NHSE/I consultation on

“Integrating care: Next steps to building strong and effective
integrated care systems across England”

Response to the consultation by

Professor Allyson Pollock and Peter Roderick, Population Health Sciences Institute, Newcastle University; and David Price, independent researcher

8 January 2021

  1. Overview

Publication of the next steps document during the covid-19 pandemic comes at a remarkable moment. Significant shortcomings have been exposed in the NHS[1], in the systems for communicable disease control and public health,[2] in the procurement system[3] and in the social care system.[4] The lack of hospital and ICU capacity have been major drivers of national lockdowns in March 2020 and January 2021 and the causes of severe winter pressures in previous years.

At the same time, the pandemic has demonstrated the obstacles created by market bureaucracy and heavy-handed and centralised market regulation which have developed over decades in the NHS.

The document hints at positive effects of the pandemic (paragraph 2.1) and refers in general terms to some of them (e.g., 2.72), which have played a part in “increas[ing] the appetite for statutory ‘clarity’ for ICSs and the organisations within them.” (3.8). It also recognises “the persistent complexity and fragmentation” which is rightly complained about (1.3).

This is largely the product of reforms premised on competitive relations and contracting among health bodies. Finally a new anti-competition consensus appears to have emerged in NHS reform[5] which has found its way, though problematically, into the document.

But as David Lock QC has said in 2019: “The big picture is that you have a market system. If you do not want a market system and you want to run a public service, you need a different form of legal structure.” And this obvious truth raises fundamental questions, which the document seems to glimpse, but which it is unwilling to grasp.

Why, for example, continue to insist on running health organisations as businesses if the aim is collaboration instead of competition? How should needs-assessment and population planning be undertaken if the aim is to secure comprehensive health and social care for geographic areas? Where should they be located and on which bodies does the statutory duty of universality fall? How can major political questions surrounding resource distribution be undertaken consensually outside established political processes? Equitable access and solidarity require risk-pooling and a community response.

Rather than rising to the challenge of these questions in ways which could reliably “provide[] the right foundation for the NHS over the next decade” (page 31), the document puts forward substantial de-regulatory proposals which continue to ‘work-around’ the current statutory market­based framework and undermine risk-pooling, even when proposing legislative change; much essential detail is omitted.

As they stand, the proposals seek to achieve integration by focussing on increasing freedoms of the various bodies involved in commissioning and contracting. They rely on general exhortations to counter deregulation. Laudable “fundamental purposes” inform an “aim” of “a progressively deepening relationship between the NHS and local authorities”. Three “important observations” which may or may not be aims relate to more local decision-making, more collaboration and economies of scale. A “triple aim” duty of unspecified strength relates to “better health for the whole population, better quality care for all patients and financially sustainable services for the taxpayer” (1.3, 1.8, 1.9, 3.3).

The approach however leaves substantially unchanged the legal powers of the many incorporated bodies active in the health care market among which collaboration is expected but from which disintegration has spread. If the aim is “rebalancing the focus on competition” (3.3) a concrete administrative alternative is required. None is offered. Seeking to promote greater integration whilst retaining commercial autonomy will not work.

In summary, the proposals:

  • leave in place the purchaser-provider split and commercial contracting;
  • continue the ability to give further contracts to private companies, including, it seems, integrated care provider contracts;
  • provide no response to the finding of the National Audit Office in 2017 that “The Departments have not yet established a robust evidence base to show that integration leads to better outcomes for patients”;
  • favour no controls on ICS membership;
  • give immense and barely-regulated power to monopoly providers and clinical networks
  • contain no controls on the composition of “provider collaboratives”, which could include, for example, large private hospitals;
  • are silent on public accountability mechanisms at a system level, and at the non-statutory “place” level;
  • repeal section 75 of the 2012 Act, revoke some of the ‘section 75 regulations’ and remove commissioning of NHS healthcare services from the Public Contracts Regulations 2015 – which are welcome – but are silent on the safeguards against corruption and conflicts of interest, and some of the section 75 regulations would seemingly be retained;
  • emphasise the importance of strategic needs assessment – which is also welcome – but do not require the assessment to frame provision or to qualify the power of providers and clinical networks;
  • do not appear to make ICSs responsible for all people in an area, and there are unresolved difficulties for integrating health and social care because of different funding bases for different populations;
  • are silent on whether individuals on GP lists will transfer to an ICS body, a provider or a provider collaborative;
  • are unclear on the fate of CCGs in Option 2;
  • contain no explanation of how capital investment strategies will operate, and whether charges on capital, including PFI charges, will change;
  • do not address the powers of NHS foundation trusts;
  • are unclear on how local authority public health funding will be protected;
  • are unclear on how social care funding will be protected, and how the currently different funding bases for health and social services will be addressed;
  • are silent about workforce planning;
  • envisage, but are unclear about, moving staff between organisations, and their terms and conditions.

We discuss the details in the following two sections.

  1. ICSs during 2021/22 and before legislation

The document seems to have two purposes: to further progress ICSs and the merger of CCGs ahead of legislation; and to explain changes to the NHSE/I’s legislative proposals published in September 2019.

Our understanding of what an ICS will be and do, before legislation, is set out in the Box below.

Box: What will an ICS be and do before legislation – as far as we can make out?

  1. An ICS will not have legal form and will consist of:
  • provider organisations as part of one or more undefined and self-determined “provider collaboratives” operating within and beyond the ICS playing “an active and strong leadership role” and being “a principal engine of transformation”(2.4, 2.31, 2.63); and
  • place-based partnerships”, defined by each ICS but seemingly comprising providers of primary care, community health and mental health services, social care and support, community diagnostics and urgent and emergency care – i.e., excluding secondary care, but including local authorities, Directors of Public Health and Healthwatch, and “may” include acute providers, ambulance trusts, the voluntary

sector and other – undefined – partners (2.31, 1.16).

  1. It will receive a “single pot budget” which would comprise “current CCG commissioning budgets, primary care budgets, the majority of specialised commissioning spend, the budgets for certain other directly commissioned services, central support or sustainability funding and nationally-held transformation funding that is allocated to systems” (2.40), and will decide how that budget should be delegated to local “places” within the ICS.
  2. Providers will “agree proposals developed by [undefined and self-determined] clinical and operational networks” and will “implement resulting changes” including “implementing standard operating procedures to support agreed practice; designating services to ensure their sustainability; or wider service reconfiguration”; and will “shape the strategic health and care priorities for the populations they serve, and new opportunities – whether through lead provider models at place level or through fully-fledged integrated care provider contractual models – to determine how services are funded and delivered, and how different bodies involved in providing joined-up care work together” (2.11, 1.44).
  3. The ICS will undertake more strategic needs assessment and planning than CCGs can do, resulting in “the organisational form of C.’CGs…evolv|ing|” (2.62-2.63).
  4. The ICS will be subject to governance and public accountability arrangements that are said to be “clear but flexible”, but will not be statutory. (2.28-28, 2.19)

We make a number of key points under the following headings:

  • Strategic needs assessment
  • The emphasis on strategic needs-based assessment and planning is welcome, yet there will be no single body which has the responsibility to carry it out and no legal mandating of it. This is likely to lead to buck-passing. Perhaps more importantly, it is also likely to lead to needs-based planning being overridden by increasingly powerful monopoly providers having pivotal influence over a single budget, and over its allocation both for non-secondary care services to undefined “places” with no statutory identity, and for secondary (and tertiary) care.
  • Moreover, it seems highly unlikely that services provided would be based on the needs assessment, because clinical networks are expected to carry out “clinical service strategy reviews on behalf of the ICS” and “develop proposals and recommendations” which providers will agree.

Indeed, “[c]linical networks and provider collaborations will drive…service change” (2.26, 2.11, 2.72). No tie-in to the strategic needs assessment is proposed, let alone a requirement for it to frame provision.

  • Public health experts have traditionally performed the functions of needs assessment, facilitating service development and service planning. However, public health sits outside of health services and is further fragmented between local authorities and the Secretary of State (Public Health England, to be replaced by another non-statutory body, the National Institute for Health Protection) as a result of the 2012 Act.

Clinical Support Units provide information and support for commercial contracting. They are not substitutes for public health, are not integrated into CCGs or local public health departments, and do not inform strategic needs assessment and service planning.

  • The single pot budget

It appears – certainly before, and perhaps after, legislation – that ICSs will not be responsible for all people within an ICS area. That term – an ICS area – is conspicuously absent from the proposals. The CCG membership model (‘persons for whom they are responsible’) cannot be changed without legislation and so will presumably be ‘scaled-up’ to cover all the CCGs involved.

We have previously expressed[6] concern about how Accountable Care Organisations would have been able to integrate health and social care services because their funding would have been for a different population (GP lists versus local authority), and would not have health service funding allocated for unregistered CCG residents who might be eligible for local authority social services. This concern still applies in relation to ICSs, including provider collaboratives and place-based partnerships, both with and without legislation, and with and without integrated provider care contracts.

In addition, the bases upon which resources will be allocated to secondary (and tertiary) care and to place-based partnerships, and within those partnerships are entirely unclear. This is presumably deliberate. Already there has been a marked decrease in administrative accountability for spending, and multiple contracts and subcontracts – which will continue – make it increasingly impossible to ‘follow the money’, let alone to assess the costs of contract administration. Detailed financial reporting to NHSE/I is obviously essential and may be provided for, but public transparency in funding as between primary care, community and mental health services, and acute, secondary and specialist care, including sub-contracting, is also essential.

  • Provider collaboratives

No control is proposed over the composition of these collaboratives. They could and presumably will consist of private as well as public providers, e.g., of mental health services, residential and nursing care, acute hospital care and pathology services. The potential inclusion, for example, of large private hospitals, which have been contracted during the pandemic, needs to be clarified immediately. No control is proposed over the granting of contracts to providers within these collaboratives, who may in fact be distant from and have no connection with the local community and be subject to commercially-driven mergers, acquisitions and closures that threaten patient care.[7]

Full integrated care provider contracts can be awarded, though there is no reference to the House of Commons Health and Social Care Committee in June 2019 having “strongly recommend[ed] that legislation should rule out the option of non-statutory providers holding an ICP contract [in order to] allay fears that ICP contracts provide a vehicle for extending the scope of privatisation in the English NHS”. In September 2019, NHSE/I acknowledged this and stated that it supported the recommendation. If private companies are not likely to be awarded such contracts, then what is lost by legislating to that effect? And what prevented a clear statement to that effect being made in this document?

Neither is there any reference to the HSC Committee’s recommendation that “ICP contracts should be piloted only in a small number of local areas and subject to careful evaluation”.

  • ICS membership

There are two potential aspects in this regard.

The document proposes for legislative change Option 2 that the ICS body should be able to appoint such members to the ICS body as it deems appropriate “allowing for maximum flexibility for systems to shape their membership to suit the needs of their populations” (3.19). It seems that this will be possible de facto before legislation, e.g., via the unspecified provider collaboratives. This risks giving private companies influence over the allocation of NHS funding: “they are there to make money from the NHS” in the words of Dr Graham Winyard – and should not be admitted as members. Yet the document is silent on this point.

As for patients, the document is silent on whether individuals on GP lists will transfer to any provider (e.g. under an integrated care provider contract), or even to a provider collaborative – or, after legislation based on Option 2, to an ICS body; and, if so, how that would be achieved and whether individuals would have any choice in the matter. In addition, will individuals be able to move from one ICS to another? And what happens, for example, if an individual is on the list of a GP (or provider or provider collaborative) within the ICS, but lives in a local authority area within another ICS and requires social care?

NHSE/I should clarify these issues as soon as possible.

  • Public accountability

ICSs will be making major resource allocation decisions, which will often be controversial. Transparency and scrutiny will be critical. However, the document says nothing about how current public accountability requirements and mechanisms will work in an ICS context. These mechanisms are based mainly around CCGs and local authorities, but in reality these bodies will no longer be the decision-makers. Actual decision-making will be de-coupled from legal functions and the effectiveness of public accountability will be diminished in the process.

  • Competition and contracting

Proposals to remove market competition, compulsory contracting and the commissioning of NHS healthcare services (only) from the Public Contracts Regulations 2015 – which are welcome – cannot happen without statutory change; the rights of private providers and the purchaser-provider split remain in place. The work-arounds continue.

  • Social care

Adult social services are means-tested. Health services are not. Providers of social care and support are said to be included in place-based partnerships, but the allocation of resources to and within the partnerships is entirely unclear. There is no mention of any safeguards to prevent services which are currently free from being re-designated as social care and so subject to means-testing and possible charges.

  • Public health

Local authority public health will fall within place-based partnerships. As for other services covered by these non-statutory partnerships, there is no mention of how protecting public health funding will be achieved in the face of the power of provider collaboratives and clinical networks operating at the level of the ICS and beyond. Representation by DPHs and other local authorities is unlikely to be enough.

  • Workforce planning

The next steps document is silent about work force planning. Lack of doctors and staff is already a serious issue after years of fragmentation, lack of investment and, appallingly, absence of a strategy: the Kings Fund described it recently as “a workforce crisis”. NHSE/I need to be clear about how attempts to improve this critical function would operate in the ICS context.

  • Moving staff and their terms and conditions

It is proposed that there should be “frictionless movement of staff across organisational boundaries” (bizarrely in the context of data and digital technology, page 20). This is capable of different meanings across a spectrum, but nothing more is said about this, nor on the terms and conditions of staff in the ICS context. Much more information should be provided.

  1. ICSs after legislation

There is much less information on legislative changes in the next steps document than was contained in NHSE/I’s September 2019 document entitled The NHS’s recommendations to Government and Parliament for an NHS Bill. The next steps document lists some of those recommendations and states, oddly, “We believe these proposals still stand” (3.3, 3.4). This statement makes it unclear whether they continue to be proposals.

The next steps document proposes two options for legislation.

Option 1 would establish the ICS as a mandatory statutory ICS Board in the form of a joint committee of NHS commissioners, providers and local authorities with an Accountable Officer, and with one CCG only per ICS footprint which would be able to delegate “many of its population health functions to providers” (page 29).

Option 2 would set up a new statutory ICS body as an NHS body by “repurposing” CCGs, taking on their commissioning functions, plus additional duties and powers, and having “the primary duty…to secure the effective provision of health services to meet the needs of the system population, working in collaboration with partner organisations”. It would have “flexibility to make arrangements with providers through contracts or by delegating responsibility for arranging specified services to one or more providers”. It would have a board of representatives of system partners (NHS providers, primary care and local government alongside a Chair, a Chief Executive and a Chief Financial Officer as a minimum) with the ability to appoint such other members as the ICS deems appropriate “for maximum flexibility for systems to shape their membership to suit the needs of their populations” (page 30).

NHSE/I prefer Option 2.

Most of the points we have made pre-legislation continue to apply. We expand on some of those and add to them as follows:

  • Major reorganisation

It is striking that despite the apparent opportunity for primary legislation following the Queen’s Speech neither Option grapples with the fundamental questions posed in the Overview above, which flow from the anti-competitive consensus (if such there be). This might be because NHSE/I wish to avoid being seen to be proposing a major reorganisation. But this is exactly what is happening, even without legislation.

In September 2019, NHSE/I stated:

“The Select Committee [in July 2019] agreed that NHS commissioners and providers should be newly allowed to form joint decision-making committees on a voluntary basis, rather than the alternative of creating Integrated Care Systems (ICS) as new statutory bodies, which would necessitate a major NHS reorganisation.” (emphasis added)

  • Competition and contracting

No legislative changes are proposed to the purchaser-provider split. Whilst repeal of procurement rules under section 75 of the 2012 Act and removal of commissioning of NHS healthcare services (only) from the Public Contracts Regulations 2015 are welcome, the document is silent on safeguards against corruption and conflicts of interest.

It is also important to recall that in September 2019 NHSE/I stated that it would retain a number of the provisions of the NHS (Procurement, Patient Choice and Competition) (No.2) Regulations 2013 – commonly referred to as the ‘section 75 regulations’. Of particular worry, exacerbated by the covid- 19 pandemic, is retention of “the requirement to put in place arrangements to ensure that patients are offered a choice of alternative providers in certain circumstances where they will not receive treatment within maximum waiting times”. The possibility of the use of private providers in these circumstances, rather than increasing NHS capacity, is obvious.

  • Fate of CCGs

NHSE/I still seem undecided about the fate of CCGs in Option 2. Under both Options, the document states that “current CCG functions would subsequently be absorbed to become core ICS business” (2.64). Yet the document only proposes, in relation to Option 2, to replace the CCG governing body and GP membership, but for some unknown reason does not state that CCGs will be abolished, which presumably they must be, under Option 2, with no replacement.

  • ICS membership

The document proposes in Option 2 – though we are not clear why this is not a possibility in Option 1 nor de facto from now onwards (see section 2(4) above) – that the ICS body should be able to appoint such members as it deems appropriate. This would be a blatant undermining of the ICS as an NHS body.

In addition, as stated above (section 2(4)), it is unclear whether individuals on GP lists would be transferred to the ICS body.

  • Missing proposals
  • Even though both Options propose primary legislation, the document contains no proposal for ICS- specific public accountability mechanisms, for abolishing the purchaser-provider split, or to give place-based partnerships a legal identity.

  • A fundamental omission is how capital investment strategies will operate and whether charges on capital will change. NHS Property Services is now charging market rent for property occupied by Trusts, CCGs and some GP premises. Foundation trusts have autonomy over the property they hold and investment decisions. However, the Private Finance Initiative has left a legacy of major debt in health services and in local authorities. There has been no public scrutiny of the impact of the covid- 19 pandemic on PFI contracts, on debt repayments and on renegotiation of the exorbitant rates of interest being paid out as part of the annual payments.

  • The powers of FTs are not addressed not least the ability to generate up to half their income from outside the NHS, at a time when public capacity is reducing and waiting lists, e.g., for surgery and cancer care, are growing. Nor is it made clear whether current contracts with large private hospital chains (SPIRE et al.) are long-term and whether they will be involved in provider collaboratives.

  • In September 2019, NHSE/I recommended abolishing the prospective repeal of the power to designate NHS trusts that was enacted in the 2012 Act but never brought into force, to support the creation of integrated care providers. The next steps document only mentions this in passing (3.3). It remains unclear if this still being proposed and, if it is, the circumstances in which it could be exercised.

  1. Conclusion

These proposals are incoherent, de-regulatory and unclear, and are not equal to the existential threat that is posed by the current government to the NHS as a universal, comprehensive, publicly- provided service free at the point of delivery. This has been amply demonstrated by the government’s response to the covid-19 pandemic which has directed billions of pounds to private companies to provide services that should have been provided by the NHS, Public Health England and local authorities. The proposals allow this to continue and increase.

Neither can the ambition of providing a sound foundation for the next decade be sensibly addressed without considering the inevitable but uncertain changes that will be necessary post-pandemic to the public health and social care systems, and to the functions of local authorities.

The challenge now is much greater than it was in 2019, when the difficulties of getting major NHS legislation through the House of Commons was used as a reason/excuse for not proposing legislation equal to the task of taking the market out of NHS once and for all. We urge MPs who are committed to the NHS as a public service to support scrapping the 2012 Health and Social Care Act in its entirety and to support the NHS Reinstatement Bill which would put back the government’s duty to provide key services, delegated to Strategic Integrated Health Boards and Local Integrated Health Boards.

END

[1] E.g., lack staff, beds and other capacity following inadequate investment and the absence of a workforce planning strategy over many years; inadequate planning and personal protective equipment (PPE); marginalising GPs.

[2] E.g., devaluing local authorities and the NHS by centralising and privatising tracking, tracing and testing; spending hundreds of millions of pounds on inaccurate lateral flow tests; by-passing the established system for notifying suspected cases.

[3] E.g., spending billions of pounds on untendered contracts, including to companies with no track record.

[4] E.g., shortages of staff and PPE; high excess deaths; inappropriate discharge of hospital patients to care homes.

[5]  “These developments [of STPs and ICSs] represent an important shift in direction for NHS policy. The 2012 Act aimed to strengthen the role of competition in the NHS, consolidating a market-based approach to reform that has been in place since the establishment of the internal market in 1991. By 2019, however, competition rarely gets mentioned in NHS policy. Instead, the Five Year Forward View, STPs, and ICSs are based on the idea that collaboration – not competition – is essential to improve care and manage resources, including between commissioners and providers”. Health Foundation submission to the Health and Social Care Select Committee inquiry into legislative proposals in response to the NHS Long Term Plan, April 2019

[6] Pollock AM, Roderick P. Why we should be concerned about accountable care organisations in England’s

NHS. BMJ. 2018;360:k343. https://allysonpollock.com/?page id=11

[7] E.g., Care Home Professional, Terra Firma close to £160m care home sale to Barchester Healthcare, 15 November 2019, https://www.carehomeprofessional.com/terra-firma-close-to-160m-ca re-home-sale-to- barchester-healthcare-report/

 

ICS Next steps Consultation Response 08Jan21

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2 Comments

  1. Andy Hanson says:

    excellent analysis as always

  2. Roger says:

    These were my own notes on the subject which I am pleased to say support Pollock but with a slightly different perspective.

    • The notion that there is universal approval to the notion of INTEGRATED CARE systems; that this has already been agreed and the only thing left to debate is the route to implementation is rejected.
    • It needs to be well understood that there was a lot of input into the 2012 Health and Social Care Act establishing principles of local commissioning and provider competition within a quasi- NHS market regulated by a competition and markets Regulator Monitor https://en.wikipedia.org/wiki/Monitor_(NHS)
    • That has proved inconvenient to senior managers of the NHS who have their own ideas of the principles on which the NHS should be based: principally the newly appointed (in 2014) Chief Executive of NHS England Simon Stevens who wished to introduce Accountable care organisations into the UK from the USA.
    • The concept of accountable care organisations was introduced into the vocabulary of the NHS within the Five year forward plan published in 2015. The obvious links to the US model became an embarrassment and a name change was introduced: thus accountable care organisations became integrated care systems in 2018. https://www.patients4nhs.org.uk/accountable-care-systems/
    • Integrated care has been a wish of many in the NHS who were opposed to the fragmentation of the NHS into commodified contracts and who have been willing to lend support to the idea of integrated care. The NAO and the Nuffield Trust have identified the nebulous nature of the concept however and what is really at stake in proposals being made here is the overthrow of the 2012 Act and its replacement by different principles and ways of working.
    • Normally this would be done by the presentation of green papers by the government and a period of consultation culminating in draft legislation and debate in Parliament.
    • None of this has been done in this case as the initiative is not from Government but the Chief executive and senior officers of the NHS itself.
    • This is unsatisfactory as active steps have already been taken to implement significant changes, involving the dis-establishment of local Commissioning bodies (in effect if not in name) and the voluntary co-operation of statutory bodies in transferring powers to no-statutory bodies. This is both unusual and controversial.
    • A review by the Kings Fund into changes in London in 2018 concluded that legislation should be passed before further formal changes made. That conclusion appears robust in Dec 2020.
    • During 2019 further documents were produced identified in these proposals with the clear intent expressed of presenting legislative changes. In the event government turbulence associated with Brexit and in 2020 the Covid Pandemic, has changed both the strategic context and the financial background, without delivering the outstanding matters of resolution of the funding of social care, a solution to NHS workforce constraints or certainty of future financial resources.
    • The mood and space of government for a contentious debate on another re-organisation of the NHS has not existed and given the ongoing nature of Brexit and the Covid pandemic it seems unlikely that space will be found in 2021. This seems to be partly acknowledged in these proposals while they still trying to implement the changes as though legislation were already in effect. This is clearly pre-emption of Parliament .
    • As matters stand local commissioning has been destroyed with replacements not yet in place. This is an unsatisfactory state of affairs and should not have been allowed to happen.
    Our advice to the NHS has been consistently to judge implementation of changes as premature and not thought through. Events have again reinforced this advice.
    • The choice presented in these proposals is to carry on in 2021 as though nothing has happened, and endorsement is sought to acting as though legislation had already been passed. Our advice is that this is not tenable, underestimates the real depth and scope of the debate on the future of the NHS required, and we suggest a pause is implemented to allow the full results of the pandemic to be absorbed and analysed, arrangements for the future funding and staffing of both the NHS and social care to be decided and then only after a firm consensus and agreement of Parliament has been obtained should changes be made.
    • Implementing these changes is not the priority in the pandemic and pandemic management has not been hindered by lack of resolution of commissioning issues. Rather it has put them in perspective.
    • This raises the question as to why these technical changes to aspects of commissioning care are regarded by NHS England as a priority. The real answer is that Sir Simon Stevens may be approaching the end of his contract of employment and wishes to cement the changes he first proposed in 2015 in place. The strong suspicion is that Matt Hancock may view Stevens as dispensable in order to deflect blame from himself for the UK’s poor performance over the last 12 months.
    • Again the advice is that the Covid Inquiry should be conducted prior to any judgements on the future of the NHS and there is no imperative to divert management onto another reorganisation until directions are more firmly established.
    • As matters stand the Long Term Plan published in 2019 is already stalled and consists mostly of a series of good intentions. The crucial aspects regarding organisational changes supporting integrated care systems are fudged to conceal the real intent to create accountable care organisations.
    • The LTP summarises its intent as follows:
    “Parliament and the Government have both asked the NHS to make consensus proposals for how primary legislation might be adjusted to better support delivery of the agreed changes set out in this LTP. This Plan does not require changes to the law in order to be implemented. But our view is that amendment to the primary legislation would significantly accelerate progress on service integration, on administrative efficiency, and on public accountability. We recommend changes to: create publicly-accountable integrated care locally; to streamline the national administrative structures of the NHS; and remove the overly rigid competition and procurement regime applied to the NHS.

    In the meantime, within the current legal framework, the NHS and our partners will be moving to create Integrated Care Systems everywhere by April 2021, building on the progress already made. ICSs bring together local organisations in a pragmatic and practical way to deliver the ‘triple integration’ of primary and specialist care, physical and mental health services, and health with social care. They will have a key role in working with Local Authorities at ‘place’ level, and through ICSs, commissioners will make shared decisions with providers on population health, service redesign and Long Term Plan implementation”. Summary s://www.longterhttpmplan.nhs.uk/online-version/overview-and-summary/ p2

    • A legitimate response by local authorities is that there is no consensus. Legislative changes are required and should be debated up front and in plain sight. It is not clear what the true intent of these proposals are , as the proposed changes are masked in wishful thinking and claims that future good things are uniquely dependent on nebulous concepts of “ triple integration” ,” place based” commissioning and service re-design. Furthermore local authorities are not reassured by the experience in recent years of working with the NHS in a genuinely open and collaborative way, which genuinely involves and enables public scrutiny of plans.
    • As evidence of bad faith on the NHS part is the proposal to “remove the overly rigid competition and procurement regime applied to the NHS”. Thus proposals are made to scrap s 75 of the NHS Act which has been interpreted by many as the route to privatisation of the NHS .
    s.75 as passed in legislation states:
    s.75 Requirements as to procurement, patient choice and competition
    (1)Regulations may impose requirements on the National Health Service Commissioning Board and clinical commissioning groups for the purpose of securing that, in commissioning health care services for the purposes of the NHS, they—
    (a) adhere to good practice in relation to procurement;
    (b) protect and promote the right of patients to make choices with respect to treatment or other health care services provided for the purposes of the NHS;
    (c) do not engage in anti-competitive behaviour which is against the interests of people who use such services.
    (2)Requirements imposed by regulations under this section apply to an arrangement for the provision of goods and services only if the value of the consideration attributable to the services is greater than that attributable to the goods.
    (3)Regulations under this section may, in particular, impose requirements relating to—
    (a)competitive tendering for the provision of services;
    (b)the management of conflicts between the interests involved in commissioning services and the interests involved in providing them.
    (4)The regulations may provide for the requirements imposed, or such of them as are prescribed, not to apply in relation to arrangements of a prescribed description.

    This acts as a constraint on the NHS which wants to usher in multi billion pound contracts to cronies , including potentially subsidiaries of Steven’s previous employers, for vague accountable care contracts stretching far into the future. The example of contracts being allocated on Test and Trace and for PPE can show what happens when best practice procurement practices are not observed.

    The risk is that poorly supervised and unaccountable ICS’s will sub-contract to third parties “integration services “ contracts to Accountable care contractors who will offer population health commissioning services (ie treating the population as members of an insurance scheme) using data driven risk management solutions (ie means of excluding membership or charging higher premiums to the payer); place based commissioning able to ignore and overrule local commissioning; radical service design (involving hiving off disease management and specialist services to third parties); and who will be able to impose radical reconfiguration of services with no effective come back for local organisations or people adversely affected by making access more difficult.
    Already examples exist on the risks of hasty decisions on reconfigurations around the country that have ended in disputes and legal challenges.
    • Similarly proposals made:
    “ 2.45. We will deliver on the commitment set out in the Long Term Plan to mostly move away from episodic or activity-based payment, rolling out the blended payment model for secondary care services”
    These may seem uncontroversial to those in the NHS but actually what is being said here is that the NHS will be contracted to not provide services and to return to the perverse incentives that afflicted the NHS in the eighties. This risks returning to the days of unsustainable waiting lists. Unsurprisingly the details of the new financial arrangements are still being discussed but any changes risk taking away incentives to providers to provide care and treatment. This is a slippery slope leading to reducing the thresholds of care, exclusion, denial, delay, dilution, and unaccountable rationing.
    The next section:
    2.46. These changes will reduce the administrative, transactional costs of the current approach to commissioning and paying for care, and release resources for the front line – including preventative measures – that can be invested in services that are planned, designed and delivered in a more strategic way at ICS level. This is just one way in which we will ensure that each ICS has to capacity and capability to take advantage of the opportunities that these new approaches offer.
    Also seems to give the game away in that no attention will be wasted on properly costing and accounting for care, rather new approaches will be taken.
    • Finally resistance can be safely ignored in some eyes if the greater good is achieved. But there is no evidence that Accountable care holds the answer in the UK and all the evidence is that it has consolidated the outrageously expensive and unfair US system rather than making it better or cheaper. Indeed the trouble in these proposals to reassure staff that they will not be discarded and will be protected raises the doubt as to what exactly is being achieved. If not saving staff involved in commissioning then what?
    Turning to the questions raised within the proposals therefore:
    Questions
    Q. Do you agree that giving ICSs a statutory footing from 2022, alongside other legislative proposals, provides the right foundation for the NHS over the next decade?
    A. Not necessarily.
    Covid 19 has exposed a number of inadequacies in the NHS that requires a full inquiry to properly expose. It lacks capacity, resilience, staffing and an ability to acknowledge and respond appropriately to short term, medium term and long term risks.
    It is not clear that ICS’s ask the right questions let alone provide the answers.
    Is the NHS to be based on local commissioning and competition or not? Does it believe in the purchase –provider split? Is it to provide services or be merely a lead contractor whose main purposes can be sub-contracted? Has it failed as a monopsonist? Or succeeded too well? Has the NHS ignored clinical views or listened too much to their vested interests?
    As matters stand there is no consensus or sufficient debate to justify claims that ICS’s are the way forward.
    Q. Do you agree that option 2 offers a model that provides greater incentive for collaboration alongside clarity of accountability across systems, to Parliament and most importantly, to patients?
    A. Option two which recommends the creation of a new statutory body recognising the ICS as the key organisation for the NHS in future is insufficiently established in the public mind as the legitimate route for the future of the NHS.
    The ICS in most people’s mind is a muddle. Is it a vehicle for integrated accountable care organisations to be contracted out or not? Is the NHS a provider or merely a figure head?
    Is it an admission that abolishing SHA/Regions was a mistake? Or are ICS’s something entirely different? Can it endorse whatever local people decide and how will they be scrutinised effectively and controlled?
    Q. Do you agree that, other than mandatory participation of NHS bodies and Local Authorities, membership should be sufficiently permissive to allow systems to shape their own governance arrangements to best suit their populations needs?
    A. No. It would amount to allowing dominant local vested interests to get their way. Centralised control needs to be established. The tendency of the NHS is to be captured by vested interests intent on supporting local private interests; and checks and balances needs to have a determining role in ensuring this does not happen, supported by the NHS nationally and government ministers if necessary.
    Q. Do you agree, subject to appropriate safeguards and where appropriate, that services currently commissioned by NHSE should be either transferred or delegated to ICS bodies?
    A. It is not clear of the intention and the effect of this proposal. Again, as with the previous answer, it risks putting too much power in local hands at the expense of specialist services catering to wider populations, and to delegating powers too low in the chain of command to be effective in mitigating professional or industrial abuses of power. Will ICS’s really be empowered to deal adequately with nationally determined issues of ensuring sufficient supply of clinical staff or price control of drugs and supplies?.
    Further Comments
    • In the Implications and next steps section at the end of the proposals a somewhat breathless attempt is made to persuade that no further delay should take place because everyone agrees already. This misreads the evidence, appears self-serving, and puts too much onus on conviction.
    • It is not yet clear whether lessons , or the right lessons, have been drawn from the COVID experience, whether standardisation is really the problem in the NHS, whether lack of data was a real problem for the NHS or whether it was lack of investment, staff and strategic stocks and equipment.
    • The answer proposed of implementing the things that were already being done more quickly as sufficient seems opportunistic and not fully considered.
    • By further promoting the idea that leadership is the magic ingredient the risk is that better consideration of other specific measures that will not be properly assessed. (if it were simply a matter of leadership problems and solutions would be more readily identifiable).
    • Finally by appearing to ask for a green light to implement changes from April 2021 as though changes in legislation had already taken place the NHS are asking for illegality, challenges and disputes. It would be far better for due process to proceed properly after legislative changes not before.

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