Fit for the few

The Sustainability and Transformation Plan (STP) for the Cambridgeshire and Peterborough NHS footprint was published on 21 November 2016,1 as the keystone of the Fit for the Future programme. The plan reveals the scale of the deficit that is being created in the local NHS by the austerity imposed by Conservative and Conservative-led governments since 2010, which will amount to £504m by 2020/21. And it shows the narrow paths down which that strategic underfunding – or defunding – is forcing the health service.

In places, the plan seems to draw on serious thought by health workers about how they can respond to present conditions; we have reports of apparently genuine attempts to involve patients, in consultations led by clinicians. And yet the final product is one more witness to the remark that NHS plans under austerity come to look alike: 'Each starts with reference to [local] issues, each ends with a version of [NHS England chief executive Simon Stevens's] Five Year Forward View.'2 The fact is that continued defunding forecloses all but a very few basic options.

The £504m question

The Cambridgeshire and Peterborough STP tactfully explains the huge projected local deficit by costly payments under private finance initiatives (PFI), the expensive e-hospital system introduced by the Cambridge University Hospitals trust, and 'historical underfunding in both health and social care' (10). We accept all these factors (and the mention of PFI reminds us that the dismantling of the public NHS did not start in 2010) – but they omit the massive, acute, and unprecedented3 underfunding in the present. This is only glimpsed in the summary booklet published for patients alongside the STP, which reveals that half of the projected deficit, £250m, consists of the 'efficiency savings' demanded for the period by the Conservative government:4 'cuts, to put it bluntly', as Aidan Thomas, chief executive of Cambridgeshire and Peterborough Foundation Trust, said in 2015.5

It's not only arbitrary requirements for savings that undermine the claims by austerity governments to have 'protected' the NHS budget. Barely to maintain real (inflation-adjusted) spending on the NHS for seven years while medical needs are growing is itself a defunding tactic; and that those needs are growing is due not only to the growth and rising average age of the population, but the government's destruction, through slashed council budgets, of the social services which prevent care needs escalating into acute medical needs. To look only at Cambridgeshire, the withdrawal of central funding has led the county council to plan £124m of spending cuts between 2016/17 and 2020/21,6 on top of £218m of cuts in the first austerity period.7

Rationing

What are the options that Conservative defunding leaves to the local NHS? One is to further increase the rationing of healthcare. The Cambridgeshire and Peterborough STP projects that £71.2m can be saved by reducing demand, and £45.6m by changing pathways to shift care to lower-cost settings: that is, to keep patients out of hospital (14–19, 64). Alongside what taken alone might be a welcome commitment to preventative medicine (14–15), the plan provides for an 'integrated urgent care and clinical hub' (20) and a 'patient choice hub' (23): these seem to be referral centres, recently criticized by the British Medical Association for being (as they're designed to be) a 'block between the GP and patient treatment'.8 Clinical thresholds, defining how sick we have to be for treatment or referral, are also to be increased (13, 64). And more of our long-term care needs are to be handed over to private contractors (see below) or volunteers – if not to ourselves as patients (15–16). It's wearying to note that our self-care may involve self-rationing, in the form of personal budgets (15).

Commercialization and privatization

Another compulsory option is increased commercialization. The plan projects raising £20.3m through increasing private patient volumes, repatriating patients from the private sector, 'increas[ing] commercial income' (not further explained), and 'external opportunities' specifically for the Cambridge University Hospitals trust (64): these opportunities clearly motivate 'efforts to leverage the "Cambridge research" brand' (12). 'Land development' – that is, selling land for development – is set down as another way to raise non-clinical income (13), and an additional £15m is expected from the 'strategic management' of NHS estates (64). (The plan observes that 'with so much building development happening in Cambridgeshire there are opportunities for new commercial ventures … on, for example, the [Hinchingbrooke] campus': 31.) We want to remember here Deborah Harrington's warning in a 2015 article:

Once [estates] are transferred ... out of public ownership, the cost of reclaiming them in the future is always just out of reach ... Just as PFI increases the financial drag away from clinical care into buildings and maintenance, so long-term ownership of our assets decreases it.9

The Cambridgeshire and Peterborough STP is a plan not only for commercialization, but for privatization; and not only privatization of estates, but of care. We know that under the coalition government's Health and Social Care Act 2012, those of us steered away from hospitals (14–19, and see above) may be delivered into the hands of private sector 'NHS partners',10 who will be able to tender for the contracts to provide the new 'neighbourhood care hubs' (16–19).11

Moving services out of hospital and integration with social care creates huge opportunities for [private] providers to deliver services with cheaper non-clinical staff, and to relabel these services as – chargeable – social care.12

What we face and have to resist is cut-price care by private companies, with profits put above our needs as patients.

The American model

A third compulsory option is the continued imitation of American models, famous for delivering poor care to ordinary patients and large profits to shareholders. The 'unifying ambition' in the Cambridgeshire and Peterborough STP is for the local NHS to move closer to becoming an accountable care organization, or ACO (2, 11), a structure recently promoted in the United States by which, as Stewart Player has explained, 'a group of ... firms agrees to take responsibility for providing care for a given population for a defined period of time under a contractual arrangement with a commissioner.'

ACOs use a variety of market-based mechanisms to lower costs whilst achieving a set of [agreed] quality outcomes. This is mainly accomplished by 'aligning incentives' between providers and commissioners, or in other words, sharing any budget savings between hospitals, doctors and the commissioning [US government] Medicare programme itself.13

Player cites research suggesting that between 2011 and 2014, the bonuses and subsidies paid to ACOs meant they delivered no overall savings, and even slightly increased the cost of the Medicare programme. Since his article was published, a pilot ACO in England has failed because of overspending: in January the Torbay and South Devon NHS Trust withdrew from the risk-sharing agreement linked to the same area's 'Integrated Care Organization', after the latter overspent by £12m in its first year.14

But more alarming is Player's argument that ACOs are little more than a 'rebranding' of an established structure in US healthcare, that of the health maintenance organizations (HMOs) which 'act as financial intermediaries between customers and providers, collecting payments from the former and arranging their care with the latter'. No one will be surprised at how 'incentives' work in this model: according to Player, HMOs are known for 'routine denial of patients' access to medically necessary treatment' as well as for 'fighting claims, screening out the sick, paying exorbitant [executive] salaries, and undertaking systemic fraud.'15

Adopting the 'behaviours' of an ACO, as the beginning of a process projected to take a decade or more, is seen to encompass all the other proposals of the Cambridgeshire and Peterborough STP (11–12). But the structure seems especially relevant to two major directions for cost-cutting we haven't yet discussed: that of 'standardized care to minimize unit costs' (12), supposed to save £58.2m (64), and that of a 'reduc[ed] unit of care cost in existing settings', supposed to save £137m (64). The risk for patients is that as in the US examples above, market mechanisms encourage participants to 'game' the system, bringing the 'agreed quality outcomes' into conflict with our real clinical needs.

Narrow paths

Rationing, commercialization and privatization, and the imitation of a dubious American model: these are the narrow paths ahead of our NHS after nearly seven years of austerity. We reaffirm our view that this STP is designed to make sustainable not the NHS, but its underfunding.16 It's a plan not 'for the future', but for the few: those who see the NHS as a standing insult to their private wealth, and those who will profit from its surrender of medical needs to the market. Today, they share a political instrument in the Conservative Party.

Against those few and against their party, we repeat our promise to co-operate with Cambridge Keep Our NHS Public, Hands Off Hinchingbrooke, other activist and community groups, and local trade unions to fight the damaging proposals in the Cambridgeshire and Peterborough STP and to campaign for an NHS that's owned in common, funded in common, universal, and truly sustainable.

Cambridge People's Assembly

16 March 2017

Notes

1. Cambridgeshire and Peterborough Health and Care System Sustainability and Transformation Plan (Fulbourn: Fit for the Future, 2016). We'll give page references to this document below in brackets in the text. Its publication was reported at the time by Steve Sweeney, 'Cambridge Cuts Plan Confirms Tory Plot to Destroy Our NHS', Morning Star, 22 November 2016.

2. 'The Five Year Forward View', National Health Action Wiki, no date (spring 2016?).

3. Nuffield Trust, Health Foundation, King's Fund, The Spending Review: What Does It Mean for Health and Social Care? (London: Nuffield Trust, 2015), 1. 'Overall, the NHS is halfway through the most austere decade in its history.'

4. How Health and Care Services in Cambridgeshire and Peterborough Are Changing (Fulbourn: Fit for the Future, 2016), 17.

5. Aidan Thomas, 'New Government Must Increase Investment in Health', Cambridgeshire and Peterborough NHS Foundation Trust Latest News, 13 May 2015.

6. Cambridgeshire County Council, Business Plan 2016–17, section 1, Strategic Framework (Cambridge: Cambridgeshire County Council, 2016), 3.

7. 'Cambridgeshire's £100 Million Budget Challenge', Cambridgeshire County Council, accessed 16 March 2017. We take this undated document to have been published in autumn 2015.

8. Patrick Clahane, 'Referral Centres Cause "Dangerous" NHS Delays, BMA Warns', BBC News, 16 January 2017.

9. Deborah Harrington, 'Going, Going, Gone: The Great Hospital Sell-Off?', OpenDemocracy, 5 February 2015.

10. As they now call themselves. 'The NHS Partners Network is the trade association representing the widest range of independent sector providers of NHS clinical services.' Home page, NHS Partners Network, accessed 16 March 2017.

11. Debbie Abrahams, 'Privatisation in the NHS', Socialist Health Association, 21 June 2014. 'The section 75 regulations relating to the Health and Social Care Act in effect mean that local commissioners are forced to put services out to tender ... If contracts are not opened to the market then [commissioners] fear the prospect of costly legal action from the private sector.'

12. Carol Ackroyd, 'NHS Managers Are Being Forced to Lie to the Public', OpenDemocracy, 20 May 2016.

13. Stewart Player, ' "Accountable Care": The American Import that's the Last Thing England's NHS Needs', OpenDemocracy, 1 March 2016.

14. Keith Cooper, 'Combined Health and Social Care Organisation Poses "Financial Risk" to Local Authority', British Medical Association News, 19 January 2017.

15. Player, 'Accountable Care'.

16. Cambridge People's Assembly, 'Against the NHS Sustainability and Transformation Plans', The People's Assembly Against Austerity, Cambridge Group, 8 November 2016.

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