Can we afford to close any more A&E departments ? Evidence from North West London

Research paper by Dr Gurjinder Singh Sandhu, published by the Centre for Health and the Public Interest on 19th April 2017. You can read it here (14 pages).

The following graph shows that the closure of Hammersmith and Central Middlesex A&E departments in Sept 2014 caused a very serious decline in the performance of the remaining A&E departments, that they recovered only a little in the summer months and that the trend is downwards.


Dr Sandhu has provided unequivocal evidence using statistics from NHS and other public bodies (Jan 2012- Jan 2017) for the Mansfield Commission findings that SaHF, and by extension the NW London STP, can be shown to fall foul of (1) equalities (BME) legislation and (2) discrimination on grounds of age. 



Since the closure of Emergency Departments in North West London in September 2014, each successive winter has seen deterioration in Type 1 A&E Performance. For some hospitals there has been no recovery over the summer months and emergency care has been in perpetual state of crisis. Ambulance response times are deteriorating, A&E units are unable to offload ambulances, and patients are waiting longer on emergency department trolleys to be assessed, treated and bedded where necessary. For time- sensitive conditions such as sepsis, respiratory failure, kidney failure and the unconscious patient, all this lost time equates to cellular death and eventually patient deaths. A lack of critical care and high dependency unit beds for the sickest patients is the greatest cause for concern.

In North West London A&E closures have also had significant effects on the performance of neighbouring A&E departments. STP footprints are not isolated: the STP for South West London also proposes to downgrade one of five A&Es, which will have a knock-on effect on North West London, and vice versa.

There has been a lack of equality impact assessment on the effects on deprived communities and the elderly in the NW London STP plan. Poverty is shifting from the centre of London to the outskirts, yet across London it is in these areas that clinical networks between a hospital, GPs and social care are being dismantled.

Whilst isolated deaths due to pressures on the emergency system have been reported by the media, disinvestment in NHS and social care services has been explored in one recent study as a factor contributing to nearly 30,000 extra annual deaths in 2015. The authors* expressed significant concerns that a pattern of rising mortality each year is emerging and called for further in-depth scrutiny of what caused this marked increase in mortality. Despite a dangerous deterioration in A&E performance since the closure of two local A&E Departments, the North West London STP still envisages closing a further two A&E units at some point in the future. Future planning needs to learn lessons from the reconfigurations that have already taken place and not continue with A&E closures based on assumptions which have not been borne out in reality."


* Prof Martin McKee, Lucinda Hiam, Prof Danny Dorling and Dominic Harrison.



Private firms receive £2.3m to draw up STP plan for North Central London

Peter Blackburn for BMA 19th January 2017


Private firms have been paid a ‘shocking’ £2.3m to draw up controversial plans which will cut health and social care spending by more than £1bn in a part of London.

According to health leaders drawing up the North Central London STP (sustainability and transformation plan), six-figure sums were paid to eight different companies – including accountants Deloitte and management consultants McKinsey – for services stretching from ‘administrative support’ and ‘financial modelling’ to ‘communications support’.

A firm called Consultants Methods Advisory Ltd, which describes itself as ‘shaping public services for the digital age’, racked up the biggest costs, invoicing £617,850 for ‘programme management office and strategy support’.

Doctors leaders described the figures as ‘appalling’.

BMA council chair Mark Porter said: ‘While hospitals fall into crisis, social care hits rock bottom and the Government blames hard-working GPs for its political choice to underfund the NHS, every penny of health service money becomes more desperately valuable and doctors will find it galling to see that so much vital resource has been handed to consultancy firms for their part in failing plans which, ultimately, may never come to fruition, while frontline staff struggle to provide safe patient care in a service increasingly becoming unfit for purpose.’


Pick and choose

BMA News analysis last year revealed that the STP process – which has seen England divided into 44 ‘footprint’ areas, with each asked to produce a plan to integrate and transform local services – will need to cut some £26bn from their budgets by 2021.

And in December an NHS Improvement board paper revealed that only projects which were ‘shovel ready’ would be likely to be funded – with capital resource too tight to pay for all the projects.

Dr Porter added: ‘NHS Improvement has admitted that it will pick and choose the parts of these vast, bewildering plans it can actually put into action and, as such, it leads me to question whether all of this money handed out to private companies will be completely wasted – yet another example of vital resource being frittered away in a health service devoid of direction and leadership and lurching from one unnecessary crisis to another.’

The North Central London STP – and its final iteration: a 68-page word document in PDF format – aims to combine ‘radical service transformation and incremental improvements’. It reveals that the area faces a funding shortfall of £1.2bn in 2020/21 if spending and funding levels continue as expected.

In the plan, health leaders admit to ‘not having all the answers’ and still expects its NHS organisations to be in the red by £75m in five years – even after all the cuts.


'Shocking, disgusting and appalling'

Camden GP and local medical committee chair Farah Jameel said: 'As a practising GP struggling to meet patient needs with ever tighter resources, the words that come to mind when presented with these financial figures are shocking, disgusting, appalling and ultimately not surprising.

'The Government should be held accountable for allowing this inappropriate use of funds and be encouraged to focus attention on addressing the very real challenges affecting those who work in and rely on the NHS.

'We are in the midst of a winter crisis, the NHS has systematically been stripped of much needed resources translating into services performing under extreme pressure and stress, in this context these monies would be much better spent on frontline services like A&E's and General Practice.

'I remain acutely aware of the Government's agenda to transform and reconfigure services to better suit the needs of the population within the constraints of a shrinking financial envelope.

'With that in mind the absence of strong clinical input regarding service capacity and patient need in the planning process is frankly disappointing, especially given the large figures of tax payers' money involved.'


A new norm?

In total 17 different firms were paid for their involvement in putting together the STP.

McKinsey and Company were given £360,000 for ‘strategy assessment’ and ‘financial modelling’ particularly related to mental health services and initiatives.

Deloitte LLP was given £257,336 for ‘finance and activity modelling’.

And recruitment specialists Hunter Healthcare Resourcing charged £282,518 for administrative support.

Methods Advisory Ltd did not respond to BMA News’ request for comment. But a column on its website said: ‘We have worked in health and care for over 25 years, with all its incarnations and ambitions.

'This gives us the ability to know what has worked (or not) before, alongside knowing what the potential… [to be] the "new normal” in health and care.’


Leaked costs

The revelations come months after a letter was leaked to the BBC revealing the cost of external providers to an STP in Cheshire and Merseyside.

PricewaterhouseCoopers were paid £300,000 – less than a seventh of the total cost in North Central London – to help draw up the Cheshire and Merseyside STP, a plan which requires savings of £999m within five years.

Explaining the costs, Louise Shepherd, lead for the Cheshire and Merseyside STP, said: ‘This is to provide additional capacity and expertise to help and support our clinicians and managers design our future care models while still delivering a very challenging “day job”.’

NHS Improvement and the North Central STP lead have been contacted for comment.

The North Central London patch includes: Barnet, Enfield and Haringey Mental Health NHS Trust; Camden and Islington NHS Foundation Trust; Central and North West London NHS Foundation Trust; Central London Community Health Care NHS Trust; Great Ormond Street Hospital; Moorfields Eye Hospital; North Middlesex University Hospital NHS Trust; Royal Free London NHS Foundation Trust; Royal National Orthopaedic Hospital; Tavistock and Portman NHS Foundation Trust; University College London; and Whittington Hospital.


The internal market: The billions of wasted NHS cash no-one wants to mention

by Caroline Molloy  - published 10th October 2014 in OpenDemocracy/OurNHS....

.....and STILL relevant


As calls mount for the NHS cash crisis to be 'solved' by charging patients, there is one pot of money that sits glistening and untouched...

Calls to solve the NHS cash crisis by charging patients have mounted this week, with the NHS Confederation calling for £75 a night ‘hotel fees’ for hospital stays, or much longer waiting lists.

But there is one pot of money that sits curiously unexamined, glistening and untouched.

It’s the cost of the NHS ‘market’ itself. Administering the hugely expensive artificial ‘marketplace’ created by successive governments to allow both NHS and private ‘providers’ to compete with each other to offer services to NHS and other ‘purchasers’.

No-one knows the exact cost of this bureaucratic ‘marketplace’. A recent estimate by rebel Lib Dems put the figure as high as £30billion a year. Dr Jacky Davis and other doctors and campaigners including the National Health Action Party have put it at £10billion a year. The Centre of Health & the Public Interest put it at a ‘conservative’ £4.5billion a year.

Even the most conservative of these estimates is a yearly amount which would, if re-directed away from useless market activities, fund both the £2billion annual NHS shortfall and free critical social care to everyone, which the Kings Fund’s Barker Commission recently said would cost  ‘substantially less’ than £3billion a year.

Despite fierce urging from expert MPs to look at what the ‘market’ costs the NHS more closely, the government, mainstream media, think tanks and policy makers have dismissed, ignored and even suppressed this information, with unevidenced assertions that ‘modern healthcare systems’ need vastly expensive bureaucracy, market or no market.

Successive governments wedded to ‘market reform’ have refused to produce useful figures that would definitively establish the cost of the NHS market. It has been left to academics, MPs and activists to try and fill the void, through historical and international comparisons, as well as tentative attempts to cost different activities that are forced on the NHS by the ‘market’.


Hiding the figures

In 2010 the Health Select Committee found that running the NHS as a ‘market’ cost the NHS 14% of its budget a year.

The Select Committee noted that the NHS would have some administration expenses even if it didn’t run itself as a ‘market’. But they noted evidence from the NHS Chief Historian, Professor Charles Webster that in the pre-market late-80s, the NHS spent only 5% of its budget on administration.

The difference in administration costs pre- and post-market - 9% of the NHS budget - is over £10billion a year of the current £120bn budget. That’s more than the entire cost of every GP in the land.

The government tried to suppress the 14% figure, which was in a York University report it commissioned then refused to publish for 5 years. The York study found that ‘market’ mechanisms like “the purchaser-provider split, private finance, national tariffs…mean…transactions costs of providing care have increased, and may continue to increase.”

The Select Committee report suggested that “the purchaser / provider split may need to be abolished”. They added that they were “appalled” that the Department of Health “was unable to give us accurate figures for staffing levels and costs dedicated to commissioning and billing.”

MPs concluded “the suspicion must remain that the Department of Health does not want the full story to be revealed.”


£10billion a year may be a conservative estimate

In fact the increase in administration costs due to the ‘market’ is likely to be even higher than £10bn.

Professor Colin Leys, author of ‘The Plot Against the NHS’, told OurNHS that these figures relate to 2003, before the second big wave of market ‘reforms’ including “the Independent Sector Treatment programme, the huge expansion of the Commercial Directorate of the Department of Health, the marketing division set up to help trusts learn to advertise and sell their services, the Competition and Cooperation panel, Monitor’s vast expansion...”

The key driver of high NHS inflation is rising drug and medical device costs, new, expensive clinical possibilities, and rising demand as the population ages, runs the accepted wisdom. So why have administration costs kept pace with - or even outstripped - these unavoidable inflationary drivers? Shouldn’t we expect to see administration costs forming a falling proportion of NHS costs?

Professor Webster told OurNHS that instead, “serial reorganisations and escalating marketisation are imposing enormous cost and waste on the NHS, with administrative costs spiralling out of control since 1980.”

Professor Leys adds, “It of course depends on how much you think admin costs would have risen anyway to deal with more complex interactions of modern health care, but to my mind attributing 20% of all NHS costs to admin costs [ie about £25billion], and half of that to the costs of operating as a market, is very reasonable.”

Professor Paton takes a more conservative view, halving the £10billion figure to conclude that “the recurrent annual costs of the market can be estimated (conservatively) at £4.5 billion”.

He concludes in his report earlier this year that the NHS market itself is “an unaffordable ideological luxury”, with few if any discernible benefits.


he market and 'transaction costs'

Away from the academic estimates, though, a quick glimpse at the empty hospital carpark after the managers and admin staff have left for the day, brings home the reality of how much must be being spent on paperwork and IT white elephants to administer the market.

The market introduces ‘transaction costs’ - advertising, negotiating, contracting, invoicing, billing, auditing, monitoring contracts, collecting information, resolving disputes both in courts and out, all employing and training a ballooning bureaucracy - even leaving aside any profits extracted by the private sector.

At the grassroots, Hackney GP Jonathan Tomlinson told OurNHS that applying the ‘market’ adds huge costs at every stage, “because they diffuse through every interaction, from a decision to prescribe or perform a scan, make a referral, set up a service or close a hospital.”

Then there’s what Paton calls the “circular re-organisation”, with endless “re-invention of expensive agencies under different names supposedly abolished, alongside the costly complexity of the new, often overlapping, agencies ...”


How many managers does it take to change a health system?

Each competing NHS ‘provider’ Hospital and Ambulance Trust has executive officers on 6 figure sums, with their Chief Executives often earning more than the Prime Minister. Most spend millions on hiring even higher-paid management consultants in year after year, too - though these figures aren’t centrally collected anywhere.

Then there’s the 211 Clinical commissioning Groups, advised by soon-to-be privatised Commissioning Support Units and NHS England (the biggest quango in history). All of them shove a lot of cash at the management consultants, too (under central quango instructions).

Then there’s the ballooning bureaucracy created to regulate and further marketise this decentralised jumble - the NHS Trust Development Authority, Monitor, the Care Quality Commission, NHS Professionals, NHS Property Services, Healthcare UK... Some of these bodies are soon to be privatised themselves - but, just like the rest of the ‘shadow state’ of management consultants and thinktanks, they’ll still be receiving huge chunks of public money.

Just one of those organisations - West and South Yorkshire and Bassetlaw Commissioning Support Unit - employed 36 public relations workers at a cost of more than £1.4million a year.

Of course the NHS needs managers - but this many? Duplicated across so many fragmented, competing, deficit-ridden organisations?

There have been recent tentative attempts to cost some of the individual elements of the market. Just the legal fees to comply with one Clause of the Health & Social Care Act cost local Clinical Commissioning Groups £77million a year, Labour uncovered earlier this year.

However the Opposition’s critique focuses mainly on the £1.5-£3billion cost of the latest re-organisation -  allowing the government to claim that these are one-off costs they’ll recoup in the long run.


Not one-off costs

The ongoing costs of the current system, however, are huge.

It costs the ‘purchasers’ a fortune. The government is now putting the ‘commissioning support’ infrastructure itself out to tender. It is offering to pay private companies another £5bn - not even to provide healthcare, but just to provide yet more advice on how to run the NHS as a market.

And hospital cash is sucked up in fending off the private sector, too. Earlier this year, the competition to run just one hospital - George Eliot - cost at least one and a half million pounds of public money, my Freedom of Information requests revealed. Over half, £771,000, went straight into the pockets of the big 4 management consultancy firms. Such sums are not atypical - nor is the fact this process changed absolutely nothing, in the end.

Another million pounds has just been blown on tendering ‘older people’s services’ in the East of England - again for the private sector to try (and fail) to demonstrate they could do a better job. But the private sector has got deep pockets - and will keep trying.

There are tens of thousands more of these expensive tenders underway or in the pipeline in every part of the NHS. Dr Tomlinson says “we had to cough up £40k to tender for a local practice that we were already successfully running - and at least that to tender for the Out of Hours contract.”


International comparisons

International comparisons are also helpful. A recent Commonwealth Fund reports suggest that the - til recently - less marketised UK system has been the most cost efficient in the developed world. A still more recent report found that Scotland now spends substantially less on hospital administration, than does England’s increasingly marketised system.

The Liberal Democrat conference this week heard a minority report from the NHS working group which suggested that scrapping the NHS market could save as much as 25% of the annual NHS budget. But their proposals to scrap the market were denied a vote by the party leadership.

The report noted that “countries where there is market competition in healthcare spend between 20% and 40% of their healthcare expenditure on administration”. It highlighted evidence from international experts that the increased use of markets in healthcare sharply increased administrative costs in New Zealand. Canada, Australia and Germany - soaring in the latter case by 63.3% between 1992 and 2003 and now standing at 20% of their health systems costs.

In the most marketised system of all, the USA, one healthcare dollar in every three is spent on adminstration of a system that delivers far poorer outcomes than the NHS. The Lib Dem report points out that healthcare billing alone cost up to 13%, noting “billing costs in healthcare providers are ten times the average of all businesses in the US. There is an inherent complexity to the business of delivering healthcare.”

These arguments are frequently dismissed by opponents. Former Editor of NHS managers bible the Health Services Journal, Richard Vize dismissed Labour’s tentative efforts to cost the market as “The old line that culling bureaucrats and lawyers is all that's needed to fund new services...does not stand up to scrutiny.”


But where is that scrutiny?

The government told the Health Select Committee that the NHS still had “consistently low management and administration costs, ranging from 3-8%.[26]”. But MPs on the Select Committee found “considerable lack of clarity and consistency in … these data.”

Professor Webster (former NHS Chief Historian and Fellow of All Souls) says the “the managerial lobby” have mounted “a clever distraction…a defensive response…artfully disguis(ing) the scale of the increase by accounting procedures, such as concentrating on Managers and Senior Managers, to the exclusion of other relevant staff categories, reducing ‘administrative’ costs back to 5 or even 3 per cent.” But even this, he adds, cannot disguise that “the percentage of admin and clerical staff in the NHS has doubled (from 12%) since 1980”.

The government now boasts of ‘cutting red tape’, saying “There are now over 20,500 fewer managers, senior managers and admin staff, and nearly 14,500 more professionally qualified clinicians than there were in 2010.”

But as Dr Tomlinson says, any reduction in admin staff doesn’t mean a reduction in admin costs,necessarily, as now “medical professionals are doing a lot of the work such as choose and book, coding, and so on, that could be said to be market costs.”

OurNHS asked Kings Fund Chief Economist John Appleby if the recent influential Barker Commission on the future of health and social care funding had looked at the cost of the NHS market.

Appleby replied “no it didn't. wld need to look at net change..might not be net 'saving' as you assume.”

 “One problem is no study yet to test cost-effectiveness of market in NHS”, Appleby added.

His own Kings Fund 2011 study on the market ‘reforms’ to date merely said the cost was ‘expensive’ but ‘unknowable’.

Who is served by the lack of intellectual curiosity by these unaccountable ‘think tanks’ to whom the Department of Health has largely outsourced policy-making? Although their accounts are not very helpful, insiders tell me that the Kings Fund make a substantial proportion of their income from advising this sprawling bureaucracy how to deal with the permanent revolution of the marketplace.


Privatisation doesn’t work

If competition and markets improved health, perhaps the extra costs would be worth it.

We’ve had twenty years of being told the NHS should be run like a supermarket, most recently from M&S man Sir Stuart Rose.

And - as an inquiry convened by Debbie Abrahams MP found earlier this year, there’s scant evidence the market improves quality or health equity (and plenty of evidence it worsens both),whilst costing considerably more.

Just about the only academic study that claimed some ‘cost-effective’ benefits for NHS competition has been criticised for its “heroic” assumptions and failing to factor in the “whole system costs” of competition.

But then, we’ve known since the pioneering work of Nobel Laureate Kenneth Arrow in 1963 that markets in health care simply don’t work. Being a ‘customer’ of healthcare is not like being a customer of, say, oranges - it takes expertise that you and I simply don’t have, and the consequences of the wrong ‘choice’, or a provider closing down, are far more serious.

Bevan and Beveridge’s vision was for not for pseudo-‘choice’ but for local, skilled professionals making decisions on the basis of a ‘strong public sector ethos characterised by commitment and altruism’. They recognised only a publicly owned system could avoid ‘opportunistic behaviour by those who would seek to profit from illness’, with incentives to over-treat and over-investigate, stimulate patient demand through advertising.

Few health economists can agree whether NHS ‘productivity’ has improved, declined, or isn’t an appropriate measure. But evidence from the ground shows patient satisfaction and NHS staff morale are now declining rapidly.

For the cost of the market isn’t just financial. Patients are inconvenienced and even endangered as they are shunted between competing hospitals, GPs, community services and ambulances, all trying to dump costs on each other. The Francis report into the failures of care at Mid Staffordshire found that drive to market-friendly ‘Foundation Trust’ status had created a “supposed ethos of competition and commercial negotiation” which promoted secrecy and undermined co-operation between medical professionals.

Hinchingbrooke, the first NHS hospital to be fully handed over to the private sector - is still a financial basket case, despite having cut corners - and staffing - to the extent that everyone from the Royal College of Nursing to the Care Quality Commission are united in their condemnation of poor standards ofcare and demoralised staff.

Imagine what improvements to our healthcare could have been made, had NHS financial and leadership resources not been squandered on creating a market. As Paton comments, the ‘opportunity costs’ are huge.


So how do we rid ourselves of the creaking edifice of the NHS market?

The market system is now so entrenched it has been compared by demoralised staff to Stalinism.

But the Berlin Wall could yet crumble. Professor Allyson Pollock this week launched a ‘Campaign for an NHS Reinstatement Bill’ which provides a legal route map to sweep away most of the trappings of the NHS ‘market’ and restore it as a publicly owned, publicly provided service. They’ve already done it in Scotland, abolishing Trusts and most of the ‘market’ trappings following devolution. And - unlike England - Scottish patients now report rapidly rising satisfaction with their NHS.

The proposed Bill has already attracted support from Lord David Owen, Green MP Caroline Lucas and the Green Party leadership, Labour Parliamentary candidates, the National Health Action Party and the author of the recent minority Lib Dem report on the NHS, Charles West.

Getting rid of the market would be uncomfortable for the cadre of NHS managers, management consultants and think tanks whose main skill is permanent reorganisation. But it wouldn’t happen all at once. They’d have one last big job on their hands before retraining as something more useful to society, leaving a slimmed down management and a beefed up medical workforce to get on with the job of running an NHS in the interests of patients, not profits. 





NAO report on health and social care integration 8th Feb 2017


For the last two years (since April 2014) NHS England has run a number of experiments (called "Pioneer" programmes), including in NW London, to try to integrate health (hospital) and social care, which is essential for reducing demand for hospital services and is a central part of "Sustainability and Transformation Plans" for the 44 "footprints" of England.

The National Audit Office published its findings on Wednesday 8th Feb. It said: "Integrating the health and social care sectors is a significant challenge in normal times, let alone times when both sectors are under such severe pressure. So far, benefits have fallen far short of plans, despite much effort." "Nearly 20 years of initiatives to join up health and social care by successive governments has not led to system-wide integrated services" "The Departments [of Health and Local Government] have not yet established a robust evidence base to show that integration leads to better outcomes for patients" and finally "There is no compelling evidence to show that integration in England leads to sustainable financial savings or reduced hospital activity".

Trying to mix health and social care is like trying to mix oil and water, due to the different funding and cultures.

See NAO report:
And BBC news:


STP finance figures in spreadsheets and Delivery Plan "incorrect" - or not?

At a presentation to Kensington and Chelsea Healthwatch members and residents on Tuesday 31st January, the STP team were challenged by Merril Hammer, Chair of Save Our Hospitals, about the figures revealed recently by a FOI request to NW London CCGs. The finance figures were contained in a "workbook", a set of spreadsheeets submitted with the Oct 2016 STP. Merril referred to the plans for the loss of 3,658 NHS jobs in NW London next year 17/18, rising to 7,753 job losses by 20/21.

When NHSE, an executive body of the Dept of Health, publishes information, especially as a result of a Freedom of Information request, the public has a right to be able to rely on its contents.

But in the question and answer session Christian Cubbitt, Director of Communications for NHS NW London Collaboration of CCGs, publicly retracted the figures. He said that they were "incorrect" and that there would not be nearly 8,000 job losses. He said that the "correct" figures would be produced, but did not give any deadline.

Given that the objective of the STP is to find £1.3Bn of savings and that the template of the STP is set by the Dept of Health, it is impossible that the final numbers will be very different from the ones just published, using the same categories. SOH and its advisers have looked closely at all the pages in the workbook, including the "solutions" which are the balancing figures between the "Do Nothing" and the "Do Something" scenarios. Most of the solutions include words like "these costs have not been finalised". For Solution 4 (NHSE Specialised Commissioning) it says: "We have not yet developed the "solution" for closing the gap, however it is assumed that this gap will be closed. This is a placeholder".

The Delivery Plan is obviously nearly right too.

The denial by NW London CCGs is a clumsy attempt to limit the harm after the release of highly damaging information which should not have been disclosed on the grounds that its release would prejudice incomplete development of the plans. But then the FOI request would probably have been forwarded to the Information Commissioner and SOH would have made a big fuss about the refusal and about the fact that the figures were still being worked on three months after submission to NHSE on 21st October as a "final" version.

That is why the current dispute about the status of the information produced by the NHS's NW London Collaboration of Clinical Commissioning Groups reveals even more than the figures themselves

Brent Patient Voice have discussed the huge cuts in "Losing the power to shock".