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Last week I reported on a very well attended meeting on 15th August in opposition to proposed cutbacks in the availability of procedures on the NHS (the so-called Adherence to Evidence-Based Medicine process).  I've now received a much more detailed account of the meeting, written by Frances Warboys of Defend Enfield NHS.  As well as providing more information about what was said, it shows the value of being able to take shorthand notes!

Note:  The article was edited on 24th August to correct Wendy Berry's affiliation.  She works for Carers and Parents in Enfield (CAPE), not Enfield Carers Centre.  Apologies for any confusion - this error was not in Frances Warboys' original notes but occurred when I added some sub-headings to indicate speakers.

aebm meeting at beaumont august 2017cENFIELD OVER 50's FORUM MEETING

Tuesday 15th August 2017
Beaumont Care Home, Cannon Hill, Southgate N14 7DJ
(Meeting open to the general public)

More Pain for Patients... Unless...

Panel:  Vivien Giladi (Forum Health Lead in the Chair), Monty Meth (Forum President), Deborah Fowler (retiring Chair of Healthwatch), Bambos Charalambous MP, Jeffrey Lever (Defend Enfield NHS)

Chair (Vivian Giladi, Enfield Over 50s Forum)

The Chair welcomed all present and performed introductions.  She outlined the agenda and said that, firstly, a few minutes would be devoted to Wendy Berry (WB) from the Carers' Association which had also been subject to consultation, namely on costings for care and charging for care.

Wendy Berry, Carers And Parents in Enfield (CAPE)

WB asked that everyone get involved with a consultation being held on the Adult Social Care Charging Policy.  Currently people who received care in their homes, mainly elderly and disabled people, and who received an amount for night care were allowed to keep it.  That was being changed resulting in £27.45 per week being taken from them.  That was a cost to disabled people.  The disabled and the elderly were being picked on.  She explained that in 2000, in the courts, this was found to be unfair.  Enfield overriding that could be unlawful and was certainly immoral.

People needed to stand up and be counted, to take part in the consultation and say that they did not agree with this proposal, they did not approve of it.  Forms for response were available and to respond on-line go to enfield.gov.consultation.adult social care.  The deadline was noted as 10th October.

The Chair thanked WB for this information and then went on to outline the main reason for the meeting, discussion of the consultation on Adherence to Evidence-Based Medicines (AEBM).  These proposals insulted doctors' clinical judgements.  The Forum was on the side of GPs, of which there was a shortage in Enfield and for which recruitment had dropped like a stone.  The proposals were not being introduced because they were useful but because they were cheaper Enfield Clinical Commissioning Group (CCG) had produced a list of things they wanted to cut back but these had not been properly costed.  The list included procedures for hernia, hips, knees and breast reconstruction, homeopathy and hearing aids.

Enfield was the weakest CCG in the five (NCL) boroughs.  If the proposals were agreed they would be rolled out.  They were cuts masquerading as a good thing but would mean people being in pain or discomfort for longer, and may even put them at risk.

Monty Meth, Enfield Over 50s Forum

The Chair then invited Monty Meth (MM) to speak.

MM expressed his delight that so many people (approx. 150) had attended, including new MP, Bambos Charalambous.  The Over 50s Forum had existed for 18 years and this was the most important meeting held in all that time.  He outlined battles fought previously, for digital hearing aids, community schemes and more money for pavement repairs to prevent falls.  There had also been a petition to the NHS on more money for Enfield which had been won.

This was another battle to be fought and won.  The Forum and other organisations in Enfield were challenging attempts made by the CCG to make savings at the expense of clinical treatment, particularly where directed at older people.  This did not ignore the fact that the NHS faced a financial crisis.

The CCG was responsible for buying most of the patient services in use.   This year's budget was £400 million but there was a debt of £34 million. The CCG had also been charged to make savings this year of £17 million.  This CCG, being in special measures, cannot spend money without permission from NHS England and instead had come up with this AEBM.
NHS England (NHSE) appointed a Director of Recovery and there was a plan to get out of debt.  This, however, did not include campaigning for more money for Enfield with its high level of elderly population and ill-health.  GPs had always approved and prescribed medicines but the CCG was seeking to make "efficiency savings" by making people wait longer for treatment and introducing new criteria, all at an unknown cost to the patient.

MM deplored the situation whereby a plan of action had been produced with no plan of what it would cost, and no impact assessment of what the proposals would mean.  Unknown, too, were the names of any clinician or consultant prepared to publicly advocate any single one of these changes. Who were they, where were they? They were just called "clinicians".

The consultation was originally scheduled for just 30 days but had been extended at a meeting on March 2nd.  It had also been requested that the document be withdrawn and a revised one drawn up based on medical evidence but that had never been done.  MM added that he had attended four consultation meetings and had heard not a single voice in favour.  Because of the huge number of responses the CCG was paying The Campaign Company some £7,000 to assess the consultation.  Decision day was Wednesday 20th September.

There remained a month in which to object. The council leader would be meeting with the new chief operating officer, Helen Petterson, and the local Enfield Medical Committee, representing the professional interests of all GPs in the borough.  Many doctors had expressed their concerns at this challenge to the professional competence of GPs.

MM said that every one of the 49 surgeries in Enfield had a Patient Participation Group (PPG) and many would meet before September 20th.  He urged everyone to belong to their PPG and encourage local GPs to oppose the cuts.  In order to hold the CCG to their "vision" of what they should be doing in Enfield, he asked that as many people as possible lobby the meeting on Wednesday 20th September at 11.00 am. by which time the outcome would be known.

The Chair added that she belonged to a small cross-borough group set up to put pressure.  This meeting would be asked to support a motion asking for the proposals to be dropped.  Enfield was supposed to receive money from Camden but Camden was not happy about that.

Deborah Fowler, Healthwatch Enfield

The Chair then invited Deborah Fowler (DF) to speak.

DF also welcomed the number of people present, referred to the financial issues facing the NHS in general and Enfield in particular and cautioned that a big effort at a one-off protest would not be enough.  The issues would remain and Enfield would still be told to save millions, so if not this it would be something else.  There may be more requests to respond to consultations.

She then explained that Healthwatch Enfield was set up, in law, four years ago to try to get health and social care organisations to listen to the voice of local people.  To try to get health and social care (including the council) to take account of what they say, involving them, listening to them, and telling them what was being done about what had been said.

DF gave an example of real evidence-based medicine, which could change over time as new treatments came forward, that of treating children born with a club foot.
If that was what this was about people might be more positive.  It was important to keep an open mind.  There had been a lot of feedback on this consultation, lots of views collated, and one of the meetings had been hosted by Healthwatch.  People were not in favour generally.  A letter had been sent to the CCG in June summarising some of these views.  People did not want to be left isolated by lack of a hearing aid.  It had also been commented that a number of people were concerned about the lack of an Equality Impact Assessment.  It was a legal requirement to look at the impact on different groups of people and the CCG had acknowledged that they had not really done that yet.

Healthwatch recommended that the process should be suspended and that the CCG should do more work with people first to see whether there were other ways of treating people and saving money.  No-one thought this would be easy.  People would be willing to work in a genuine way but not where there seemed to be no justification.  They should work with people to provide services that people need.

Bambos Charalambous MP, Enfield Southgate

The Chair thanked MM and invited the Bambos Charalambous MP (BC) to speak.

BC expressed the view that the amazing turnout for the meeting showed how concerned people were about the consultation which was simply a fig leaf, a sham to provide the savings the CCG wanted in order to reduce its deficit.

In June 2016 Enfield CCG was one of a number placed in special measures, this was in addition to being subject to direction by NHSE since 2015.  A Director of Recovery had been appointed and a recovery plan drawn up which had been renamed QIPP.  It was clear that the CCG was planning to implement these changes regardless of the consultation.  Reference was made to the minutes of the last CCG Governing Body meeting, and the report of the Accountable Officer wherein it said that the plan for 2017/18 was to deliver £20.9 million, to be largely delivered through a comprehensive transformation programme which would see changes in the way services were delivered to patients.  It was very clear that the CCG wanted to make these changes.   That was why it was a sham.

This would be done by looking at non-essential, non-urgent procedures as set out in the consultation paper.  The website gave the cost of procedures carried out over the year for hip and knee replacements; hernia operations; gallstone operations, and others, showing that this was how they wanted to save money.  Treatment would only be provided in the most urgent cases.  Comparisons had been drawn with other CCGs but other boroughs did not have the same problems as Enfield.

The actual questions did not lend themselves to a fair consultation.  Questions included:  Do you understand the reason that Enfield is considering this? It did not say, what is your view? It was a deliberately flawed consultation and far from being patient driven it was finance driven.

BC concluded by saying that he and his fellow MPs, Joan Ryan and Kate Osamor, were of the same opinion and planned to hold the CCG to account and to endeavour to help obtain the best service possible.  Taxation was viewed as the way forward.  One pointer as to what was happening to the NHS was where, contrary to the principles outlined by Nye Bevan, one website said, have you thought about getting your hearing aids from private companies!

The Chair thanked BC for his contribution.  She went on to refer to use of the term "deficit".  This was really under-funding. (This comment drew a round of applause.) Most people in the room would have no objection to paying more in taxation.  A criticism that some of the big companies were paying only 0.8% tax drew further applause.

Jeff Lever, Defend Enfield NHS

The Chair then invited Jeff Lever (JL) to speak on NHS affordability and the sale of assets.

JL said that he was born in 1948, the same year as the NHS, and he tabled a leaflet produced by the then government which proclaimed:
The new National Health Service.  Your new NHS begins on 5th July.  What is it? How do you get it? It will provide all medical, dental and nursing care.  Everyone can use it.  There are no charges.  No insurance qualifications.  It is not a charity.  You are all paying for it through taxation.

It was in robust, plain language in sharp contrast to the documentation provided by government today.

JL then drew attention to the tabled paper on Affordability and the Naylor Review.

We can afford the NHS: this talks about the US think tank that found the British NHS was the best in comparison with ten other countries and was praised for its safety, affordability and efficiency. It was not top in certain outcomes such as preventative medicine and cancer survival where deliberate under-funding was having a bad effect.  Compiled by a US think tank, where the rankings showed the UK to be top it also showed that the US, with its private health system, was at the bottom.

Health spending per head of population showed that the UK, at £3,000 a year underspent compared with France and Germany by about £1,000 or a quarter of their cost.  That underspending would be justified if the UK were a poor country.  "But were we?"

The last column compared the percentage of GDP spent to assess affordability.  France and Germany spent about 11.5% on health.  The UK spent 9%, or 2.5% less than them.

Underspending on the NHS was running at about £1.85 billion a year at the moment.  If spending were the same as for France and Germany an additional £49 billion would be available.  This was not an opinion.  These were the facts, as taken from World Bank data.

JL then referred to another atrocity, the plan to sell off the land and assets of the NHS.  The plan was to use the revenue, some £5 billion, for the NHS but this was simply the conversion of capital into spending money.  To do this as quickly as possible incentives were being offered to NHS managers to carry out these sales.  For every sale achieved they would get the same amount of money from the government.  It was also planned to set up a Strategic Land Board to implement these proposals.

The report referred to a time scale of five years but anyone managing property or development would know that this was done on a 15 year basis and infrastructure was based on 30 years.  So it ignored the potential future needs of the NHS for land and was just a mechanism to relieve the government of the duty to finance it properly.

Much of the land was accumulated over four or five centuries, given by people or local organisations and charities.  An example was given of Chase Farm Hospital which was bought by the Poor Law Guardians, used first as a children's home, then an old people's home, then became a hospital.  The government thought it was right to turn it into revenue for the NHS.

Finally, JL referred to the motion comprising alternative proposals and which had been adopted by the Health Campaigns Together organisation on 24th June.

Action on Hearing Loss

The Chair thanked JL and said that a motion would be put to this meeting before the end.  She then invited a representative from Action on Hearing loss to speak.

It was explained that Action on Hearing Loss was the largest organisation in the UK which represented people with hearing loss.  They had been working with CCGs around the country, where 13 had proposed cuts on hearing support but only one had gone ahead to implement this.  Proposals were based on various misconceptions: that people did not want hearing aids; and that hearing aids were not cost effective.  Those misconceptions had been challenged and evidence presented to show how they were beneficial, particularly because of the need to address hearing loss at the early stages.  Working with CCGs to find other ways had been largely successful elsewhere.  Enfield had been contacted and it was hoped this CCG would not go ahead but at the present time AHL was still waiting to hear from them.

Questions and points from the floor

The Chair thanked the AHL representative and then invited questions.  These encompassed:

1.    Does Bambos have any plans to try to persuade his colleagues to adopt a progressive alliance with other parties who would like to get rid of the present government as soon as possible and get a more sensible approach to the NHS?

2.    Are any of these properties covered by covenants which could prevent this going ahead?

3.    What about all those people with hearing loss who in two years' time will be much worse.  It is such a short term saving?

BC acknowledged that because, in Parliament, the Tories did not have a majority, there was a definite possibility of working with other parties.  It was noted that before the last election the NHS was what people were most concerned about.

JL said that the question of covenants was being considered and the intention was to obtain legal advice on this.  Until the 20th century a property was considered to be in perpetuity but this had since changed.

DF agreed short term savings could lead to problems later on.  She invited audience members to contact Healthwatch, whose role it was to obtain patient comment, with their experiences of the NHS.  If you are having any problems, if experiences are getting worse.  Or if you think you are not being treated properly, Healthwatch wanted to hear about it.

4.    Not so much a comment on lack of funds, this was more of a scathing comment on the £42,000 spent by Jeremy Hunt on his new toilet.

5.    A visitor from Haringey said, we have seen something like this before. Cut the finance and then say the NHS is not fit for purpose.  The American influence for privatisation was trying to impose this upon us.

6.    Profits on contracts should be limited.  People should come first, not profit.

DF referred to mental health which was not included in the consultation but that did not mean there were no problems.  Enfield's problems were increasing and it had not been able to put as much money into mental health as was required nationally.

BC agreed that "Our NHS" should not be for profit and that information on profits made from NHS contracts should be made available.

7.    I understand there will be a lobby at the next CCG meeting.  Can I suggest we all pile in and disrupt the meeting? There may be a case for indirect discrimination in what they are proposing because most cuts they are talking about affect older people.

8.    Could the members of the panel suggest one thing for us to do.

9.    Appreciation for the information provided was expressed to the panel.  Also, can the panel assure us, is there any way that we, the public, could make ourselves more responsible in our use of the NHS, perhaps by cutting the number of "no shows" for appointments?  We take the NHS for granted.  We need to take, as a nation, more responsibility in maintaining and defending this wonderful service.

The Chair said that the Forum was working with the CCG on "no shows" but that for many of the people who did not turn up, it was because they really could not make it.

BC endorsed the need to protest but cautioned against disrupting a meeting as this would simply then be held in private.  The word needed to be spread and pressure put in any way possible.

10.    On under-funding, the question arose as to how much, after funding cuts, was still going into the privatisation of services which eventually costs more because companies have to make profits for their shareholders.  Campaigning also needed to be against privatisation.

11.    A CCG Governing Body member representing Practice Managers, welcomed all of the views heard and praised the reference to "under-funding" rather than "deficit".  Reference was also made to the change in treatments over time and the need not to make a case for change at the expense of patient care.  Equality assessment was important as was the need to work together.  In reference to hearing aids it was acknowledged that hearing loss leading to isolation was a form of discrimination.  Attendance at the meeting was appreciated.

12.    A final comment was on the sheer bureaucracy of the CCG, as for example the number of committees and information in the last report on how much was spent on administration.  This, too, should be looked at.

The Chair said that this was on the agenda for the forthcoming meeting with Helen Petterson.  The CCG had to buy in "experts".

MM also thanked the CCG representative and reiterated that it was vital to attend the CCG Governing Body meeting on 20th September but there was no need to be disruptive, simply to ask questions.  He added that the following week, on the Wednesday at 1.00 pm, the CCG would hold its AGM and that would be the opportunity for everyone to speak about the performance of the CCG over the past year.

MM then read out the proposed motion and sought the agreement of the meeting:

Motion: This meeting of Enfield residents urges the Governing Body of Enfield Clinical Commissioning Group to reject the Adherence to Evidence-Based Medicines proposals and instead to work with local people to reduce health inequalities in the Borough and join the Campaign for Fairer Funding for Enfield.

Upon a show of hands, the motion was carried with one abstention and none against.

The Chair thanked the panel and everyone for their attendance and the meeting closed.

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