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Health & NHS

Better Care Fund for Wiltshire: the costs, the rewards and the risks

Having just successfully sorted out the change from Primary Care Trust to Clinical Commissioning Group – or for that matter from Lansley to Hunt – there’s a new health service name claiming its place in the headlines:  Better Care Fund.

It has not yet been reduced to a generally accepted acronym (which it surely must if it is to be fully accepted in the NHS) because they cannot make their minds up whether it should be known generically as a Fund or a Plan.  Some term the whole scheme ‘the Better Care Fund plan’. That’s a bit confusing.

We will stick with Better Care Fund and for now ‘BCF’.  But then, in Wiltshire the BCF has already given birth to a fully-fledged plan – a joint venture by the Clinical Commissioning Group (CCG) and Wiltshire Council.  What’s more it has become one of the first five in England to be officially signed off by the government.

The idea of the BCF is to concentrate more treatment in the community so as to keep people out of acute hospitals – the average bed in an acute hospital costs £1,785 per week before you count in treatment costs.  And hospital is certainly not always the best place to be, especially for the elderly.

Most of the money for the BCF is not new but comes from funds re-assigned to a pooled budget for use in integrated care by the CCG and Council working together.

Wiltshire’s Health and Wellbeing Board (HWB - set up under the Lansley reorganisation) is the body responsible for the BCF.  Jane Scott, leader of Wiltshire Council and chair of the HWB, wanted the fund to cover patients from cradle to grave.  But the government decreed that in its first full year (2015-2016) it must be restricted to the ‘frail elderly’.

Jane Scott was at the Marlborough Area Board on Tuesday (September 30) to explain the BCF.  Also there were Maggie Rae (Wiltshire’s public health chief), Simon Truelove (the CCG’s head of finance), Dr Jonathan Rayner (Ramsbury GP and a leader of our area’s locality group of the CCG), Dr Abi Griffiths (from the Marlborough Medical Practice) and two frontline representatives from GWH’s community health service.

Wiltshire’s scheme is being piloted this year in three areas – Calne, Salisbury and Bradford on Avon – with brand new integrated teams of social care and health professionals.  

It will only get its full budget of £27million next year to develop integrated community based service teams across the county which should reduce the need for hospital care and protect the existing level of social care services.  The aim is to provide teams for each community of 20,000 centred on GP practices. (Our area’s size will be larger - over 30,000.)

Of the BCF’s £27 million, £15.5 million will be top-sliced off the CCG’s budget – that’s three per cent of the CCG’s total funding for 2015-2016.

Official government guidance states that the ‘expected minimum target’ for BCF plans (there we go again) is a 3.5 per cent reduction in emergency admissions to hospital.  But four of the first five plans have set reductions below that figure.

Wiltshire’s plan is aiming for a 3.75 per cent reduction, but only after the expected annual rise of 2 per cent in non-elective hospital admissions is taken into account.  This equates to a reduction of just under two per cent or, over the next two years, 37,000 bed days.

In financial terms this should save Wiltshire CCG in the Fund’s first full year £3.6 million of its ‘purchase’ of beds in the main three acute hospitals that serve the county.

If it worries readers that the CCG is foregoing £15.5 million of its budget in order to save £3.6 million – the Better Care Fund is not just about money.  It is aiming, as it says on the tin, to provide ‘better care’ – better care before hospital admission becomes essential.

Wiltshire’s Better Care Plan originally envisaged a reduction in hospital admissions of 4.75 per cent, but the government became anxious about the effects on the finances of hospitals and ordered a reduction in the ‘admission avoidance ambition’ to a more realistic level.

The continuing year-on-year rise in hospital admissions has been worrying many acute hospitals.  The Great Western Hospital believes the BCF will allow it to keep operating safely with its existing number of beds.  

Indeed they had expected a shortfall of 55 beds by the end of 2016 if there had not been a change in the care system such as the BCF should provide.

The basic tenet behind the BCF was spelled out by Jane Scott: “We want care in our home…the last place we want to be, unless we have to, is in an acute hospital or care home for the rest of our lives.”  Not everyone, it should be said, agrees with that – among them people who have had experience of services to the frail elderly in their own homes.

There is recognition in Whitehall that the BCF may cause problems – notably that reduced income – for acute hospitals.  So it has been made mandatory to have a “Risk Share agreement with Acute hospitals in the event that acute activity does not reduce in line with plans.”  

But Simon Truelove told the meeting that the BCF was not at all about destabilising the acute hospitals – like the GWH, Salisbury Hospital and RUH Bath: “We absolutely need our three acute hospitals with their specialist care.”

Apart from the risk that there are bound to be cases where people are not admitted to hospital soon enough, there are other risks as responsibilities blur between CCG and Council.

When the BCF plan went before Wiltshire Council’s cabinet, Cllr Ron Hubbard questioned why it stated there were no direct safeguarding implications – his question was brushed away on the grounds that “Officers would of course continue to work closely with the Safeguarding team.”

As Jane Scott told the Area Board: “Funding is going to be a huge challenge – on top of the funding challenges that the Council has, which are huge.”  One risk for the BCF is the looming cost of the new Care Act, which may, from April 2016, set the Council back an extra £15 million.

And there is always the risk of friction between the Council and the CCG.  Already there was talk about this at the Health Fair in the Town Hall before the Area Board met.  

The Council feel they are helping through their efforts on the social care side of the partnership to make savings on treatment costs, which accrue solely to the CCG.  This they feel is not fair.

This quite overlooks the fact that even before the BCF hove into view, the CCG was helping with social care costs. They were, for example, funding quicker exits of patients from hospital – reducing the dreaded ‘delayed transfers of care’ or ‘bed blocking’.  

As we have seen, most of the BCF for Wiltshire comes directly from the CCG’s budget.  And from the pooled BCF budget there is £9.18 million set aside both this year and next to support such Council social care responsibilities as care home admissions, the Council’s Help to Live at Home Service and hospital social work services.

What was that about robbing Peter to pay Paul?

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The NHS and privatisation: now GP practices will be opened up to private providers


They’re marching from Jarrow again – this time it is not about the lack of jobs during the 1930s depression. (*) This time the protest is against the creeping privatisation of the NHS.

A local expression of this dismay and concern came in a recent letter to The Observer  (August 10) – written in response to an example of inappropriate commercialisation of a learning disabilities care home in Doncaster.

The writer, Dr Mike Bishop, is a retired GP who served the NHS for 40 years and now lives in West Overton.  He highlights the ‘tragic effects of profit before care’:  “In an area where hands-on care is the business, the most valuable resource a company takes on is the existing staff.”

“To reduce the pay of experienced, committed staff by up to 35 per cent shows ignorance and disrespect.  For this group to withdraw their services and reconsider their futures is a tragedy for vulnerable patients and a recipe for a commercial and public-relations disaster.”

The way, he wrote, “some areas of the service are being degraded makes me weep”. And he asked when the politicians will wake-up to what is happening to the NHS.

Campaigners against NHS privatisation have just been presented with another target: NHS England has said that all new GP contracts will be open to private providers.  As the doctors’ journal PULSE asked in its headline: “Is this the ‘death knell’ of traditional general practice?”

The Section 75 regulations, which are part of the coalition government’s root and branch NHS reforms, finally made it through the House of Lords after a rearguard action against failed.  They quite blatantly open the NHS up to competition law – and thus to some mandatory tendering of services to private companies.

These regulations have not been gathering dust.  The majority of new contracts to provide NHS services signed off last year went to private companies.  The Financial Times recently estimated that about £5.8billion of NHS contracts are currently being advertised to private sector providers.

Recently a government MP (not the MP for Devizes) wrote to his local newspaper saying all was well with the NHS.  At one point he stated: “The reforms which we have introduced are enabling £1bn in back office savings to be redirected into front line care enabling 1,700 more nurses and 7,000 more doctors to be employed.”

We can note his sly “…to be redirected…” rather than “…have been redirected…”.  But he gives no source at all for this figure and it is doubtful he can find one.

We know in Wiltshire that the Clinical Commissioning Group (CCG) is spending more on ‘back office’ costs than its predecessor Primary Care Trust.  And we know that the budgets for the three regulators (CQC, Monitor and the Trust Development Authority) have all gone up this year – one of them wanted a 66 per cent increase.

Part of the ‘back office’ – the polite word for the more usual ‘NHS bureaucracy’ – work is now done by the Clinical Support Units (CSUs) which were set up to provide these services for CCGs.  They employed thousands of staff from the PCTs and other bodies the reforms abolished – and were supposed to become stand-alone, autonomous organisations by 2016.

This process is steaming ahead and has already opened the door to bidders from outside the NHS.  So the fate of CSUs brings us back to privatisation – or externalisation as the official transitional documents euphemistically put it.

Sixteen bidders have been selected in the first stage of re-defining the CSUs.  These include all the current CSUs either on their own or with third parties including Capita, BT and KPMG – i.e. multinationals into which the CSUs may be consumed.

One NHS manager explained to Marlborough News Online that this could solve the NHS’s ‘CSU problem’ in one of two ways: “Either the private organisations will pitch this as loss leaders and knock the CSUs out of the picture, or the CSUs will be swallowed up by the likes of Capita and BT because of their staffs’ knowledge and specialisms.”

And we are not talking about a negligible part of the NHS empire.  The combined income of the nineteen CSUs is about £800million.

So this ‘all’s well on the Titanic’ MP will now have to subtract from his £1bn in savings money that will go not to frontline staff, but to shareholders of companies and to pay first the inflated salaries of their directors, and secondly the inflated salaries private companies will offer to lure staff away from the NHS.

The future of GP surgeries following the government’s decision embodied in Section 75 will be uncertain to say the least.  There are, of course, private GP practices, but the vast majority are and always have been independent partnerships funded and regulated by the NHS.

How the arrival on the GPs’ doorsteps of the big beasts of private health care will fare is anyone’s guess.  The problem is that doctors, despite their involvement in the CCGs as commissioners of services, are not a happy bunch – many believe they are sailing pretty close to the iceberg.

This is how one GP Partner responded to PULSE’s exclusive report on the opening of new GP contracts to private providers: “Next it will be opening up existing contracts to all private providers…however I suspect many of us would probably feel relieved if our contracts were taken over by someone else.  The current contract gives GPs totally unfair contract terms and a level of funding that makes practices almost non-viable.”

“The patients (which includes us) will suffer most. It can’t get much worse than it already is for primary care medical staff.”

There is one unintended consequence for this move towards privatising GPs: what happens when doctors working for “Angel Healthcare Inc” sit on a CCG (which has to have clinical membership) and hands out a huge contract for another primary care or acute service to “Angel Healthcare Inc”?

Or perhaps it is an intended consequence – completing the privatisation circle.

However, the privatisation bandwagon has just shed a wheel.  Serco has announced it is withdrawing from its clinical NHS contracts – having lost £18million.

As the respected health service blogger Roy Lilley wrote: “Why should the private sector be any better at running NHS services than the NHS? The simple answer is it isn't.”

“Because NHS staff come to work and wear a different badge does not make the systemic problems of the NHS go away. There are too many patients and not enough money. Sustainability is as much of a problem to the private sector as it is the NHS.”

* You can follow the march here – they reach London on Saturday (September 6.) 


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Is the NHS about to be caught in another and lengthy political fire storm?

It seems the NHS just cannot avoid the headlines – whether it is being named as the top of the league health service (by the American Commonwealth Fund) or whether it is failing one group of patients on Monday and another on Wednesday.  What is going on behind the headlines and at our local hospital?

First though, the endless run of headlines is partly explained by the NHS’ expected position as a key issue in next year’s general election.  This will put the NHS high up the news agenda of newspapers which back the Conservative party – and they will not be looking on the bright side of the NHS.

Two recent polls may have ensured many months of the NHS’ role as main political football even while the election campaign is still fairly distant.  

A ‘phone poll by Lord Ashcroft (who polls for the Conservative party) found that 31 per cent of voters thought ‘public services like the NHS’ would now be better if Labour had won in 2010 – while 48 per cent thought it would make no difference and 16 per cent said the services would be worse.

Another, wider and independent poll of voters across England by the Health Service Journal (HSJ) and FTI Consulting, revealed a widespread fear for the future of free health care.   

With funding at the heart of the political debate, this poll showed 90 per cent of voters agreeing that spending on the NHS should rise as the economy improves.

When asked to score out of 100 how much they agreed with the assertion “free care is under threat”, one in four said 100 per cent.

The average score was 70 per cent – even though no major political party has actually suggested an end to the principle of healthcare free at the point of use – and they are not likely to do so publicly.  

The results also revealed real concerns about the role of the private sector in the NHS.
Which chimes with the new chair of the House of Commons’ Health Select Committee, Dr Sarah Wollaston MP, telling readers of the Daily Telegraph: “Of course, there are…questions to be asked about whether the increased transactional costs from marketization have genuinely improved choice and efficiency.”

“Did we get more bang for our buck alongside better care because of the [Lansley] reorganisation, or was that outweighed by disruptive fragmentation?”  She already seems well-versed in the language of committee-ese.

In the HSJ/FTI Consulting survey the public’s continued support for the NHS is over whelming: 97 per cent of voters believe it is worth fighting for.

Meantime, the NHS carries on.  And so does the Great Western Hospital which serves the wider Marlborough area as well as Swindon.
Recent headlines have highlighted claims that the winter pressures experienced by hospitals have continued as ‘summer pressures’.  In January 2014 GWH had 6,089 attendances at their emergency department (or ED – formerly known as A&E.)  The figure for May 2014 was 6,634.

GWH is busy all the year round as demands on the NHS grow from long-term illnesses, an older population and increasingly complex and expensive treatments.

Elizabeth Price, GWH’s associate medical director for unscheduled care, told Marlborough News Online: “The emergency department is extremely busy all year and although we are seeing slightly fewer ED attendances compared with last year, this is because we are streaming some patients direct to medical and surgical assessment areas and other services.”

“Overall demand for Trust services continues to increase and emergency admissions to the Trust have actually increased 11% since April 1st.”

In fact efforts to reduce attendances at their ED have begun to pay off: last year from January to May 32,458 people went to GWH’s ED.  The same period in 2014 saw a four per cent drop to 31,278.

GWH have not only re-designed and enlarged their ED (and added a children’s ED) and recruited more staff.  They have also been working with other providers to make sure people who think they should ‘Go to A&E’, actually go to the right place where they will get the most appropriate attention and treatment.

GWH is also working with GPs to make sure patients go to the right department within GWH and  has supported the Choose Well campaign run by Wiltshire and Swindon CCGs.

And choosing well is important since it is estimated that at least one in four people attending ED could be treated more quickly and effectively elsewhere.

In addition there is the new urgent care centre on the GWH site open 24/7/365 to provide advice and treatment outside normal surgery hours.
With pressure still on GWH and another winter looming, Swindon CCG are planning to pilot new walk-in centres to help keep people from clogging up the hospital unnecessarily.

Last winter the NHS England handed out extra money to help hospitals through the winter.  GWH applied for £4.2 million and got nothing.  The Royal United in Bath got £4.4 million.

In a second round of extra money (in November 2013) Swindon CCG got £1.1 million.  None of this money went directly to GWH.

More than half of it went to SEQOL – a social enterprise organisation that provides health and social care services in Swindon. £300,000 went to fund additional beds within nursing homes.

The emphasis was on reducing “unnecessary admissions to hospital”, getting patients out of hospital faster, caring for the frail elderly at home.

Which brings us to the stark warning from Dr Wollaston’s Commons committee that cutting back on hospital services in England before community services are ready to provide ‘care close to home’, is a “recipe for disaster.”

The committee’s warning looks ahead to the Better Care Fund which starts this year, but comes into full effect next year.  This ‘Fund’ takes huge sums of money from hospitals and hands it to social care.

As Marlborough News Online has reported, the process of making this change rings alarms bells and will turn risk registers across the NHS in England bright red for danger.

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Is a serious shortage of GPs the next major crisis to hit the NHS?

Many experts believe the next crisis to hit the NHS will be a perfect financial storm which will make landfall just before or just after the 2015 general election.

It does not give much reassurance when, at the end of the last financial year, Wiltshire’s Clinical Commissioning Group (CCG) has to return £5million to the Department of Health – a percentage of its budget that dwarves the increase it was given at the start of that year.

Just yesterday (May 21) the Health Service Journal discovered - under Freedom of Information requests - cases of hospitals asking for extra cash to fend off unpaid suppliers and keep the electricity from being cut off.

However, anxieties expressed forcefully at this week’s board meeting of Wiltshire CCG indicate that there may well be a ‘shortage of GPs’ crisis that will hit the NHS even sooner than the full force of the financial crisis.

With GP numbers down across England, Celia Grummitt put the matter plainly: “GPs are feeling under pressure and under-resourced. We need to send a message to the centre: the NHS is not looking well and they need to do something.”

Dr Grummitt, who is vice chair of the CCG’s Sarum Group and a GP at the Cross Plain Practice with surgeries in Shrewton and Durrington, went on: “We are losing young doctors from this country in droves.”

Dr Toby Davies, chair of the CCG’s Sarum Group, gave an example of the number of GPs opting for retirement in one area set against the number of newly trained doctors leaving the country. He cited the pressures on GPs from the coalition government’s recent contract for GPs.

“The new contract makes it worse.”  How, he asked, were GPs to find the time to fulfil the need for two per cent of their patients to be given individual care plans?

The pressures on GPs do not only come from the new contract.  Under the coalition government’s root and branch restructuring of the NHS to Andrew Lansley’s plan, GPs have been mandated a central role in commissioning – and for some GPs that takes up a considerable amount of their time.  As Dr Grummitt put it: “We are under pressure to get back to the practice.”

So why are newly trained leaving the country?  It is clear that financial rewards for GPs have been reduced.  So to make up for that loss, they are planning to bid to undertake more treatment services in their surgeries – and that puts new pressures on them.

It probably does not help keep them in this country that the government insists on day-to-day micro-management of the NHS and talks down the qualities of the NHS and talks up the value of private, commercial providers.

News of this looming shortage comes hard on the heels of the critical shortage of nurses in England’s hospitals following the 2010 general election: “Number of NHS nurses falls despite coalition pledge to protect frontline – Almost 6,000 nurses’ posts have disappeared since the general election, official figures show” (Guardian – September 2012.)

For hospitals now facing demands to publicise ward-by-ward staffing levels, the nursing shortage is by no means resolved.  Great Western Hospital has not been alone in sending staff to recruit trained nurses in Ireland and mainland Europe.

But we should perhaps remind ourselves that last summer there was a similar ‘doctors shortage’ scare: “Shortage of GPs will undermine the future of the NHS” (King’s Fund – July 2013).  And a few weeks ago it was a shortage of hospitals’ A&E doctors: “Jeremy Hunt has ‘no clear plan over chronic shortage’ of emergency doctors” (Daily Mirror on a report from MPs - March 4.)

Send MNO a letter if you have had unusual difficulty getting an appointment with your GP: This email address is being protected from spambots. You need JavaScript enabled to view it.

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How are hospitals like the Great Western coping with the new NHS – and how will it survive the Better Care Fund?

First year report on the coalition government’s major NHS shake-up – part three

Hospitals were the one major part of the NHS in England not directly affected by the Lansley restructuring through the Health and Social Care Act.  But during the past year, hospitals have been in the eye of an NHS storm – not least because of their finances.  

Last month the trusts’ regulator, Monitor, announced that the number of NHS Foundation Trusts in England in financial difficulty had doubled over twelve months from 21 to 39 - of these 33 were acute hospitals.  

They have been caught in the down-draught from the Act – most notably from the requirement to put services out to tender and the increasing moves to favour commercial providers.

Acute hospitals – like the Great Western – are reeling under the pressures of increasing demands for treatment at a time of highly constrained budgets.  This may be partly because of the restructuring and partly because of other more general causes.

This unparalleled demand stems also from the growing population and its increasing longevity, from increases in chronic disease like diabetes (often connected to obesity), coronary and respiratory conditions – and the costs of new treatments.

The restructuring has undoubtedly given unprecedented commissioning power to GPs who are keen to enhance local primary care services and keep as many patients as possible away from expensive hospital beds and even more expensive hospital operating theatres.

But it was the aftermath of the Mid-Staffordshire hospital scandal in the shape of the Francis Report that has concentrated minds within hospitals and given politicians free rein to take pot shots at them.

That hospitals should have sufficient numbers of nurses was one of the key points of the Francis Report.  During the first years of the coalition government, nursing numbers fell disastrously – between 2010 and 2012 the NHS lost 4,028 full-time equivalent qualified nursing posts.  The GWH has been running a costly and successful recruitment campaign.

When reports on Mid-Staffs were published, nurses became the target of criticisms by right wing politicians and newspapers, not just because they were employed in the public sector, but because they were ‘too posh to wash’ or were not being ‘taught compassion’.

As winter approached the number of nurses (like GPs, many nurses choose to work part time, so these numbers are in terms of full time equivalents) rose dramatically: between September and November last year the NHS employed 4,500 additional full-time equivalent nurses for acute and older people’s wards – a three per cent increase in staffing levels at April 2013.

Even so, hospitals reported their budgets for agency nurses were going through the proverbial roof.  And it was only in January that the government allowed an increasing in student nursing places.

The general slide towards privatisation of NHS services reached its peak when the chairman of the Care Quality Commission, David Prior, (a former deputy chairman and chief executive of the Conservative party and a former Conservative MP) announced recently that ‘failing’ hospital trusts should sold off to European or American ‘hospital chains’.

He said up to thirty hospitals could end up being sold off to private operators.  This puts hospitals, whether they are Foundation Trusts or not, on notice that the government’s preferred way of solving costly problems in the NHS is by ordering fire sales.

As if the Health and Social Care Act was not enough, there will soon be the Care Act (which is expected to become law later this year.)  This Bill has had tacked onto it a clause (Clause 119) that may affect all hospitals.  

Health Secretary, Jeremy Hunt is changing the law so he can close down hospitals without reference to troublesome things like local opinion and competition issues.  This Bill - with its Clause 119 safely approved by MPs - is about to go back to the House of Lords for its final parliamentary scrutiny.

The NHS’ first year under the new regime ends just as winter pressures are beginning to ease. GWH has not had an easy winter.  
It bid for £4.2 million to help it through the winter – and got nothing.  The RUH in Bath got £4.4 million and Oxford University Hospitals NHS Trust got £10 million.

For many weeks over the winter GWH has failed to hit the target figure that 95 per cent of people coming to A&E should be seen within four hours. And it has suffered from all the connected problems of overcrowded emergency departments – ambulances queuing, trolley waits and blocked beds.

One Commentator has called A&E “the canary in the mine; it tells the story of what is going on elsewhere in the service.”

GWH has been working closely with GPs to make sure patients are referred directly to the right department and do not just show up at the emergency department.  A new urgent care centre managed by SEQOL opened on the GWH site in September. SEQOL is a Swindon based social enterprise organisation – “a business with a social purpose”.

And GWH is working with Wiltshire CCG on the Choose Well campaign – another way of encouraging patients not to use the emergency department as a first port of call.

Then in November NHS England found more money to prevent a winter breakdown at hospitals. £711,000 went to Wiltshire CCG and was passed on to Salisbury Foundation Trust hospital which used it for seven projects to help directly with winter pressures:

•    extending their discharge lounge to help the flow of patients.
•    establishing a unit for rapid assessment of the frail elderly.
•    an enhanced paediatric service.
•    extra support for its seven day service.
•    additional bed capacity.
•    extra ward staff to help reduce length of stay.
•    addition weekend trauma surgery capacity.

In November Swindon CCG received £1.208 million pounds for winter pressure.  This was not passed on to the Great Western Hospital and we have not heard in detail how it was spent.  We do know that the CCG’s board was told the money “has now been fully committed.”

No sooner is winter over than hospitals will have to turn to coping with the Better Care Fund (BCF - see the second article in this series.)  

The Fund will not start in earnest until 2015-16, but in the coming year it will begin to change how NHS money is used – with a switch of quite large sums away from acute hospitals to the joint CCG-Council BCF.  

Will the BCF be able to keep enough of the frail and elderly out of hospitals to allow the hospitals to reduce their capacity – as, with less funding, they will be forced to do. NHS bosses believe that the switch in funding will only work if hospitals can reduce their activity by 15 per cent – and yet hospitals, even without the pressures of winter, are at full stretch.  

Not only are they at full stretch as regards staff and patients.  They are also at full stretch as regards their budgets.  

For some full stretch has given way to over spend.  It was reported last week that trust hospitals are seeking £376 million in bailouts for the financial year just ending.  These hospitals are not yet being named, but they include five in the south of England which are asking for a total of £73 million.

Great Western Hospital is likely to break even.  With the Better Care Fund about to start gnawing at its funding, how long will it be able to stay out of the red?  And how loudly will GPs howl when services at the hospital are reduced because of the BCF?

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GWH’s new chairman looks ahead as the NHS changes – and to Savernake Hospital’s role

Trust Chairman Roger HillTrust Chairman Roger HillRoger Hill has been chairman of the Great Western Hospital Foundation Trust (GWH) for just two months. But he has been a non-executive director there since 2008 so he knows the hospital and its staff well.

He could not have taken up his important new post at a more testing time for major NHS hospitals.  As he told MNO:  “The era we are moving into is the most complex, most difficult and most high risk.  If we get it wrong…what’s next?”

The challenges increase by the week. GWH has had a pretty fraught winter with staff stretched and target watchers circling.  This year sees the start of the government’s Better Care Plan which will scoop money from hospital budgets.  And there are vital contracts to be tendered for.

Roger Hill retired some years ago after an international and successful career in the computer business – he was chairman and managing director of the UK subsidiary of the American computer giant Intergraph.  And he has also set up companies himself.

He lives in Aldbourne and has been chairman of Marlborough Golf club for four years.

GWH seen from the southGWH seen from the southMany people see GWH as Swindon’s hospital – even Swindon’s ‘community hospital’. But one third of its patients for acute treatment and of its income comes from Wiltshire.  It also attracts patients from Gloucestershire, West Berkshire and Oxfordshire.

One of its problems is Swindon’s ever growing population.  Another is the ageing of the population: “There is a material increase in the older population and a growing need for us to provide care for the frail elderly.”

GWH has just recruited three more consultants to their geriatrics team.  Their successful drive to recruit more nurses continues and they have already increased nursing staff in the last year by 130 - over and above nurses retiring and leaving the area.

This has been a very tough winter for the GWH.  Having put into action a whole list of ways to cope with extra pressures – those pressures kept on coming.  They did not meet the target for 95 per cent of A&E patients to be seen with four hours – and for one week were in the bottom ten of hospitals in England.

Having analysed the statistics for the whole hospital rather than just their emergency department, Roger Hill knows that their ambulatory care unit (for walk in rather than ambulance delivered patients) and their surgical assessment unit certainly helped filter patients through the system.

Now with winter over some of the extra beds are being mothballed again and planning has already started for next winter.  

However, GWH is facing a year-round and steep rise in the number of patients it sees. In January and February this year they saw a ten per cent increase in patients who have not chosen to have operations – the majority following referrals by GPs.

Recently GWH, with about 500 beds, has been accepting 350 admissions every week. To handle that level of demand needs some very astute planning and a tight control over ‘blocked beds’ so people can leave hospital quickly when they are ready to.

How will a hospital under such pressures cope when the Better Care Fund not only takes away some of its budget, but with the integration of health and social care for the frail elderly also tries to keep them away from hospital?

Hospitals will have to change their ways.  Roger Hill tells MNO that GWH has saved £500,000 in the last year by holding thousands of ‘virtual clinics’: if a patient needs no further treatment, they can be signed off over the ‘phone by their consultant rather than having to make time to travel to GWH.

As it costs £1 million a year to run a ward, that £500,000 is a very worthwhile saving.

Roger Hill believes the NHS in Wiltshire is “ahead of the game” when it comes to integration of health and social care services.  He is full of praise for the Council’s Health and Wellbeing Board and the way the Wiltshire Clinical Commissioning Group is working.  And GWH is fully on board: “All the time we are actively involved in the integration of care – we want to participate in the way care is delivered.”

They have employed the new Care Coordinators that are the advance guard of the Better Care Fund’s aim to treat people at home for as long as possible. Some are clinically trained, but in the Marlborough Area they are trained in social care.

As Roger Hill sees these developments, it helps both provider and patient when instead of sending three services to look after a frail and elderly person, you can send just one.

As someone who has first-hand experience of computers, he wants to get GWH staff in the field fully set up with appropriate IT systems.  That is a challenge when Wiltshire’s open spaces have gaps in mobile ‘phone coverage.

A distinct change in the life of a hospital administrator is the constant round of tendering.  The bid to continue GWH’s contract for community maternity services was not successful – the service went to the Royal United Hospital in Bath.

Now they are starting their bid for children’s community health services in Wiltshire.  This is complex because while at present GWH runs the main part of the service, there are several other providers, some of them working across county borders.

Wiltshire CCG wants either to give the whole service to one provider, or to find an organisation that would have overall responsibility for a group of providers.  

GWH has found, Roger Hill tells MNO, it needs a small team looking after all the Trust’s bids for service contracts: “We have to be able to manage bids professionally.”  

Not exactly a boost to the front line of the NHS and another unintended consequence of the Health and Social Care Act’s policy to favour non-NHS providers.

Roger Hill is bullish about the role for Savernake Hospital – which GWH now owns.  He says the hospital’s space is full at the moment and he is pleased consultant clinics are being held there, extra beds are in place and the mobile chemo truck visits.

GWH is now looking to see how they and the Prospect Hospice (which serves the Marlborough area) can accommodate an end of life ward at Savernake.  This would support the work Prospect does with its home care service.

As always there is an element of uncertainty about Savernake’s future – something GWH’s new chairman is very aware of.  Next year GWH will be tendering for the contract to provide adult community health care across Wiltshire.

The results of that competition could mean Savernake Hospital – and its hefty annual PFI payments – might be sold.

How does Roger Hill sum up the coming years? “Significant strides have been made as to how we are going to achieve integrated care – it’s got to be done as a system – and there is no evidence that the acute [hospital] element of the NHS is under threat.  I am fairly confident we will make it happen.”

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After NHS restructuring, the Better Care Fund is a real step change – or is it a leap in the dark?

First year report on the coalition government’s major NHS shake-up – part two

The NHS is about to begin yet another major change in direction.  April 2014 sees the inauguration of the coalition government’s Better Care Fund (BCF) which will put NHS money into social care in a bid to reduce the NHS’ fast rising costs – largely fuelled by the ever increasing age of the population and the complexity of long-term illnesses.

The size of the problem is best seen in numbers: in Wiltshire the over 65s make up 21.8 per cent of the population.  But, Wiltshire Clinical Commissioning Group (CCG) reckon they use 47.4 per cent of the health services the CCG commissions.

Or, to put it another way, the CCG’s annual spend per head of Wiltshire’s 479,992 population is £1,023.  This increases to £1,600 for those between 65 and 74, to £2,917 for those between 75 and 84, and to £4,913 for those over 85 years old.

Wiltshire's Better Care Fund planWiltshire's Better Care Fund planThe BCF aims to reduce these costs by providing better social care for the ‘frail elderly’ in their own homes, treating them locally and avoiding inappropriate admissions to hospital.  And if they do have to be admitted it wants to make their length of stay shorter.

The basic means to those ends is the close integration of social care (the responsibility of the Council) and health care (the responsibility of the CCG.)  

The Fund was originally given the descriptive title of ‘Integration Transformation Fund’, then political spinners re-christened it with an aspirational title: ‘Better Care Fund’ – more like an election manifesto headline.  Will it deliver what it aspires to deliver?

In 2014-2015 the BCF will start with modest pots of money – Wiltshire’s will be £22.37 million some of which will come from the CCG’s budget.  In the first year, this money will be used “as a catalyst for stimulating integration of health and social services.”

For 2015-2016 Wiltshire’s BCF pot will rise to £29.51 million.  The money will only be available once each local authority-and-CCG has a jointly agreed plan that is approved (by ministers) detailing how the fund will be used.

The BCF will rely on projects and commissioned services agreed, planned and run jointly by the CCG and the Council acting under the Wiltshire Health and Wellbeing Board (HWB) which was set-up under the Lansley reorganisation.

There is one somewhat grey area: some of the fund will be allowed to fund mandatory changes brought in soon by the Care Bill (now before Parliament.)  And at least one CCG has agreed that it should fund existing social services on the grounds that they come under ‘preventative health measures’.

The BCF’s budget will not be new money.  So where is it coming from?  The BCF will largely be funded by ‘top-slicing the CCG’s annual budget’.
In Wiltshire it will mean the CCG surrendering – or ‘top-slicing’ – £15.52 million from its budget for 2015-2016.  This will go into the pooled budget together with existing council social care funds.

While this sounds eminently sensible and laudable, there are four main risks around the BCF.  

The first is that the CCG top-slicing will in fact come totally from the budgets of the foundation trust hospitals like the Great Western Hospital which would further destabilise this vital part of the NHS’ cradle to grave treatment regime.

When a Wiltshire Council committee examined the Council’s budget for 2014-2015, they delivered this analysis of the BCF: “The funding …will be drawn from the acute hospitals in the form of top slicing three per cent from their budgets to streamline services and form a centralised system aimed at providing more community care.”

If that becomes the norm England’s already struggling hospitals could become endangered species.  And when frail elderly people – not to mention other patients – are too ill or their condition too complex to be treated ‘close to home’, will there be beds and expertise left in the acute hospitals to treat them?

De-stabilising the acute hospitals is something that Wiltshire CCG’s finance director, Simon Truelove, has been warning against during the past year.  All the BCF money is going to social care and community health care – there is no money in the fund to bring about the necessary changes in our hospitals.

At the March board meeting of NHS England (NHSE), its chairman, Sir Malcolm Grant, gave a stark warning about the BCF: “I think this is one of the most challenging and daunting things that lies ahead of us…I think it carries very high risks.”

NHS England's Jane CummingsNHS England's Jane CummingsNHSE’s Chief Nursing Officer, Jane Cummings explained the BCF’s inherent risks: “We anticipate that emergency activity [in hospitals] will need to reduce by about 15 per cent.  There will be a massive risk if we continue to have the same system of patients in hospital and try and create this fund…there is quite a lot of risk associated with this.”

Where the BCF will show bright red on NHS risk registers is over the inevitable time lag between the steady build-up of relevant social services resulting in the promised “better care”, and the withdrawal of funds from acute hospitals leading to a swift reduction in their capacity.

The Wiltshire BCF plan lists seven areas of risk and they are all rated as ‘high’. The risk of destabilising hospitals is not among those risks – that is somebody else’s risk.

Outgoing NHS chief Sir David Nicholson warned the board meeting about the consequences of missing that 15 per cent reduction target:  “We’ve never quite done it in that way.  If we can’t do that we have to get hospitals to provide not [the existing] four per cent efficiency, but eight per cent – which I think is simply impossible.”

Or as one commentator put it: “Top slicing CCGs is fine, but there is the risk that the benefits of community oriented integrated care conforms to a longer timetable than that of the loss of funding created locally.”

Julie Jordan of the law firm Mills and Reeve, who specialises in health matters both NHS and independent, calls the BCF an “effective cut in the acute care budget” and she identifies another hurdle in the process of setting up the BCF.

This second risk stems from the change in CCG’s spending which will have to take place:  “The mechanics of extracting such a large amount from acute service contracts must demand a degree of service reconfiguration, so we should expect to see a raft of public consultations on proposed service changes in the months leading up to April 2015.”

“Won’t that be jolly when it coincides with the final months of the current parliament, as we head for a general election on 7 May 2015?”  (The Secretary of State’s new powers in Clause 119 of the Care Bill [see the third article in this series] may pre-empt any consultation.)

The third risk is that the money transferred from the CCG and from other NHS budgets will not be ring-fenced when it reaches the new pooled pot and may not be used only for its agreed purposes.

Ms Jordan, writing in the Health Service Journal, believes new legislation will be necessary to ensure ring-fencing is robust. And NHS England’s deputy chairman, Ed Smith, warned against “the diversion of money into other activities.”

And this brings us to the BCF’s final risk factor:  it is being overseen locally by the HWBs which are committees of local authorities and very new, untried institutions.

Wiltshire’s HWB is chaired by the Council’s leader, Jane Scott, with the Chair of the CCG, Dr Steve Rowlands, as her deputy.  It now meets in public and is responsible for the broad strategy for health and social care provision within the county.

But the CCG retains legal responsibility for the services it commissions.  If it sees money from its allocated budget going into social care services it does not rate or which are non-health social care services, sparks may fly.

Julie Jordan again: “Some CCGs have already expressed concerns that the pooling of budgets will in effect result in the NHS subsidising non-health social care services.  Not exactly the health and social care ‘happy families’ the government intended.”

MPs have called for HWBs to have a greater role in the move to integrated care.   The Commons health committee’s chairman, Stephen Dorrell, said HWBs should become “commissioners of joined up health and care services.”

But the committee also said that without ring fencing of social care funds, “…there is a serious risk to both the quality and availability of care services to vulnerable people in years ahead.”

Ed Smith again: “We are reliant on the HWBs.  I think the jury is out at the moment on whether they are sufficiently robust to be able to provide the assurances we need.”  

It should be noted that at the March meeting of the Wiltshire HWB Jane Scott said: “I don’t think it’s going to be easy – it’s going to be quite challenging for all of us.”  And she added that she was disappointed the BCF was restricted to the frail elderly.  She wanted to include disabled adults and children and mental health patients.

The outline plan for Wiltshire’s BCF had to be drawn up in a great hurry to meet government deadlines.  It already carries a list of seven risks rated ‘High’ with an outline of measures needed to mitigate those risks.

According to an NHSE executive the Wiltshire BCF plan has been “very well received – as being people centred.”

In its section on ‘Integration Aims and Objectives’ the glossy covered plan includes 17 principles for the integrated plan.  They include principles of very great interest to everyone in the county:

•    “Our principle: we will shift our services from being paternalistic to ensuring that services are designed for and with the people who use them.
•    Our objectives for integration: People will be involved in the redesign of integrated services.
•    Our measures: patients and service users will be involved in pathway reviews, service specifications and tendering.”

Whether it is ‘people’ or ‘patients’ or ‘service users’, Wiltshire Council and Wiltshire CCG are now committed to listen to and consult a very large proportion of the county’s population. We will see over the coming year how they intend to do that.

Marlborough News Online will be reporting on the specific projects the BCF is providing for Wiltshire.

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