The latest, shocking statistics showing the scale of the decline of NHS performance on almost all of its key targets raise serious questions, not only about the need for more staff and more funding to run services and invest in new and improved buildings and new equipment, but also about the senior management of NHS England and its chief executive Simon Stevens.
The priorities, policies and attitude to staff and to public accountability of Stevens and the team around him have shaped the service, and must be seen as partly responsible for the decline in performance of NHS services.
They must also share the responsibility for the grim revelations of the scandals of mistreatment of maternity cases in Shrewsbury and Telford Hospitals Trust, which seem certain to reach a scale far worse than the previous worst maternity scandal at Morecambe Bay, and eclipse the scale and severity of the Mid Staffordshire Hospitals scandal in the mid 2000s.
If Stevens had performed on a similar level as manager of a Premier League football team or many private businesses he would have been out on his ear several years ago.
It’s now more than five years since Stevens, a former Labour councillor and advisor to Tony Blair’s government, took over at NHS England after working nine years as a vice president of US health insurance giant United Health. Six months later he published a major policy document, the Five Year Forward View (FYFV).
Latest figures confirm downward trend in NHS performance
Looking back at the 44-page FYFV is like stepping into a museum: most of the key commitments have long ago been sidelined or reduced to token gestures, not least the insistence that:
“The future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health.”
But while the plan presumed improved public health, since 2014 we have seen year after year of cuts to public health budgets which are supposed to fund schemes to help tackle obesity and reduce consumption of alcohol, drugs, and tobacco. This is not Stevens’ fault: but what is his fault is that his plan rested on such unrealistic assumptions.
Main ideas
Many of the main FYFV ideas, whether people agreed with them or not, have also remained little more than words. For instance patients were to be given control over shared budgets for health and social care – a controversial idea with many campaigners, and one which lacks sound evidence that it can work in the NHS. Stevens in a July speech in 2014 suggested “north of 5 million” such personal budgets might be operational by 2018, sharing £5 billion between them.
But this apparently bold proposal, if funded at that level, would have meant average payments of just £1,000 per year, £20 per week – well short of the amount required to secure any meaningful care package for any but the most minor health needs – even if the services required were available, and the patient/client was confident enough and able to sort out their own care.
Moreover the latest figures show that the vision was unrealistic on almost every level: the number of personal health budgets has apparently been rising each year since they launched in 2014, but there were fewer than 23,000 people receiving one in the first nine months of 2017/18 – a long way short of 5 million.
Carers, too, were promised new support by the FYFV (not for the first time, and no doubt not for the last). Yet the plight of carers remains desperate, with increased misery for many of them hit by the succession of welfare cuts and the nightmare of universal credit.
Barriers
According to the FYFV, barriers between GPs and hospitals, physical and mental health and health and social care were going to be broken down.
A “Forward View” for GPs has since been published: but there was also supposed to be a shift of investment from secondary care into primary care, which has not happened (how many times have governments proposed that since the 1980s?).
So barriers are still intact. Overworked, under-staffed GPs face ever-increasing demands, with no sign of the promised increase in numbers or resources; in frustration they are now calling for an end to the requirement to do home visits.
The FYFV also made bold promises to invest in more staff and improved services for mental health. Predictably none of these things have happened. Instead there are still thousands fewer mental health nursing staff now than there were in 2010, and the performance on almost every measure is as bad or worse than 2014.
It also went on to propose new “models of care”, including Primary and Acute Care services (PACS).
Stevens compared these with “Accountable Care Organisations that are emerging in Spain, the United States, Singapore, and a number of other countries.”
Given his previous employment, this understandably led to widespread fears of ‘Americanisation’ – despite the fact that few such organisations have been proposed here, and even fewer launched, none of them involving private companies.
Long Term Plan
After such a comprehensive failure to deliver almost any significant element of the FYFV, the likelihood of making the TEN year Long Term Plan (LTP), published back in January, any more than a wish list or a pious declaration seems to be vanishingly small.
The Long Term Plan does contain a few positive concessions to the pressure of campaigners and the needs of patients:
New waiting time targets are to be introduced for adult and child mental health – although these are far from ambitious and without extra funding imply cutbacks elsewhere;
A promise of action to address unexplained mortality for people with learning disability and autism and the long waits they experience;
No explicit call to close acute hospital beds;
The idea is floated that the NHS take back responsibility for some public health provision.
These few positive elements must not distract us from the hard proposals in the LTP for a further top-down reorganisation of England’s NHS – into a centralised structure of 44 “Integrated Care Systems” (ICSs) which are to “grow out of the current network of Sustainability and Transformation Partnerships” (STPs) within two years.
They are to be policed by regional directors and a network of ‘joint NHS England and NHS Improvement regional directorates’ announced in November. That’s the meat of the Plan.
As proposed in the LTP, none of these new structures will be in any way accountable to the local people and communities they cover.
Each ICS would work to an ‘Integrated Provider Contract’ – along the lines proposed by NHS England in 2018, and opposed by many campaigners. Once again there is no guarantee that the new contracts could not be sub-contracted to the private sector.
The Plan also requires a series of mergers to reduce from 191 Clinical Commissioning Groups to just ONE CCG per ICS. The remaining CCGs are also required to cut their management costs by another 20%, ensuring they are reduced to rump bodies with residual token power, in practice accountable to nobody. Trusts, too, would be required to collaborate with the wider ICSs.
With local authorities once again not even consulted on the Plan, it’s clear that just like the “Sustainability and Transformation Plans” that were hatched up in secret in 2016, none of the Plan would be subject to any consultation with staff, the public, or anyone else.
Private hospitals
Tucked away in the Plan are more hard-edged proposals for increased use of private hospitals to deliver NHS funded care to limit waiting times (already being surreptitiously driven through by NHS England), as well as new pressure on trusts to increase their links with the private sector to “grow their external (non-NHS) income” and “work towards securing the benchmarked potential for commercial income growth.”
There is also an implicit threat of privatisation in the LTP proposals for new pathology networks and imaging networks to be established, in the absence of the necessary NHS capital for investment.
Trusts are told they must also aim to increase the funds they get from charging patients for treatment – “overseas visitor cost recovery” – a policy which will raise little money in relative terms, but which will deter some patients from accessing the services they need, undermines the principles and values of the NHS, and which is opposed by the medical Royal Colleges.
CCGs and trusts with the toughest financial problems, and often with the most inadequate resources, face the hardest targets and the harshest treatment.
The Operational Planning and Contracting document, published on 21 December 2018 (and subsequently re-issued in January 2019) set out proposals for “savings” of more than £200m a year to be delivered from restrictions on GPs prescribing a growing list of drugs and treatments.
Some CCGs have already gone well beyond the initial list of exclusions drawn up by NHS England, and in a number of cases the private sector is eagerly lining up to offer to sell patients the operations and treatments they can no longer routinely get on the NHS.
To sugar the pill, the Long Term Plan has to say something and so it rattles out upwards of 60 uncosted commitments to improve, expand or establish new services. Most of them, if taken at face value would be most welcome – but taken together in this context they are completely unaffordable, unrealistic and incapable of implementation.
There is promise after promise, many of them sounding great: prompt response services, proactive care, flexible teams, neighbourhood teams, primary and community care teams, community multidisciplinary teams and upgraded support. All these are presented in happy-clappy, completely abstract terms, without explaining how they were chosen, who would be responsible, or the timescale for implementation.
The Plan insists on a ‘digital first’ option for most consultations in ten years, a vision of future services that many patients would view with trepidation:
The obsession with digital access runs as a theme through the Plan, and ignores recent research that showed Skype-type online consultations are suitable for only small minority (2-22%) of hospital outpatients, with many clinics finding them completely impractical.
There is growing evidence of the weaknesses and limitations of the much vaunted Artificial Intelligence chatbot produced by Babylon, and similar digital innovations lack evidence they are effective, or cost effective.
Fatal omissions
Of course it’s impossible to discuss the LTP’s content without also addressing the vital issues that are omitted from it. An enormous number of major issues are either ignored completely or blithely brushed aside in the 136-page Plan.
These include the declining actual performance of trusts; the inexorable rise in emergency caseload; the insufficient capacity in acute and mental health services and bed shortages; the £6.6 billion and rising bill for backlog maintenance; the cuts inflicted in mental health and community services; the impact of repeated cuts in public health budgets; the widening gap in society between rich and poor and the resultant inequalities in health – exacerbated by unchanged austerity and reactionary government policies on housing, welfare, education, and local government: and of course the gathering crisis of a dysfunctional social care system, for which the long-promised Green Paper has repeatedly been postponed.
No serious workforce plan has yet been published, and there is no evidence work on this has advanced at all; and there is clearly not enough money in the pot to pay for all the new ideas, or the extra staff that are needed.
Staffing crisis puts patients at risk
Every informed observer has warned that the famous £20.5 billion real terms “extra” funding over five years repeatedly announced since last summer [and now misleadingly rebadged by PM Johnson as a £33.9bn increase in cash terms]is not enough to do much more than stabilise the NHS and keep the lights on.
Sadly it’s clear that with the financial constraints limiting any real improvement, and a new system being imposed from top down and accountable only upwards to NHS England, patients and the public will have less voice and influence than ever in the shape of services and their access to them. Everything about us would be decided without us.
The Long Term Plan is a medium term threat to the services we all depend upon – and our ability to find out what’s happening and fight back locally to defend the services we need.
In the past five years US health corporations have made no real attempt to exploit the market established by the 2012 Health and Social Care Act to win contracts to deliver health care, hospital services or even health insurance in England, and remain largely on the sidelines, seeking lucrative but relatively small scale back office roles in the NHS.
If Simon Stevens is their Trojan Horse, designed to “Americanise” the NHS, there is little sign the conspiracy is succeeding.
Rather than developing complex theories about the extent to which Simon Stevens is promoting US corporate interests we need to focus on flaws inherent in his “reforms” and organisational changes since 2014. These have been:
Outside the law, and therefore lacking, and avoiding, any proper scrutiny by parliament, local government or local people;
Centred on creating local and regional level organisations which also lack any accountability to local communities;
Aimed at centralising services, at the expense of closures and downgrades of local A&E and other services, while lacking the capital to provide or expand alternative services;
Focused on inappropriate and ineffective US-style “integrated care” despite the lack of evidence this can limit demand for care, or deliver any significant benefit to patients;
Lacking any focus on workforce strategy and training of sufficient numbers of professional staff, while also turning a blind eye to efforts by hospital trusts to dodge VAT and other taxes by transferring their own support staff against their will into wholly owned companies outside the NHS – thereby undermining the integrity of the existing workforce and quality of services;
Indifferent to the continually worsening performance being delivered month after month by underfunded, overstretched and under staffed hospitals and mental health services;
Increasingly putting patients’ lives at risk by putting front line staff under impossible pressure and worsening the recruitment and retention of staff vital to quality care.
The pattern has been one of consistent failure masked by the rhetoric of grand, impractical plans, few of which have been carried through.
It’s time Mr Stevens was properly called to account.
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