Prof Chris Ham, chief executive of The King’s Fund, writes: The Coalition Government’s NHS reforms have resulted in a degree of complexity never seen before. The reforms have also extended the use of competition by requiring many services to be put out to tender and giving the OFT a role in reviewing proposed mergers between NHS providers. Both the organisation of care and how it is provided have become more fragmented as result. Is it therefore credible for Jeremy Hunt and Norman Lamb to argue that care needs to be integrated to meet the needs of older people and others with complex needs? The answer depends on whether Ministers are prepared to provide the means that are required to deliver integrated care.
A welcome start has been made with the decision to grant 14 areas of England the status of pioneer communities with support to take forward integrated care at scale and pace. Equally important is the transfer of almost £4 billion from the NHS ring fenced budget into the Better Care Fund. This will be available to all areas of England to pump prime services that bring together health and social care. Ministers must also be willing to review the role of the OFT in mergers, ensure the Care Quality Commission assesses how organisations work together, and insist that the right incentives are in place to develop integrated care. They must make it clear that competition should be used selectively rather than as an organising principle. Failure to do so will make the government vulnerable to the charge that it is intent on undermining an institution that remains dear to the hearts of the British people.
The NHS is more fragmented than ever (The Independent: 13 January 2014)
The Coalition Government’s NHS reforms have resulted in a degree of complexity never seen before. The reforms have also extended the use of competition by requiring many services to be put out to tender and giving the OFT a role in reviewing proposed mergers between NHS providers. Both the organisation of care and how it is provided have become more fragmented as result. Is it therefore credible for Jeremy Hunt and Norman Lamb to argue that care needs to be integrated to meet the needs of older people and others with complex needs?
HIV care warning - specialists' concern over the future of HIV care after NHS changes (BBC News: 1 December 2013)
Specialists in the field of HIV care have warned that the changes that are being made to the NHS could affect the provision of HIV treatment in the future. As part of the reorganisation of the health service, responsibility for sexual health has been passed to local authorities, but treatment for the effects of HIV is still in the hands of the NHS. A significant proportion of specialists in HIV treatment felt that this arrangement has worsened patient care, when responding to a survey carried out by the British HIV Association. One third of the 100 HIV specialists surveyed thought that HIV care had worsened since the re-organisation in April, and two-thirds thought that care is set to deteriorate further. Dr Janet Wilson, president of the British Association for Sexual Health and HIV (BASHH), said: "Sexual health clinicians have been sounding the warnings around restructuring since the introduction of the government's health reforms.” She added: "We need government, national and local agencies to urgently work together to prevent HIV and GUM (genitourinary medicine) care going backwards."
MPs slam NHS re-organisation (Unite: 7 November 2013)
North London Labour MPs David Lammy and Jeremy Corbyn and former Islington council leader Catherine West joined more than a dozen campaigners and patients highlighting attacks on the NHS at a public meeting in Archway on 1 November. “I don’t know where to go to challenge decisions that are now being made,” said Tottenham MP David Lammy. “The landscape of health organisation is very confusing. It’s difficult for me as an MP. God knows what it is like for constituents.” He registered particular concerns over the closure of mental health crisis centres in Enfield and Haringey. “It is unacceptable that people suffering acute mental disorder and psychotic episodes should have to present themselves in A&E. I can tell you now there will be a terrible tragedy. Islington North MP, Jeremy Corbyn, said, “I am fearful for the future of the NHS. GPs are under enormous pressure and patients are reporting growing difficulties getting appointments and access to healthcare. Instead of sensibly planning how to meet health needs, we have duplication of resources and competition among hospitals,” said Jeremy Corbyn.
Concerns over single-specialism 'integration' plans (HSJ: 1 October 2013)
Senior figures in healthcare have questioned moves by clinical commissioning groups to introduce “integrated” care pathways for single clinical specialisms, such as cancer or cardiology.
The King’s Fund think tank has led calls for a focus on integrated care in recent years. However, several of its leaders told HSJ they were now concerned that redesigned services focused on a single issue – described as “carve-outs” – could cause fragmentation, and create new “silos”.
HSJ reported last month that many CCGs had begun tendering, or were planning to tender, for contracts to provide redesigned services for single-specialism care pathways.
Examples include Bedfordshire CCG, which plans to contract Circle as its prime provider for all musculoskeletal services; Bexley CCG, which is consulting providers over integrating cardiac services; and Tameside and Glossop CCG, which is planning a single contract for diabetes care.
Meanwhile, a group of Staffordshire CCGs wants to establish a single contract for cancer services.
King’s Fund senior policy fellow Nigel Edwards told HSJ: “The minute you bunch stuff up together, you run the risk of creating new and different problems with integration.
“If you integrate one vertical silo you create new opportunities for a lack of integration with other ones.”
Some contracts currently being considered appeared to be a “carve out” of particular services rather than an integration project, he added.
Mr Edwards said integrated services should ideally cover a broader population than a cohort of patients with a particular condition.
He said separating specialisms was more problematic for conditions whose care pathways more commonly overlap with others, such as cardiac or cancer care. In these cases a patient with more than one long term condition could see their care fragmented between separate contracts.
Cornwall's health service 'fragmented', hospital governor says (BBC News: 25 October 2013)
A bed-blocking row has highlighted Cornwall's "fragmented" health service, a local health governor has claimed. The Royal Cornwall Hospital Trust (RHCT) cancelled 14 operations on 7 October because it was unable to discharge patients. It cited a lack of community beds and social care support - services provided by Peninsula Community Health Trust and Cornwall Council. RCHT governor Graham Webster said agencies had a lack of communication. "The system has become very fragmented," Mr Webster, who is also vice chair of Health Initiative Cornwall, told BBC News. He added it was concerning that some elements of health care were no longer part of the NHS, but provided by what were "essentially private contractors". "A lot of these agencies have been working in their own interest, rather than in the interest of patients," he added. Mr Webster said demonstrated the poor communication between the different partnerships. He said: "There was quite clearly a cap in the various procedures and systems which should have been followed. "We weren't even working to the same policy, which is very surprising and very disappointing."
Serco condemned over move to offload troubled GP service in Cornwall. (The Guardian: 11 October 2013)
Serco, the private contractor that falsified its NHS data in Cornwall, is looking to pass on its troubled GP out-of-hours service in the county to a subcontractor. The Guardian has learned that Serco has been in talks with the NHS to hand delivery of the service to Devon Doctors, a not-for-profit enterprise run by GPs in neighbouring Devon. Margaret Hodge, chair of the parliamentary accounts committee (PAC), which held an inquiry into Serco's performance in Cornwall earlier this year, described the move to offload the contract as outrageous. "It's absurd that the government contracts with one company, which can't cope and misleads us all, and the company then just hands the job over to another. How on earth can you have proper accountability like this ?" she said. Serco's negotiations over subcontracting follow a Guardian investigation which revealed it had falsified its performance data when reporting to the local NHS trust so that it appeared to meet targets in the contract that it failed to achieve…. Clare Gerada, chair of the Royal College of GPs, said subcontracting NHS contracts would lead to a fragmentation of service, which could damage patients' interests. "Serco hugely underestimated the complexity of out-of-hours provision in bidding for the contract," she said. "Now commissioners are tied up in a contractual and competition nightmare, when the most sensible thing would be to break the contract and invite local doctors to provide the service, which is what they were doing before the existing co-op was dismantled for this contract."
Record number of private operations in 'two-tier' health service (The Mirror: 20 September 2013)
Hard-up NHS hospitals are doing record numbers of private operations to stay afloat. Shock figures show their income from private patients rose 12% last year – with a further 10% rise forecast for the next 12 months. Worried doctors fear the figures reveal the Tories are creating a two-tier NHS – with those who pay gobbling up scarce resources. Under the controversial NHS shake-up, hospitals can now earn up to 50% of income from private work. A Freedom of Information request by Labour MP Gareth Thomas revealed English NHS hospitals earned £434 million from private patients in 2012/13, up £47 million in a year. Hospitals are forecasting they will earn even more this year (2013/14), raking in some £480 million from private work.
Campaigners trying to save hospital services launch a further Protest (Hastings and St Leonards Observer: 11 September 2013)
Hospital campaigners battling to save services at the Conquest from being cut have protested against NHS bosses’ latest proposals.
Members of Hands off the Conquest staged the demonstration in Priory Meadow Shopping Centre at the same time hospital managers held a meeting to explain their plans to change general surgery services, musculoskeletal and orthopaedic services, and stroke services. Health bosses have admitted up to 15 patients a day will have to travel either to Eastbourne or Hastings if the proposals come into effect. General surgery deals with abdominal organs, such as the stomach and intestines, and the higher risk and emergency work will be based at either the Conquest or Eastbourne’s DGH. Emergency orthopaedics, such as fractured hips, would also be centralised at one or the other hospital, similarly with stroke services. Margaret Williams, chairman of Hands of the Conquest, said: “We have had members of the public coming up to us worried that the Conquest will close eventually. They all think it’s about saving money.”
CCGs line up raft of 'prime contractor' deals (HSJ: 14 August 2013)
Dozens of clinical commissioning groups are devising innovative contracts in which a lead provider receives an outcomes based payment to integrate an entire care pathway, HSJ can reveal.
The news comes after Bedfordshire CCG on Monday named private company Circle as its preferred bidder to be “prime contractor” for an integrated musculoskeletal service.
If the £120m deal is finalised, Circle − which also runs Hinchingbrooke Health Care Trust − will be financially and clinically accountable to commissioners for the whole pathway. The CCG said this previously involved 20 contracts across primary, secondary and community services.
Bedfordshire is the most advanced CCG in introducing this type of system but HSJ has identified a raft of similar deals in the pipeline.
These include a group of CCGs in Staffordshire planning to commission cancer and end of life care based on outcomes, and Oxfordshire’s proposal to bring in lead providers to integrate maternity, mental health and older people’s services.
Bedfordshire CCG director of strategy and system redesign Diane Gray told HSJ: “About 30-odd CCGs have been in contact with us about the work we are doing here.”
She said they fell into two categories: those considering delivering integrated musculoskeletal services and those interested in outcomes based approaches. It is understood neighbouring Cambridgeshire and Peterborough CCG, which is tendering older people’s services worth £1bn, is among those in contact.
The prime contractor model involves a single organisation subcontracting work to other providers to integrate services across a pathway. A proportion of payments is dependent on the achievement of specific outcomes.
About £4m-£6m of the Bedfordshire contract is dependent on Circle making “game changing” alterations that will improve patient outcomes and service sustainability. HSJ understands the CCG is working informally with consultants to ensure the contract gives it sufficient power over the lead provider.
NHS Partners Network chief executive David Worskett welcomed the model as an “innovative and imaginative” commissioning solution. However, Sir John Oldham, who led a series of integrated care pilots for the Department of Health, said other models could be better suited to some areas of provision.
He said “alliance contracting” − in which a commissioner issues one contract binding several providers − scored highly in the year of care capitation tariff pilots, which looked at people with multiple long term conditions.
Commissioners found this model “created the more cooperative behaviours… in the system” while the prime contractor model risked creating “adversarial” relationships between prime and subcontractors, he added.
Eastbourne Hospital paediatricians in 'catastrophe' warning (BBC News Sussex: 24 May 2013)
Consultant paediatricians at Eastbourne District General Hospital have said that the newly configured children’s services are unsafe. The altered services came into operation at the beginning of May. East Sussex Hospitals Trust said the move to a midwife-led maternity centre in Eastbourne, with consultants based in Hastings, was a temporary measure needed to cope with staffing shortages. However, in an open letter, nine consultant paediatricians said: " said there was a risk of “catastrophes and serious failure.”
GP raises alarm over fragmentation of practice services (BMA: 30 April 2013)
A GP has expressed concern about the fragmentation of NHS care after ancillary services were moved from her surgery. Lancashire GP Margaret France said many older patients now had to travel more than an hour on public transport for general podiatry services that used to be housed within her practice.
Lancashire Care NHS Foundation Trust, which holds the contracts for such services, has also transferred health visitor services from Dr France’s Withnell Health Centre to the new Buckshaw Village Health Centre about 10.5km (6.5 miles)