This is a longer version of a post by STP Agony Aunt on the stopthestps website.
Secret Theft Plans – the so-called Sustainability and Transformation Plans (STPs) – intend to turn the NHS into a copy of the US Medicare system – a publicly-funded, insurance-based system that buys care from private health companies, for those who can’t get private health insurance.
An end to the NHS as a comprehensive health service that provides healthcare to us all, based on our clinical needs
The Secret Theft Plan system undermines the basic principle and obligation of the NHS: to provide appropriate treatment based on clinical need to everyone who comes through the door.
Instead, Secret Theft Plans aim to create a health service that operates on a fixed budget, (based on a set amount per head of the population in a designated area) and “manages demand” to make sure that it limits numbers of patients and the treatments they receive to what is affordable on this fixed per capita budget.
The Secret Theft Plans sketch these systems of “place based care” “capitated payment” and “demand management”.
They don’t explain that this mean-spirited restriction of treatments and patient numbers is based on an American health insurance system variously called managed care, health maintenance organisations or accountable care organisations.
How Accountable Care Systems work
An Accountable Care Organisation or System is accountable to the health insurance company that pays for treatments available to the population that is covered by the Accountable Care Organisation or System. This is usually around 50K people – compare this with the 2k-6K population that is usually registered with a UK GP surgery.
The health insurance company specifies what treatments are available (managed care) and which patients can access them (the ones who are cheapest to treat and who offer the best chance of recovery), as well as setting the overall annual population budget that the Accountable Care Organisation has to stick to. If it comes in under budget it can keep what it hasn’t spent.
The spin is that this incentivises efficiency. The reality is it leads to cherry picking patients and restrictions and denial of care. This is called ‘demand management.’ There is a LOT about demand management in the STPs.
By imposing managed care pathways – ie telling doctors what treatments they can provide and how to provide them – Accountable Care Organisations de-professionalise doctors and other health workers and destroy the individual patient- health worker relationship.
This is clearly not the NHS as a publicly owned, funded and run comprehensive health service, or as an empathetic, person-centred health service.
Accountable Care Organisations are a highway to stealth NHS privatisation
With its budget to provide an area’s whole range of health and social care, provided by NHS, private and third sector companies, Accountable Care Organisations or Systems amount to a private-public partnership – like PFI, but for health care services as well as buildings.
Like PFI, it seems they will be run through a Special Purpose Vehicle – if the Northumberland Accountable Care Organisation, which will go live in April 2017, is anything to go by.
Its Special Purpose Vehicle will handle the Clinical Commissioning Group’s and primary care budgets and nearly all the functions of Northumberland Clinical Commissioning Group.
If like me you don’t know what a Special Purpose Vehicle is, here is Investopedia’s definition:
“a subsidiary company with an asset/liability structure and legal status that makes its obligations secure even if the parent company goes bankrupt. An SPV/SPE is also a subsidiary corporation designed to serve as a counterparty for swaps and other credit sensitive derivative instruments. Although the SPVs/SPEs are used to isolate financial risk, due to accounting loopholes, these vehicles may become a financially devastating way for Chief Finance Officers to hide debt, as with the Enron bankruptcy.”
Why is this an appropriate way to run our NHS? What is the Special Purpose? Secret Privatisation?
The UN says the creation of a Special Purpose/Project Vehicle (SPV) is a key feature of most Public Private Partnerships. All contractual agreements between the various parties are negotiated between themselves and the SPV.
I wonder how this sits with the NHS Confederation’s statement (p16) that STPs are a way to bring a lot of private money into the NHS via Local Economic Partnerships and that by the end of 2020/21 private money would match public money in the NHS.
The Autumn 2015 Comprehensive Spending Review, which announced the extra Sustainability and Transformation funding, committed the government to encouraging long term partnerships with the private sector in the development of Accountable Care Organisations and hospital groups and acute care collaborations.
The NHS Confederation is now pushing hard on its claim that private sector money is going to save the NHS
Of course they ignore the growing slew of privatisation gone wrong, where patient care and staff have suffered badly at the hands of private and third sector health companies; and where private providers have just walked away when they realise they can’t make a profit and provide the necessary care.
There are many examples here.
But the privatisation stakes are upped hugely by NHS England’s plan to use funding through STPs to convert 50% of the NHS in England to systems similar to the Northumberland Accountable Care Organisation by 2020 ( Newcastle Hospitals NHS Foundation Trust Executive Report – Current Issues, October 2016).
Accountable Care Organisations in the NHS seem to be of dubious legality
PA Consulting states that
“Legislative change is required, to enable the creation of genuine Accountable Care Organisations (ACOs); enabling behavioural and structural change as well as relocation of funding.”
Andrew Cash, chief executive of Sheffield Teaching Hospitals FT and leader of the South Yorkshire and Bassetlaw Sustainability and Transformation Plan – which also plans to set up an Accountable Care Organisation in 2017 – also says that regulatory change is needed, since Accountable Care Organisations and footprint-wide financial controls (that will allow funding to switch between organisations), go against current NHS legislation.
But the government isn’t talking about legislating for these changes.
Are we going to sit by and let a load of bandits make off with our valuable NHS? Over my gin-soaked body!
Accountable Care Organisations are an opportunity for fraud
Newcastle Hospitals NHS Trust Board of Directors Meeting of 23 Sept 2015 noted:
“The impending establishment of two so-called Accountable Care Organisations by the North Tyneside and Northumberland CCGs, essentially handing commissioning responsibility to a local provider organisation…”
The Clinical Commissioning Group will transfer its funding for most core NHS services to the accountable care organisation, which will operate as a partnership between Northumbria Foundation Trust; Northumberland, Tyne and Wear NHS Foundation Trust; the mental health provider, and other providers. Northumbria Foundation Trust will hold the formal contract, but it will be managed through a type of partnership arrangement with the other providers.
However, at the Autumn 2016 Health Service Journal Commissioning Summit, Simon Stevens recognised that, although Accountable Care Organisations could take on the CCGs’ functions of planning and funding as well as delivering care,
“…at some fundamental level there will still need to be a legal distinction between the accountability that goes with planning and funding on the one hand, and care delivery and animation on the other.
How that develops will probably evolve in difference [sic] ways in different parts of the country”.
A 2015 National Audit Office report identified some 1,100 conflicts of interest in Clinical Commissioning Groups.
How many will they be counting when 50% of the NHS is made up of a variety of new Accountable Care Systems, differing from region to region, that have both planning, commissioning and providing responsibilities and encompass a range of public and private organisations?
It seems like a recipe for fraud – as already practiced in the USA by the United Health Subsidiary Optum, which is increasingly a major player in both NHS commissioning, via the newly privatised Commissioning Support Units, and in healthcare provision, via a variety of privatised contracts, particularly for public health in the South West.
Accountable Care Organisations are a way to destabilise primary care and acute hospitals
Setting up Accountable Care Organisations/Systems in the NHS not only has privatisation implications and is of doubtful legality – it also destabilises the bits of the NHS that remain outside Accountable Care Organisations.
At the Newcastle Hospitals NHS Trust Board of Directors Meeting of 23 Sept 2015, the Chairman commented that combining commissioning and provision in two new Accountable Care Organisations put NHS Foundation Trust principles under threat.
The Trust Board Minutes seem wary of the effect on the Trust of the nearby Northumberland ACO. As one of the Accountable Care Organisation members, Northumbria Healthcare NHS Foundation Trust will be involved in planning and commissioning health services for the area, as well as providing them.
The implication seems to be that it might choose to commission services from itself, to the detriment of other nearby hospitals.
The reconfiguration of hospital services – the first phase in setting up the Northumberland Accountable Care Organisation – has already put pressure on the neighbouring Newcastle Hospitals Trust.
This hospitals “reconfiguration” set up the new specialist emergency care hospital at Cramlington, and separated the delivery of urgent and elective care on different sites, with the downgrade of 3 A&Es to urgent care centres in the three “satellite” hospitals that became elective care hospitals.
The second phase was to consolidate primary care and develop primary and community services to provide care out of hospital. The third and final phase was to make the necessary changes to budgets, incentives and the provider system necessary to operate an accountable care organisation.
The Newcastle Hospitals NHS Trust Board Meeting September 2015 Minutes show that Northumbria Healthcare NHS Foundation Trust’s new specialist emergency care hospital at Cramlington had not taken pressure off Newcastle – instead, emergency caseload had increasing there, including an additional 8-12 ‘blue light’ ambulances per day and receipt of more routine cases from Tynedale. (This is one of the 3 Northumbria Healthcare NHS Foundation Trust hospitals that had their A&E downgraded to an urgent care centre when the Cramlington specialist emergency care hospital was set up). Repatriation to local District General Hospitals was increasingly challenging.
Hospital mergers and acquisitions: centralisation and cuts to enable Accountable Care Organisations to take over
As well as being part of the new Northumberland Accountable Care Organisation, with NHS Improvement accreditation Northumbria Healthcare NHS Foundation Trust is also setting up the Northumbria Foundation Group, with authority to lead groups or chairs of NHS Providers.
The creation of Foundation Groups is part of several Secret Theft Plans.
The aim of the new Foundation Group hospitals is
“to progress options to lead chains, focussing upon improved clinical and financial viability via buddying; partnerships; federations of hospitals; and mergers and acquisitions”.
Through the Northumbria Foundation Group Multispecialty Chain Project, the Northumbria Healthcare NHS Foundation Trust is already the “appointed acquisition partner and buddy of North Cumbria University Hospitals Trust.”
The destabilisation of hospitals that are not part of the new Accountable Care Organisations is intensified by other changes, driven by the Secretary of State Jeremy Hunt’s view that there were “too many Trusts in the NHS” and a need to “up the pace of work on hospital chains and other provider reforms”.
These changes are being imposed by the boss of NHS Improvement, Jim Mackey, who as the seconded head of the Northumbria Healthcare NHS Foundation Trust has a distinct conflict of interest in the matter.
Accept financial control totals or be subject to NHS Improvement’s “support” or “special measures”
Under the Sustainability and Transformation Plan, hospitals have to accept a financial control total set by NHS England and NHS Improvement. The Newcastle Hospitals Trust Council of Governors meeting on 15 Sept 2016 described financial control totals as
“non-evidence based”, contrary to “good governance” and “if acceded to simply then served in turn to bring about adverse knock on consequences as to viability and a loss of freedoms of action as encompassed by the Foundation licence.”
NHS Improvement’s Single Oversight Framework, which was published 13th September 2016 and came into force on 1st October 2016, sets out that hospitals that don’t accept the STP control totals will be put in the category of needing either ‘target support’, ‘mandated support’ or special measures.
This means NHS Improvement tells them what to do and almost certainly makes them pay a private management/accountancy consultancy company like KPMG, PWC or Ernst & YOung to come in and take control of their financial planning.
As a result, the Council of Governors have required the Board of Directors to further address the future viability and status of the Newcastle upon Tyne Hospitals as a distinct and effective entity.
This was discussed at the Newcastle Hospitals Trust Board Sept 2016 meeting, in private so who knows what happened.
Back in the USA – things have never been worse for patients
Linda Peeno, whistle blower for the US ‘managed care model’, said in 2009:
“Things have never been worse for patients. The corporate machines are well-developed and expertly operational. The methods are more insidious, covert and devious. In addition to outright denials of care, new tactics proliferate to avoid, delay, limit, substitute, and manipulate care for the maximization of profits. ”
Regardless, this US health care system is the chosen destination for the NHS as far as the STPs are concerned.
We the public have other ideas.
Information about how to Stop the Secret Theft Plans