28. North Central London
What does the STP mean for your area?
Documents leaked to The Guardian in June 2017 indicated major cuts were planned to save £183 million. The documents showed that:
- Some patients will be denied treatment
- Operation waiting times will increase
- A&E maternity units may be shut
- Doctors in five London boroughs will have to spend less on drugs
- Fewer patients will be referred to hospital
- Support for people with severe health needs will be cut.
The leaked documents admit the cuts will be unpopular, hard to explain and result in a lower standard of care.
Moorfields eye hospital is to be relocated to St Pancras and the Moorfields site sold to boost funds.
Development of primary care to treat more complex patients, moving care away from hospitals to the community.
What are the proposed aims of the STP?
- Elimination of a projected 2020/21 deficit of £876 million;
- Development of primary care hubs to enable extended access and range of services to the community;
- Development of federations of GP practices to deliver an enhanced, equitable offer to all patients;
- To upgrade out of hospital care and support for individuals with different levels and types of needs to reduce the need for hospital care;
- Development of an approach to population health to achieve better health and better care at lower cost, with a reduction in health inequalities;
- Transformation of mental health services;
- Overall, the aim of the STP is to reduce the use of the acute sector and move care into the community.
The STP does not contain details of how exactly the deficit will be eliminated and the other aims realised. After the publication of the plan in November 2016, David Stout, director of the North Central London STP, told councillors that he did not know how to ward off an impending £876 million health budget deficit.
In October 2016, when the STP was made public, the plan was at a very early stage of development with little in the way of concrete proposals. In terms of funding, the STP proposes that the money raised from capital sales be used to pay off PFI debts "and/or a commitment by national partners to renegotiation of such agreements, where they have been identified as a significant barrier to financial sustainability and/or the facility is less than 50% utilised and no other utilisation solution will address the issue."
The STP acknowledges that investment in GP capacity through additional staff is needed if any changes are to take place to the way GP practices work.
Primary care hubs will be developed "to enable extended access and range of services to the community, integrating a range of health and wellbeing services around the individuals to support early intervention and prevent demand."
Primary care is to be developed to cope with more complex patients, with a range of approaches offered: advice only; an urgent 'hot clinic' appointment in an outpatient clinic; assessment in an ambulatory emergency care facility; and admission to an acute assessment unit. In addition, consultant-led clinical assessment and treatment services will enable more patients to be managed in the primary care setting. Specialties to be considered include gynaecology; ENT; urology; dermatology; musculo-skeletal; and ophthalmology.
In order to extend primary care specialities it is proposed that GP practices develop into federations.
The STP includes a transformation of the urgent and emergency care system, aligning it closely with the care closer to home model. Wherever possible patients will be treated at home by community and ambulance services.
All urgent care (NHS 111, GP OOH and urgent care centres) will be run as an integrated service.
Wherever possible patients will be treated at home by community and ambulance services; this hopes to achieve:
Up to 150,000 fewer emergency department attendances
63,000 fewer non-elective admissions
35,000 fewer outpatient attendances
Changes across the area
In June 2017 the HSJ reported on discussions between NHS Improvement and NHS England on what certain over-spending CCG areas will be required to do to enable them to spend less money and remain within a budget known as a 'control total' for 2017/18. The 14 target areas include North Central London. The measures under discussion include the following:
- Limiting the number of operations carried out by non-NHS providers so the funding stays within the NHS. Considerations differ between areas but include both limiting patients’ choice of providers, and reducing work which is outsourced by NHS trusts. In some cases it would require the NHS to find the capacity to carry out more operations.
- Systematically drawing out waiting times for planned care, including explicit consideration of breaching NHS constitution standards. Some plan to target delays at specialties/areas where waits are currently lower than average.
- Stopping NHS funding for some treatments, including extending limits on IVF, adding to lists of “low value” treatments, and seeking to delay or avoid funding some treatments newly approved by the National Institute of Health and Care Excellence.
- Closing wards and theatres and reducing staffing, while seeking to maintain enough emergency care capacity to deal with winter pressures.
- Closing or downgrading services, with some considering changes to flagship departments like emergency and maternity - though these would normally take too long to deliver savings this year.
- Selling estate and other “property related transactions”.
- Stopping prescriptions for some items, as suggested by NHS Clinical Commissioners earlier this year.
In July 2017 the BMA reported that staff involved in the North Central London STP were told to find £61m more savings by March 2018, despite having already produced a 78-page plan detailing major efficiencies as part of the CEP ‘capped expenditure process’ to enable the area to stay within its control total.
Health managers reviewed the plans that had already been drawn up and analysed possible measures, including reductions in treatments or services, to attempt to meet the demands but told the BMA they do not support the proposals or actions they were forced to draw up.
The commissioners in the area told the HSJ that they have been told to examine “difficult decisions” and “think the unthinkable”, including modelling changes which are normally avoided as they are too unpleasant, unpopular or controversial.
The North Central STP document was the second to be made public when Camden Council published it on its website. The council have criticised the STP for the lack of transparency in the process and its lack of focus on adult social care. Camden Council leader Sarah Hayward said she had “serious reservations” about the STP, which also covers Barnet, Islington, Haringey and Enfield. Islington Council leader Richard Watts has also criticised the STP, saying “They feel much more like a way of making short term budgetary savings rather than any meaningful way of transforming services."
In early January 2017, the BMA revealed the amount paid to management consultants involved with drawing up the London North Central STP: "six-figure sums were paid to eight different companies – including accountants Deloitte and management consultants McKinsey – for services stretching from ‘administrative support’ and ‘financial modelling’ to ‘communications support’. A firm called Consultants Methods Advisory Ltd, which describes itself as ‘shaping public services for the digital age’, racked up the biggest costs, invoicing £617,850 for ‘programme management office and strategy support’."