Care Closer to Home – 94% Cut to Calderdale Vanguard Funding

NHS England has just told Calderdale Clinical Commissioning Group that it has cut 94% of the 2016-17 funding for the Calderdale Multi-speciality Community Provider Vanguard scheme. This money was to pay for setting up Care Closer to Home schemes to replace hospital services that are to be cut as part of the contentious Right Care Right Place Right Time scheme.

Instead, the stealth-privatising quango NHS England is putting the Vanguard money into a new Sustainability and Transformation Fund – a carrot to reward areas (known as Sustainability and Transformation Fund Footprints) that eliminate the NHS deficit across their area and carry out various schemes that include – huge irony alert – requiring local partners to achieve investment in out of hospital provision.

The STP stick is that if STP footprints don’t eliminate the area-wide NHS deficit, they will not be eligible for any STP funding. This so-called Transformation Funding will from now on be the only available additional funds available – no more going to the Department of Health for bail outs.

What does this mean for the proposed hospital cuts and reconfiguration, that depend on Treasury approval for an extra £490m for CHFT, including £170m for deficit reduction? At the 18th May hospital cuts consultation drop in, I asked the CHFT Assistant Director of Strategic Planning, Katherine Riley. She said,

“STP has happened to us. This Consultation started in good faith. If circumstances have changed and we can’t deliver that model there’d be further consultations. Ask Matt Walsh about how the STP would affect the Treasury’s backing for the Plan.”

What is Care Closer to Home about?

Care Closer to Home is a scheme for the 8% or so of the public who have what’s called a Long Term Condition – eg frailty (as in frail and elderly), children with complex needs, and things like chronic respiratory and heart conditions and diabetes.

It aims to provide more care out of hospital so that people’s conditions don’t reach a crisis point so often, and if they do, care is available for them at home so they don’t have to go into hospital for emergency/acute care.

This sounds sensible and feasible. It doesn’t sound as if it needs a massive upheaval – just better coordination of existing services for this small proportion of the population. So why the current massive upheaval?

Something else is going on – that this otherwise straightforward expansion and improvement of primary and community care is a pretext for.

What is Care Closer to Home really about? A skid row NHS

Bean counters in the marketised, privatising NHS talk about Care Closer to Home in the same breath as QIPP and transformation. This is code for cuts and sell offs.

QIPP – Quality Innovation Performance and Productivity – is the brainchild of McKinsey, the global management consultancy company called in by the New Labour government after it had spent £trillions of public money on bailing out the bankers in the 2008 financial crash, that was brought about through the financial sector’s greed and criminality.

The government told McKinsey to come up with ways of cutting future NHS spending and McKinsey duly did so, identifying ways of reducing future NHS spending by £30bn by 2015. This became known as the Nicholson Challenge and was implemented by the Coalition Government in 2010. It is why CHFT and most other hospitals in England are now in debt.

Care Closer to Home is basically a plan to take services out of hospitals and totally reshape primary and community care in order to deliver services that were formerly provided in hospitals.

It has been in the pipeline since the New Labour government brought McKinsey and Kaiser Permanente staff into the Department of Health – around the time of its 2000 Concordat between the NHS and private health care companies. This was an agreement to open up the NHS to private companies.

Care Closer to Home – done properly – is more costly than care in hospital, as retired consultant Colin Hutchinson has explained to Calderdale & Kirklees Joint Health Scrutiny Committee:

“It takes more staff to deliver care in patients’ homes, because you can only treat one patient at a time, whereas on a ward, you can be treating and supervising the treatment of a number of patients. The staff also need to be trained to a higher level, as they do not have direct access to back up from more experienced nursing and medical staff.”

But Care Closer to Home is planning to run on far fewer qualified doctors and nurses, and far more less qualified, new grades of staff like physician associates, unpaid family carers and voluntary sector organisations. This is what NHS England’s Five year Forward View calls a “modern workforce”. The Right Care Right Time Right Place Pre-Consultation Business Case calls it:

“Enhancing generalist and collaborative skills for the Trust’s workforce across primary and secondary care to support delivery of the Commissioners’ QIPP requirements”

QIPP requirements are to cut spending or deliver more services for the same money, so this means there will be new grades of jobs that will be cheaper than the current ones.

Dr Bob Gill says this is about down-skilling. GPs will have a new title of consultant generalist and be supervising a less qualified team so the system will need fewer GPs. Those GPs prepared to work in the system will be providing medico – legal cover for a vastly lower quality service.

Dr Bob Gill calls it,

“A skid row NHS to drive us to take out private health insurance.”

So if Care Closer to Home is about cutting costs – but if properly delivered, it would cost more to deliver than existing hospital-based care, what is it really, really about? Beyond QIPP/cuts?

What Care Closer to Home is really, really about – Goodbye NHS – Hello USA Medicare!

Care Closer to Home is really, really about chopping up the NHS into organisations modelled on American private health insurance organisations called Health Maintenance Organisations – or their more recent version, Accountable Care Organisations. These health insurance organisations provide limited, cost-cutting health care for the publicly-funded Medicare/Medicaid system that covers Americans who are too poor or old to pay for private health insurance.

This comes right from the top – as  Jeremy Hunt MP told the House of Commons Health Select Committee on 9 March 2016:

The Government’s 2015 Spending Review settlement for the NHS committed the government to encouraging long-term partnerships with the private sector in a number of key areas – including development of new models of care including Accountable Care Organisations.

Here are Jeremy Hunt and Hebden Bridge GP Dr Mark Davies, in his other role as clinical lead at the Health & Social Care Information Centre (since renamed NHS Digital), visiting one of the main American companies that operate through Health Maintenance Organisations/ Accountable Care Organisations –  Kaiser Permanente

The promotion of Kaiser Permanente models of ‘integrated care’ as a template for the NHS has been going on at least since the late 1980s. When Thatcher’s 1990 NHS and Community Care Bill was introduced to Parliament, Kaiser Permanente’s contribution was explicitly acknowledged.  Once the New Labour government took over, it introduced Kaiser Permanente pilots in four areas of England.

Health Maintenance Organisations (HMOs) were promoted by President Nixon through the HMO Act of 1973, before he resigned in 1974 to escape impeachment for obstruction of justice, abuse of power, and contempt of Congress.  John Ehrlichman – later imprisoned for his role in the Watergate scandal – persuaded Nixon that HMOs were the future for American healthcare on the grounds that:

“All the incentives are toward less medical care, because the less care they give them, the more money they make.”

This seems to chime with Dr Judith Parker’s statement at Greater Huddersfield CCG’s 2015 AGM, about

“…realigning patients’ and carers’ mindsets towards…a different way of health services – enabling and empowering people to take care of themselves and control of their health needs.”

Why should the patients, carers and health workers who are going to be affected by Care Closer to Home need their “mindsets” “realigning” to its “vision”? Particularly since the CCGs are at pains to say that Care Closer to Home is giving patients what they’ve told the CCGs they want.

But “resilience” and “enabling and empowering people” are Big Society code words for cutting public services, making patients and carers take the burden of care, and radically downgrading clinicians’ working practices, terms and conditions.

New organisational forms based on Accountable Care Organisations

Care Closer to Home is meant to “wrap” community and social care services around GP practices – but the GP practices will be almost unrecognisable when the CCGs’ new primary care strategy kicks in.

This is all about delivering GP services “at scale” based on large GP Federations covering very large populations. This is despite the fact that the General Practice Committee deputy chair Dr Richard Vautrey says this isn’t going to solve the problems facing General Practice. He told Pulse Online:

“The bottom line is that there is only three-quarters of the historical investment left in general practice and working at scale won’t help solve this problem. We need to get back to 11% of NHS funding spent on general practice to have any chance of addressing the current crisis.”

A Multispeciality Community Provider (MCP), to be set up by the Calderdale Vanguard scheme, is a large scale, GP-led company – designed to serve a population of around 300K – that is a “lead provider” of:

• primary care (GP services, dental care, pharmacy, eye care)
• community health services
• specialised hospital care
• some urgent care

Being a lead provider means it provides most services itself and subcontracts out the rest.

In Calderdale, the GP -led company that is intended to become the Vanguard Multispeciality Community Provider is Wainhouse Healthcare Ltd, a private shareholder limited company also known as Pennine GP Alliance.

I asked Dr Nigel Taylor if Calderdale CCG sees Wainhouse Healthcare Ltd as a private sector organisation. He said,

“No – Pennine GP Alliance is not private sector, it is a GP Federation.”

All the GP members of the Calderdale Clinical Commissioning Group governing body are also GP member practices of Wainhouse Healthcare Ltd – aka Pennine GP Alliance. This presents the interesting prospect that the commissioner and lead provider for almost all Calderdale’s health services – bar some specialist acute hospital care and A&E – would be one and the same.

At the 18 May hospital cuts consultation drop in, I asked about the conflict of interest involved in Calderdale CCG awarding a lead provider contract to its own GP members, and whether this is ethical.

Dr Nigel Taylor said that there is an inevitable conflict of interest to deal with in everything the CCG GP Governing Body members do. So GPs would have to excuse themselves from that decision about awarding any contract to Pennine GP Alliance.

According to what Calderdale CCG told the March 2016 Calderdale Health & Wellbeing Board, the contract to “enhance community services” though the Care Closer to Home Vanguard scheme, will involve:

“creating an alliance model…built around the principles of Accountable Care Organisations , supported by new payment and contracting models. We will set out our high level milestones in the STP [Sustainability and Transformation Plan].”

An article by staff at Candesic, a management consultancy that advised the Department of Health on the £200m sale of our publicly-owned Plasma Operations to Bain Capital, says  that as a result of  alliance contracting:

“…great progress has been made in bringing the free market into the NHS…and…greatly increased the private sector’s involvement with (and income from) the NHS.”

Cherry picking patients

Health Maintenance Organisations like Kaiser Permanente provide less healthcare and make more money by cherry picking patients who are relatively healthy, and denying care to those who are likely to prove costly to treat.

The process that drives this cherrypicking is that Health Maintenance Organisations/ Accountable Care Organisations are paid on the basis of capitated payments. This is an average amount per patient, depending on their estimated level of need, and then the HMOs/ACOs have to provide managed care for them – in other words a set type of care that is taken to be appropriate for that patient’s condition and level of need.

Calderdale CCG plans to pay for the MCP Vanguard contract through captitated payments. Governing Body member Dr Nigel Taylor described this as:

“The Calderdale MCP lead provider will be given a cash envelope to provide the service and that this shifts the emphasis from commissioner to provider.”

This proved unworkable for the Cambridgeshire and Peterborough CCG Lead Provider contract for Integrated Care for the Elderly – worth £800-900m over 5-7 years. After a torturous procurement process, it was awarded to Uniting Care Limited Liability Partnership of Cambridgeshire and Peterborough NHS Foundation Trust and Cambridge University Hospitals NHS Foundation Trust.

In December 2015, Cambridgeshire and Peterborough CCG and UnitingCare LLP issued a statement that their contractual relationship had ended, because:

“Unfortunately both parties have concluded that the current arrangement is no longer financially sustainable…”

The idea of the capitated payment/”cash envelope” is that this will drive “efficiencies”, as doctors find ways to deliver the prescribed, controlled care more cheaply than the capitated payment, so they can make a profit.

In fact what has happened in HMOs like Kaiser Permanente, is that they’ve made money by denying patients care.

Calderdale GPs are aware of this risk – in 2014, when Calderdale CCG Governing Body was discussing whether to go to the next stage of the Right Care Right Time Right Place hospital cuts proposal (which was for the hospital Trust to produce a Strategic Outline Case), one of the GP members said that a risk of the proposed Care Closer to Home scheme was that it would have to avoid cherrypicking patients.

But this seems already to be happening in the Calderdale Support and Independence Teams’ work last year (2015). These Teams – one of the Care Closer to Home schemes – are a hospital Trust/Calderdale Council working arrangement to look after elderly people who need “reablement” after being in hospital, and who make then need further home care after being “reabled”. The S&I Teams’ 2015 Report says,

“The targetting of Reablement resource to people who are more likely to benefit – that is to say, applying clear referral criteria – is seen as highly beneficial to the outcomes achieved.”

What is this, if not cherrypicking?

Speeding up patients’ transfer from free NHS services to means-tested privatised social care

Another characteristic of this Care Closer to Home scheme is that it aims to speed up the progress of patients from free NHS care to means-tested, privatised social care – it seems that an important part of Calderdale Support and Independence Teams’ work in 2015 has been figuring out how to accelerate patients’ progress from NHS – funded reablement to an “independent sector provider”.

They have been putting more staff to work on services that patients have to pay for – “post-reablement home care waiting” and “rapid access homecare for people who would not be appropriate referrals to reablement”. Their report notes that the more patients who move quickly from reablement to an independent-sector provider, the more money the Council would save.

However, there are problems with “the capacity of the home care market.” – which Calderdale Clinical Commissioning Group’s Quality Committee have been worrying over copiously. As a result,

“Vanguard partners are progressing the development of a new care homes model.”

This will be led by Head of Commissioning Continuing Care from CCG and Head of Quality and Safeguarding from CMBC. (Calderdale CCG Governing Body, 14 April 2016 Quality and safety report and quality dashboard.)

As well as this so-called ‘integration’ of health and social care that funnels people as quickly as possible from the NHS to means-tested social care, Care Closer to Home also plans to ‘integrate’ a wide range of other public services like the Department of Works and Pensions, housing associations and leisure and recreation – along with voluntary sector organisations – in Care Closer to Home ‘hubs’. GPs (not in Calderdale or Kirklees, so far) are already protesting at having the DWP in the same premises as them, and at being expected to prescribe getting a job as a treatment for patients with long term conditions. The coercive powers of the neo-liberal state, reaching out into areas of people’s lives through bio politics, seem to be central to Care Closer to Home.

New care models – intrusive, controlling and corrosive of the idea of social solidarity

These new care models rely on shared access by all partners in the Care Closer to Home scheme to patients’ personal confidential medical data, in order to stratify patients into categories of being at risk of unplanned hospital admissions. (This is why Jeremy Hunt was accompanied on his visit to Kaiser Permanente by Dr Mark Davies in his role as clinical lead at the Health and Social Care Information Centre.)

The new care models also involve creating a managed care plan for these categories of patients.

Then they put these at-risk patients into “virtual wards”, where their medical records are scrutinised on a regular basis, to see how their managed care is working out.

There are serious implications for patients’ privacy – but no privacy impact assessment in the Right Care Right Time Right Care pre-consultation business case.

There is evidence that this doesn’t achieve the stated objective of reducing unplanned hospital admissions. Where this scheme has been carried out through a GPs’ Direct Enhanced Payment Scheme for patients with long term heart conditions, it has been found to increase unplanned hospital admissions – not reduce them.

The care plans in this new care model involve the use of behaviour change techniques to get people to improve their health. Care Closer to Home calls this preventive care – but it bears no relation to real preventive care which identifies and deals with the social, economic and environmental determinants of poor health.

For example, one of the long term conditions Care Closer to Home wants to tackle is respiratory problems. We know that air pollution in Calderdale kills scores of people each year and is the cause of respiratory problems in many other people who don’t actually die of the illness. Preventive health care that aimed to tackle respiratory problems would require regulation of vehicle emissions, as well as government and local authority investment in air quality monitoring and transport infrastructure that would bring Calderdale’s air pollution within legal limits.

All the main long term health problems except fraility and some complex children’s conditions are susceptible to public health measures – such as:

• restoring the requirement -abolished in 1984 – for schools to provide meals to specified nutritional standards
• regulating the food industry to outlaw processed foods that are high in sugar and saturated fat
• improved public transport combined with improved walkability and cyclability
• the eradication of poverty by creating decent, green skilled jobs and skills, enforcinga living wage and providing a basic citizen’s income

But because there is no such thing as society, according to Thatcher – or if there is, it’s Cameron’s Big Society where the rich take it all and the rest of us have to scrabble around shoring up the cracks and showing resilience – Care Closer to Home puts the responsibility for preventive care on the shoulders of the people who are ill – ignoring the social, economic and environmental determinants of ill health.

In its reliance on unpaid care by family and friends, Care Closer to Home is another form of privatisation.

In its used of capitated payments, Care Closer to Home opens the door to another form of privatisation – Personal Healthcare Budgets.

And the personal confidential medical data that Care Closer to Home mines is of great interest to private health insurers and digital tech companies. The whole data mining exercise of Care Closer to Home extends to the use of digital apps and websites like mystrokeguide.com

For which CK999 has awarded the Calderdale MCP Vanguard partners a Regional i-Arse+ award.

This website, which Calderdale CCG has commissioned to help stroke patients self-manage their care, states that:

“My Stroke Guide has…been designed to capture user data and information which gives service providers and commissioning bodies valuable information…”