 https://goo.gl/kQun69

7 LCR Local Enterprise Partnership 17 Sep 2015 https://goo.gl/XXoevl

8 HM Treasury and LCR 18 Nov 2015 https://goo.gl/QZPE7M

9 LCR Combined Authority 20 Nov 2015 http://goo.gl/Lo3J35

10 LCR Combined Authority 18 Dec 2015 http://goo.gl/3wNw4V

11 Liverpool City Council 8 Jan 2016 http://goo.gl/7uQZtA 12 NHS England 2016 https://www.england.nhs.uk/ourwork/part-rel/transformation-fund/bcf-plan/