Nottinghamshire is one of the eight “first wave” Integrated Care Systems being established by NHS England, and discussed at length in the NHS Long Term Plan (LTP) published in January. It was also one that experimented with a short-term contract to enlist the services of US health insurance corporation Centene (headed in Britain by former high-flying NHS boss Samantha Jones) to help design new services, though there is now no sign of any continued US involvement.
Nottinghamshire’s ICS appears to be functioning on a very different basis from the obsessive secrecy and efforts to ensure centralised control that have marred most other proposals billed as “integration”. Partly as a result of pressure from Nottingham’s Labour-led City Council, which walked away from the process last December, complaining of “lack of democratic oversight,” the Leadership Board of the Nottingham and Nottinghamshire Integrated Care System (ICS) has agreed to hold its meetings in public, doing so for the first time in April. It has also begun publishing its board papers and minutes of meetings.
The Leadership Board also agreed that rather than dividing Nottingham and Nottinghamshire into two “Integrated Care Systems” it will instead have three — with a separate one for the city of Nottingham, one for Southern Nottinghamshire and another for mid Nottinghamshire. Whether this still complies with the notion of “integration” in any meaningful sense of the word is debateable.
However responding to these developments, the City Council agreed in April that it would rejoin the ICS as a full member – provided that the ICS agreed to bring in a system of unanimous voting on “any proposals that might lead to outsourcing or privatisation of NHS services.”
So it’s already clear that the process is proving very different from that spelled out in the LTP. That describes a network of ICSs to cover the whole of England “growing out of the current network of Sustainability and Transformation Partnerships (STPs),” and takes a very different approach:
“Every ICS will need streamlined commissioning arrangements to enable a single set of commissioning decisions at system level. This will typically involve a single CCG for each ICS area.” (p29).
Far from streamlining, Nottinghamshire health chiefs appear to have bought an appearance of unity by adopting a fragmented model, in which not only the council but any one of the constituent bodies would potentially be able to exercise a veto, by preventing the required unanimous vote.
In other respects, too, the Nottingham and Nottinghamshire Health and Care Integrated Care System (ICS) System Operating Plan 2019/20 shows a complete departure from much of the original STP plan that was cobbled together during 2016, and rubber stamped by NHS England at the end of that year. That plan is understandably barely mentioned at all, given that it was based on assumptions that have already proved false, including:
· Reduce “mental emergency attendances” and readmissions over the next two years by 10% (p10)
· 20-40% reduction in non-elective admissions
· 15.1% reduction in A&E attendances
· 30.5% reduction in Non elective acute bed days
· 25% reduction in admissions to nursing and residential homes
· 9.8% reduction in secondary care elective referrals (p68)
The STP’s authors expected these very substantial (and largely imaginary) reductions in acute activity (a reduction of 30% in south Nottinghamshire and 19.5% in mid-Nottinghamshire, p10) would make it possible to reduce numbers of acute hospital beds – by 200 (p68). Specifically City Hospital was to be “downsized,” with its estate reduced by 20%, with further estate sales at Kings Mill (p54).
Instead the plan was to provide care in (undefined) “alternative settings that are more appropriate for our citizens.”
“Care will be reprovisioned to short term residential/community beds, short term assessment beds, standard residential beds and also supported at home living.” (p69) According to an 11-page annex to the STP (which now appears to be no longer available online) the plans also involved a 2.7% (562 FTE) overall reduction in workforce over 5 years, centred on acute services, with a proposed reduction of 647 staff in urgent care and 691 in planned care, despite an expected 9.3% increase in demand over the same period.
In fact NHS figures show that emergency admissions, total admissions and A&E attendances have each gone up over the past two years at both Nottingham University Hospitals and at Sherwood Forest Hospitals trust. Moreover the new Operating Plan (page 86) now expects future numbers of both emergency and elective admissions to increase even faster, by 5.6% and 3.8% respectively in 2019/20, and A&E attendances to increase by 3.3%
The staffing plans have also been quietly abandoned: between May 2016 and January 2018, both acute trusts increased their staff numbers – NUH by 15%, SFH by 7.7%: only the mental health trust (Nottinghamshire Healthcare Trust) slightly reduced its numbers of staff.
The ICS Operating Plan, which went to trust boards and governing bodies in April, now faces both ways on cuts. On page 32, a diagram calls for action to save £12m in 2019/20 by:
· Reduce A&E attendances
· Reduce emergency admissions
· Reduce long term placements
· Reduce long term placement costs
Under Urgent and Emergency Care, it seeks to save £14m, by
· Reduce bed days
· Reduce long term placements
· Reduce long term placement costs
In addition, cuts in numbers of outpatient appointments are projected to save £10m, and reduction in Musculoskeletal (MKS) services is expected to save another £5m. Mental health is also expected to save £5m – despite all the fine words in the Long Term Plan about improving access and imposing maximum waiting times for mental health care. Across the ICS there are vague proposals to save £9m from “back office” services – that run the risk of dumping admin work onto clinical staff – and £10m from “procurement”.
None of these proposed savings come with any detailed explanation, and there is a large caveat to the whole page highlighted in a red box which states “Note: all opportunity figures (in bubbles) – £m – are gross, high level and indicative”. In other words they have little value.
Despite these apparent targets, the rest of the document appears to be proposing nothing but service improvements, and are inconsistent with the notional target of reducing spending.
However anyone seeking any serious analysis from the document should take it with a generous pinch of salt. The March meeting of the ICS Board (minutes published in April) urged anyone drafting documents always to accentuate the positive, even to the extent of inverting the facts:
“Where possible outcomes should be described as ‘increases’ rather than ‘reductions’ so they are described in a positive frame” (p4)
The same Board discussion seems to have reacted with alarm to the idea that resources might be redirected to deprived areas:
“It was queried as to whether the framework might drive resource to deprived areas which may have an impact on other areas. WS responded that this would need to be thought through; adding that reducing inequalities may mean spending differently.”
Some of the most remarkable innovation is in the eccentric and jargonised use of language. We are left to puzzle for the meaning of the statement on page 40 that:
“Continuous improvement work continues on the front door pathways which started in December 2018. Working with the front door teams to allow access to back door discharge to assess services.”
Is there any scope for patient care in between being speeded in through the front door and bundled out of the back? Further down the same page we find a discussion of “Options to develop additional acute capacity”, which states:
“in addition to the focus on redesign, work is also being undertaken to develop potential options for the provision of additional acute capacity in case insufficient alternative schemes can be identified to mitigate the current forecast gap in capacity vs expected demand in 2019/20.”
There is a striking lack of either estimated costs for some positive proposals to expand social care and reduced delayed discharge, or any workforce plan. So questions remain over plans to develop a “Home First Strategy” to provide “adequate capacity and capability within the domiciliary home care market,” or the prospects if increasing “large care packages >27hrs/week & 4x a day double ups”. (p40)
Nor is there any estimate of costs or staffing implications in establishing “emergency ambulatory care”, or reducing long lengths of stay in hospital “to ensure we have fewer than 199 patients in hospital with a length of stay more than 20 days”. (p41)
The plan proposes to “Improve the acuity capability of community beds” but also increase utilisation of community beds “from 85 % to 92 % occupancy”. (p42)
On mental health, where spending cuts are planned, the less than ambitious proposals include increasing provision of services for Children and Young People – to reach just over a third of the numbers needing support:
“Develop actions to support the 19/20 requirement of increasing access to 34% of estimated 2004 CYP prevalence” (p49)
The challenge of recruiting and adequately training sufficient mental health staff is referred to, but not the cost. Instead the ICS vaguely promises to “build towards” 1,700 new staff by 2020/21.” (p50)
There are contradictory proposals to regularise use of private beds: “Transfer 16 spot purchased beds into a sub-contract in order to achieve better value and ensure care is closer to home.” (p49).
Yet on the same page is a proposal to “develop a full business case for inpatient provision in Nottinghamshire Healthcare Trust.” The scale of the problem of inappropriate out of area placements is enormous, with 20,488 bed days in 12 months to October 2018, and 150-180 additional beds needed by 2020/21).
The document continues in similar vein, with plans for the various provider trusts. But the problems faced by the trusts are glossed over. Nottingham University Hospitals for example is projecting a deficit of £68m for 2019/20: they have a 19% vacancy rate among nurses. Mental health services are short of 158 staff including 60 nurses. Nottinghamshire is also short 77 GPs – yet the ICS plans to increase the rate of referrals of urgent care patients to GPs from 6% to 25%.
Far from any streamlined, no nonsense integration of services the ICS confirms that Nottinghamshire’s NHS remains divided on many levels, locked in a crisis lacking staff, funds and beds, and dogged by continued production of hopelessly vague and unrealistic plans which are discarded some time later without learning any lessons.
In future issues of The Lowdown we will investigate other ICS plans to see if this is the norm.