As the Sustainability and Transformation Plans (STPs) for England, announced in NHS planning guidance published in December 2015 and since prepared in secret in 44 "footprint" areas, are now being revealed, so is the opposition to them beginning to gather momentum.[i]

The STPs have been prepared in great secrecy by bodies that have no democratic accountability and in an absurdly short space of time.[ii]

One such STP is that of North East London (NEL), and a campaign is being fought exposing its implications, its underlying aims and its detrimental effect on health care.

The North-East London STP appears to incorporate the five-year plan known as Transforming Services Together (TST), drawn up between 2014 and 2016 to radically reconfigure health services in the London boroughs of Newham, Tower Hamlets and Waltham Forest.

In an Expert Witness Statement to the Inner London Joint Overview and Scrutiny Committee (JOSC), presented on December 13, Mary Burnett and Terry Day point out that a Freedom of Information request for financial and working details of the NEL STP was rejected in November on the grounds that disclosure "would be likely to inhibit the ability of public authority staff ... to express themselves openly ... and explore extreme options ... Deliberation needs to be made in a 'safe space' to develop ideas and to reach decisions away from external interference which may occur if there is premature public or media involvement".

This is not only an insult to everyone concerned over the direction in which the NHS is being driven, but to public authorities which are meant to scrutinise plans.

The Expert Witness Statement points out that Operational Planning and Contracting Guidance from NHS England 2017-2019 requires that all contracts between purchasers and providers to be based on the STP plan. The total cost must not exceed the STP financial control total and the contracts must be signed off by December 23, 2016. Mary Burnett and Terry Day ask: "How then can there be proper scrutiny, how can there be meaningful public engagement, let alone consultation, when the plans will be embedded in contracts by December 23? And how can this be described as a collaborative, system wide transformation of our health service?"

They go on to point out that out-of-hospital and integrated community care is the mantra informing all the STPs. Out-of-hospital care is predicated on "transforming" care in the community. The STP says: "The implementation of our common framework for better care and wellbeing, and the development of accountable care systems, require the radical transformation of primary care to lead the progression and development of a successful out of hospital health and care system." The point is that this is nothing but a cost-cutting exercise in the context in which it is being put forward. It is dangerously like a guidance that first and foremost "lower-risk" patients must fend for themselves or ring the NHS 111 number to be screened before booking appointments for community-based urgent care. This is being called "self-care".

The Expert Witness Statement says that "the STP still proposes it can transform a deficit of £578m in 2021 to a potential surplus of £37m and improve the service. You've read Julia Simmons quote of blue sky thinking and lies. It's unsurprising given the scale and speed of the plans, and that they are, in fact, an artifice for massive spending cuts. If implemented, they will cause enormous pressure across health and social care, harm to patients, and pressure on carers. They will, in effect, shift risk into the community, onto the most vulnerable people. Harm will get lost behind closed doors."

A paper produced last month for the Centre for Health and the Public Interest (CHPI) by Vivek Kotecha and Colin Leys has this to say: "Over the next fifteen years East London's population is projected to increase by some 270,000 (30%), while government spending on health services per head is set to fall. The main hospital provider in the area, Barts Health, has the biggest deficit of any hospital trust in England. So the area's Clinical Commissioning Groups (CCGs) are being required to move away from reliance on hospital-based services to providing much more care in the community." It continues: "At the same time primary and community care services will be radically changed. The planners predict a need for 195 additional GPs by 2025 but by then there will be a third fewer GPs than at present down from 600 to 400. Instead much of the work now done by GPs will be done by nurses, physician associates (science graduates with a two-year postgraduate diploma) and pharmacists leaving GPs to deal with only the most serious cases."

Can there be any doubt where this is leading? The NHS is being wrecked under the mantra of integrating health and social care and primary and community care. Serious trouble is brewing for the NHS into which gap will increasingly step the private health companies, delivering health care privately, and can charging for health care be far behind?

North-east London STP Adjournment Debate in the House of Commons, December 16

Labour MP for Ilford South, Mike Gapes, led a debate on the North East London Sustainability and Transformation Plan in the Commons on Friday.

He introduced the debate by saying: "Changes to our national health service are being planned all over the country, which are going to have profound implications for the quality of health, the availability of both primary and secondary services and for the size and location of our hospitals. There has been justified criticism of the secrecy with which this process of producing so-called sustainability and transformation plans has been carried out. The Department of Health has produced a five year forward view and a very large number of plans. I want to focus on the north-east London sustainability and transformation plan draft, which was published on 21 October, and on the eight delivery plans supposedly to implement it."

Mike Gapes continued: "My local council, Redbridge Council, has been concerned that it has not been adequately involved in the process. It has made it clear that it will act in the interests of our local community and that Redbridge will not be signing off or endorsing the STP unless we are satisfied that it is in the interests of Redbridge residents

"I understand that the STP programme boards are not required to hold meetings in public, and no agenda or minutes are published. The secrecy surrounding this process has not been helpful in building public trust and has caused suspicion within communities all over the country - I speak particularly from local experience - as to the intentions of the proposals. In many respects what could be a reasonable response in the circumstances to the crisis we face in terms of future funding, the ageing population and other challenges to the NHS, is being undermined because of process issues. The NHS needs to learn from these experiences about how better to engage with the public and key stakeholders, including elected local representatives."

The Labour MP went on: "Today we have seen news about the reality we face in our NHS: large numbers of hospitals with dangerously high bed-occupancy levels and little or no flexibility. The CQC's chief executive recently talked about hospitals being dangerously full. On 26 November, a leaked memo from NHS England revealed that hospitals were being banned from declaring so-called 'black alerts' and told to prepare for the winter crisis by passing on scheduled surgery to private hospitals and discharging thousands of patients to get bed occupancy down from a national average of 89% to 85%.

"However, north-east London's population is massively increasing. The report states that the population of north-east London boroughs will increase by 18% over the next 15 years - equivalent to a new city - and yet there is no plan for an additional hospital to cope with that change. In fact, page 20 of the draft policy states that building an additional hospital is 'not practical or realistic'. Indeed, the situation is worse than that. Not only is there no extra hospital, there is the planned closure of the A&E at King George hospital in my constituency. The plan is to stop overnight ambulances sometime next year, with a total closure in 2019. The STP is calling for that not only because it would meet some savings and restructuring requirements, but also because there are unsustainable costs. The previous Health Secretary announced in 2011 that the A&E at King George would close in 'around two years'. That has not happened because it was deemed unsafe and because there is insufficient capacity at Queen's hospital in Romford or at Whipps Cross university hospital in Waltham Forest to cope with the increased demand.

"Despite our excellent and hard-working staff, all the hospitals in north-east London are in crisis. With pressure for early discharges, but inadequate social care and community support, we have large-scale bed blocking and delayed discharges. Sick patients then get readmitted because they cannot get GP appointments due to the pressures that exist in that sector. The STP sees out-of-hospital and integrated community care as the way forward. However, Dame Julie Moore, who in 2014 chaired a commission on hospital care for frail elderly people, said:

'As much as it suits us all to have one nice neat solution to the problem of our growing, ageing population...
the truth is that as a catch-all answer it is simply wishful thinking. Integrated community care is a good thing...
but this can never be a substitution for hospital care.'"

Mike Gapes goes on to say: "The STP executive summary states: 'Our total financial challenge in a "do nothing" scenario would be £578m by 2021. Achieving ambitious "business as usual" cost improvements as we have done in the past would still leave us with a funding gap of £336m by 2021.' Those are eye-watering figures. The claim is made that 'we have identified a range of opportunities and interventions to help reduce the gap significantly'. However, the £240 million gap between the 'business as usual' case model and the actual predicted figure requires a series of other measures, including significant funding from the sustainability and transformation fund, reductions and changes in specialised commissioning, and what is called 'potential support for excess Public Finance Initiative (PFI) costs'. That covers Whipps Cross hospital, Queen's hospital, Romford, and, to some extent, King George hospital. 'Potential', what a lovely word. So this is not real and it is not even planned - it is just 'potential'."

He concluded: "There will be enormous pressure on my local council because of budget problems, and I am worried about the situation. I am glad that the STP highlights the social care challenge, but it needs to be taken seriously by the Government if we are truly to have an effective health and social care system. The statement in this House yesterday did not offer a solution to my borough. It did not answer the challenge that boroughs such as Redbridge are facing. These boroughs are already ahead of the game in the integration of health and adult social services and are working with neighbours to take up the challenge by being a pilot for the development of an accountable care system.

"Yet with all that transformation, Redbridge still faces a huge social care challenge. That is made worse by a triple whammy of public sector funding reductions to local government - my borough has lost 40% of its income since 2010 - chronic underfunding of adult social care by the Government and the fact that Redbridge does not get a fair funding level in the first place. There is, potentially, a major problem. We face a shortfall of about £4 million in social care and the 1% extra on council tax raises less than £1 million. The responses that we have heard from the Government in recent days have been inadequate - indeed they have been worse even than the silence from the Chancellor in the autumn statement. They offer no real solutions to the growing crisis that will impact on some of the most vulnerable in our society.

"I conclude with this plea: please will the Government look at the situation in north-east London and will the Minister meet me to discuss the fact that this plan is unrealistic, incredible, unachievable and will lead to disaster?"

(i) For further background explaining the significance of the STPs, see Workers' Weekly Internet Edition, December 10, 2016
[http://www.rcpbml.org.uk/wwie-16/ww16-24/ww16-24-01.htm]

(ii) For further elaboration regarding the secrecy over STPs, see Workers' Weekly Internet Edition, December 10, 2016
[http://www.rcpbml.org.uk/wwie-16/ww16-24/ww16-24-02.htm]

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