The end of the NHS as we know it
By Trevor Carbin
We live in a place called BSW.
Actually its not a place but a footprint.
If you know what I'm talking about then you're already familiar with the latest National Health Service (NHS) jargon, and may even have read the Sustainability and Transformation Plan (STP) for the Bath & NE Somerset, Swindon and Wiltshire (BSW) area.
Sustainability means keeping alive whilst Transformation means changing. How do we change the NHS into something sustainable?
The reason it's not sustainable now is that the government is sucking money out of it. Without money it can't do the things it does, so will have to change.
So given that the purpose of the NHS is to deal with people who are unwell, how do we change it? Well the answer's obvious - you stop people getting unwell.
So everybody wins - we're all healthier, the NHS can get smaller and the people who work for it don't have to work so hard, and the government gets lots of its money back.
If you want to read the full document here's a link to the WC website - bring up the supplement.
Or if you don't want to here's a summary with extracts and comments:
"As our population continues to grow and people are living longer, often with long-term health conditions, the increasing demand being placed on our health and care services is falling out of line with the amount of available funding."
Which is the consequence of a political decision - we could fund the NHS adequately, but we choose not to.
"...if we continue to provide services in exactly the same way we will have a financial gap of £74 million in 2017/18."
"The vision describes the opportunities and challenges facing the NHS for the future, expressed as three key 'gaps': the Health and Wellbeing Gap, the Care and Quality Gap and the Finance and Efficiency Gap."
"Our plan doesn't mean doing less for patients or reducing the quality of care provided. Neither does it mean shutting Emergency departments." (So why does that need to be said?)
"It means working with you to enable you to take more responsibility for your health and wellbeing."
Costs are to be shunted on to individuals, charities and 'community partners'.
There are three major hospitals within BSW - the Royal United (RUH) in Bath, The Great Western (GWH) in Swindon, and Salisbury District. The STP says there are 'no plans' to merge them as they're too far apart geographically. However:
"A single view of the NHS estate has been established and there's a commitment to plan our estate at STP level."
BSW had a budget of £1.4bn in 2015/16 but came out with a deficit of £6million. 'Deficit' in this context means the difference between what the government told the NHS to spend and what it actually needed to spend. The budget for 2017/18 remains at £1.4bn, and 'efficiency savings' (cuts) of from 2% to 4.3% are required from the three Foundation Trusts and the mental health provider.
The STP sets out five priorities for change as:
1. The development of locality-based integrated teams supporting primary care. (Re-inventing General Practice)
2. Shifting the focus of care from treatment to prevention and proactive care. (!)
3. Redefining the ways we work together to deliver better patient care. (Another NHS re-organisation)
4. Establishing a flexible and collaborative approach to workforce. (Sacking people)
5. Further enabling acute collaboration and sustainability. (Cost-cutting)
It's not all negative - here's a good bit for those who've been arguing for parity of esteem between physical and mental illness: "The STP is determined to embed parity between mental and physical health care. This document should therefore be read with the implicit assumption that all initiatives relate equally to mental and physical health and social care."
The STP sees a variation of problems across BSW. In Swindon people are fat and smoke a lot, whilst in BaNES they're more likely to self-harm. In Wiltshire we suffer from hypertension. Across the patch not enough is being done for diabetes patients, and social inequality means wealthier people live longer by as much as 11.7 years. This fact leads to an interesting bit of jargon - there is apparently less 'affluent dilution' in Swindon. Affluent dilution sounds like what they do at the sewage works but it actually means better-off people mingling with the general population.
Here are some more budget figures to compare and contrast with the ones given above:
• Funding (income) available to the STP rises from £1.7 billion in 2017/18 to £1.9 billion in 2020/21
• Expenditure projections rise from £1.8 billion to £2.2 billion over the same period
• The funding gap rises from £100 million (6% of income) to £290 million (15% of income) by 2020/21.
The other thread running through the document, apart from self-help, is getting health and social care to work together so people stay in their own homes rather than ending up in hospital. Or if they must go to hospital getting them out as soon as possible and, preferably, back into their own homes. The nirvana of a fusion of health and social care has been talked about for years but hasn't really happened. When progress is made it can be unmade by budget cuts which force the NHS and the Local Authority care services into a competitive rather than a co-operative paradigm. It is though both desirable and achievable with a bit of effort on all sides.
At the Primary Care (GP) level the report promises more re-organisation, with GPs looking for economies of scale by coming together into networks serving 20,000 to 50,000 people.
Here's a bit of NHS-speak I haven't been able to translate - if you can put this into English or any other known language then please do:
"The complexity in understanding the capacity and demand of the entire health system is a challenge facing all footprints and our current thinking reflects the need to take a population-based approach to planning."
An interesting and slightly worrying promise is that "Care Co-ordinators (will be) allocated to each GP practice, reducing unnecessary acute/care home admissions."
Another literary question - should it be an aging population or an ageing population? The report uses both spellings at random. Personally I'd prefer to be ageing, but perhaps it's a matter of individual choice.
The second priority is the Big One. Treatment is out, prevention and proactivity is in.
People are to be encouraged not to use hospitals by "Enabling access to alternative sources of urgent care through an enhanced Primary Care Model" (getting GPs to deal with emergencies) and "the integration of key professionals within the hubs including community pharmacists and improved links between GPs and secondary care consultants will reduce unnecessary admissions"
We're told that 10% of the NHS budget is spent on diabetes care, and that Long Term Conditions (LTCs) account for a significant proportion (up to two thirds) of expenditure. The cure for this apparently is to "Embed prevention and self-management along identified LTC pathways" and to make more use of volunteers - "Harnessing the voluntary sector will reduce pressure on the workforce"
If you work in the NHS you may have noticed the STP's aspiration to "Take a broad look at who is the health and care workforce and consider the way different roles work together."
At the same time social marketing is to be used to encourage people to take their flu jab.
Under planned care, a "new system-wide Referral Management Service" is to be introduced to control hospital admissions. This will act as the bouncer at the hospital door: "This initiative would replace the Referral Support Services that currently exist and we envisage making referral via this new route mandatory. The service has the potential to both reduce clinical variation in referrals and reduce the total numbers of referrals into secondary care settings."
I haven't yet got to the p-word. We've been told that STPs will result in the privatisation of the NHS. The STP documentation doesn't mention privatisation, but privatisation lurks between the lines. Under the subject heading of commissioning and contracting for example, "we intend to seek alternative methods of contracting to encourage better management of supply across pathways or sub-geographies, using incentives to support the management of care delivery."
The STP's third priority deals with infrastructure. "Our estate comprises c200 sites across BSW and costs £175m per year to operate."
Self-care, better IT, merging of health and social care etc, mean that less of this will be needed in future. So buildings will be sold off. Ominously for those who like the local community hospitals: "There is awareness of the huge public attachment (and reassurance) in having a community hospital or health centre in close proximity to their home and therefore our estates plan is intrinsically linked to the design of new care models and establishing a compelling vision for the future."
And: "Our estates plan will be developed in conjunction with the One Public Estate programme being led by Wiltshire Council."
The fourth priority deals with the 40,000 strong workforce. All the right pronouncements are made: "Our workforce will be enabled to work flexibly, supported by IT, and will be sustainable and highly motivated. The new employment offer will attract, retain and deliver an improved experience for our workforce"
But wages cost £850million in 2015/16, though an aspiration to reduce agency staff could result in a £14million saving. There will be reduced numbers of corporate and support service staff.
What happens next? From January to March there will be a programme of public events and briefings to sell the STP to you. The next version of the STP will then emerge in May. Any significant closures of services or buildings would require their own formal consultation process. You can email comments to ruh-tr.STP-BSW@nhs.net
Going back to the document there's an interesting appendix on the financial drivers. Private providers "have been represented in planning the finances, savings priorities and discussions on collaborative transformation."
"These savings have to be delivered by service providers; and the solution will have to involve collaborative thinking and genuinely transformational change in all sectors in order for the financial gap to be closed. It is important to note that this transformation cannot be just about reducing expenditure in the system, it is also about managing demand and changing how our service users use our services."
Cuts and more cuts. Merging with social care is fine but those budgets are being cut as well. The government has allowed an extra council tax rise to help but it won't be enough. Cuts have consequences. If all the medicine prescribed in the STP does its work we'll have a healthier population less dependent on big hospitals and the NHS generally. If it doesn't, we'll continue to see a service bursting at the seams with poor outcomes for patients and an increasingly overworked frontline staff.