Questions re Hackney Devo pilot, Outline Business Case, November 2017
Comments and questions from Hackney Keep Our NHS Public 5 March 2018. CA
1.1
General
We note:
Given the scale of these challenges, we find it impossible to believe assertions that either health or social care will remain safe over the coming period. We understand that elected politicians and managers have no choice but to manage within a fixed and drastically reducing budget.
Q. However we also seek assurance that our elected representatives will act politically by:
i.Endeavouring to bring local services into line with national Labour policy as set out in the NHS motion passed overwhelmingly at 2017 conference, including, opposition to marketisation of services, bringing outsourced services back in house, opposing development of ACOs
ii.ensuring local people are given the best possible information about the impact of austerity and government policies and are involved and consulted to the fullest extent in local policy and service development
iii.working with other local authorities to raise awareness of Government actions resulting in the dire situation for many of our most vulnerable people
2.
Homerton A&E
We note that Homerton hospital has consistently delivered 95% A&E targets and performs well against other key national targets. P19
There are several references to services that will continue to be provided by Homerton Hospital. We are concerned that they do not mention Accident and Emergency Services. This omission is especially concerning given the concerted drive at national level to make huge reductions in the number of hospitals offering A&E services.
Q. Please can you confirm:
Whether A&E will continue to be commissioned at local CCG level, or are among the services that will be commissioned at STP-level.
3.
Homerton Pathology
We note there is no reference in the document to plans for Pathology services which are currently located at Homerton Hospital.
Q. Please can you confirm:
4.
Discharge to Assess
Details of this pilot are set out in a Report by Tracy Fletcher to Integrated Commissioning Board in December 2017 which gave the go ahead for this pilot scheme, despite huge reservations by the Patient and User Experience Group – which we share.
This report states: “A discharge to assess model is where as soon as a patient is medically optimised, they are provided immediate support to be able to go home, and then are assessed in their own homes, providing better more accurate assessments in the environment someone will live”.
We are extremely concerned that the definition above is not in line NHSE Guidance set out in italics below, which states explicitly that a patient who is ‘medically optimised’ may well need further therapy or social care which should be provided in, for instance, an intermediate care bed.
We note that The Patient and User Experience Group (PUEG) expressed strong concerns about this pilot, believing that targets set are unrealistic. They also expressed concern at the capacity of current services to deliver this change safely. Specifically, they doubt there is sufficient staff capacity to manage the shift in service. Representatives also stated that intermediate care beds needs to be part of the options available to patients as not all people could be cared for at home.
Q: We share the enormous concerns expressed by the Patient User Experience Group. We believe the scheme will be unsafe and unacceptable unless and until Hackney has adequate step-down and rehabilitation services in place to support those many people who cannot manage safely at home for whatever reason.
NHSE Quick Guide definitions
Medically Optimised (Medically Fit for Discharge)
A medically optimised patient is one who has completed acute care and who is now fit for discharge from a medical perspective. All relevant investigations have been completed and none further are anticipated. The patient may, require further therapy or social care input. This should be provided in an alternative setting, e.g. intermediate care bed.
Discharge to Assess (D2A)
“Where people who are clinically optimised and do not require an acute hospital bed, but may still require care services are provided with short term, funded support to be discharged to their own home (where appropriate) or another community setting. Assessment for longer-term care and support needs is then undertaken in the most appropriate setting and at the right time for the person. Commonly used terms for this are: ‘discharge to assess’, ‘home first’, ‘safely home’, ‘and step down’”. (The NHSE Quick Guide)
5.
Move towards an Accountable Care System / Integrated Care Partnership
The devolution report talks (p29) about establishment of an accountable care system across Hackney and the City by April 2018. It also proposes to develop fully aligned contracts during 2018. NHSE policy (5YFV Next Steps) expects these partnerships to ‘evolve’ and eventually, over time, to merge into a single organisation.
It’s important to note: there are two ‘S75s’, relating to different legislation and completely different issues, which are relevant to this.
Most current NHS services are not currently procured through competitive tender for commercial contracts (commissioners have relied on potential exemptions to S75 H&SCA 2012 Regs). However the NHSE has stated repeatedly that the expectation is for STPs to ‘evolve’ into an Accountable Care System and, finally, into an Accountable Care Organisation. (now re-branded as Integrated Care Organisations ICOs or Partnerships ICPs).
NHSE’s model contract for ACOs involves a commercial contract, which is intended to be procured through competitive tender.
The process and NHSE’s ACO contract are currently the subject of two Judicial Reviews brought by NHS campaigners. NHS campaigners are extremely concerned that competitive procurement of a commercial contract for all health and social care services in an area could well result in bids from giant healthcare corporates, resulting in wholesale privatisation of all NHS and social care services within an area in one fell swoop. (Alternatively, there may be joint bids from NHS FTs with finance corporates – which would be equally disastrous).
So long as the H&SC Act 2012 Remains in place, NHSE bodies have the power to demand that commissioners put their newly integrated health & social care organisation out to commercial tender, risking wholesale privatisation of health and social care in Hackney.
Q: what thoughts have local commissioners given to these risks, and what do you intend to do to mitigate this massive risk to our NHS?
6.
Care closer to home / Out of Hospital care model
Integrated Independence Team consisting of health and social care professionals supporting care closer to home. Intensive care for up to 6 weeks; arranges ongoing support for those with longer care needs. (p18). Our concerns about the ability of patients to manage early discharge are set out in other sections.
Q: what review has been undertaken to assess the level of need and additional services that will be required to meet the health and care needs of people discharged from hospital who may be medically fit for discharge but who are not able to care for themselves?
Please can we see this assessment.
Q: will this new care out of hospital service be deemed healthcare – free at the point of delivery, or will it be charged-for social care?
7.
Minimal length of hospital stay: Step-down / rehabilitation
We note that the plans make no reference to step-down or rehabilitation services other than in the person’s own home.
Q: If you do have plans for step-down or rehabilitation services, please can you explain what these are.
Q: please can you assure us that there will be no attempt to put patients in 'Airbnb style ' local homes as previously suggested by Southend University Hospital. We understand that Cambridgeshire County Council is considering a similar proposal. https://carerooms.com/hosts/
Q: please assure us that any step-down or rehabilitation services will be provided free as healthcare, and will not be subject to charging.
8.
Self-care and support for independence
We support the motherhood and apple-pie ambition to support people to care for themselves and to live independent lives. However we are all too aware that the rhetoric of ‘self care’ and ‘independent living’ is often little more than a cynical cover for withdrawal of support and actual neglect.
We expect to see evidence from high quality, peer evaluated research projects, published in reputable journals to support this expectation of increased self-care. We do not accept that anecdotal evidence – which has predominated in this wholesale top down reorganisation of the NHS - is any basis on which to base our future NHS or social care services.
Q. What evidence are you drawing on to deduce that self-care and independent living can adequately substitute for direct services?
9.
Fully integrated health and social care
KONP shares the desire for improved co-ordination of health and social care services, but has significant concerns about proposals for a fully integrated services for the following reasons.
Poor co-ordination has been a source of immense hardship and frustration for staff and people seeking services, while improved co-ordination has been a repeated goal of service managers and social policy for many decades from 1990 and before. KONP recognizes there are many unnecessary barriers to co-ordinated care and shares the desire to overcome these and improve co-ordination. KONP supports in principle the notion of a National Health and Social Care Service – provided this takes account of the factors set out below.
KONP refers to ‘co-ordination’ rather than ‘integration’ for a number of reasons, which have conceptual, practical and political roots.
Conceptual: the NHS and social care have very different aims and approaches. The NHS aims to treat illness and (help people to) manage conditions. This is very different from the broader stated aims of social care which involve supporting people to have healthy, fulfilling and meaningful lives. In practice, massively constrained budgets means social care is often reduced to little more than making sure a person can be fed and washed – but this is far from the stated goals. Many of those who are pushing for ‘integration’ would be only too happy to accept social care limited to a feeding and bathing service. KONP believes it’s vital to hold on to the wider perspective and reinstate those aspirations, and we are concerned they may be lost if health and social care are merged – particularly in the current climate.
Practical issues: Becoming part of a single organization is neither necessary nor sufficient to ensure good co-ordination. Decades of experience of many multi-disciplinary NHS and social care teams have shown that even sharing an office and the same manager is no guarantee of effective co-ordination. Conversely, many separate organisations have managed extremely effective joint work by developing cross-organisational procedures and understandings.
Political: The real reasons behind the current Government push for organizational integration of health and social care are political and economic. KONP’s opposition to merging NHS and social care organisations is based on:
Q: How will you address the concerns set out above?
10.
Service model
We do not believe it will be practical or allow best practice to insure a fully integrated community health and social care team in each of the four quadrants. Specialist services are required within both health and social care.
Some specialist services will be much better provided as single integrated teams working across the four quadrants. There will not be sufficient level of need and associated staffing to warrant a complete team in each quadrant, and specialist knowledge and expertise will be diluted and lost if specialist staff are integrated into a single team.
This is true for instance with learning disability teams as well as with teams providing specialist healthcare. There is a major risk of losing specialist expertise that has been built up over decades in specialist teams if staff are managed as part of an integrated generic team.
Q: how will you ensure that the expertise of small specialist teams is not lost and diluted if the team is split into quadrants and staff are managed through generic teams where managers lack the specialist expertise in these areas?
11.
Workforce
We are very concerned about proposals to restructure staffing to replace qualified doctors and healthcare professionals with staff with much less experience. An excellent health service requires staff with a thorough professional understanding of their role, enabling them to make relatively autonomous decisions about patient care needs within a limited framework.
However in many settings, professional judgement is being replaced by a staff with inadequate knowledge and skills operating through a protocol-driven approach.
Q. What assumptions have been made about the potential to replace qualified doctors, nurses and other healthcare staff in hospital, primary care and community settings with physician associates or other lower qualified (and, as yet, unregulated) support staff?
Q: what high quality, peer-reviewed evidence has been used to justify this approach?
12.
Outcome-based contracting
We are concerned that outcome-based contracting has as little evidence-base and as many drawbacks as other contracting forms. All models focus managers’ attention on a limited number of KPIs and are open to gaming the system. Of course we need to keep track of how well a service is performing against a wide range of measures. But ultimately we would be much better served by allowing professional bodies to set and monitor standards, setting up good systems of peer review, locally and nationally, supporting managers to develop local services in line with best practice nationally, supporting staff to work in line with professional guidelines, making sure staff at all levels and patients and public are thoroughly involved in review and development of services. Where services are not performing well, please let’s bring in support so they can do better.
Service monitoring via commercial contracts for health – and especially social care – is notoriously unreliable and a terrible way of assessing quality of service.
Q: Please can we end commercial contracting of health and social care services, bring all services back in-house and reinstate the kind of support systems set out above that we know can make a direct difference!
13.
NHS Estate
94 properties across Hackney. 19% owned by NHS Prop Co and 14% by GPs – so that’s 33% NHS, so about 31 properties currently used by the NHS. We have already flagged up our grave concerns about NHSE proposals to conduct a firesale of £5.7bn of NHS properties.
Q: When will we see details of the local NHS and social care estate strategy, showing clearly what proposals managers have for the future these 31 NHS and social care sites and implications for future use of all current estate?
Q: We attach below a draft proposal for the beneficial use of NHS land. Will managers consider an estate strategy that is in line with these principles?
WE WANT THE FOLLOWING BENEFICIAL USES OF NHS LAND
Any NHS land that is not in clinical use at present should be used for health and wellbeing purposes, to be considered in priority order, as follows:
1. The NHS should consult fully and agree plans with local people. It should identify any land that may be required for expansion or rebuilding of existing hospitals or clinics, or needed for publicly-provided shared health and social care. This land cannot be sold.
2. The NHS should build “step-down care” and rehabilitation centres to care temporarily for the 6,000 patients who are medically fit, but still need care and are occupying expensive acute care beds. Figures show that this would pay for itself in only one or two years, and is far better value for money than selling land.
3. Land not needed for NHS care should be considered for publicly-provided social care, or used to build low rent housing for NHS employees. This would improve recruitment, reduce length of journeys to work, and reduce fatigue for NHS staff, so improving patient safety, and releasing the housing presently occupied by the rehoused staff.
4. Publicly-owned supported accommodation for elderly and vulnerable people should be developed on remaining NHS land, near to medical facilities, to meet the acute need for such homes. This would also free up housing occupied by vulnerable people for use by others.
5. Any remaining NHS sites should be used for social housing, provided at genuinely affordable rents. The destructive “right-to-buy” policy that has depleted the affordable public housing stock since the Thatcher era should not apply, and in any case should be abolished by legislation.
6. Any NHS land that is not suitable for the purposes above should be included in a local public land bank, to be considered for land swaps under the direction of the local planning authorities to improve the quality and allocation of public land.
Only after full consideration of all these uses (in priority order) should NHS land be released for commercial sale. All money from sales should be paid into NHS capital accounts and used for buildings and maintenance, not to compensate for NHS revenue underfunding.
14.
Co-location in places of worship p24
We note that within the public estate mentioned, a significant proportion, 14% is owned by the Church of England. We are unclear about the relevance of this, and would like to hear more.
We note the ‘Community Wholecare Project’ proposes development of local community centres providing health social and spiritual care on land adjacent to CofE churches, with 13 potential sites! (p42).
We are extremely concerned about any proposal to link generic NHS or social care services to any faith institutions. We are very aware of the damage done to UK’s secular education system through state funding of faith schools and direct links to a wide range of faith communities. We believe it is vital to maintain a complete separation between state provided, secular, health and social care and any faith communities.
Q: Can you assure us that you will retain a clear and absolute separation between state-provided services and faith provision, including, for instance, no shared physical access to premises, no faith-based access requirements, and no shared staffing.
15.
CHUUSE
The service has been extended to 2019 pending further consultation/ development. We welcome the retention of this service and hope it will be extended beyond 2019.
Comments and questions from Hackney Keep Our NHS Public 5 March 2018. CA
1.1
General
We note:
- expected population growth of 12% by 2025 – fastest growth among over 65s.
- 12,654 patients currently identified as at high risk of hospital admission.
- Financial challenge: loss of between £20m - £78m by 2021.
- £12.8m cuts in spend on social care between 2012 and 2015 (p21)
Given the scale of these challenges, we find it impossible to believe assertions that either health or social care will remain safe over the coming period. We understand that elected politicians and managers have no choice but to manage within a fixed and drastically reducing budget.
Q. However we also seek assurance that our elected representatives will act politically by:
i.Endeavouring to bring local services into line with national Labour policy as set out in the NHS motion passed overwhelmingly at 2017 conference, including, opposition to marketisation of services, bringing outsourced services back in house, opposing development of ACOs
ii.ensuring local people are given the best possible information about the impact of austerity and government policies and are involved and consulted to the fullest extent in local policy and service development
iii.working with other local authorities to raise awareness of Government actions resulting in the dire situation for many of our most vulnerable people
2.
Homerton A&E
We note that Homerton hospital has consistently delivered 95% A&E targets and performs well against other key national targets. P19
There are several references to services that will continue to be provided by Homerton Hospital. We are concerned that they do not mention Accident and Emergency Services. This omission is especially concerning given the concerted drive at national level to make huge reductions in the number of hospitals offering A&E services.
Q. Please can you confirm:
Whether A&E will continue to be commissioned at local CCG level, or are among the services that will be commissioned at STP-level.
- Whether you are aware of any proposals at local or STP level to stop providing a full A&E service at Homerton or to downgrade the service to an Urgent Care Centre or similar?
- If so, please inform us of:
- the clinical information-base used for any draft proposals, and also,
- what information you have sought regarding impact on travelling times and convenience of journeys for patients, especially vulnerable patients and those with additional needs; and
- what consultation has taken place with patients.
3.
Homerton Pathology
We note there is no reference in the document to plans for Pathology services which are currently located at Homerton Hospital.
Q. Please can you confirm:
- whether pathology services will continue to be commissioned at local CCG level or at STP level?
- What draft or other proposals are there for the future of Pathology services currently provided at Homerton Hospital.
4.
Discharge to Assess
Details of this pilot are set out in a Report by Tracy Fletcher to Integrated Commissioning Board in December 2017 which gave the go ahead for this pilot scheme, despite huge reservations by the Patient and User Experience Group – which we share.
This report states: “A discharge to assess model is where as soon as a patient is medically optimised, they are provided immediate support to be able to go home, and then are assessed in their own homes, providing better more accurate assessments in the environment someone will live”.
We are extremely concerned that the definition above is not in line NHSE Guidance set out in italics below, which states explicitly that a patient who is ‘medically optimised’ may well need further therapy or social care which should be provided in, for instance, an intermediate care bed.
We note that The Patient and User Experience Group (PUEG) expressed strong concerns about this pilot, believing that targets set are unrealistic. They also expressed concern at the capacity of current services to deliver this change safely. Specifically, they doubt there is sufficient staff capacity to manage the shift in service. Representatives also stated that intermediate care beds needs to be part of the options available to patients as not all people could be cared for at home.
Q: We share the enormous concerns expressed by the Patient User Experience Group. We believe the scheme will be unsafe and unacceptable unless and until Hackney has adequate step-down and rehabilitation services in place to support those many people who cannot manage safely at home for whatever reason.
NHSE Quick Guide definitions
Medically Optimised (Medically Fit for Discharge)
A medically optimised patient is one who has completed acute care and who is now fit for discharge from a medical perspective. All relevant investigations have been completed and none further are anticipated. The patient may, require further therapy or social care input. This should be provided in an alternative setting, e.g. intermediate care bed.
Discharge to Assess (D2A)
“Where people who are clinically optimised and do not require an acute hospital bed, but may still require care services are provided with short term, funded support to be discharged to their own home (where appropriate) or another community setting. Assessment for longer-term care and support needs is then undertaken in the most appropriate setting and at the right time for the person. Commonly used terms for this are: ‘discharge to assess’, ‘home first’, ‘safely home’, ‘and step down’”. (The NHSE Quick Guide)
5.
Move towards an Accountable Care System / Integrated Care Partnership
The devolution report talks (p29) about establishment of an accountable care system across Hackney and the City by April 2018. It also proposes to develop fully aligned contracts during 2018. NHSE policy (5YFV Next Steps) expects these partnerships to ‘evolve’ and eventually, over time, to merge into a single organisation.
It’s important to note: there are two ‘S75s’, relating to different legislation and completely different issues, which are relevant to this.
- S75 of The NHS Act 2006 relates to the ability to pool health and social care budgets (with some exceptions). This is the ‘S75’ which is referred to in the Devolution Report.
- S75 of the Health and Social Care Act 2012, (and specifically, the Regulations made under S75) relates to the requirement to put services out to competitive tender. This S75 is not mentioned in the Devolution report – and this is a highly significant and shocking omission.
Most current NHS services are not currently procured through competitive tender for commercial contracts (commissioners have relied on potential exemptions to S75 H&SCA 2012 Regs). However the NHSE has stated repeatedly that the expectation is for STPs to ‘evolve’ into an Accountable Care System and, finally, into an Accountable Care Organisation. (now re-branded as Integrated Care Organisations ICOs or Partnerships ICPs).
NHSE’s model contract for ACOs involves a commercial contract, which is intended to be procured through competitive tender.
The process and NHSE’s ACO contract are currently the subject of two Judicial Reviews brought by NHS campaigners. NHS campaigners are extremely concerned that competitive procurement of a commercial contract for all health and social care services in an area could well result in bids from giant healthcare corporates, resulting in wholesale privatisation of all NHS and social care services within an area in one fell swoop. (Alternatively, there may be joint bids from NHS FTs with finance corporates – which would be equally disastrous).
So long as the H&SC Act 2012 Remains in place, NHSE bodies have the power to demand that commissioners put their newly integrated health & social care organisation out to commercial tender, risking wholesale privatisation of health and social care in Hackney.
Q: what thoughts have local commissioners given to these risks, and what do you intend to do to mitigate this massive risk to our NHS?
6.
Care closer to home / Out of Hospital care model
Integrated Independence Team consisting of health and social care professionals supporting care closer to home. Intensive care for up to 6 weeks; arranges ongoing support for those with longer care needs. (p18). Our concerns about the ability of patients to manage early discharge are set out in other sections.
Q: what review has been undertaken to assess the level of need and additional services that will be required to meet the health and care needs of people discharged from hospital who may be medically fit for discharge but who are not able to care for themselves?
Please can we see this assessment.
Q: will this new care out of hospital service be deemed healthcare – free at the point of delivery, or will it be charged-for social care?
7.
Minimal length of hospital stay: Step-down / rehabilitation
We note that the plans make no reference to step-down or rehabilitation services other than in the person’s own home.
Q: If you do have plans for step-down or rehabilitation services, please can you explain what these are.
Q: please can you assure us that there will be no attempt to put patients in 'Airbnb style ' local homes as previously suggested by Southend University Hospital. We understand that Cambridgeshire County Council is considering a similar proposal. https://carerooms.com/hosts/
Q: please assure us that any step-down or rehabilitation services will be provided free as healthcare, and will not be subject to charging.
8.
Self-care and support for independence
We support the motherhood and apple-pie ambition to support people to care for themselves and to live independent lives. However we are all too aware that the rhetoric of ‘self care’ and ‘independent living’ is often little more than a cynical cover for withdrawal of support and actual neglect.
We expect to see evidence from high quality, peer evaluated research projects, published in reputable journals to support this expectation of increased self-care. We do not accept that anecdotal evidence – which has predominated in this wholesale top down reorganisation of the NHS - is any basis on which to base our future NHS or social care services.
Q. What evidence are you drawing on to deduce that self-care and independent living can adequately substitute for direct services?
9.
Fully integrated health and social care
KONP shares the desire for improved co-ordination of health and social care services, but has significant concerns about proposals for a fully integrated services for the following reasons.
Poor co-ordination has been a source of immense hardship and frustration for staff and people seeking services, while improved co-ordination has been a repeated goal of service managers and social policy for many decades from 1990 and before. KONP recognizes there are many unnecessary barriers to co-ordinated care and shares the desire to overcome these and improve co-ordination. KONP supports in principle the notion of a National Health and Social Care Service – provided this takes account of the factors set out below.
KONP refers to ‘co-ordination’ rather than ‘integration’ for a number of reasons, which have conceptual, practical and political roots.
Conceptual: the NHS and social care have very different aims and approaches. The NHS aims to treat illness and (help people to) manage conditions. This is very different from the broader stated aims of social care which involve supporting people to have healthy, fulfilling and meaningful lives. In practice, massively constrained budgets means social care is often reduced to little more than making sure a person can be fed and washed – but this is far from the stated goals. Many of those who are pushing for ‘integration’ would be only too happy to accept social care limited to a feeding and bathing service. KONP believes it’s vital to hold on to the wider perspective and reinstate those aspirations, and we are concerned they may be lost if health and social care are merged – particularly in the current climate.
Practical issues: Becoming part of a single organization is neither necessary nor sufficient to ensure good co-ordination. Decades of experience of many multi-disciplinary NHS and social care teams have shown that even sharing an office and the same manager is no guarantee of effective co-ordination. Conversely, many separate organisations have managed extremely effective joint work by developing cross-organisational procedures and understandings.
Political: The real reasons behind the current Government push for organizational integration of health and social care are political and economic. KONP’s opposition to merging NHS and social care organisations is based on:
- Concerns set out above that, with assessments conducted by a commercial organisation, ‘social care’ will be further reduced to become little more than a feeding and bathing service.
- Concerns that in a single organization resources will inevitably be drawn towards healthcare, and particularly medical needs, again reducing resources available to meet social care needs.
- NHS services are free at the point of need; social care is charged for (even people on benefits will normally pay something) and this represents a huge drain on income. Most people in receipt of social care will continue to need support for the rest of their lives. There is no clear boundary between what’s classified as ‘health care’ and what is ‘social care’ and many activities that used to be undertaken by nurses are now classed as social care. A single organization will find it all the easier to shift that boundary, designating ever more care as paid for ‘social care’ rather than free ‘health care’.
Q: How will you address the concerns set out above?
10.
Service model
We do not believe it will be practical or allow best practice to insure a fully integrated community health and social care team in each of the four quadrants. Specialist services are required within both health and social care.
Some specialist services will be much better provided as single integrated teams working across the four quadrants. There will not be sufficient level of need and associated staffing to warrant a complete team in each quadrant, and specialist knowledge and expertise will be diluted and lost if specialist staff are integrated into a single team.
This is true for instance with learning disability teams as well as with teams providing specialist healthcare. There is a major risk of losing specialist expertise that has been built up over decades in specialist teams if staff are managed as part of an integrated generic team.
Q: how will you ensure that the expertise of small specialist teams is not lost and diluted if the team is split into quadrants and staff are managed through generic teams where managers lack the specialist expertise in these areas?
11.
Workforce
We are very concerned about proposals to restructure staffing to replace qualified doctors and healthcare professionals with staff with much less experience. An excellent health service requires staff with a thorough professional understanding of their role, enabling them to make relatively autonomous decisions about patient care needs within a limited framework.
However in many settings, professional judgement is being replaced by a staff with inadequate knowledge and skills operating through a protocol-driven approach.
Q. What assumptions have been made about the potential to replace qualified doctors, nurses and other healthcare staff in hospital, primary care and community settings with physician associates or other lower qualified (and, as yet, unregulated) support staff?
Q: what high quality, peer-reviewed evidence has been used to justify this approach?
12.
Outcome-based contracting
We are concerned that outcome-based contracting has as little evidence-base and as many drawbacks as other contracting forms. All models focus managers’ attention on a limited number of KPIs and are open to gaming the system. Of course we need to keep track of how well a service is performing against a wide range of measures. But ultimately we would be much better served by allowing professional bodies to set and monitor standards, setting up good systems of peer review, locally and nationally, supporting managers to develop local services in line with best practice nationally, supporting staff to work in line with professional guidelines, making sure staff at all levels and patients and public are thoroughly involved in review and development of services. Where services are not performing well, please let’s bring in support so they can do better.
Service monitoring via commercial contracts for health – and especially social care – is notoriously unreliable and a terrible way of assessing quality of service.
Q: Please can we end commercial contracting of health and social care services, bring all services back in-house and reinstate the kind of support systems set out above that we know can make a direct difference!
13.
NHS Estate
94 properties across Hackney. 19% owned by NHS Prop Co and 14% by GPs – so that’s 33% NHS, so about 31 properties currently used by the NHS. We have already flagged up our grave concerns about NHSE proposals to conduct a firesale of £5.7bn of NHS properties.
Q: When will we see details of the local NHS and social care estate strategy, showing clearly what proposals managers have for the future these 31 NHS and social care sites and implications for future use of all current estate?
Q: We attach below a draft proposal for the beneficial use of NHS land. Will managers consider an estate strategy that is in line with these principles?
WE WANT THE FOLLOWING BENEFICIAL USES OF NHS LAND
Any NHS land that is not in clinical use at present should be used for health and wellbeing purposes, to be considered in priority order, as follows:
1. The NHS should consult fully and agree plans with local people. It should identify any land that may be required for expansion or rebuilding of existing hospitals or clinics, or needed for publicly-provided shared health and social care. This land cannot be sold.
2. The NHS should build “step-down care” and rehabilitation centres to care temporarily for the 6,000 patients who are medically fit, but still need care and are occupying expensive acute care beds. Figures show that this would pay for itself in only one or two years, and is far better value for money than selling land.
3. Land not needed for NHS care should be considered for publicly-provided social care, or used to build low rent housing for NHS employees. This would improve recruitment, reduce length of journeys to work, and reduce fatigue for NHS staff, so improving patient safety, and releasing the housing presently occupied by the rehoused staff.
4. Publicly-owned supported accommodation for elderly and vulnerable people should be developed on remaining NHS land, near to medical facilities, to meet the acute need for such homes. This would also free up housing occupied by vulnerable people for use by others.
5. Any remaining NHS sites should be used for social housing, provided at genuinely affordable rents. The destructive “right-to-buy” policy that has depleted the affordable public housing stock since the Thatcher era should not apply, and in any case should be abolished by legislation.
6. Any NHS land that is not suitable for the purposes above should be included in a local public land bank, to be considered for land swaps under the direction of the local planning authorities to improve the quality and allocation of public land.
Only after full consideration of all these uses (in priority order) should NHS land be released for commercial sale. All money from sales should be paid into NHS capital accounts and used for buildings and maintenance, not to compensate for NHS revenue underfunding.
14.
Co-location in places of worship p24
We note that within the public estate mentioned, a significant proportion, 14% is owned by the Church of England. We are unclear about the relevance of this, and would like to hear more.
We note the ‘Community Wholecare Project’ proposes development of local community centres providing health social and spiritual care on land adjacent to CofE churches, with 13 potential sites! (p42).
We are extremely concerned about any proposal to link generic NHS or social care services to any faith institutions. We are very aware of the damage done to UK’s secular education system through state funding of faith schools and direct links to a wide range of faith communities. We believe it is vital to maintain a complete separation between state provided, secular, health and social care and any faith communities.
Q: Can you assure us that you will retain a clear and absolute separation between state-provided services and faith provision, including, for instance, no shared physical access to premises, no faith-based access requirements, and no shared staffing.
15.
CHUUSE
The service has been extended to 2019 pending further consultation/ development. We welcome the retention of this service and hope it will be extended beyond 2019.
