The NHS seems to be in a constant state of change, and over the next few years it will be transformed. Whether that is actually beneficial to the patient is difficult to assess. Funding of the NHS is hugely political, and whether the money is wisely spent is a moot point. Health in Derby is served by many organisations inside and outside of the NHS. How this works, whether we get value for money and how it’s performing needs to be more visible to the people of Derby
NHS England receives just over £100bn from the Department of Health to pay for all health-related services. Around £70bn of this is distributed to the 211 local Clinical Commissioning Groups (CCG) who then contract to deliver all GP practices, hospitals, local care; only some specialist services are managed directly by NHS England. The CCG covering Derby is the Southern Derbyshire CCG (SDCCG) which covers the region up to Alfreton, Ashbourne and east towards the boundary of the County but excluding Erewash which is covered by its own CCG. SDCCG receives approx. £750m per year funding from NHS England.
SDCCG is a complex structure; it is overseen by a clinician led Governing body which also includes lay representatives, officers of the CCG and representatives of Derby City Council. This body meets every 2 months , the last one being August 19th. The meeting notes were a 413 page pack of documents – some of the key issues are highlighted below.
Emergency Ambulance performance.
This service is contracted to East Midlands Ambulance Service NHS Trust (EMAS) for £16m – theoretically it could be run by a different regional Ambulance NHS Trust. The report in the August meeting was about how EMAS was underperforming on some key measures.
Red 1 / Red 2– this is for highly critical emergencies like cardiac arrests, strokes etc. The target is that 75% of ambulances reach the patient within 8 minutes. The actual achievement was 63%
The average response time for EMAS for RED1/2 is 16 minutes. The national average is 12 minutes
A19 – 95% of all ambulances for Red1/2 calls should reach the patient within 19 minutes. Actual achievement was 93%.
The Red1/2 response times have deteriorated since last month. This whole issue was raised as a major concern by the Governing Body. There was no clear understanding of why EMAS was having these problems and reference was made to an independent review on how this performance could be improved. One of the lay members felt that “escalation is inadequate” and that there was “no confidence in EMAS”. Although it would be possible to go elsewhere this was felt to be impractical. A report would be produced for issue in November that would analyse this situation in more detail.
Non-Emergency Patient Transport Service (NEPTS)
Somewhat ironically, given the above, EMAS won the contract to provide this service which starts in August 2016. This service is for patients who are unable to get to NHS appointments due to problems associated with their medical condition. There are criteria which are applied to determine if the individual qualifies for the service. It would appear ( and this came out in the tendering process) that the previous contractor was more liberal in their interpretation of the rules than they should have been. This will most likely mean that many people who benefited on the basis of more social care, or financial reasons will no longer enjoy this service.
The implementation will need to be sensitive and an audit is being carried out to mitigate the impact to those who will no longer qualify
The budget for 2016/17 is £746m. 50% of this is used to pay for hospitals, the majority of which is for the Royal Derby Hospital and London Road Community Hospital. 20% pays for the GP practices, and the remainder is on Community Services, Mental Health and Continuing Health care. After 4 months of 2016/17, the plan is still to deliver within the budget.
Of the £746m, £102m (13%) is paid to non-NHS providers ( privately owned/run organisations). This covers contacts on care homes, some primary care services, Better care Fund, Nuffield Hospital services, community hospices and voluntary groups.
Although some of this could be considered to be the “privatisation of the NHS” it was reported that there were no plans to change the level of service contracted outside of the NHS.
Conflicts of interest (COI)
As the NHS is a complex, inter-twined organisation and large procurement contracts are on offer to many private organisations as well those controlled within the NHS, there is real scope for people to have conflicts of interest. This is inevitable and is not, in itself, a problem providing such conflicts are transparent and managed properly. There already exist COI procedures but a new set of guidelines were issued in June 2016 which strengthened the procedure
“The plans are designed to bring a stronger, more consistent approach to managing potential and existing conflicts of interest across the NHS, meaning patients and the public can have full confidence in how NHS funding is invested.”
Sustainability and Transformation Plans (STP)
This was the subject of the Chair’s opening presentation and will be an important part of how the NHS and health care in Derby is delivered for the future.
In order for the NHS to keep pace with the demands on its service, in the context of a budget which might not increase at a consistent rate, it needs to consider how to change in ways which make a large but sustainable difference. It will be the case that a £100bn organisation will have massive inefficiencies which need to be addressed. This won’t be solved by 211 CCG’s tackling their part of the problem, individually. Neither will much progress be made at a total NHS level – it is too big.
To make the task manageable the country has been broken down into 44 “footprints”. Locally, this means that the 4 CCG’s in Derbyshire will work together on this initiative as the Derbyshire “STP footprint”. This covers the county of Derbyshire less the section around Glossop which is in a Manchester based CCG.
Their task is to develop plans ( and the first draft has been submitted to NHS England) that propose transformational ideas that will secure delivery of the NHS’s 5 year plan. The public issue of this in Derbyshire will be October and will be subject to consultation – this may include changes that some people may not find favourable.
Accident and Emergency – failure to meet 95% target for a max. 4 hr wait
It was highlighted that in June2016 the CCG failed against the target and only achieved 89% – this was attributable to the performance in Derby and Burton hospitals. Although raised as a major issue in the meeting, the graph presented indicated an improving trend and that in the last 6 weeks, 3 of those weeks were better than the 95% target.
CCG Annual Assessment.
This is reviewed each year by NHS England and was issued in July 2016 – SDCCG was given a headline rating of “Requires Improvement”. In the report NHS England concluded :
“The CCG must maintain the good progress made in cancer and ‘Referral To Treatment’ (RTT) waiting times. In addition, the CCG must support Derby Hospitals NHS Foundation Trust to deliver and maintain the Emergency Department 4 hour wait target throughout the year in line with Sustainability and Transformational Fund trajectories. It is in part, the failure to deliver these targets consistently during 2015/16 which has prevented the CCG from being ‘Assured as Good’ by NHS England”
The SDCCG were very transparent in the issues that were presented, and the meeting was run very professionally with the opportunity for the public to ask questions ( no requirement to submit in advance). The answers that were given were honest and thorough – no politicians were involved! I made a statement / raised questions around budgetary support for disabled people and how the process was unnecessarily painful for the individual concerned. This was addressed to both the CCG attendees on the Body and Parveez Sadiq who is Acting Strategic Director Adult, Health and Housing for Derby City Council ( who is also a member of the Body) I was invited to a follow up meeting where I could discuss my thoughts and concerns in more detail.
There are many issues that will affect people in Derby especially the proposals in the STP, and the impact of poor performance in A&E, and the Ambulance service. Whilst Conflicts of Interest will not be immediately evident to the average patient, it does represent a potential drain, or diversion of resources – one to watch closely!
The summary from NHS England in its assessment was deservedly upbeat:
“Overall we would like to congratulate you on the progress you have made over the last year, particularly in relation to RTT and Cancer which have seen good overall performance and improvement despite considerable challenge in the system.”