The NHS, a postcard from the frontline
pharmafile | February 24, 2012 | Feature | Business Services, Manufacturing and Production, Medical Communications, Research and Development, Sales and Marketing | Brighton, NHS, Sussex, reforms
It is January 2012, and the NHS in England is under huge strain. This is because it is being asked to undertake its biggest ever cost-cutting exercise, and at the same time implement its biggest ever structural reorganisation.
In every region, Primary Care Trusts have been amalgamated into clusters, and senior managers are being asked to shave tens of millions from local budgets while maintaining service standards, and at the same time prepare to hand over power to new GP-led groups.
The QIPP savings target is now familiar to everyone in the NHS – savings of £20 billion over five years – and is equivalent to 4% of the budget for each of those years. A 4% efficiency saving is a feat that has never been achieved by the NHS in one financial year, let alone five consecutive years, and many observers fear too much is being asked of the system.
So can health service managers pull it off, or is it inevitable that patient services will suffer and local NHS organisations sink into disarray and deficit?
The health service is now 10 months through its first year of QIPP, and despite the difficulty of the task, many NHS organisations are either on course to meet their targets, or not far off.
However, a report published at the end of January by the Commons Health Select Committee warned that many parts of the NHS are making short-term ‘salami slicing’ cuts to budgets, which will help them meet targets this year, but cannot be sustained over the five year period.
On the same day the Select Committee’s report was published, I attended the board meeting of my local PCT cluster, which covers the whole of Sussex, to see how things really are on the frontline.
Already lagging behind
The board of the Sussex Cluster is at pains to give the public across the region the chance to sit in on its meetings, and recently the board convened in the seaside town of Durrington.
Shut down for the winter, there are no holidaymakers in the town to send postcards, but the public and press gallery at the meeting is full, with local residents and the media eager to cross-examine the board about its plans.
A review by the strategic health authority of all PCT Clusters in the South of England region concluded the financial picture was good – with the exception of NHS Sussex, where it said: “There are challenges across the Cluster, particularly in West Sussex and across all providers.”
The Sussex Cluster has been charged with finding £111.7 million in savings from its £2.64 billion budget this financial year. But at the Cluster meeting, the board admitted it is falling short of its QIPP targets, and forecast that it would miss its target by a full 40 per cent.
Several acute trusts and PCTs are struggling to control debts, but many of the financial problems are deep rooted.
Cluster chief executive Amanda Fadero and her board are finalising ‘Sussex Together’ which will be a strategic plan for the region, which should create a more coherent and joined-up picture for the area, and set out how money can be saved while improving (or at least maintaining) patient services. If the Commons Health Select Committee and many health think tanks are to be believed, the plan will have to include some bold decisions to reorganise services, including the closure of some local services and wards, if a long-term financial health is to be guaranteed.
The Cluster board says its Sussex Together plans will produce a “clear picture of the current and future health needs of people in Sussex, and options for delivering services to meet those needs that make the best use of our people, skills, money, buildings and equipment”.
Transition to CCGs
The Cluster is moving ahead with the transition of power to CCGs, with the aim of giving some groups control of budgets from 1 April 2012. There are seven CCGs in the Sussex area and these have all just completed their validation process in December.
The most prominent of the CCGs are Coastal West Sussex Federation and the North West Sussex GP Commissioning Association, both aiming to take on shadow commissioning roles from April.
However, the Cluster board restated that it will remain the accountable organisation until April 2013. Changes to the national reform plans last summer made it clear that the April 2013 date will not be a ‘big bang’ transition – power will only be handed over to CCGs judged to be ready on that date – those that are not ready will take on powers only once they have met the required criteria.
The Cluster admits that preparing for the transition has been hard: chair Denise Harker says it is trying to “achieve a lot in a short period of time”, but with fewer staff and more responsibility, which has created additional pressure on the organisation.
Harker warned that as the PCT system comes to the end of its life, there was still a lot of uncertainty, for both the public and for staff. As shadow CCGs come into force in just two months’ time, she admitted that there is “still a lack of clarity on how these new functions [the CCGs] will operate”.
The Cluster is currently making its financial plans for next year alongside the CCGs, and Fadero said it was a ‘frenetic’ time for all involved, especially as it will miss its savings target for this year. A final budget for the CCGs is also being discussed, as well as the amount of savings it will be responsible for in the next financial year.
All of the CCGs in the area have entered the Kent/Surrey/Sussex CCG ‘development pipe-line’, and were due to have a development plan by the end of January 2012. CCGs need to demonstrate five competancies before taking on the shadow role:
• the management of budgets
• the delivery of their relevant QIPP target
• evidence of their active role in the planning function for 2012/13
• evidence of their support of the wider integrated plan.
Hospital and medicines in the crosshairs
The two biggest savings should be coming from planned and acute hospital care, but they are currently not delivering on their targets.
The East Sussex Hospitals Trust is facing the most serious financial problems of the six trusts in the region, and has only saved £6.7 million of its £20 million target for the year so far. This could be dangerous for the hospitals involved and they could face mergers, reconfiguration or even closure if they are unable to turn things around.
Medicines management has the third highest savings target, but at the beginning of the financial year the Cluster was struggling to reduce its spend on drugs. But the board says it has worked hard to make up this shortfall, and is now on target to meet its full year savings of £12.7 million.
This has been done primarily by switching patients – where clinically appropriate – from branded medicines to generic treatments. This includes making simvastatin the first choice of medicine to treat high cholesterol, ahead of Pfizer’s branded medicine Lipitor.
Prescribing reports in the region also advise switching all osteoporosis patients from Merck’s Fosamax to generic alendronate, as the treatment of choice for osteoporosis. It is also looking at how to reduce medicines wastage by improving patient adherence, something that costs the NHS in England around £400 million a year.
Local concern
When it comes to what the general public in the region are most concerned about, it seems Sussex is no exception to the national picture – the future of hospitals is the one overriding concern. Specifically, residents in the coastal town of Littlehampton have been promised a new community hospital six years ago, but it has still not materialised.
A final decision is expected by April, and campaigners will be disappointed if the Cluster concludes the new hospital is not part of a forward-thinking strategy for the local health economy. This is the nub of the entire process – how to maintain quality services in a time of unprecedented financial pressure, while re-designing care pathways and management structures simultaneously.
Back on the national level, the Health Select Committee report says it is still too early fully to assess the types of savings being made in 2011-12, the first year of the QIPP programme, but said it had misgivings about how local NHS organisations were making savings.
The report warned that some NHS trusts were focused on “achieving short-term savings which allow them to meet their financial objectives in the current year, apparently at the expense of planning service changes which would allow them to meet their financial and quality objectives in later years.”
It seems clear that a region like Sussex, which is already falling short of its first year QIPP, is in for a rough ride over the next four years.
Moreover, the GP leaders of the nascent CCGs, who have limited or no experience of overseeing an entire health economy, will be taking on a mammoth task.
CCGs in Sussex
Coastal West Sussex
Geographical area: Chichester, Bognor Regis, Arun, Adur, Worthing and Chanctonbury
Chair Steve Pollock
Contact: Dr Katie Armstrong
The Surgery
Green Lane Close
Arundel
West Sussex
BN18 9HG
T: 01903 882191.
Mid-Sussex Consortium
Contact: Dr Minesh Patel
T: 01342 327555.
Horsham Consortium
Dr Simon Dean
T: 0844 815 1511
c/o Crawley Hospital
West Green Drive
Crawley
RH11 7DH.
Brighton and Hove Transitional Consortium
Chair: Dr Xavier Nalletamby.
Crawley Consortium
Contact: Dr Amit Bhargava
c/o Crawley Hospital
West Green Drive
Crawley, West Sussex
RH11 7DH
T: 0844 815 1220.
Coastal Community Healthcare Consortium
Geographical area: East Sussex Coast
Contact: Dr Martin Writer
Park Practice
Eastbourne Park
Primary Care Centre
Broadwater Way
Eastbourne, East Sussex
BN22 9PQ
T: 01323 502200.
Hastings and Rother
Geographical area: East Sussex Coast
Contact: Dr Roger Elias
Pebsham Surgery
Seabourne Road
Pebsham
Bexhill on Sea
TN40 2SD
T: 08444 778 690.
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