“Public Accounts Committee calls for ‘step change’ in transparency in local public bodies”

“There is a need for a step change in transparency by local public bodies and particularly those in the NHS, MPs have said.

In a report, Auditing local government, the Public Accounts Committee noted that in 2017-18, auditors found that more than 1 in 5 local public bodies did not have proper arrangements in place to secure value for money for taxpayers.

“The numbers are worst for local NHS bodies such as clinical commissioning groups and hospital trusts, where 38% did not have proper arrangements,” it said.

The MPs added that some local bodies were not putting enough information in the public domain about their performance, including reports from their external auditors.

The report called on central government departments to make clear their expectations, “not only for what is made publicly available, but also for making the information accessible to users and so helping citizens to hold local bodies to account”.

The PAC said there appeared to be few consequences for those local bodies who did not take auditors’ concerns seriously and address them promptly. “Even where local auditors use their additional reporting powers to highlight failings, this does not always lead to the bodies taking immediate action.”

The report also recorded the MPs’ concern that, as partnership working becomes more complex, accountability arrangements will be weakened, and the performance of individual local bodies will become less transparent.

Meg Hillier MP, chair of the committee, said: “Taxpayers must be assured that their money is well-spent but in too many cases local bodies cannot properly safeguard value. Particularly concerning are NHS bodies such as Clinical Commissioning Groups and hospital trusts: last year almost two in five did not have adequate arrangements.

“As we reported last week, many CCGs are underperforming and this must improve as they take on responsibility for commissioning services across larger populations.”

Hillier added: “It is vital that local bodies take auditors’ concerns seriously, address them swiftly and ensure meaningful information on performance is made accessible to the public.

“Our report sets out ways central government can help to drive improvements at local level and we urge it to respond positively to our recommendations.” …”

https://www.localgovernmentlawyer.co.uk/governance/396-governance-news/40088-public-accounts-committee-calls-for-step-change-in-transparency-in-local-public-bodies

Chilling report on NHS sustainability – it isn’t sustainable

Owl says: anyone who cares about the NHS should read EVERY PAGE of this 58-page report, which is written in clear and accessible language.

Every page signals a death-knell for the NHS sooner rather than later.

It is hard to pick out anything – every page tells a story of (deliberate?) mismanagement, underfunding and chaotic accounting.

For example:

“Key findings

The funding settlement for the NHS long-term plan

8 The long-term funding settlement does not cover key areas of health spending. The 3.4% average uplift in funding applies to the budget for NHS England and not to the Department’s entire budget. The Department’s budget covers other important areas of health spending such as most capital investment for buildings and equipment, prevention initiatives run by Public Health England and local authorities, and funding for doctors’ and nurses’ training. Spending in these areas could affect the NHS’s ability to deliver the priorities of the long-term plan, especially if funding for these areas reduces. The government will consider proposals in these areas as part of its 2019 Spending Review. In addition, without a long-term funding settlement for social care, local NHS bodies are concerned that it will be very difficult to make the NHS sustainable (paragraphs 2.27 and 2.28).

9 There is a risk that the NHS will be unable to use the extra funding optimally because of staff shortages. Difficulties in recruiting NHS staff presents a real risk that some of the extra £20.5 billion funding will either not be used optimally (more expensive agency staff will need to be used to deliver additional services) or will go unspent as even if commissioners have the resources to commission additional activity, health care providers may not have the staff to deliver it (paragraphs 1.19 and 2.29).

10 From what we have seen so far, the NHS long-term plan sets out a prudent approach to achieving the priorities and tests set by the government, but a number of risks remain. The long-term plan describes how the NHS aims to achieve the range of priorities and five financial tests, set by the government in return for the long-term funding settlement, which NHS England believes are stretching but feasible. As with all long-term plans, it provides a helpful indicator of the direction of travel, but significant internal and external risks remain to making the plan happen. These risks include: growing pressures on services; staffing shortages; funding for social care and public health; and the strength of the economy. Our reports have highlighted how previous funding boosts appear to have mostly been spent on dealing with current pressures rather than making the changes that are needed to put the NHS on a sustainable footing (paragraphs 2.24 to 2.26).

Financial and operational performance of NHS bodies

11 In 2017-18, NHS commissioners and trusts reported a combined deficit of £21 million. This was made up of:

The combined deficit of £21 million does not include adjustments needed to report against the Department’s budget for day-to-day resources and administration costs.

12 It is not clear that funding is reaching the right parts of the system.
The overspends by trusts and CCGs were broadly offset by the underspend by NHS England. In 2017-18, NHS England’s underspend included: £962 million from non-recurrent central programme costs, including efficiencies from vacancies;

a £280 million contribution to the risk reserve and £223 million from centrally commissioned services, mostly specialised services (paragraphs 1.4 and 1.8).

13 Most of the combined trust deficit is accounted for by a small number of trusts, while the number of CCGs in deficit increased in 2017-18. The net trust deficit hides wide variation in performance between trusts, with 100 out of 232 trusts in deficit. In 2017-18, 69% of the total trust deficit was accounted for by 10 trusts. NHS Improvement has committed to returning the trust sector to balance in 2020-21, but it is difficult to see how this will be achieved for the worst-performing trusts under current arrangements. Although support provided to trusts in NHS Improvement’s financial special measures programme has been successful in improving the position of some trusts (by £49 million in 2017-18), the financial performance of the 10 worst-performing trusts deteriorated significantly in 2017-18. Between 2016-17 and 2017-18, the number of CCGs reporting overspends against their planned position increased from 57 to 75. The NHS long-term plan sets out the national bodies’ aim that no NHS organisation is reporting a deficit by 2023-24 (paragraphs 1.6 and 1.11).

14 There are indications that the underlying financial health in some trusts
is getting worse. In 2017-18, trusts reported that their combined underlying deficit was £4.3 billion, or £1.85 billion if the Provider Sustainability Fund (which replaced the Sustainability and Transformation Fund in 2018-19) is allocated to trusts in future years. There is no historical data on the underlying deficit that takes account of one-off savings, emergency extra cash and other short-term fixes that boost the financial position of the NHS, so it is not clear whether this position is getting better or worse. However, indicators such as cash support and one-off efficiency savings suggest the position has not improved. For example, in 2017-18, the Department gave £3.2 billion in loans to support trusts in difficulty, up from £2.8 billion in 2016-17. In 2017-18, 26% of trusts’ savings were one-off. Trusts will need to make additional savings in 2018-19 to replace these one-off savings (paragraphs 1.13, 1.14, 2.13, 2.17 and 2.18).”

https://www.nao.org.uk/wp-content/uploads/2019/01/NHS-financial-sustainability_.pdf

“Andrew Lansley law that forced hospitals to compete could be axed”

Note: this 10-year plan does not tackle the crisis in social care nor the bigger crises of not having enough staff for either service.

[Andrew Lansley’s 2012 act made local GP groups “customers” to buy services from competing hospitals]

“Implementing the new ten-year plan could involve the reversal of market-based reforms introduced in 2012 by the former health secretary Andrew Lansley.

More than 100 local bodies would be merged under proposals to move away from internal health service competition and make parts of the NHS work more closely together.

The request for new laws by Simon Stevens, head of NHS England, sets the government up for a battle in the Commons. The reversal of the reforms is also likely to prove embarrassing for the Conservatives. Labour has already demanded an apology for a “bureaucratic disaster” that it says wasted billions.

The Health and Social Care Act 2012 made local GP groups “customers” to buy services from competing hospitals and other providers. It provoked opposition from health unions who said that it would fragment care. Senior Tories came to regard it as the coalition government’s biggest mistake.

Ministers will seek to present the changes as commonsense tidying up measures requested by the NHS. They hope that this will avoid a divisive political battle, but while opposition to privatisation was a key Labour objection to the act the party is unlikely to back a Conservative NHS reform.

In the ten-year plan Mr Stevens argues that there are too many NHS institutions working autonomously when they need to work together to join up care for patients. While arguing that his plan could be achieved in current structures, he said that changes to the law “would support more rapid progress”.

Matt Hancock, the health secretary, said: “We want to foster a culture of ambition and innovation in the way our health sector organises the services it delivers. I am prepared to make the changes necessary for this to become a reality, including changing the law.”

Jonathan Ashworth, the shadow health secretary, said: “The fact NHS bosses are now proposing significant changes to the Health and Social Care Act confirms what a wasteful, bureaucratic disaster it was in the first place.”

Source: The Times (paywall)

NHS – inequality between regions

“The government must show more urgency in addressing regional health funding imbalances, MPs have warned.

The Public Accounts Committee has also expressed concern about the Department of Health and Social Care’s lack of planning for staffing and medical equipment after Brexit, in a report out today.

The MPs noted there was “significant regional variation” in funding of NHS providers and clinical commissioning groups. DHSC’s 2017-18 annual report and accounts suggest an improvement in finances when taken as a whole but this “masks the underlying deficits at local level”, the PAC report said.

MPs said the department was performing a “balancing act” by offsetting NHS providers’ deficits with a surplus from NHS England’s finances. In 2017-18, 101 of 234 NHS providers were in deficit, although this was mitigated by NHS England’s surplus, the report said. Although, 75 of the 207 CCGs reporting an overspend in the same year.

PAC chair, Meg Hillier, said the number of CCGs overspending was “concerning”.

She added: “The Department of Health and Social Care must show far more urgency in getting to grips with regional funding imbalances and demonstrate it understand the effects these have at the frontline.”

The report was also critical of DHSC’s planning for Brexit, especially around staffing and medical equipment.

It said there is a “lack of a clear plan” for recruiting staff post-Brexit and added: “We are not reassured by the department’s assertion that it has not seen a large exodus of staff since the referendum and that the number of people from the EU working in the NHS has increased.”

Health bodies recently warned that the NHS workforce shortfall could jump from 100,000 at present to almost 250,000 by 2030 without effective planning.

Despite the NHS procuring 56% of medical consumables (gloves, dressings, syringes) from, or via, the EU, DHSC is not putting specific contingency measures in place to stockpile this type of equipment, the PAC revealed.

Hillier said: “The department’s lack of clear Brexit planning could threaten the supply of medical equipment. Staff shortages could deepen. The potential consequences for patients are serious.

“These and other uncertainties are amplified by the continued absence of the government’s promised 10-year plan for the NHS, its promised plans for social care, and its promised plans for immigration.” A DHSC source has confirmed to PF the social care green paper and NHS 10-year plan are now likely to be published in the new year, rather than by the end of this year, as originally intended.

Regional variances in staff vacancies could also be overlooked, the PAC noted. The NHS examines vacancy rates at a national level – rather than a local level – which “hides underlying disparities in specific specialisms and local areas and does not allow them to fully understand the impact of staff shortages,” the report said.

The report also expressed concern that the NHS staff pay rise announced earlier this year would not be distributed fairly. By funding pay awards through the National Tariff the PAC is concerned that NHS Providers in more affluent areas will receive “disproportionately higher share of funding” because the tariff accounts for the cost of operating in different geographical locations.

DHSC has been contacted for comment.”

https://www.publicfinance.co.uk/news/2018/12/government-must-address-health-funding-imbalances-say-mps

“NHS commissioning ‘needs period of stability to transform’ “

Owl says: You cannot make it up – body set up to transform the NHS needs time to transform itself before issuing its transformation policies to transform anything else!

“NHS commissioning needs a prolonged period of organisational stability after almost three decades of change, according to the UK’s spending watchdog.

Continued organisational restructuring causes major upheaval and commissioning in the health services needs stability to transform, the National Audit Office urged in a report released today.

Amyas Morse, head of the NAO, said: “We have seen almost three decades of change to NHS commissioning.

“It would be a huge waste if in five years’ time NHS commissioning is undergoing yet another cycle of reorganisation resulting in significant upheaval.”

He added: “The current restructuring of Clinical Commissioning Groups must deliver balanced and effective organisations that can support the long-term aims of the NHS and deliver a much-needed prolonged period of stability.”

A period of stability would allow commissioning groups to focus on transforming and integrating health and care services rather than on reorganising themselves, the report said.

Since CCGs replaced primary care trusts in April 2013, there have been eight formal mergers, reducing their numbers from 211 to 195 in April this year. Further mergers are expected.

The report also highlighted an increasing number of NHS commissioning bodies in England were exceeding their planned expenditure.

A total of 75 of 207 (36%) CCGs went over their budgets in 2017-18, the NAO noted. The total overspend across the groups was £213m.

This compared to 57 CCGs over spending on their budgets in 2016-2017 and 56 in 2015-2016.

“Many CCGs are struggling to operate within their planned expenditure limits despite remaining within their separate running cost allowance,” the report warned.

Increased pressures, the uncertain futures of CCGs and a lack of access to training and development were cited as reasons for the continuing issue of commissioning bodies being unable to attract and retain high-quality leaders.

Even though “both NHS England and the CCGs stressed [to the NAO] the importance of high-quality leadership”.

The watchdog also warned with further mergers there was “a risk that working across greater areas will make it more difficult for CCGs to design local health services that are responsive to patients’ needs”.

The total net expenditure of CCGs in England in 2017-18 was £81.2bn with net running costs at £1.1bn. Staff costs made up 57% (£693 million) of CCGs’ running costs, the NAO noted.

A 10-year long-term plan for the NHS and how it will spend an extra £20.5m a year was expected to be released by the end of this year.

A source from the Department of Health and Social Care has confirmed to PF it is now “likely” this plan will be release next year.

Responding to the report, chair of the Public Accounts Committee Meg Hillier said: “We should be concerned that increasing numbers [of CCGs] are overspending against their budgets.

“Like previous changes to NHS commissioning, CCGs are going through more change and the NHS is crying out for stability.”

She added: “It is vital that further restructuring supports the 10-year plan and isn’t an unnecessary distraction to addressing the real challenges in the health service.”

https://www.publicfinance.co.uk/news/2018/12/nhs-commissioning-needs-period-stability-transform

Another NHS campaigner speaks out

Roseanne Edwards, who is fighting to “Keep Our Horton General” in Oxfordshire writes:

“From our fellow campaigners who are fighting as hard as we are for their local hospital. It is a copy of what is being done to services in Oxfordshire. It is happening all over England.

The background their hospital is set against is the same politically inspired NHS reorganisation we are all victims of.

“Following the 2010 election which returned a Coalition Government of Conservatives and Liberal Democrats, the Department of Health was too busy with the torturous passage through the House of Commons and Lords of the Health and Social Care Bill, which became the Health and Social Care Act 2012, and took their eye off the ball, neglecting to commission training places in Universities for Doctors, nurses physiotherapists and other valuable and essential health professionals.

This resulted in a national shortage which we are seeing today, in A&E surgeons, paediatricians, nurses and other staff.

The outcome may have been intentional. Michael Portillo speaking on the BBC Parliament channel following the election, said that the Conservatives kept quiet about their intentions for the health service because they knew that if their plans became known, they would not be elected.

The intended change was to the fundamental foundation of what used to be the National Health Service, the Secretary of State’s duty to provide, which was removed and a system of contracting services out to tender to enable more profit making companies to siphon off the NHS revenue put in place with competition law operational.

Martin Barkley says that the Care Closer to Home model of service provision will be sustainable. This is government propaganda. What does sustainable mean? The funding for the health service is a matter of choice. Government chooses to fund it or not. This government and the Coalition, chose not to. Even when ‘Care Closer to Home’ is put in place and Dewsbury Hospital downgraded, completely as planned for spring 2017, the government could choose to reduce funding still further.

This is exactly what is happening with the mandatory and secretive Sustainability and Transformation Plan (STP) agenda, being worked up by the Councils, CCGs and Trusts, in West Yorkshire footprint number 5. The West Yorkshire STP has to save money as part of West Yorkshire’s share of the £22billion ‘efficiency savings.’

There is NO EVIDENCE to show that the cuts to hospital provision and services at home, are less expensive than inpatient stays. The pilots in Torbay were inconclusive. In fact they may prove to be more expensive. The expenditure of the National Health Service model as it had been and the treatment it carried out, was consistently found by OECD studies to be the most cost effective in the developed world, treating everyone according to need. This was the case even including the increased costs and associated difficulties caused by the marketised Foundation Trust system.

(The CCG CEP) Dr Kelly outlines what he describes as a “whole system change” in the NHS. What the describes, is chopping the services into tiny bits and letting private profit making companies provide the cheaper, less complex services, such as the dermatology he mentioned http://www.priderm.co.uk and the opticians on the high street. This denies revenue to the Hospital Trust, destabilising it. A new contract announced after the public meeting for Musculo- Skeletal services has gone toprivate company ConnectHealth:

http://www.connecthealth.co.uk

redirecting even more revenue away from the Trust:

https://www.northkirkleesccg.nhs.uk/news/patients-shape-musculoskeletal-service./.

The ‘Right Care ‘ initiative mentioned is an import from the US. What does ‘redesigning therapies’ mean? The Right Care programme, is looking at money. Is this the first step to withdrawing what was once available?

The Royal College of Surgeons has criticised the policy of withdrawing treatments now evaluated as procedures of limited clinical effectiveness (PoLCE) or procedures of limited clinical value (PoLCV). There is no national list of these, as CCGs are free to choose which ones to fund and which to not. The Royal College of Surgeons states that the growing list is “extremely detrimental to patients across the NHS, removing equality of access to treatment, creating postcode lotteries, lowering the standard of care provided in the NHS and potentially reducing the quality of life for some patients.”

Following the fragmentation described here, the architects of the STPlans want an Accountable Care Organisation (ACO) to put it back together, with the private sector cocooned and shareholding, in the provider structure.

Dr Kelly speaks of the Hospital Avoidance Team, going into hospitals to facilitate early discharge. What we have learned since the public meeting is that there is a postcode lottery with regard to what is on offer following a hospital stay and hospital nurses and other staff have to know where you live, because North Kirklees patients can not have what Wakefield patients get.”

NHS: Ministers want NHS head to promise he can run the service with unicorns

Owl says: Actually the government just wants him to lie for their next manifesto – and then, when it all comes tumbling down, they will then probably fire him – for lying.

“The head of the NHS and the government are at loggerheads over how much the health service can be improved for the £20.5bn extra Theresa May has pledged to give it, the Guardian can reveal.

Simon Stevens, the chief executive of NHS England, has been having major disagreements behind the scenes in recent weeks with Downing Street, the Treasury and Department of Health and Social Care about how much the forthcoming NHS long-term plan can promise to boost care.

“Tension” and “difficulties” have emerged during detailed horsetrading between the two sides amid sharp differences of opinion over the extent of the document’s ambitions, well-placed NHS and Whitehall sources have told the Guardian.

Negotiations have left ministers “fed up” and “deeply irritated” that Stevens is refusing to include explicit guarantees they believe will reassure voters that the service will improve dramatically over the next five years thanks to the extra money.

The plan, which will set out how the extra money will be spent, had been due to come out earlier this week but was delayed and is likely to finally appear in the week after next, subject to events at Westminster and further discussions between Stevens and ministers about its contents.

Ministers have told NHS England the plan should include specific annual improvements it will promise to make every year between 2019-20 and 2023-24 in its most challenging areas.

They want milestones written into it spelling out how close in percentage terms the NHS will get every year to once again meeting key waiting time targets covering A&E care, cancer treatment and planned operations, and also by how much the service’s dire finances will be turned round.

However, Stevens has left ministers frustrated by telling them privately that their ambitions are not realistic. Allies say he believes the £20.5bn more by 2023-24 is not enough for hospitals to get waiting times back on track after years of struggling to meet them and simultaneously honour headline-grabbing promises May and Philip Hammond have made recently, ahead of the plan being published, to expand and improve cancer and mental health care. They also want the money to pay for care to be transformed, with a major expansion of out-of-hospital services.

NHS England set up 14 different “workstreams” in the summer to draw up detailed proposals for how key areas of care needed to change to improve the nation’s health and keep the NHS sustainable, given the pressures of the ageing and growing population.

Stevens’s realism about the limits of the plan’s ambition has been reinforced by that process identifying improvements that would between them cost £80bn a year extra, four times the £20.5bn May has pledged. That has forced him to order a drastic culling of those proposals that are too costly to include in the plan.

Stevens has also warned them that the NHS’s chronic lack of staff – it is short of 103,000 doctors, nurses and other personnel – will also make it hard to drive the measurable progress they are seeking. Gaping holes in the NHS workforce are “dreadful and getting worse”, one senior figure said.

“Simon wants one thing and the politicians want another. The Treasury want to pin him to the floor over the action he will take to get all the waiting time targets back on track over the next few years, and he is resisting that. He wants flexibility,” said one source close to the discussions.

The Treasury is particularly exasperated by Stevens’s stance. But allies of the NHS chief say that he does not want to have his hands tied, sign up to timescales for progress that are likely to prove impossible to meet and to open himself up to criticism in the future for not delivering them.

One ally said: “The Treasury are the ones who are especially looking for high-profile and concrete improvements in care that the government can sell to the public in return for the £20bn. There is a lot of anxiety [among NHS leaders] because everyone knows the extra money is barely enough to maintain current standards, let alone transform services.”

Stevens is understood to feel unable to make public his reservations about how much progress ministers should expect for the £20.5bn given that he welcomed the money – which May gave to mark the NHS’s 70th birthday in July – at the time as “a change of gear, a step up” after eight years of tiny 1% annual increases. Its budget will rise from £115bn now to £135bn in April 2023.

Another NHS leader said: “Ministers want all the key targets back to where they used to be, the £1bn annual deficit down to zero and a host of new commitments delivered, all within the 3.4% annual budget rises over the next five years that the £20bn involves. But the numbers, and the whole thing, just don’t add up. You simply can’t get all those improvements on those timescales on 3.4%. It isn’t deliverable. But that’s what the government wants.”

NHS Improvement, the service’s financial regulator, is helping to draw up the plan. It warned last week that hospitals had already overspent by £1.23bn by the end of September, halfway through the service’s financial year, and that it may take five years to restore waiting time performance.

Niall Dickson, chief executive of the NHS Confederation, which represents organisations across the healthcare sector, urged ministers and the public to be realistic.

“The NHS long-term plan is a vital opportunity to improve patient care and change the way we deliver services to the public. But we should not underestimate how difficult it will be to recover performance on waiting times and to move NHS trusts and other organisations back into the black.

“We must be realistic about what is possible within the extra £20bn – the last thing we need is to set local services up to fail. And, above all, we will need a plan for securing the staff we need to respond to changing healthcare needs.”

NHS England denied a rift, saying: “The NHS, patient groups, clinicians and government are working closely together to finalise the NHS long term plan ready for publication before Christmas.” The Department of Health and Social Care also said there was no dispute, and they were “working closely with NHS England and NHS Improvement to develop an ambitious long term plan for our health service.”

https://www.theguardian.com/society/2018/dec/06/ministers-and-nhs-england-chief-at-loggerheads-over-targets