The body that commissions and pays for NHS services in Enfield is being forced to make sharp reductions in expenditure over the next two years which will inevitably affect the availability of services.
In addition, over the next five years the NHS in the five "North Central London" boroughs will be required to reduce the level of annual expenditure by around £771 million, to be achieved through implementing "Sustainability & Transformation Plans". These savings are required because government funding of the NHS in England will be at a level which is £22 billion less than the amount which the head of NHS England says is needed if current ways of working remain unchanged.
Health Service commissioning in Enfield: Significant spending cuts required and soon
Enfield Clinical Commissioning Group (CCG), responsible for commissioning NHS services in the borough, was recently put under "special measures" because its performance has been rated as "inadequate". Under the special measures regime all its spending will be closely monitored and controlled by NHS England.
The "inadequate" rating appears to relate primarily to its failure to limits its spending to the amount that it is allocated annually by NHS.
Members of Enfield Over 50s Forum were yesterday briefed by the CCG's senior managers about the methods that they intend to use to bring its income and spending into balance by 2018/19. They involve identifying "Quality, Innovation, Productivity and Prevention" opportunities which (in theory at least) will improve the way services are provided, but whose primary purpose is to cut spending by some £10 million a year. While we probably can expect some genuine improvements in some respects, some cuts in available services seem inevitable.
For more detailed information about yesterday's meeting, see the box at the end of this article (click here to jump straight to it).
Further ahead: What can we expect from NHS Sustainability and Transformation Plans?
Across the whole of England NHS managers are currently working on Sustainability and Transformation Plans (STPs). The country has been divided into 44 "footprints", within which NHS organisations are being brought together to draw up radical plans to improve health outcomes and the quality of services. However, they have to deliver these outcomes and services "sustainably", meaning that they cost no more than the amount of money that NHS England will be providing (ultimately, of course, it is the government which decides how much to spend on the NHS). And the head of NHS England, Simon Stevens, has indicated that the amount of money which the government has said it will provide is £22 billion less than is required to provide services using current ways of operating. In other words, the STPs must cut costs by £22 billion a year. These savings must be in place by 2020/21.
The STPs are being devised hurriedly and largely behind closed doors, but the campaigning group 38 Degrees has been gathering all the information it can find and has commissioned an analysis of all available data. It shows that some footprints are planning measures including closing or downgrading A&E departments, reducing the number of hospital beds and selling off land.
Sustainability & Transformation Plans - sources of information about their impact
STP - Early Areas of Action
Last Saturday's i newspaper led on the implications of the STPs (report by Incisive Health commissioned by 38 Degrees)
38 Degrees NHS plans investigation: the results (spreadsheet listing what is known about the plans for each footprint)
North Central London, Sector Transformation Plan (as at April 2016 - with some useful finance figures)
North Central London STP - progress by 30 June 2016 (document prepared for North London CCGs)
STPs: A Mile Wide and an Inch Deep (interview with head of the New NHS Alliance, who says that STPs are "more about slash and burn rather than transformation"
NHS draws up plans for major cuts across England (article in i newspaper)
Plan to 'transform' NHS could lead to downgrade of major London hospitals (Guardian article about STP plans for North West London)
The NHS secret is out. And local communities won't like it (Guardian article)
As regards North Central London, the following can be deduced:
By 2021, the health and social care system in North Central London is projected to be £771 million short of the funds it needs to balance its books while maintaining the same level of care for patients
The plan proposes changes to frontline NHS services - including having to "rationalise mental health inpatient services"
Historically in the NHS, rationalisation has meant cuts.
In neighbouring North West London, the STP has to reduce spending by over £1bn a year and envisages the loss of 500 hospital beds.
Enfield CCG's current situation: Points from a meeting of the Enfield Over 50s Forum on 30 August 2016
Points from the meeting based on my notes and on information in the slides pack that was provided. This is not a complete or authoritative account of the meeting and relies on my interpretations of things that were said, which may be mistaken.
There is some confusion about the financial figures in this summary and others that were quoted at the meeting. The CCG's chief finance officer attempted to clarify these, but (certainly as far as I was concerned) didn't really succeed.
For fuller and more reliable information, I recommend attending the Patient and Public Engagement meeting on 16th November (2pm to 5pm, venue to be advised).
Underfunding of the NHS in Enfield
Enfield CCG's chief finance officer, Rob Whiteford, spoke about the level of underfunding of the NHS in Enfield, which in 2014/15 had amounted to £33 million. He listed some of the ireasons why Enfield CCG had been unable to make do with the amount provided under the NHS funding formula, which did not take full account of some of the many factors which lead to differences in per capita health costs between different areas of London and of England as a whole.
For example, the number of care homes in a borough is significant because of the above average volume of prescription medications their residents need. Enfield has many care homes - more than 100 - while neighbouring Haringey has only four.
The "financial challenge"
The CCG finance officer outlined the scale of the "financial challenge". In 2014/15 the actual in-year deficit was £18.9 million and in 2015/16 £14.4 million. Because this was considered unacceptable by NHS England, the CCG was put under Legal Direction. All its spending now has to be ratified by NHS England, who are enforcing a cut in the 2016/17 deficit to £7.7 million and requiring that the CCG break even in 2017/18.
Underfunding or inefficiency?
Interestingly, the wording used by the CCG managers suggested that they see the overspends as the result of underfunding. However, from the viewpoint of NHS England (and, apparently, of a former Conservative councillor in the audience) the overspends are the consequence of poor management and inefficiency, which is why the CCG was recently taken into "special measures" by NHS England.
Eliminating the deficit
The enforced deficit reductions will be brought about through "Quality, Innovation, Productivity and Prevention" (QIPP) "opportunities". The CCG will have to identify and implement these "opportunities" with some urgency in order to bring spending into balance in 2017/18.
We were assured that the necessary changes would all be "clinically led" and that the Forum would be among the stakeholders to be consulted.
The Right Care Programme
Unfortunately, due to time constraints, nothing was said about the Right Care Programme for Enfield, but the slide pack did list the areas covered:
- CVD (cardio-vascular disease)
- Cancer
- MSK (musculo-skeletal)
- Mental Health
- Respiratory
- Neurological
- Complex Patients
As with most of the topics discussed at the meeting, this is designed to kill two birds with one stone, ie improve patient outcomes but at the same time deliver significant cost savings.
The slide stated that "Our RightCare opportunities are £10.3m per annum and £1.3m in 2016/17".
Reducing the prescriptions bill
Paul Gouldstone, the CCG's head of medicines management, provided some detail about the "opportunities" for reducing the amount spent on medicines.
In 2015/16 Enfield GPs prescribed 5.2 million items at a cost of £37.8 million, almost all (>95%) to patients not paying for prescriptions. This amounted to 10 per cent of the CCG's total budget.
To reduce the prescriptions bill the CCG will be instructing GPs to:
- encourage patients to carry out more "self care" by visiting pharmacies instead of GPs (this will also help the problem with getting GP appointments)
- continue to reduce prescription of antibiotics
- stop prescribing vitamins, omega 3 fish oils and gluten-free products except in clinically justified circumstances
- stop prescribing items that can be bought over the counter (with exceptions for some patients).
While the first three of these make good clinical sense, they are likely to be unpopular with patients. The over-the-counter medicines instruction has already created controversy, with good cause, because not all such medicines are cheap (eg eye drops at £9.99) and many patients have almost no money to spare.
Tackling the repeat prescriptions problem
The CCG will be taking measures to reduce wasted spending on items included in repeat prescriptions but not actually needed. The problem arises when pharmacies or "third parties" order repeat prescriptions without checking with patients to see if they are needed. The solutions - contacting patients before ordering, insisting that patients tick off and initial repeat prescription forms - will be tiresome and probably resented by some people, but sound necessary to me.
