Current issues in the delivery of health care in NW London - Report for H&F Health Care Audit by Boyle and Steer - March 2018



1. The original analysis on which SaHF was based failed to take adequateaccount of likely increases in population over time. The current population isalready greater than SaHF had estimated for 2022, and SOC1 projects it will grow by 14% by 2026.

2. NW London has a different pattern of use of emergency services with greater use of minor A&E units than other parts of London, and the rest of England. Attendances at acute A&E units have fallen by 16.5% since 2011/12 compared with an increase in the rest of London of 10.5%, and in England of 8.8%. However attendances at minor A&Es have increased dramatically, so that taking all attendances together there has been an increase of 12.2% compared with 3.5% in the rest of London and 7.7% in England.

3. There is no evidence that NW London uses more A&E emergency services than other parts of England, or London. The level of emergency admissions through A&E in NW London has fallen between 2011/12 and 2016/17. But this was more than compensated by a dramatic rise in the number of emergency admissions taken through alternative routes, eg direct admission by GPs, which went from over 12,000 to over 29,000 over the same period. This translates into a small rise of just over 8% in total emergency admissions; at the same time, emergency admissions in England as a whole increased by almost 14% and in the rest of London by 16%.

4. There has been a considerable deterioration in A&E pe rformance measured as the proportion of people attending A&E who are not dealt with within four hours. NW London, in the first quarter of 2011/12, was better than the rest of England and London, and well within the margin of the government target of 5%. However, more recent performance and in particular since the closure of two A&E units in NW London (on 10 September 2014) shows a considerable deterioration, and now performance in NW London is consistently poorer than elsewhere In England or London.

5. Another measure of A&E quality is how long it takes a patient to be admitted to a bed once the decision has been made to do so. In many cases this can take up to 12 hours, and increasingly over 12 hours. Performance in NW London has deteriorated sharply since the closure of two A&Es. In the third quarter of 2017/18, 5.3% of patients in NW London A&Es waited up to 12 hours for admission, 2.7% in other parts of London, and 4.1% in the rest of England.2

6. Throughout January and February 2018, the Imperial Trust sites: St Mary’s and Charing Cross, have been experiencing severe pressure and have had to declare black alerts on almost all days, indicating severe bed shortages and an inability to cope. Over the winter of 2018 LNWHT and Hillingdon trusts consistently had ambulances waiting longer than is appropriate to discharge patients into the care of the hospital, and sometimes twice as long as the England or London average. One in five ambulance patients in NW London
waited more than 30 minutes.

7. Acute bed capacity has fallen in NW London by 270 beds between 2009/10 and 2017/18. SaHF indicated that over 1,000 beds would eventually be closed. At the same time NW London hospitals have a lower LOS than the England average, possibly indicating that they are already operating more efficiently than elsewhere. In the winter of 2017 they also had very high bed occupancy levels, upwards of 95%, indicating extreme pressure on the system.

8. There is no evidence that there has been a successful diversion of hospital activity into out-of-hospital facilities although SOC1 still claims the intended hubs will result in a reduction of 22,000 emergency admissions.

9. Partial implementation of a programme of closures of acute services before an adequate business case was produced, has increased the pressure on the health system and had a detrimental effect on the delivery of services in NW London. It is becoming almost impossible to run the system due to a lack of financial resources combined with a lack of acute bed facilities shortfalls in staffing throughout the area.

10. The deterioration in A&E services suggests that any plans for further closures of acute services at Charing Cross and Ealing are ill-founded. These should be halted and sufficient resources made available to retain existing services and staff.

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Ealing Save Our NHS evidence to NHS about pressures for acute provision in NW London 6th Feb 2018

Our sister campaign, Ealing Save Our NHS, submitted detailed evidence in a letter to NHSI and NHSE of the increasing (not decreasing) need for acute provision by the 8 CCGs in NW London. We reproduce it below.


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The big questions about ACOs - BMJ infographic


"Accountable Care Organisations" will run health and social care services starting in test "STP footprints" in 2018 - but how?

The complexity of the proposed arrangements, the lack of accountability (transparency and democratic accountability) and the poor or non-existent governance arrangements are just some of the questions which we should be asking about the new bodies. These questions prompted the appeal for the Judicial Review brought by Profs Pollock, Hawking, Richards and others.

The following infographic by Allyson Pollock and Peter Roderick - published by BMJ Publishing Group Ltd 2018 gives an idea on one page of the problems with ACOs:



Short Cuts by Dave Lindorff - London Review of Books Nov 2017

is the author of Marketplace Medicine: The Rise of the For-Profit Hospital Chains.

In late September, AmerisourceBergen, one of the world’s biggest pharmaceutical distribution companies with revenue of $150 billion, was fined $260 million by the US Food and Drug Administration for emptying pre-filled glass syringes of expensive cancer drugs and reloading the drugs, in slightly smaller doses, into cheap plastic syringes before distributing them to oncology centres. For years, the company allegedly pocketed the profits obtained by creating and selling 10 per cent more pre-dosed syringes in this manner. Prosecutors claimed that because the refilling process was not conducted under sterile conditions, it led to ‘floaters’ and bacterial contamination, putting at risk the health of thousands of cancer patients with compromised immune systems.

Earlier this year, the Justice Department filed a lawsuit, based on evidence from a whistleblower, against UnitedHealth Group, the largest provider of subsidised private medical insurance for the elderly, accusing it of overcharging the government by more than $1 billion, by claiming patients were sicker than they actually were.

The FBI estimates that fraud, both private and public, accounts for up to 10 per cent of total US healthcare expenditure, or about $350 billion, of the annual $3.54 trillion that Americans spend on healthcare. The scale of medical fraud in the UK is still small by comparison, but some of the companies that have paid huge fraud fines in the US – including UnitedHealth, McKesson, Celgene and the Hospital Corporation of America – are becoming increasingly involved in NHS privatisation schemes, in accordance with the government’s wishes.

The Health and Social Care Act pushed through by Andrew Lansley as health secretary in 2012 was intended to increase privatisation, outsourcing, inter-regional competition and ‘marketisation’ in an already strained system. There is little sign that it is improving services or reducing costs, but private firms see profits to be made.

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NHS Support Federation report into state of tendering of NHS contracts - Dec 2017


In this report we explore the evidence about which NHS contracts are being tendered, who is winning them and how these trends form part of the new direction the NHS is now taking. Our data is based largely on a process of analysing published awards, a data base that we have compiled from observations over the last 4 years. 

We also review the catalogue of problems that have emerged in the various types of outsourcing that have been tried, as part of the NHS market experiment. Some of these failures have undoubtedly influenced the current changes in strategic approach and led to the widely supported view that this experiment should end.

It is time to act on the knowledge that has been built up about how outsourcing in the NHS can negatively impact upon patients, staff, the level of resources and other NHS services. This evidence makes a compelling case and we would therefore urge the government to repeal its competition legislation and focus on building an adequate level of publicly-provided NHS services.



1. Activity in the market for NHS contracts remains high despite a signaled shift away from competition by the Chief Executive of the NHS. Over the last year (Apr 2016/17) £7.1 billion worth of NHS clinical contracts has been awarded through the tendering process. This is on a par with the preceding year. £1.6bn worth of NHS contracts were advertised in the first quarter of the current financial year (2017/18); which brings the total value of contracts awarded through the market to around £25bn, since the Health and Social Care Act (2012) came into force. The number of high value clinical contracts that have been advertised, worth over £100 million pounds each, has almost doubled in the last year, rising from 11 to 20, of which eight were won by the private sector.

2. The private sector share of NHS contracts is rising, as they focus increasingly on growing opportunities to provide community health services. For-profit companies won £3.1 billion worth of new contracts in the last year (16/17). This was 43% of the total value of awards advertised and their share has risen from 34% (15/16). Companies are turning their attention to new opportunities offered by the intention to treat more patients in the community and less in hospital, an NHS wide policy. Circle – the company that walked away from a contract to run the NHS Hinchingbrooke hospital, is now investing in intermediate care, intending to offer care beds outside hospital to look after NHS patients that hospitals want to discharge.

3. Virgin Care has been the most successful company in winning NHS clinical contracts - mostly to provide community healthcare, picking up over £1bn worth of NHS awards in 2016/17. Its latest awards are a £355m contract to provide children’s health services in Essex and a £65m award to run community health in West Lancashire. In each case the company is taking over services from the NHS and non-profit making providers. Virgin care is now the dominant private provider in the NHS market – winning a third of the total value of contracts won by non-NHS providers over the last year. The number of services the company provides to the NHS has risen from 230 to 400 over last 12 months, according to its website.

4. There is compelling evidence that the competition regulations under section 75 of the Health and Social Care Act (2012) - introduced in April 2013 are dysfunctional and have resulted in numerous failed outsourcing projects. In a growing number of instances NHS organisations are starting to game-play the procurement rules to avoid open competition. At the same time private companies are using the courts and competition law to try to maintain their access to NHS contracts. Competitive tendering was put at the heart of healthcare planning by the Health and Social Care Act (2012) and was a catalyst for numerous experiments with the outsourcing of NHS clinical services. Just five years on there is now a substantial body of examples to show how outsourcing arranged under these procurement regulations often results in contract failures and serious breakdowns in the delivery and quality of care. All at a cost to patients, staff, NHS services and the tax payer.

5. There is a growing consensus that the competition framework needs to be replaced and yet party-political concerns are preventing it, a situation which will leave the NHS with a failing procurement model and could result in a further £10bn in NHS contracts going to the private sector over the next 3 years. In March, NHS Chief Simon Stevens confirmed that the arrival of STPs would “effectively end the purchaser-provider split for the first time since 1990”. This represented a major shift in policy away from the themes of competition and patient choice - the Lansley era. The current health secretary, Jeremy Hunt also backs the need for new legislation, an intention outlined in the Conservative’s election manifesto. After the election however, he acknowledged that the government’s precarious Parliamentary situation had effectively removed the possibility. This means that the current legal framework around tendering will remain in place, which on current trends will lead to the private sector winning a further £10bn of NHS clinical contracts over the next 3 years.

6. Accountable Care Systems have been flagged as the new model for local healthcare planning in the NHS. The future role for private companies has not been clarified, but commercial opportunities are far from being capped. Only a handful of examples of new models of care are fully developed and so far the private sector have not been bidding for the multi-billion contracts. However, in Nottingham, Capita and Centene have been employed to help develop the Accountable Care System. Healthcare companies are also well placed to bid to market their cost-saving solutions to ACOs, who will operate with capped budgets. Virgin and Care UK have already landed over £2bn worth of NHS business and the government has not signaled that it will inhibit this kind of sub-contracting or outsourcing. An even bigger role for business is possible though. The ACO contract that has been drawn up by NHS England does not preclude the private sector from bidding for them, although the major players in the international market, companies like United Health and Humana and Centene could will want to assess the business risk.

7. The scale of private sector involvement in the NHS is regularly downplayed in departmental and ministerial statements, but the H&SC Act has ensured that non-NHS providers have been able to establish a substantial foothold in local NHS provision. A survey of CCG accounts for 2016/17 by the NHS Support Federation shows that these commissioners spend around 15% of their operating expenses on employing private companies and charities to deliver healthcare to CCGs. This is higher than the 11% figure shown in the national accounts - which expresses the spending on non-NHS organisations as a % of the overall DEL (Departmental Expenditure Limit). The value of the contracts awarded through market procurement is now seven times higher than in 2013.

8. Over the last 3 years the types of services being tendered has shifted almost entirely towards those that are delivered in community settings, outside of hospitals. The private sector and charities win a majority share of these contracts. Three years ago, hospital based care contracts accounted for 40% of the value of those clinical services put up for tender. Services delivered in hospital now account for less than 10% of the value of tenders, with the vast majority being contracts delivered in the community. Contracts to deliver services in the community cover a wide range of services including; out of hours GP care, community nursing, public health and children’s health services. In the last year the private sector and charities won over 60% of the value of these contracts.