Comment / News review

July

As the UK sweltered in the July heat, much of the talk about the NHS was negative. From the hangover of the allegations in June about the Care Quality Commission’s handling of University Hospitals of Morecambe Bay NHS Foundation Trust, to concern over emergency care and fears for the coming winter, there was a lot of doom and gloom. But the biggest story came at the end of the month, when recommendations on the future of services at another troubled trust, Mid Staffordshire NHS Foundation Trust, were made.

Draft recommendations from the joint trust special administrators (TSAs) said the trust should be dissolved but more than 90% of current patient visits should continue to take place locally at Stafford (left) and Cannock Chase hospitals. These units would be run by other organisations. The TSAs, appointed in April, said their proposals would provide ‘safe affordable services for the next decade’. While most acute and some enhanced services would remain at Stafford, some would be moved. The TSAs proposed that accident and emergency would remain at Stafford Hospital, running from 8am to 10pm every day. An increased choice of consultants and specialists would also be available at both hospitals. Stafford Hospital maternity services, emergency surgery and children’s inpatient services would also move to a larger local hospital or specialist centres. Under the plans, changes would take place over two to three years and the consultation runs until the beginning of October. ?

Despite the heatwave, much attention was on the coming winter and the ability of the health service to cope with increased demand at A&E. The Foundation Trust Network (FTN) warned that plans to avoid a repeat of problems last winter were failing. Clinical commissioning groups, working with providers and NHS England local teams, were to have created urgent care board plans by the end of June. The plans would be funded by the money retained from the marginal tariff for emergency admissions. But in an FTN survey of foundation and NHS trusts, a quarter of respondents said the plans had not been agreed or did not exist. While 58% described plans as underfunded, 7% said funding was adequate. Less than half the 45 foundation and NHS trusts that replied felt they were fully engaged in the planning process. ?

A report from the Commons health committee warned that NHS emergency and urgent care services were working under stress and there was insufficient resilience in the system. The report, Urgent and emergency services, said the marginal rate emergency tariff was adding to the challenge facing A&E departments, and the current payment arrangements were no longer viable. It questioned the adequacy of staffing levels and current plans to address pressures, and called on NHS England to ensure that urgent care plans are agreed for each area before 30 September.

The row over the efficacy of NHS 111 services continued as NHS Direct announced that it aimed to gradually withdraw from its remaining contracts for the NHS 111 service. NHS England promised to support commissioners of NHS 111 services to put in place alternative providers to take over the 111 services provided by NHS Direct. NHS England said existing NHS Direct contracts would be phased out in 2013/14.

Concern over winter preparations and out-of-hours care came hot on the heels of the findings of reviews of the quality of care at 14 trusts. As a result of the reviews, led by NHS medical director Professor Bruce Keogh (left), 11 hospitals were placed in special measures for fundamental breaches of care. Health secretary Jeremy Hunt said none of the 14 hospitals were providing consistently high-quality care to patients. Three foundations were not placed in special measures as Monitor was confident the leaders could deliver the review recommendations.

The reviews were announced in the government’s response to the Francis report, and its message on quality appears to be having an impact on trust plans. According to three-year plans submitted to Monitor, foundations intend to recruit 10,000 more clinical staff to raise quality of care. The regulator's annual review of plans shows trusts are forecasting they will take on 1,134 permanent consultants, 1,273 junior doctors and 4,133 nurses and midwives in 2013/14. The number of healthcare assistants, ambulance paramedics, social care and theatre staff will also rise. The recruitment drive will cost an extra £500m (2% of current staffing costs). Monitor said it looks as though foundation finances will ‘continue to be resilient in the short term, although some individual trusts will struggle’. But it warned that as efficiencies got harder to deliver, the balance of longer-term risks ‘has shifted to the downside’.

The High Court quashed plans to downgrade maternity and emergency services at Lewisham Hospital. Earlier this year, the TSA for the nearby financially challenged South London Healthcare NHS Trust also made recommendations for changes to services at Lewisham. But at the end of July, the High Court ruled that the TSA acted outside its powers in making these broader recommendations. The Department of Health, which has launched an appeal, said it was disappointed, but planned to go ahead with other elements of the changes, including the dissolution of the South London Healthcare NHS Trust, planned for 1 October.

Finally in July, a levy on migrants from outside the European Economic Area was one option being put forward as part of a Home Office consultation on short-term migrants’ access to the NHS. The government said it wanted to ensure short-term migrants made a financial contribution to the cost of their care. Currently, those coming to study or work for a short time, but with more than six months on their visa, are likely to qualify for free care as soon as they arrive, it said. The proposed levy could be purchased with a visa, it added. The Department of Health said a ‘refreshed’ Mandate for NHS England could include a requirement to ensure NHS organisations recover the cost of treating overseas visitors, where appropriate.

August

While July was marked by concern over quality and the ability of the health and social care system to cope with winter pressures, the August narrative was much less prosaic. Within a week the government appeared to ‘kill’ the winter worries stories. It announced that A&E departments under the greatest pressure from increased demand would share an additional £500m over the next two years. The prime minister said the funding would be used to ease the pressure over winter, both by increasing capacity in A&Es and taking steps to minimise attendances. David Cameron said he wanted hospitals to take action now to ensure they were well prepared for the winter. ?

Concern over the quality of services and the patient experience remains high on the agenda. This was highlighted at the end of July when the first friends

and family test results were published. More than 400,000 patients took part in the survey in the first three months of the year, and, as expected, there were wide variations in patients’ opinions of the services they received. Accident and emergency departments picked up a score of 53 (on a scale of 100 to -100). Inpatient services received a score of 70 overall. However, there is concern that the question – whether they would recommend the ward or A&E to

their friends or family – is too narrow and that low response rates could have a disproportionate impact on trust and ward scores.

The friends and family scores were a warm-up for the main event – Professor Don Berwick’s report on making zero harm a reality in the health service. In making his recommendations, Professor Berwick (below) paid a lot of attention to the culture in the NHS. The service must adopt a learning culture and ensure staffing levels are based on evidence, he said. The report made a distinction between mistakes and wilful or reckless neglect. It insists the service should not apportion blame in the former and punish the latter through new criminal offences. Professor Berwick added that the NHS should treat targets, particularly financial goals, carefully. He said financial targets required special caution: they reflected proper stewardship and prudence, but were only a means to support the mission of the NHS. Quantitative and financial goals should not override patients’ interests. Safety and quality are most likely to be improved when all of the drivers in the system – including financial incentives, regulation and competition – point in the same direction, he insisted.

NHS Employers wrote to the Treasury to warn that the NHS could not afford its proposed draft directions to recalculate the value of public sector pensions. The employers’ body estimated that the draft directions, outlined in a recent Treasury consultation paper, would cost the NHS an additional £1.7bn from 2015. The impact of the Treasury’s proposals could be discussed by the NHS working longer review, set up to consider the possible impact of a raised pension age in the NHS.

Staying with remuneration, the Department of Health insisted the NHS pay review body should take account of incremental pay that staff are set to receive in 2014/15 and the need for pay restraint and affordability. Setting out the review body’s remit for the 2014/15 pay round, health minister Dan Poulter (left) said that other considerations should include the government inflation target, equal pay for work of equal value, as well as the recruitment, retention and motivation of staff. ?

Summertime is accounts season, with the publication of four reports on financial standing in the NHS. Foundations had an overall surplus of £487m in 2012/13 and cash balances of £4.5bn, according to the foundation trust consolidated accounts. There were deficits at 21 FTs. In its annual report and accounts, the Department of Health said £5bn of efficiency savings were delivered in 2012/13. Giving its verdict on the 2012/13 accounts, the Audit Commission said financial reporting was strong, but it was concerned about the financial resilience of a quarter of NHS trusts. In its 2012/13 update on indicators of financial stability in the NHS, the National Audit Office said the service had produced a £2.1bn surplus (the same as in the previous year) and financial performance appeared stronger. While the number of foundation and NHS trusts in deficit had fallen to 25 (31 in 2011/12), there were signs of increased pressure – the Department issued revenue-based public dividend capital to 12 trusts because of concern over their financial viability. 

The amount of drugs prescribed from the cancer drugs fund list increased between April and June this year, according to NHS England. It said that more drugs previously only available through the fund are now routinely available in the NHS, while it has added five new drugs to the cancer fund list.

The number of prescription items dispensed in Wales increased by more than 52% between 2002/03 and 2012/13, according to figures released by National Statistics. The net ingredient cost (NIC) of prescription items prescribed by GPs increased by 9.5% to £557.5m. Compared with other parts of the UK, Wales dispensed the highest number of items per head and had the second highest NIC per head. However, Wales had the lowest NIC per prescription item. ?

The Cooperation and Competition Panel (CCP) gave the go-ahead to the proposed merger of the Royal Free London NHS Foundation Trust (right) and Barnet and Chase Farm Hospitals NHS Trust. It said the proposed new trust would face a range of competition from other providers and the merger was unlikely to add significant costs to patients or taxpayers as a result of loss of competition. However, should the trusts decide to proceed with the merger, they must assure Monitor on the new trust’s financial health and governance. ?

Monitor launched a probe into NHS England commissioning of cancer surgery services in Greater Manchester after complaints from two foundations. The regulator said University Hospital of South Manchester NHS FT and Stockport NHS FT had claimed the process adopted to select providers of some cancer surgery services was not based on quality of services, patient outcomes or patient preferences.