Social Scare

The unseemly collapse of Cambridgeshire and Peterborough’s older people’s services contract is another smoke alarm for the NHS and social care – and highlights the folly of putting highly complex care out to tender. The £800 million contract over five years sounds a lot until you realise it’s supposed to transform care for frail, vulnerable older people often with multiple diagnoses across England’s largest clinical commissioning group. The plan was to join up services and keep the neediest patients well and out of hospital (particularly emergency departments) – and to discharge those patients who neither need nor want to be in hospital more quickly.

Cambridgeshire and Peterborough CCG spent over a year and £1 million on ‘the tendering process’ with the help of assorted management consultants and NHS England’s Strategic Projects Team (SPT). Part of the payment for the contract was to be dependent on successful outcomes (such as keeping patients out of hospital). Several private companies looked at the deal and pulled out, and the tender was awarded to the NHS, or rather ‘UnitingCare’, a limited liability partnership established by Cambridgeshire and Peterborough Foundation Trust, and Cambridge University Hospitals FT. It began running services in April 2015 and 1,200 staff were transferred to the new employers. After 8 months UnitingCare and the CCG have terminated the deal as it is “no longer financially sustainable”.

Cambridgeshire and the SPT have form in calamitous tendering. When Circle pulled out of Hinchingbrooke Health Care Trust, at least it tried to explained its reasoning in public before passing the buck onto the CQC, but no detail has been given on the latest failure. NHS England is planning to roll out similar schemes with capitated budgets for entire populations and payment by outcome, but if the budgets remain absurdly tight and neither the commissioners nor providers have the financial nous or knowledge of complex systems to make it work, there could be a few more ‘de-tenders.’

One difficulty with outcomes based payments is that the ultimate outcome for all of us is death. It can be a gentle and welcome release or a very long, expensive and unpleasant process. Keeping death at bay is more to do with individual behaviour and life circumstance than health services. All providers of social care are struggling to give high quality care for the elderly on such a tight budget. The demands of paying for the living wage, pensions, travelling time, regulatory and training burdens, and the longer visits these patients needs makes it almost impossible to break even.

Debt and bankruptcy amongst social care providers could spell disaster for the NHS. There are currently more than 12,000 organisations, from big corporate chains to small family-run businesses, charities and social enterprises, fighting for custom. Less than 10 per cent of social care is now provided by councils or the NHS (long term care fell off the NHS with little debate under the Thatcher government). There are three times more care home places than hospital beds, and half a million people have home care services to be able to live at home. Many of these providers are in dire financial straits particularly the larger chains that rely on local authority funding.

The amount local authorities pay for this care has fallen 5% in real terms over 5 years. Many care homes now charge up to 40% higher for self-funding people to compensate for the shortfall in local authority funding. Others are simply refusing to accept state funded placements. Rumours abound that another ‘Southern Cross’ style failure of a big social care provider is imminent.

As with the NHS, there is a shortage of nurses and high spends on agency staff. In 2014, the Care Quality Commission found 20% of nursing homes did not have enough staff to provide good, safe care. The CQC also lacks the resources to pick up and close down rogue operators who keep re-registering under different names. The social care system has been underfunded for decades, and failed to keep pace with increasing life expectancy, frailty and dementia. In shifting social care to a private business model, both good and bad care homes go bankrupt in times of austerity. And now state providers in the new NHS market are pulling out of care for the most vulnerable and needy patients because the figures don’t add up. Those most in need of care are least likely to get the care they need. Without investing in social care, the NHS will be forever in debt. Happy New Year.

MD’s book, Staying Alive – How to Get the Best from the NHS – is available here

What is a ‘truly 7 day NHS?’

Jeremy Hunt’s belated U turn on ACAS mediation with the BMA over the junior doctors’ contract postponed strike action but came too late to prevent the cancellation of 600 operations and 3,500 outpatient appointments. This could have been avoided had Hunt taken up the offer of ACAS talks on November 19, rather than a week later. Hunt may have been teasing George Osborne, using the threat of a strike to force a better than expected deal for the NHS from the spending review. Or he may simply have blinked first when he realised junior doctors were serious about strike action.

Osborne was also pressured by NHS chief executive Simon Stevens who publically asked for £4 billion of the £8 billion promised by 2020 to be ‘front-loaded’ next year, and then secured himself a slot on ‘Any Questions’ on Friday in case it wasn’t. Osborne had the last laugh by claiming to give £3.8 billion next year and making lots of absurd claims about how many more doctors, nurses and operations it would buy. In fact, £1.5 billion has been stolen from existing Department of Health budgets, cutting the budget for public health (such as smoking cessation and sexual health) and clinical training (including the cost of junior doctor placements and nurse bursaries).

Stevens wanted additional funding for ‘a seven day NHS’ but this has now to be found from existing budgets. Overall, 2010-2020 will be the tightest 10 years of in the history of the NHS, with an average annual increase of under 1%, and lagging further behind GDP health spend of France and Germany. £3.8 billion will just about pay off this year’s debt and keep the lights on for another year. Hunt may have to choose between being remembered as the Health Secretary who prioritised patient safety but failed to stick to an impossibly tight budget or trying to please Osborne and risk harming patients.

Hunt’s further difficulty is that the government has made a manifesto pledge about a ‘truly 7 day NHS’ that no one understands. The NHS already provides round the clock emergency services that doubtless could be better staffed, but not for free. If the government demands 7 day non-emergency services with identical outpatient appointment times, operation slots across all specialties every day, and GP surgeries open 7 days a week, that clearly has significant resource and staffing implications that Osborne won’t pay for. Hunt and David Cameron have repeatedly sighted Salford Royal NHS FT as a hospital that already provides ‘truly 7 day working’ but the staff on the ground are less convinced. These quotes from SRNFT doctors were collected by GP and journalist Dr Faye Kirkland:

“I work at Salford. They do not have 7 day working yet. The weekends are ‘on call’ cover only.”
“There is excellent daytime anaesthetic cover at the weekend but the only lists are emergency lists.”

“Neurosurgery is 7 day full emergency cover and elective ops only take place Monday to Friday.”
“We do not do what Hunt claims. We have also not told him that we do. I doubt the trust will rebut & risk both sides turning on them. Don’t get me wrong – I am immensely proud to work at Salford and think we do a load of things brilliantly. But there’s loads we don’t and we have to save money now so definitely can’t expand into weekends in the way the press reports.”

Dr Pete Turkington, Salford Royal Medical Director, said: “Our vision of a seven day service has been primarily focussed on providing reliable and standardised emergency care (non-elective) every day of the week. It has never been our intention to have a full seven day elective service. We’ve made enormous strides in delivering a safe and effective emergency service to our patients across the entire week.”

If Hunt and Cameron are to regain the trust of doctors and other NHS staff, and avoid the huge risk of strikes in the middle of January, they must stop spinning and start telling the truth. Staff and patients need to know exactly how much is available and what services can safely be provided at a time of such austerity without spreading them so thin that they collapse entirely. A ‘truly 7 day NHS’ is a pipe dream, the focus must be on providing the best emergency care, 24/7, including Christmas.

MD’s book, Staying Alive – How to Get the Best from the NHS – is available here