The start of the letter sent to the head of NHS England. The full text is at the end of this article.Leaders of five North London boroughs have requested a meeting with the head of the NHS in England to discuss their very serious concerns about evolving plans to transform the delivery of health services in their area. The council leaders complain that, despite the stated aim of working in collaboration with councils to improve services and health outcomes, they are in practice being sidelined rather than treated as equal partners. They write that the plans are being drafted in a way that "service cuts and rationing health services are on the table" while "there is minimal investment in prevention".
The letter to Simon Stevens, Chief Executive of NHS England, bears the signatures of the leaders of Barnet, Camden, Haringey, Enfield and Islington councils. It relates to the ongoing development of a "Sustainability and Transformation Plan" (STP) for the NHS in the five boroughs. This is one of 44 STPs, each covering a different geographical "footprint", and is being developed by a multitude of NHS bodies (known collectively as the North London Partnership in Health and Care) and, in theory at least, in collaboration with borough councils. However, work is being closely monitored by NHS England, which has to approve the plans. Senior NHS managers have been brought in to run the STP, with annual salaries totalling more than £900,000.
Short-term cost cutting
In the letter the council leaders complain about a "focus on short-term cost cutting at the expense of longer-term transformation" and ask for an assurance that there will be "no reduction in health services, or service standards (including no detrimental changes in access to services)" and that additional funding will be forthcoming if needed to assure this.
While the North Central London (NCL) STP is about more than saving money, there can be no doubt that short-term cost cutting is a key element. The NCL STP "footprint" is one of several (including others in London) which are regarded by NHS England as being particularly at fault in terms of "overspending" and are being subjected to a "capped expenditure process". In our case NHS bodies in the five boroughs are being required to turn a £200 million "deficit" into a £38 million surplus over the course of a single year. But is the deficit really caused by overspending? A more likely explanation is that the NHS in North Central London cannot live within its means because since the 2012 NHS reforms clinical commissioning groups in the five boroughs have never been allocated sufficient money by NHS England.
Listening to the people of North London
Keeping track of and making sense of the huge output of documents generated by the STP process is time-consuming and difficult. In order to tackle this essential task, various NHS campaigning groups have set up an umbrella body - "NCL STP Watch" - which this month issued a report with the title "Public Voices, Public Service: Listening to the People of North Central London". This analyses published information about the STP and examines its potential impact on particular segments of the population. Its key findings are summarised under the following headlines:
- Healthcare for older people will be downgraded
- Major health inequalities will not be addressed
- Individual patient need/medical judgement will become less important
- Parity of esteem for mental health is unlikely
- The involvement of local authorities in STP plans appears as an afterthought
- The delivery of the STP is too dependent upon the estates strategy as discussed in the Naylor report (ie on a one-off sale of land currently owned by the NHS).
Refusing to kowtow
The letter from the five council leaders isn't the only recent example of our locally elected representatives refusing to kowtow to pressure from the people pushing the latest NHS reorganiisation agenda. On 22nd September the Joint Health Overview Committee (made up of councillors from the five boroughs) refused to endorse a plan to extend the "adherence to evidence-based medicine" stricter criteria across North Central London. This refers to stricter criteria for carrying out certain procedures on the NHS, decided on last week by Enfield Clinical Commissioning Group after a controversial consultation process.
Local campaigning group Defend Enfield NHS, whose intervention undoubtedly influenced the committee's decision, celebrated the outcome on their Facebook page:
Newsflash - on Friday 22nd September, senior health managers were refused permission to start consulting on rationing treatments across the whole of North Central London. The leaders of the five councils affected have written to Simon Stevens, head of NHS England, saying that they will not accept reductions in the level of care and that funding needs to be found. This follows campaigning by NHS supporters in Enfield, Haringey, Islington, Barnet and Camden. DENHS is proud to be part of this people-powered, winning team. Please join us - there is a long way to go to get our NHS back on track and fit for our 21st century needs.
The council leaders' letter to Simon Stevens
Dear Simon,
As the five Leaders of the boroughs within the North Central London Sustainability and Transformation Plan we are writing to you to set out our views on where we have got to in our region. In particular, we want to express our increasing concern about the focus on short-term cost cutting at the expense of longer-term transformation, particularly the experience of the Capped Expenditure Process.
When STPs emerged almost 18 months ago, we saw an opportunity to work with local partners and develop a plan that would address some of the biggest challenges facing health and care locally. It could have been a chance for the NHS, local Councils, the voluntary and community sector and other partners to look across systems and organisational boundaries to develop a long-term and system-wide plan to address health and care inequalities.
We had hoped to be equal partners alongside our NHS colleagues, bringing to the table our vast experience and skills in meeting growing needs whilst continuing to deliver a balanced budget each year, despite years of budget cuts. We know from our experience that investing in prevention and early intervention is the sensible and successful way of approaching large scale transformation. 18 months on, we feel that the ambition for this to be a joint, population based approach that will transform the health and care of local people is not yet being realised. There is plenty of willingness of local partners to rise to the original ambitions, but they are hindered by a range of systemic problems that are driving them to focus on short termism.
Specifically, the main focus of NHS colleagues for many months earlier this year was on savings through the directed Capped Expenditure Process (CEP) which only looked at in year positions and not transformational change. It was not acceptable to learn from local newspapers during this time that this directed process was resulting in lists of proposals for cuts to local services and a reduction in standards. Despite months of effort, none of this CEP work has dealt with some of the core problems in the local system including that: 1) North Central London is expected to deliver a surplus control total this year of £38m despite the high levels of deprivation and significant health inequalities in this part of London; this control total seems to be an accident of history with no rationale behind it; 2) NCL is not receiving all the sustainability and transformation funding it was allocated because of the way the rules mean the Royal Free is not eligible for its allocated amount; 3) the approach to the Royal Free’s financial position is failing to recognise the challenge s it has faced in resolving systemic issues it inherited during its expansion in recent years. This Capped Expenditure Process suggests to us that the STP is being forced to be focussed on shortterm issues in the NHS rather than a truly sustainable and transformational system for health and care locally in North London.
We do need to take issue with a recent NHS media statement on the matter of the surplus control total. You may not be aware, but a press notice earlier this summer suggested that doing away with the surplus in NCL would result in us “taking less than our fair share” compared to other areas of the country. This provocative statement was a clear dismissal of the legitimate concerns of local people and their elected representatives and showed a complete lack of understanding of the make-up of our populations and the health and care challenges we face. We know that colleagues locally have been working hard to identify how to contain budgets whilst finding effective ways of improving the health and wellbeing of residents, and meeting the requirements of the NHS constitution. We are of course fully aware of the pressure NHS budgets are under and we remain committed to working with colleagues on local health Trust and Clinical Commissioning Group (CCG) boards to help create an affordable health and care system that continues to meet our residents’ needs and aspirations. We agree that there are improvements to be made and that some are vitally important. But when the focus on balancing budgets has reached the stage where service cuts and rationing health services are on the table, where there is minimal investment in prevention and yet when there are significant unresolved accounting issues, the process must surely be broken.
Looking ahead we believe that there are some important steps to be taken to re -build trust and confidence and to move us all forward. We therefore urge you to commit to the following:
- No reduction in health services, or service standards (including no detrimental changes in access to services) in North Central London as a result of pressures on CCG, the current exercise or the STP;
- Additional funding if required to guarantee the above, including resolving the funding/ accounting issues we have mentioned in this letter;
- Full and proper consultation with residents and patients on any proposals for health service changes, meaning that they will be involved in re-designing services;
- Return the focus of NHS leaders in North London to long-term transformational change over the STP period, working across the health and care system with Councils as equal partners;
- Returning to your ambition for local flexibility in determining our health and care system, reducing the central control exercised over the system;
- Encourage NHS leaders to invest in long-term prevention activity, which by 2020/21 will reduce the demand for expensive health and care.
We would very much welcome a meeting to discuss our concerns.
Richard Cornelius Leader Barnet
Georgia Gould Leader Camden
Claire Kober Leader Haringey
Doug Taylor Leader Enfield
Richard Watts Leader Islington
