1. At 02:39 pm on 02th Mar Chris Wakefield wrote:
Everyone knows and trusts the NHS to do the best it can, all the time, in spite of the pressure it is under. The same cannot be said of the Success Regime, whose attentions to local Heath and Social care provisions via STP appear purposefully malignant. I’ve read their Pre Consultation Business Case (PCBC) again in the hope of enlightenment, but there it little to recommend it - even though it remains the ‘evidence’ base for the forthcoming blitz on hospital beds. No surprise really - The Success Regime’s director Ruth Carnall confesses ‘I had to spend over 10 years in finance, and even become a finance director despite being no good with figures and having no process skills’, and you’d have to agree with her, reading the PCBC, which is an accountant’s eye view, and a poor one at that, of how to run a local health service.
Just to recap - the Sustainabillity and Transformation Plan (STP) is designed to steer the economics of local health policy towards demand reduction, and thus cost reduction, in our county based NHS. There is nothing morally reprehensible in trying to do things more efficiently, but if the prime objectives are cost reduction (which they are in this case) then planned changes tend to rest on attempts to cost the uncostable, followed by lots of counting, to see if an answer emerges from shrinking the numbers. The PCBC was an effort to do just that and falls well short of the mark.
The STP rests on two premises (three if you count in preventive care, which I don’t in this note) - The first is moving long-term bed-blocking patients out of the NHS and (quickly) into the Social Care sphere, which is largely in the remit of the local authority and therefore represents a cost saving to the NHS. The second is removing the beds that these people once occupied and then removing the space that the beds themselves once occupied in Community hospitals. That space is then converted to an asset for generating income (in essence, privatised), or if that fails it can be sold off.
If you are trying to cut resources, that is a plan. But without certain starting conditions, provision to manage and fund the transformation from existing to new systems, and a commitment to funding, reviewing and redesigning in the future as indicated by some properly objective health targets - it is not a workable plan. The pressure for instant results has pushed this scheme along and implemented un-evidenced desired results ahead of the conditions that were meant to produce them.
North Devon - the case that proves everything.
PCBC (dated September 2016) is confident that North Devon is doing well with hardly any community beds: ‘Northern Devon has spare capacity even at its current level of beds (32) which indicates that the new model of care is capable of driving even greater efficiency’.(PCBC p12)
Later on we hear more figures. Community bed numbers for North Devon on p38 - Figure 5-f: Capacity in community hospitals in NEW Devon (June 2016)) shows 96 in total for North Devon, which includes 12 stroke beds, 32 medical, 52 Mothballed beds. Presumably mothballed beds exist but are not permitted in use and the 12 stroke beds don’t count as proper beds for some reason.
Later we hear… ‘Detailed bed modelling was undertaken and a reduction in the requirement for community hospital beds to 40 identified. Northern Devon Hospital Trust (NDHT) then undertook a consultation in the summer of 2015 called Safe and Effective Care within a Budget which proposed the development of community health and social care teams to be a single point of co-ordination for people with complex needs and a reduction in community hospital facilities. This consultation was successfully concluded in October 2015 and implementation is underway’. (p61) So a further 8 beds have disappeared somewhere from the 40 ‘identified’.
If we look for the latest position, the North Devon Healthcare Trust website tells us: ‘The Trust’s 5 community hospitals provide local hubs of healthcare for their communities and a range of services that are easily accessible to the local population, including approximately 300 inpatient beds (the Trust actively ﬂexes bed numbers up and down according to local demand)’. This is dated Oct 11th 2016 - http://www.northdevonhealth.nhs.uk/about/community-hospitals/ accessed 28/2/2017.
So these’s no clear baseline value from which to extrapolate any conclusion about what North Devon is, or is not, doing or if it will work, or not, in East Devon. North Devon have ‘flexed’ back some beds from somewhere, unless they have just mistaken their resources by a factor of about 10. This needs an explanation. What is the current state of beds in North Devon? What does that imply for the planned cuts in East Devon.
The cost of a bed.
The savings claimed in the PCBC depend on a value derived for the cost of a bed per day. There is a selection of these too. Page 6 says £200 to £300 per bed per day; page 37 says £250 per day for an acute hospital bed and page 67 says £290 per day for a community hospital bed. So we must therefore assume that a community bed is more expensive than an acute hospital bed, which is difficult to countenance. Some detail on this would help too.
Implementation - too soon - and no proper evidence that it will work.
‘One immediate consequence of implementing this model of care is a reduction in the requirement for community hospital beds, as much of the care delivered there could be delivered in people’s homes. ’ (p7). No it couldn’t. There is a crisis in Social Care across Devon and this policy will fail if attempted in East Devon. The Exeter RDE is an overstretched regional hospital - local community hospital beds disappearing will worsen their ability to clear patients out of the hospital. So ‘…the generous provision of community beds in the Eastern locality of NEW Devon in particular reinforces the current pattern of care’ (p7) Yes it does, and for good reason. The provision can only be termed ‘generous’ in when compared to the depleted figures claimed in N and W Devon. And there is no proper evidence that STP has actually worked in North Devon.
Implementation is working back to front
‘Eastern Locality published and consulted on a document called “Pathways for the Future” in 2014-15. This document recognised the need to provide more services for people at home and that this would lead to a reduction in the need for community hospital beds over time. Following consultation, it was decided that community hospital beds would be consolidated onto fewer sites without significant change in bed numbers. It was also agreed that bed numbers and inpatient units would be reduced over time as the new model of care was implemented’.(p12)
The ‘reduction over time’ mantra repeated in the above is now abandoned it seems. A peremptory reduction of community bed numbers will obviously increase the pressure on the surviving beds - so the cart is well before the horse here again and a predicted outcome is being implemented in advance of the conditions that are supposed to make it feasible. The PCBC model assumes a ready and waiting social care resource to accept the evacuees from the 600 beds they claim are blocked. The absence of these resources capable of unblocking these beds points to a rapid failure of the new system.
‘The implementation of any significant change requires a clear understanding of the risks involved, and where the change is across a number of organisations, this understanding must be shared by each. Key conditions will need to be met during each of the three phases, pre-implementation, implementation itself and post-implementation. The purpose of these conditions is specifically to manage the risks involved in making the changes required, and a clear description of both the risks and their required mitigations also assists in balancing opposing risks, such as the risk of making the change against the risk of not doing so. A process is also required to ensure the risks and mitigations are reviewed at an appropriate level, and residual risks are shared appropriately’.(p93)
This rather assumes that the transitional plan and planned outcomes are not dysfunctional in the first place - but as they clearly are, this clause looks like the Success Regime’s ‘get out of jail free’ card, and shifts the blame for any failures in the outcome onto the people at the sharp end, imposed upon by an unworkable STP. Clever, yes?
The NHS crisis has been fuelled by the ideological obsession of recent governments to privatise as much of it as it can get away with. A £384 overspend in 2020/21 is not much in comparison to far less useful but infinitely more expensive public investments like HS2 (already costing taxpayers a £billion by some estimates, not even approved by parliament yet, and about as useful to us in the westcountry as a handbrake on a canoe); or Hinkley C, which is beset by financial and technical problems and a looming white elephant set to cost us untold billions. There is plenty of money - its just in the wrong places and way too much of it in private pockets. A case in point vis a vis the disbenefits of privatisation in the NHS is on view in the PCBC where it deals with Tiverton:
‘In all cases, Tiverton will continue to provide as many community beds as is possible because it is PFI-funded, would cost £35m should the beds be closed and provides a high quality environment delivering in-patient community beds’(p85)… suggesting perhaps that the other community hospitals in east Devon whose infrastructure was not subject to private investment provided less good service perhaps. Tiverton - with a £35m pfi in place has escaped the chop because a pfi pays out to private interests, and whereas public funds can be chopped on the whim of the government, property investors creaming those same public funds for the pfi hospital at Tivvy are left unscathed - no-one is taking their building away. This a ‘fixed point hurdle’ - in other words, public money shovelled into private pockets is fine, but the reverse case (via taxation) is naturally an utter outrage.
‘We regularly review risks to delivery. Currently, there are 21 major risks that need to be monitored and managed to enable completion of the proposed reconfiguration to the timescales indicated. We will develop robust mitigation and regularly report these risks through our governance structure as described above’ (p96).
The 21 risks are not mentioned, but I daresay restlessness among the natives is one of them which much be ‘mitigated’ to steamroller the changes through.
The Jan 2017 Healthy People Newsletter said Thank You to the 2000 people who replied to their proposals about bed cuts. But not a peep in Feb edition about what the feedback analysis revealed. Probably best to keep quiet about it. Maybe we’ll hear all about it on 13th March at Kings School 7.30pm. I doubt it somehow.
A Better Plan
My suggestion is simple - and cost nothing. The Success Regime can tell Simon Stevens now that he needs to run a bigger deficit for Devon until the funds can be found to implement such elements of the STP as seems to the CCG, after some genuine consultations, workable and useful. Then Carnall Farrer can be disposed of, followed by a ban on all future employment of private consultants.