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    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

    2 Comments

    by Esther Giles, Former Director of Finance (Specialised Services) South Region of England, SHA member”

    This article tracks the extent and nature of marketisation and privatisation in the NHS up to the current proposed move to Integrated care systems (ICSs) and argues that the current ICS proposals are the logical conclusion of the marketisation reforms implemented progressively from Thatcher onwards.

     

    Some of David Cameron’s many famous last words were his pre-election pledge in 2010 that there would be no more “top-down reorganisations” of the NHS[1]. He then presided, in 2012, over the most chaotic and unlegislated top-down upheaval of the NHS that can be imagined or remembered. The resulting fragmentation and damage were never resolved, and so the NHS goes limping in the logical conclusion of the relentless drive away from a universal national service, and towards the current proposals for Integrated Care Systems (ICSs) modelled on the US Kaiser Permanente system of Accountable Care Systems.

    The 2012 Health and Social Care Act and Marketisation

    The internal market was given a fundamental boost by the Health and Social Care Act 2012. Under this Act, all NHS services above a stated value had to be put out to competitive tender, turning the provision of healthcare into an economic activity and, as such, subject to EU competition Law.

    Thus, private providers such as Capita and Virgin have been seen bidding to provide NHS services, mainly in community services. Sometimes they win and sometimes they don’t. And if they don’t, they look for opportunity to sue. In the South West, we saw Virgin win contracts for Community Services in Devon[2] and Bath and North-East Somerset (BANES). Richard Branson’s Virgin HealthCare won £1bn worth of contracts in 2016/17. It won these services from the NHS and from non-profit making services such as community interest companies.

    NHS acute hospitals have all stayed within the NHS so far, except for a short flirtation between Hinchingbrooke Hospital and the Circle Group, which ended in disaster, with the provider being put into “special measures” in 2015. The picture is very different for mental health care, where the private sector has had continued domination of parts of the market, in 2012/13, 22% (£1.7bn) of NHS mental health spend was with the independent sector, compared with 4% (£1.8bn) of acute spend. Providers include St. Andrew’s Healthcare, Partnerships in Care, and the Priory Group. For secure MH services, they are all building ‘private’ because the NHS cannot afford the capital funding to do so, Typically, these independent sectors beds cost the NHS 20% more than NHS beds[3].

    There is no evidence that the Internal Market has been any sort of success. No evidence that competition has improved outcomes in any but a few limited examples where causality is neither clear nor proven. The costs of the internal market are huge. Administrative costs in the NHS were estimated at 14% in 2005 compared with 5% before the 1980s; costs of the internal market alone are estimated in the range of £5bn per annum.  To quote Professor Paton in his 2015 study:

    “The ‘market’ in the NHS is a major source of waste. Creating and maintaining markets has incurred huge direct costs and significant ‘opportunity costs’ – money which could have spent upon patient care and clinical redesign.”

    The Private Finance Initiative

    The Private Finance Initiative (PFI) was introduced by John Major’s Government from 1992 and was embraced by the subsequent Blair government as a means of removing spending from Government balance sheets and thus reducing public spending in the short term. Most authorities would accept that the PFI has failed, and at material cost to the taxpayer.

    The promulgation of the Neoliberal Ethos in the NHS

    Progressive neoliberal reforms have reinforced the ideology of the market. All have fragmented the provision of healthcare and siphoned public money off into private sector balance sheets, shareholder dividends and profit margins. At the same time, pressures on NHS budgets require NHS management to reduce costs. It seems that the NHS has been presented with an imperative to cut costs and handed privatisation as an alleged means to this end.

    The NHS is one of the most efficient and trusted healthcare systems in the World. One of the reasons for its efficacy and efficiency is that people are given care according to their needs and irrespective of their means. This ethos belongs to its workers as well as to the organisation; for many people who work for the NHS, it is a vocation, and they care deeply about what they do. They have the intrinsic motivation that drew me to a career in the NHS. But, over the past thirty-five years, this ethos has been progressively undermined by the neoliberal ideology that delivery and innovation must be driven by competition and the profit motive, and that input costs must be minimised. This ideology appears to have been accepted, without challenge, by every government since and by the top management of the NHS, despite many public campaigns against privatisation. The consequence of this, combined with a political austerity consensus – that the deficit must and will be reduced by cutting public spending and selling off public assets, means that cost-cutting is accepted as part of the “solution” for the NHS. In a ‘business’ where more than 70% of costs are staff related, the next leap of logic is that staff costs must be cut.[4] This is interpreted and delivered in a number of ways, all of which serve to undermine the quality and energy of the NHS workforce and which include pay freezes, dilution of skill mix, reducing “management costs “, and the outsourcing and privatisation of individual components of the NHS.

    Many people- and not just socialists- have been dismayed over the years at the continuing and relentless reorganisation, marketisation, privatisation and fragmentation of the NHS. The market, with its endless and costly hand-offs between one commercial entity and another, cripples the best efforts of professional staff and those that support them.  Not only are these hand-offs costly to procure, but they also require constant and detailed policing. Furthermore, continuous reorganisation and market testing destroy morale and organisational memory. All these results of the market take focus away from patient care. I believe that the NHS works best with a collaborative rather than a competitive ethos. Where decisions about care are driven by the needs of the patient, not by the scope for profit. Where quality is a prerogative always, not just when it helps to win a contract. Where the entire NHS budget is used to provide and support patient care.

    NHS workers bear the brunt of the rhetoric and dogma at the heart of current policy, being presented as a cost rather than a benefit, a “burden” on the state, the costs of whom must be minimised. They must” tighten their belts” like everyone else – apart from the wealthiest. Now, the biggest crisis in the NHS is the lack of qualified staff, exacerbated by the removal by the current government of bursaries for nurses and by its disastrous instrumentalisation of migrants’ rights in Brexit negotiations. ​ It is a crisis brought on by what appears to be deliberate incompetence by the Government, mitigated only by the continued introduction of qualified staff from third world countries.

    The Extent of Privatisation

    A simple measure is the proportion of NHS spend on private sector providers as reported in the Department of Health Accounts. In 2004, this was 2.8%. and in 2018/19, it was reported as 7.3%. with privatisation accelerating after the Health and Social Care Act 2012. However, these figures mask the extent of private provision within NHS providers, where many ancillary services- such as cleaning, catering, portering and pharmacy- have been outsourced since Thatcher’s 1983 initiative. There is also spending on private providers of primary care (including GPs) to take into account. After adding these into the figures, the total spend of NHS England in the private sector in 2018/19  is estimated by David Rowland, Director of the Centre for Public Health and Interest as £29bn, or 26% of NHS England spending. So, there’s little doubt that privatisation is increasing in the NHS, and that “market reforms”, compulsory tendering under EU Law (until now), and a lack of ready cash are important drivers of this. It is of huge credit to NHS workers that, despite these onslaughts and years of pay freezes and cuts to services, they soldier on.

    Consultation on Integrated Care Systems

    The fragmentation forced by the disastrous 2012 Health and Social Care Act exposed the gross dysfunction of the internal market. It set commissioners against providers in an endless spiral of tactics to gain at the expense of the other, at huge administrative and organisational cost. The concept of the ICS could, in theory, see a return to the local system approach adopted in District Health Authorities (DHAs) prior to NHS marketisation, with funding being based on populations adjusted for cross boundary flows, with no internal market, and with local systems agreeing plans and setting budgets and quality standards for local services. This would provide the opportunity to remove layers of bureaucracy and unnecessary accounting and contracting and enable savings to move out to fund the front line. But it is clear from the consultation document that this is not the intended approach. And neither was this ever intended.

     

    The very core purpose of ICSs is to drive down care based on demanding cost savings targets imposed by the Government, in a service that is already one of the most efficient in the world. The ethos, even the language[5]  is that of the American accountable care system, where being seen to be cutting costs (and creating an industry out of that) is a key organisational driver and measure of success. And it is crystal clear that the policy march started by Thatcher and continued through Major, Blair, Brown, Cameron and May was to implement the Kaiser Permanente model first introduced by Alain Enthoven, and whose thinking was adopted by the Central Policy Think Tank when the internal market was first introduced into the NHS

    Specific Areas to address in the consultation document (and for Labour to develop) are suggested as follows:

    • the document retains the language and structure of the internal market in that it refers to provider organisations and provider collaboratives, and commissioners. The inference is that fragmentation can be addressed by provider collaboration (and, presumably, ultimately merger). Thus, it intends to retain the most pernicious and inefficient components of the internal market. A socialist radical approach (and which is Labour Policy) would be to remove the internal market altogether, and focus on quality assured service provision, supported by rigorous benchmarking of quality and cost and an overarching strategic and operational planning function. Undoubtedly there are extraordinarily strong vested interests in retaining the status quo, with “providers” having developed as big businesses in their own right.
    • The consultation document refers to “digital and data” to drive system working, and yet there appears to be no single NHS solution for this. Instead, there is a “Framework” calling on a wide range of “providers”, and the suggestion that there should be “shared contracts and platforms to increase resiliency”. An alternative to this would be an NHS-wide and provided digital data and information service.
    • Each System/Geographic area will have its own pot of money covering the whole of local spending on healthcare. Transactional costs are intended to be reduced through the “blended payment” model. An alternative approach would be to remove tariffs and set budgets based on the costs of the services required by the system. These costs could be budgeted on a variable basis using agreed parameters (such as variable capacity requirements).
    • Specialised Services need to be planned on a larger geographical footprint than other general services. This will require collaboration and planning between ICSs so that the needs of each ICS population are met in an equitable and efficient way. The funding for the relevant services should sit with the local ICS (managed on the same principles as RAWP with DHAs) so that they have the funding required to budget for all their locally provided services. Whatever mechanism is put in place should minimise transaction costs.

    [1] In a speech at the Royal College of Pathologists on 2 November 2009, Cameron said: “With the Conservatives there will be no more of the tiresome, meddlesome, top-down re-structures that have dominated the last decade of the NHS.”

    [2] https://www.somersetlive.co.uk/news/health/virgin-care-set-lose-multi-2038196

    [3] Based on tariff data collected internally by NHS England in 2018/19

    [4] “‘Since it takes time to train skilled staff, (for example, up to 13 years to consult), the risk is that the NHS will lock itself into outdated models of delivery unless we radically alter the way in which we plan and train our workforce. HEE will therefore work with its statutory partners to commission and expand new health and care roles, ensuring we have a more flexible workforce […]” [5 Year Forward View, page 30.]

    [5] Along with the structures, the purpose, and the key role of US healthcare corporations in importing it to the UK, even phrases like “Right care, right time, right place” to advertise the NHS Long Term Plan’s service closures programmes, are lifted straight from the language of accountable care in the US. It is not a coincidence that the Healthcare Financial Management Association (the professional organisation representing finance professionals in the NHS) has, for many years, operated an exchange programme with the US, and with many conferences featuring US healthcare models. The HFMA offers courses based on the US model.

    6 Comments

    This is SHA’s response to NHSE’s consultation on putting ICSs on a statutory footing. It is a curation of the generous and thoughtful comments of many members. Please forward to as many of your groups and networks as possible.

     THE SOCIALIST HEALTH ASSOCIATION’S RESPONSE TO “INTEGRATING CARE –

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

    WHAT SHA WANTS TO SEE

    A cooperative and democratic health and care system, fully funded through general taxation, free at the point of use, that eliminates the privatisation of clinical services.

     SHA cannot support these proposals.

    RESPONSES TO 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?
    SHA does not agree. Our many reasons are explained below.

    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?
    SHA does not have a view on this.

    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?
    There need to be national standards, locally delivered, matched to the needs of an area. Please see SHA’s thinking on NHS democracy.

    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?

    NHSE, if it continues to exist, should plan for those requirements that are best planned at national level. These could include rare diseases and specialist services.

     SHA’s REASONS FOR REJECTING THE PROPOSALS.

    Based around place

    SHA supports the idea of services based on an area, reflecting the needs of that place. However, this document leaves place ill-defined.

    Relationships with Local Authorities

    There is poor legislative alignment of responsibilities of Local Authorities (LAs) and ICSs.  This is an issue particularly with reference to Public Contract Regulations 2015, which will still apply to Local Authorities and could increase the regulatory burden on local government, create barriers to joint planning arrangements, or result in inappropriate planning via an NHS channel as discussed elsewhere.[i]

    Interactions with local government are alluded to but only vaguely described.  For example, the document states ‘[the proposals] will in many areas provide an opportunity to align decision-making with local government’ [our emphasis]. This is very weak. How will ICS’s that do not align geographically with local authorities function in this respect?  There is a clear risk that such multi-authority ICSs will drive a ‘one-size-fits-all’ approach across diverse communities and geographies in direct opposition to the stated aims of ‘decisions taken closer to the communities’ [para 1.9].

    Overall, it looks as though this is not a collaboration of equals. An ICS as described would be led by the NHS and the LA would be very much a secondary partner. The SHA would like to see a bigger and more equitable role for LAs.

    Devolution

    The statements on devolution such as at 1.11 can be applauded but the reality we know is that since 2011 the NHS has become more centralised. There needs to be more concrete proposals on how this devolution will occur. The mandatory nature of the proposals is a concern and there should be more local discretion within National Care Frameworks and oversight.

    Governance

    Clauses 1.12 and 1.15 are good clear summaries of what the ICS should do and provide. However, 1.16 on page 7 states that primary care, community health and mental health services, social care and support, community diagnostics, urgent and emergency care will be working together with other public or voluntary services Including those providing skills training, assistance into employment, and housing. But no consistent mechanism, structure, governance, regulatory, or accountability framework is defined for this.

    Strategic commissioning/planning (P2, third bullet point) requires the resources of a CCG and of a CSU, but the proposal appears to leave the CSU as a separate organisation (see P24, 2.68) outside of the ICS. No explanation is given for why this is better. Our view is that the CSUs were created outside of the NHS to provide a first landing place in the UK for US insurers who failed to take up the challenge. The most cost-effective route to back office services and business intelligence would be to bring them back into the NHS as shared services operations.

    These clauses do nothing to strengthen the requirement for probity in contracting and appointment procedures made scandalously apparent through court actions presently being pursued in the wake of inappropriate commissioning during Covid.

    There are poorly delineated internal and external accountability processes. As others have noted[ii], [iii] this is a consequence of a lack of precision regarding the function, roles and relationships of ICS. These issues should be clarified.

    There is insufficient detail regarding the openness and transparency of appointments, decision-making and data sharing by ICS and the role of independent sector (IS) organisations in ICSs. While we note that the Government considered ‘it likely that statutory organisations will hold the ICP Contracts’. [iv] Our understanding is that ‘accredited’ companies can be brought in to draw up policies and make service decisions within ICSs. These services could include:

      • Enterprise-wide Electronic Patient Records Systems – for Acute & Community and for Mental Health Hospitals
      • Local health and care record strategy and implementation support and infrastructure
      • ICT infrastructure support and strategic ICT services
      • Informatics, analytics, digital tools to support system planning, assurance and evaluation
      • Informatics, analytics, digital tools to support care coordination, risk stratification and decision support
      • Transformation and change support
      • Patient empowerment and activation
      • Demand management and capacity planning support
      • System assurance support
      • Medicines optimisation

    The role of independent sector organizations in this context must be more clearly defined and regulated, and subject to governance appropriate to a public body. Where possible the NHS should provide such services and/or be empowered to provide any such expertise. We do not agree with private companies being brought in as decision makers. They are bound by law to maximise shareholder profit, not to provide a public service.

    In addition, the document does not address the potential difficulties arising from the requirement on ICS organisations to comply with various competition rules, such as not sharing commercial sensitive information or fixing prices.  For multi-site ICS providers, this presents a system risk in terms of having to share patient and staff data or information with other organisations.  In general, insufficient attention is given to issues around sharing personal health information by ICSs.

    Guidance should be also clearer on the overriding importance of transparency in ICSs decision making. Efforts should be made to limit the use of ‘commercially sensitivity’ as a spurious justification for subverting transparency.

    There is insufficient consideration of potential conflicts of interest within the proposed ICS (e.g. between providers and commissioners, or between public, voluntary, and commercial partners) and how these can be prevented or mitigated. Notably it has been suggested that providers will be able to influence allocations via the ICS partnership board, and there is a credible concern that ‘bigger players’ will skew funding decisions.[v]

    Governance and PCNs

    1.17 mentions PCNs but the regulatory framework through OfSted for children’s services, CQC, NHSE/I, is currently not fit for purpose because it is overlapping and contradictory. There is no governance framework at the moment for PCN collaborations with community and mental health Trusts, and accountability is difficult to pin down.

    Data

    The paper promises to invest in the infrastructure needed to deliver on the transformation plan. This will include shared contracts and platforms to increase resiliency, digitise operational services and create efficiencies, from shared data centres to common EPRs.

    Digital is essential to the current and future NHS. SHA warns against the vaunted flexibility of the transformation plan allowing personal data to be misused by commercial interests even more than it is now. SHA also warns against services rushing into digital solutions without adequate evaluation and without enabling non-digital solutions for those who still require them.

    Health Creation is not mentioned in this paper.

    SHA supports the concept of Health Creation. That is the process of bringing people in contact with each other, building confidence and thereby enabling communities to take more control of their area and their health and care.

    An option we would like to see would be mandating 1% of a PCN’s budget to community strengthening – population Health Creation

    Population health, but almost no mention of Health Inequalities

    There needs to be a clear vision of the metrics of “population health” especially if this it to be the main outcome or “productivity” upon which the NHS and its partners is being judged. The consultation  paper seems silent both  on what these metrics are and on what role the NHS is to play in delivering that outcome. For example, is the metric of population health a pre-determined blend of longevity and the quality of life delivered?  To what extent is managing the ” social determinants of health” to be allied with the NHS as opposed to being the task of wider government and indeed others?

    “Integrating Care” does not really explain “population health”, but the HSSF is more explicit:

    “Population Health Management is an approach aimed at improving the health of an

    entire population and improves population health by data driven planning and delivery

    of care to achieve maximum impact for the population.”

    Any concept of patients and staff planning and evaluating the service, which will involve decisions on what to prioritise, is absent. Instead, the HSSF accredits corporations to support an ICS in taking such decisions. We should propose a 5th principle on the necessary need to involve patients in these arrangements. There is good evidence that such effective engagements lead to better services.

    In practice the emphasis on the role of Foundation Trusts and clinician-leadership is likely to prioritise clinical service provision, whether primary or secondary care, with limited focus on prevention and population health. This is an inherent structural weakness of the ICS model as currently specified.

    SHA cannot support ICSs without a far clearer commitment to tackling health inequalities through tackling the wider determinants of health and working closely with LAs, housing and other key partners. The document states that greater co-ordination between providers at scale can support… ‘reduction of health inequalities, with fair and equal access across sites;’. It is not clear how this follows as no mechanism linking these two is articulated. Vague commitments as outlined in the document are inadequate to address this persistent and worsening problem. Specific goals and mechanisms for reducing health inequalities should be explicit in the proposals.

    Single pot for finance and the legislative proposals
    On the face of it, a single pot (2.40), linked with reducing the importance of competition seems like a significant step forward and a more equitable and efficient approach to funding. SHA is supportive to the extent that these proposals reduce the contract negotiation and monitoring which is so wasteful of time and effort in the NHS, with savings in overhead costs and improvement in services designed by providers aiming at better outcomes, not by commissioners principally aiming to reduce expenditure. There must be appropriate risk sharing because of the danger that an individual ICS could be destabilised by unforeseen and one off events.

    It is not clear how this single pot will be spent, assuring fairness, value for money, quality.

    At 2.47 there is a limited mention of capital. There is no mention in the document of NHS Property Services or Community Health Partnerships or the NHS Estate. This is a major weaknesses in the proposals.

    Taken together with “Integrating Care”, this makes clear that fixed payment to secondary care providers must conform to the ICS system plan. Initially , the fixed payment would be based on the current block payments under the heading of COVID-19, which make up the majority of current CCG budgets. Fixed payments will be determined locally. While national tariffs will no longer apply in general, they may be retained for diagnostic imaging, a highly privatised sector. Some elective activity, again involving the private sector, will also be exempt from blended payment. In other words, private sector suppliers of clinical services will be protected from any local cost reductions.

    However, we also see impossible control totals which will make investing and innovation extremely difficult and constrain ICSs for the future. In effect, this continues austerity. We want to see comprehensive funding for an expanding, publicly funded NHS.

    Allusion is frequently made to anticipated cost savings and efficiency improvements [paras 1.8, 1.9, 2.22, 2.46, 2.51] but it is unlikely that these will be realised in the short-term and short-term costs may even increase.[vi] Evidence from similar interventions in the UK and other countries provides at best equivocal evidence for longer-term improvements in efficiency.[vii], [viii], [ix] Quality rather than cost-savings should be the primary driver of any reorganisation.

    There are other concerns SHA has in respect of the apparent relaxation of privatisation.

    All clinical services should be retained in house and fall under a re-instated duty of the Secretary of State for Health to PROVIDE such services.

    Providers will still be able to use the private sector. There are contracts now through NHS Shared Business Services which appear to require no formal tendering.

    Beware of cementing existing privatisation. This can happen through sub-contracting as above and by current private sector providers expanding through what ever contracting process there may be. The most likely beneficiary is likely to be the privatisation of mental health services through the Priory and similar organisations.

    Backroom functions will continue to be privatised.

    “Integrating Care” never mentions “private”, “independent sector” or “third sector”. The document

    uses a new codeword, namely ‘others’. This suggests that NHSE fully expects the private sector to play a most important part in the future, including for clinical services. (NHSE/I “Integrating Care” KONP)

    Covid has shown us, if we needed showing, that a truly nationalised health and social care service is needed and vital, with the advantages of national estate agility, workforce planning, driven by a national public health strategy to invest in the social care infrastructure of the national economy, whilst local partnerships freed of wasteful market practices are responsible for local delivery and can be locally accountable.

    Staff

    Whilst the fixed payment would be determined locally, neither “Integrating Care” nor

    “Developing the payment system” refer to national agreements on wages, terms and conditions.

    The SHA is very concerned that, despite papers on responding to the staffing problems, we have not seen any recommendations for comprehensive staffing programmes that support pay justice and adequately protect workers.

    Despite discussion emphasizing the key role of the workforce in effecting these changes, mechanisms to allow direct representation of workers or their trade union spokespersons on ICS are entirely lacking in the proposals.

    Any proposal for ICSs should make explicit commitments to ensuring that all workers receive the National Living Wage (and preferably the real Living Wage) whether they are employed by the NHS or by subcontractors to ICSs. ICSs should commit to abolition of zero hours contracts in all its activities.

    Democracy

    Despite frequent criticism of ICSs as being distant from communities and undemocratic (as indeed is the NHS as a whole), this paper gives little confidence for any significant democratic change. Healthwatch is not sufficient, too health focused and with too few teeth.

    SHA would like to see financial transparency, accountable to communities. SHA would like to see ICSs exploring the opportunities for participatory democracy – such as community development, citizens forums, coproduction networks.

    “Current ICS arrangements are outrageously disconnected not only from real democratic structures but also from real centres of identity and community. They are administratively defined and they are under the control of officers who are not accountable to local people.

    What I would like to see is NHS Sheffield accountable to the local people of Sheffield (and likewise for other communities). It is totally inappropriate to leave accountability and governance of supposedly statutory bodies open to development and interpretation by officers of the ICS. All the assets of the ICS should be treated as public assets, especially all the capital assets and these must all be put under local (not national) control.” Duffy, SHA member

    With many thanks to all those SHA members who generously contributed to this response.

    We have also drawn on documents from Keep Our NHS Public and the Local Government Association.

    [i] Integrating care: Next steps to building strong and effective integrated care systems. Local Government Association (https://www.local.gov.uk/parliament/briefings-and-responses/integrating-care-next-steps-building-strong-and-effective accessed 23/12/20)

    [ii] Delivering together: Developing effective accountability in integrated care systems. NHS Confederation/Solace (https://www.nhsconfed.org/-/media/Confederation/Files/Publications/Delivering-together-FNL.pdf accessed 22/12/20)

    [iii] Integrated care systems (ICSs) (https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/integration/integrated-care-systems-icss accessed 24/23/20)

    [iv] Government response to the recommendations of the Health and Social Care Committee’s inquiry into ‘Integrated care: organisations, partnerships and systems’ Cm 9695 (https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiJw-_Dt-ztAhWkoVwKHXuRAkIQFjAAegQIARAC&url=https%3A%2F%2Fwww.gov.uk%2Fgovernment%2Fpublications%2Fgovernment-response-to-the-health-and-social-care-committees-report-on-integrated-care&usg=AOvVaw2k1pzGscqk30BYEL_QbNJt accessed 26/12/20)

    [v] On the day briefing: Integrating care, NHS England and NHS Improvement. NHSProviders 26 November 2020 (https://nhsproviders.org/media/690689/201126-nhs-providers-on-the-day-briefing-integrating-care.pdf accessed 26/12/20)

    [vi] House of Commons Health and Social Care Committee Integrated care: organisations, partnerships and systems Seventh Report of Session 2017–19 (https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwjb-oSstuztAhUNYsAKHabDDoYQFjAAegQIBBAC&url=https%3A%2F%2Fpublications.parliament.uk%2Fpa%2Fcm201719%2Fcmselect%2Fcmhealth%2F650%2F650.pdf%3Futm_source%3DThe%2520King%2527s%2520Fund%2520newsletters%2520%2528main%2520account%2529%26utm_medium%3Demail%26utm_campaign%3D9379676_NEWSL_ICB%25202018-06-13%26dm_i%3D21A8%2C5L1EK%2COYZ6AS%2CM5X8X%2C1&usg=AOvVaw0-ZVcp3j_Sh049yv9kdNTA accessed 26/12/20)

    [vii] John Lister, How Keep Our NHS Public should be campaigning on Integrated Care Systems. November 24 2020. (https://keepournhspublic.com/resources/how-keep-our-nhs-public-should-be-campaigning-on-integrated-care-systems/ accessed 26/12 20)

    [viii] Government response to the recommendations of the Health and Social Care Committee’s inquiry into ‘Integrated care: organisations, partnerships and systems’ Cm 9695 (https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&cad=rja&uact=8&ved=2ahUKEwiJw-_Dt-ztAhWkoVwKHXuRAkIQFjAAegQIARAC&url=https%3A%2F%2Fwww.gov.uk%2Fgovernment%2Fpublications%2Fgovernment-response-to-the-health-and-social-care-committees-report-on-integrated-care&usg=AOvVaw2k1pzGscqk30BYEL_QbNJt accessed 26/12/20)

    [ix] Scobie S (2019) ‘Are patients benefitting from better integrated care?’, QualityWatch blog. Nuffield Trust and Health Foundation. (www.nuffieldtrust.org.uk/news-item/are-patients-benefiting-from-better-integrated-care accessed 26/12/20)

    SOCIALIST HEALTH ASSOCIATION RESPONSE TO ICS CONSULTATION 7 1 21

    2 Comments

    ICS have been introduced and developed undemocratically, without consultation and with a lack of transparency.  Their aim is to impose ‘reduced per capita cost‘ control totals to force unproven and unsolicited  innovation, including elements of privatisation and paid for care, in each system’s struggle to meet local population need. This has been NHSE/I’s practice with individual Provider Trusts over recent years. Each ICS will form a new Integrated Care Provider (ICP) organisation. NHS England plans for ICP organisations to be managed through commercial contracts. We therefore call on government to ensure that:

    1. Local Authority Scrutiny Committees across England be allowed to fulfil their legal responsibilities to scrutinise fully the significant changes in NHS services that have been initiated without scrutiny under the COVID-19 emergency measures before they become any permanent part of ICS development. If the Committees decide that the changes require full Public Consultation then this must also happen before the changes are allowed to remain. These actions are well established legal process.
    2. Some democratic representation is created in the Governance structures of ICSs by: i) an increase in Local Authority Councillor representation on the Governing Bodies so as to match in numbers the NHS representation (Partnership) and ii) full public engagement and involvement for all significant changes and developments in the NHS, with full Consultation as well on the more major issues as decided by the Scrutiny Committees which have been set up in our democracy for this purpose.
    3. In the longer term there must be a return to universal risk pooling and funding with renewed efforts for National equity of care and National decisions about affordability. ICS must be replaced by Health Boards with the return to geographically based responsibility for the delivery of health to local populations. The apparatus of the market that divides the NHS must be dismantled. Health Boards as public, accountable bodies would plan and provide the full range of NHS services, with participation from elected councillors, community organisations, Neighbourhood Health Committees as advocated in our paper “Public Health and Primary Care” andtrade unions. The quality of services would then be monitored by locally-based independent bodies involving local patients and community groups, with the powers once enjoyed by Community Health Councils.

    Dr  Jackie Applebee

    Chair Doctors in Unite

     

    4 Comments

    What happened during the first wave of Coronavirus and what can be done about it

    In the first wave of the Coronavirus pandemic, mortality rates for people in care homes were shockingly high. Many people living in residential care and nursing homes have cognitive impairments that make it hard for them to agree to their living conditions. In the spring and summer of this year, rights-based legal safeguards designed to protect people seem to have been ignored or set aside. The NHS and adult social care services are currently bracing themselves for a second wave. This article asks whether the safeguards are likely to be more robust this time around, and what can be done to ensure people’s rights are upheld in the future.

    ***

    According to the Office for National Statistics, there were 19,394 Covid-related deaths among care home residents between 2/3/20 and 12/6/20. About half the people in this group were recorded as having a pre-existing condition of dementia. Many will have been assessed as not having the mental capacity to decide where to live, and consequently should have been subject to Deprivation of Liberty Safeguards (DOLS).

    DOLS were introduced in 2009 after a landmark case in the European Court of Human Rights. Deprivations of liberty can be authorised by local authorities where they are proportionate, where there is no reasonable alternative, and critically where they are in people’s best interests. Local authorities have always lacked the resources to process applications, and backlogs began to build up as soon as the safeguards were introduced. Another legal ruling in 2014 held that many more people were being deprived of their liberty than had initially been supposed, putting even more pressure on the system. In 2019 the law was amended to introduce a new, speedier system, though this was contentious because it allowed care home managers a greater role in deciding whether deprivations were necessary or proportionate. This had been due to come in this month (October 2020), but implementation has now been put back to April 2022.

    During the first wave of the pandemic, the larger numbers of people moving into care homes should have resulted in a bigger figure for DOLS applications. Instead, the Care Quality Commission (CQC) recorded a 31% reduction in DOLS applications between April and June 2020 compared to 2019. It seems that the requirement to ensure that restrictions were in people’s ‘best interests’ was being quietly ignored. As well as considering the rights of the 25,000 or so people who were discharged from hospital to care homes with Coronavirus, it’s also important to consider the risks to the much larger number who were already resident. As care home staff struggled to prevent cross-contamination with inadequate PPE and high levels of staff sickness, many residents were confined to their rooms in accordance with government advice. The Mental Capacity Act 2005 may only be used to confine people in their best interests; where the deprivation is for public health purposes different provisions should have been used. Research by Dr Lucy Series showed that public health provisions were only applied a handful of times. The point here is not to second-guess the actions of staff who were clearly doing their best to manage under very difficult circumstances, but to ask ‘What’s the point of legal safeguards if they can just be ignored?’.

    In June the Equality and Human Rights Commission recommended that  the “ … Government should urgently undertake or commission a review into deaths in care homes during the pandemic, in line with its equality and human rights obligations…”. One would have expected that in the pause afforded after the first wave of infections, lessons would have been learned and changes made.  Instead we have an adult social care winter plan that promises (but has not yet developed) a “…designation scheme with the CQC for premises that are safe for people leaving hospital who have tested positive or are awaiting a test result.” It seems that the government is anticipating that people with the virus will be discharged into care homes, but a process for this to be safely managed is not yet in place. At the same time revised guidance that suggests that where new restrictions are imposed to prevent cross-infection “…in many cases [they] will not be…” new Deprivations of Liberty. However, considering the significantly greater risk of mortality under these circumstances, it seems at least reasonable to question whether the original judgements about what is in a person’s best interests would still be valid.

    ***

    The specific issue of DOLS is one of a large number where human rights seem to have been set aside during the initial Coronavirus outbreak. A report from Amnesty International published earlier this week found that the “…UK government, national agencies, and local-level bodies have taken decisions and adopted policies during the COVID-19 pandemic that have directly violated the human rights of older residents of care homes in England—notably their right to life, their right to health, and their right to non-discrimination.” Early on in the Pandemic there was concern that the frailty scale being used to decide whether people would get life-saving treatment was being used inappropriately with younger disabled groups, leading DHSC to issue urgent ‘clarification’. Last week the CQC was asked by DHSC to review the way that Do Not Attempt Resuscitation (DNAR) notices were used by clinicians. ONS data re-analysed by Prof. Chris Hatton shows in-patients with autism and learning disabilities were subjected to more restraints during the pandemic. Organisations such as Inclusion London, Inclusion Scotland and Disability Rights UK have highlighted linked concerns among other groups of disabled people. During the outbreak the majority of disabled people experienced difficulties accessing basic care, medicines and food. Many of these organisations have joined the EHRC and Amnesty in calling for an inquiry into the events of this year, and ultimately for stronger legal guarantees.

    Another important lesson relates to funding. The lack of social work capacity for DOLS authorisations, wider under-staffing and poor pay in the care sector, and the absence of alternatives to ‘congregate’ care have all contributed to the events described in this article. Adult social care services have been subjected to growing demands and reduced resources for over a decade. Why is it that vital local social care services are still facing massive financial shortfalls at the same time that central government is putting record sums into the NHS and privatised test-and-trace services? An urgent solution to funding in adult social care is also a necessary component of any solution. Many argue that this will only be politically viable when social care is seen not as a destination but as a vehicle for helping the people we are and the people we love to lead rich and full lives. These three strands – a brighter vision, a new financial solution, and stronger support for human rights – can form a common ground for campaigning and activism that can help us future-proof social care against similar crises in the future.

    Jon Hyslop, Oxfordshire Branch, 19/10/20

    3 Comments

    A GREAT LAUNCH OF THE SHA/KONP CAMPAIGN TO END THE CRISIS IN SOCIAL CARE

    On 10th October, SHA joined forces with Keep Our NHS Public, with the support of WeOwnIt,

    to launch our campaign to transform social care.

    Watch it here

    https://www.youtube.com/watch?v=wsDY7q-rVYM&feature=youtu.be

    With over 280 people registering, it was clearly a popular and vital issue.

    The day before, a poll conducted by Survation and commissioned by WeOwnIt showed that 64% of respondents said they wanted to see care homes run by public bodies. 61% believe that private care providers prioritise profit over delivering a high quality service.

    Participants heard excellent and meaty contributions from Unison and GMB, outlining their policies on social care and the currents fights for pay justice.. Two disabled speakers offered an insightful summary of independent living and democratic co-design of services with users. The National Pensioners Convention summarised their recent publication “Goodbye Cinderella” focusing in the benefits for older people of a coordinated National Care Service. The leader of Hammersmith and Fulham Council described how they have provided free homecare and Barnet Council Labour Group showed how they have been challenging their Tory council to deliver the real spirit of the Care Act, not merely it shadowy form.

    The Women’s Budget Group offered a powerful justification for a new economic settlement based around a caring society and showed how investing in social care reaps huge economic, health and care dividends.

    Finally John McDonnell spoke clearly and passionately about the need for a National Care Service, based on the campaigns key demands. He also warned that the Tories may offer up an insurance-based service as a route to shoring up the shaky private sector market in social care.

    Speakers endorsed the 7 demands of our campaign:

    1. National Care Support and Independent Living Service (NaCSILS)
      The Government shall have responsibility for and duty to provide a National Care and Supported Living Service to provide care, independent and supported living, adopting into English Law Articles from the UN Convention on rights of disabled people that establish choice and control, dignity and respect, at the heart of person-centred planning.
    2. Fully funded through government investment and progressive taxation, free at the point of need and fully available to everyone living in this country.
    3. Publicly provided and publicly accountable:
      The NaCSILS will have overall responsibility for publicly provided residential homes and service providers and, where appropriate, for the supervision of not-for-profit organisations and user-led cooperatives funded through grants allocated by the NaCSILS. A long-term strategy would place an emphasis on de-institutionalisation and community-based independent and supported living. All provision will deliver to NaCSILS national standards. There will be no place for profiteering and the market in social care will be brought to an end.
    4. Mandated nationally, locally delivered:
      The Government will be responsible for developing within the principles of co-production, a nationally mandated set of services that will be democratically run, designed, and delivered locally. Local partnerships would be led by stakeholders who are delivering, monitoring, referring to or receiving supported services or budgets, e.g. organisations representing disabled people (DPOs), older people, and people who use mental health and other services, in partnership with local authorities and the NHS.
    5. Identify and address needs of informal carers, family and friends providing personal support:
      The NaCSILS will ensure a comprehensive level of support freeing up family members from personal and/or social support tasks so that the needs of those offering informal support, e.g. family and friends, are acknowledged in ways which values each person’s lifestyles, interests, and contributions.
    6. National NaCSILS employee strategy fit for purpose:
      The NCSLS standards for independent and supported living will be underpinned by care and support staff or personal assistants who have appropriate training, qualifications, career structure, pay and conditions to reflect the skills required to provide support services worthy of a decent society.
    7. Support the formation of a taskforce on independent and supported living with a meaningful influence, led by those who require independent living support, from all demographic backgrounds and regions. This would also make recommendations to address wider changes in public policy.

    Many people were unable to get into the meeting because it was oversubscribed. It is clear that this is a vital issue that resonates strongly with the public and that this is the most propitious time for such a campaign.

    If you were unable to attend , watch the event here

    https://www.youtube.com/watch?v=wsDY7q-rVYM&feature=youtu.be

    We shall now consider actions over the next few months that could include petitions, motions to the Labour Party, work with Parliament, continued discussion with the Shadow Health and Social Care Team.

    JOIN US!

    WE CALL ON SHA BRANCHES FOR SUPPORT

    THERE WILL BE A FOLLOW-UP MEETING ON 2ND NOVEMBER TO PLAN OUR NEXT STEPS

    Details will follow

     

     

     

    Comments Off on A great launch of the joint SHA/KONP social care campaign

    Former Health Secretary, Jeremy Hunt, probably Britain’s worst leader since General Percival surrendered an army of over 80,000 soldiers to 36,000 Japanese soldiers at Singapore in 1942. It was the worst ever British defeat and led directly to the dreadful Japanese concentration camps. Hunt was in charge of over a million highly committed NHS professionals with oversight of Social Care, looking after nearly a million people. He surrendered these to a succession of debilitating neo-liberal reorganisations, privatisations and defunding regimes. Like Percival he could have fought for his people, but chose not to, and England is paying a high price.

    Percival’s reward was the pension of a Major General. Some think Hunt’s reward may be selected as the next Prime Minister. Think again.

    Apart from his duplicity with data, his bullying of Junior Doctors, and his hypocrisy in praising the NHS and shrinking nurse’s pay, there is the question of his ability to manage. Managerial incompetence is a common trait in this Conservative government, as exemplified by Grayling, Hancock, the Prime Minister, Priti Patel and others in the Cabinet.

    Hunt the manager.

    In every good organisation there are key performance indicators whose sole function is to help the executive steer the organisation most effectively. In British Rail one was trains on time. The purpose was to keep the passengers safe and satisfied, as the most important need was reliability, not speed, as the politicians keep getting wrong.

    A key indicator in Social Care was the performance of transferring patients from the hospitals back into their homes and care homes. The indicator was called Delayed Transfer of Care (DToC), which meant that something was preventing the patient from being discharged when they were better. It was measured by the month. It was a very important indicator, for two main reasons:

    • Cost: Each time the transfer from the hospital failed on average it causes up to 31 bed delays, i.e. unavailability. The cost of this is about £400/day, compared with £90/day in a home. So each DToC generates a net loss to the NHS of at least £300×31, i.e. about £9,000. At the time of Hunt’s appointment these Social Care DToCs were averaging 1050/month – a net loss of £9.5 million per month and steady.
    • Care: Patients who are well enough to go back get more ill if they stay in hospital, especially if they are elderly, thus occupying beds for much longer. They also require extra attention from busy nursing staff who are not always used to dealing with the elderly. There is also an increased risk of readmissions.

    The Department of Health details reasons for these delays, 40% of which are generated within Social Care. These are the major reasons, respectively: Awaiting Care Package at Home, Awaiting residential home placement or availability, and Awaiting nursing home placement or availability. As all these delays generate extra bed demands in Acute Care as well as, so to address these immediately would be a win/win, an act of intelligent leadership, especially for an opportunist like Hunt.

    Now, the bad news for Hunt: He has no organisational leadership qualities at all, especially when it comes to doing what is best for the organisation, i.e. the good of the users, the employees and the community. If he had he would have predicted a serious problem emerging in social care, and consequently a rise in the transfer of social care patients into acute care.

    Hunt became Secretary of State for Health in 2012. At that point Care DToCs were running at 1050/month, but trouble was on the horizon. Back in 2011 Nicholson, the CEO, set the NHS and Social Care the challenge of taking out £18 – £20 billion by 2014. Why? It was a classic act of hubris which of, course, the health system paid for. It was to be efficiency savings; but how? The care system was short-staffed, underfunded and, because of the privatisation, in negative productivity. Overworked and underpaid staff, the main source of innovation, were in no position to study ways of improvement. Morale was falling and the staff turnover was 27%.

     

    Hunt should have stopped it, but did not care, or have the nous – or else was confusing fewer staff per user as a sign of efficiency. Either way he should have kept his eye on the statistics. Social Care is a major driver of demand in the NHS. The better the care, the lower the rate of admissions into Acute Care: a very simple equation.

    By 2015 there were ominous signs. The rate of DToCs was beginning to rise in a statistically significant way. The trend was clear. The average was rising to 1250, a 19% increase. Any executive worth their salt would have instituted an instant investigation. Hunt did not. His NHS 10 Point Efficiency Plan mandated the “freeing up about 2000 to 3000 beds by ceasing DTOC delays in social care.” Just like that, like Napoleon instructing his troops to conquer Moscow – winter. There was no strategy, no plan that mapped out the route. Just an edict, and like Napoleon, thing got a lot worse.

    The average for the years 2016 to 2018 rose to 1900 DToCs, 80% greater than in 2012 – so much for “ceasing” DToC delays. It was not a plan but a target, and a silly one. This is worth unpacking. In five years Hunt oversaw an increase of about 900 DToCs from the Care sector alone. This is an increased loss of £8.1 million per month, or close to £100 million a year.

    Just how many staff in Social Care would that have paid for at £25,000 a year? The turnover would have stopped, the facilities enhanced (including private care) and morale and user satisfaction improved.

    These cold statistics disguise the misery of the people involved, nurses, carers, families and, most of all, the users, mainly the elderly. As Neil Kinnock said prophetically of the Tories if they got in:          I warn you not to fall ill, and I warn you not to grow old.”

    In summary, in the first three years of his appointment the total loss due to DToCs was £114 million a year. In 2015 Hunt sat on his hands, no doubt transfixed by Stevens’ unnecessary reorganisation along USA private care lines. Over the next three years the total loss would be £205 million per annum. The damage to the NHS and Social Care is incalculable. And remember we are only looking at 40% of all the DToCs, i.e. half a billion pounds a year. Much of that could have gone into PPE stock replenishment.

    A final irony: In Hunt’s 2016/17 NHS 10 Point Efficiency Plan the target mandated was to “reduce Delayed Days to 4000/day, which translates into 124,000 per month by September 2018”. This equates to 4000 Delayed Transfers of Care per month across the NHS and Social Care – a figure that is actually higher (worse) than they had been achieving regularly in 2010 – 2013! But what makes it even more damning is that it was, statistically, an unachievable demand. The average for 2016/17 was 4560 DToCs and the lower control limit was 4995, which meant that statistically there was less than a 1/1000 chance that it could be achieved. Setting unachievable targets is feature of Hunt’s tenure. Caroline Molloy details these in her withering assessment of Hunt in her article What did Hunt do to the NHS – and how has he got away with it? (Open Democracy, July 13, 2019).

    Matt Hancock now grasps the poisoned chalice Hunt has handed him. Luckily he is an optimist and probably sees it as a great opportunity. One day he may also be rewarded with the Chair of the Health and Social Care Select Committee like Hunt, for the utter failures, especially the disaster of his outsourcing of test and trace to private companies (0ver £10 billion), greatly exacerbating effects of the terrible Covid-19 pandemic in 2020.

    Dr John Carlisle

    Chair, Yorkshire SHA

    Comments Off on Jeremy Hunt, the incompetent ideologue

    The Welsh Government is proposing to use its legislative powers to require local authorities and Local Health Boards to  produce a market stability assessment report on the social care sector  in their Regional Partnership Board (RPB) area.

    The legislation will be supplemented by a code of practice on the exercise of relevant functions in relation to market stability reports and statutory guidance on taking a partnership approach to preparing and publishing market stability reports.

    This innovative piece of legislation is welcomed by the Social Health Association Cymru – Wales which has responded to the Welsh Government consultation document.

    ================================================================

    Response to Welsh Government Consultation by Socialist Health Association – Cymru / Wales


    What do we want to know? Welsh Government would welcome comments on the draft regulations, code of practice and statutory guidance from local authorities, local health boards, and other organisations or sectors which are represented on RPBs or have an interest in the provision of care and support to the local population.
    It would also welcome comments from members of the public, including especially individuals who need care and support, and carers who need support. In particular, we would welcome responses to the following questions:


    Question 1 Do you agree that market stability reports should be prepared on a regional basis, by local authorities and local health boards through the regional partnership boards? If not, please give your reasons.

    A.    The Socialist Health Association Cymru believes that the business model underpinning our social care service in Wales is no longer sustainable and we need to be planning for a National Care Service.

    The independent sector continues to express concern about its marginal viability with residential care providers requiring levels of bed occupancy that go against the Welsh Government’s policy of more care in a domestic and homely community environment.

    There is a recruitment and retention crisis which is worse in the independent sector due to poorer pay and conditions, less training and fewer opportunities for career progression.

    Within this context we believe there is an urgent need to undertake regular assessments of the continuing viability of the current model of provision.

    While the consultation document proposes reports on a regional basis, it important that the geographical spread of provision in mapped at a more local level.


    Question 2 Do you agree that market stability reports should be produced on a five yearly cycle alongside the population needs assessments? If not, what alternative arrangements would you propose, and why?

    We note that the proposals recommend that a five year assessment cycle with at least a mid-cycle interim review.

    A.   We believe that the overall fragility of the sector requires a three yearly overall assessment with a yearly review.


    Question 3 Have we specified all the key matters that need to be included in market stability reports? If there are other matters you think should be included, please specify.


    A.   While we are fully aware of the sector’s legacy of being heavily dependent on for-profit providers, we are surprised at the failure of the consultation document to consider what role public bodies might play in service provision. This is only briefly mentioned in the context of a sudden closure of an established private sector provider.

    The omission is all the more surprising as it recommended that the assessments should be linked the to Regional Partnership Board needs assessment.

    The implicit assumption is that local authorities will have no role in the management or shaping of the market beyond its present contract compliance assessments. This means that it will be for others to address gaps in service provision.

    The variation in local authority fees across is Wales in considerable. It is far from clear why this is the case though these fees are at the heart of any assessment of the viability of the sector.

    Question 4 Do you agree that market stability reports should be kept under regular review and revised as necessary, but at least at the mid-way point of the five year cycle? If not, what other monitoring and review arrangements would you propose, and why?

    A.  See reply to Q2


    Question 5 In your opinion, does the draft code of practice strike the right balance between what is required of local authorities and what is left to their discretion? Are there further requirements or guidelines you would like to see added, or other ways in which the document might be improved?

    A.    The document urges “reasonable” efforts for community engagement. This is a rather elastic requirement which could result in a minimum level of engagement. It would be useful to be more specific that efforts should be made to engage with organisations such as the CarersUK, Stroke Association, Alzheimer’s Society, Mind as well as any successor organisation to Community Health Councils.

    There should be a specific reference made to any community councils in the Regional Partnership Board area.

    There only the most fleeting reference to engagement with care staff and other support / partnership professional groups. There should be a clear requirement to engage with local trade unions involved in the Education, Health & Care Sectors e.g. Unison, GMB Unite the Union, RCN, NEU and Local Medical Committee. In some areas, where there may be low levels of trade union membership, the local trades union council ( if it exists) should be consulted.

    Local groups of faith should also be specifically included in any engagement. They provide comfort and support to many of our citizens in times of difficulty and they can have important insights into the needs for particular communities.

    Question 6 In your opinion, does the draft statutory guidance set out clearly the partnership approach that local authorities and local health boards should take in preparing their market stability reports? Are there further requirements or guidelines you would like to see added, or other ways in which the document might be improved?

    A.  See replies already given.
    The document mentions the need to anticipate trends but is rather limited in the scope of the horizon scanning it envisages. This is a vulnerable sector underpinned by a fragile business model. It follows that more vision is required in looking at delivery models of care e.g. more in-house provision by public bodies, the NHS or the Third Sector.

    Question 7 What impacts do you think our proposals will have on the duties of public bodies under the Equality Act 2010, or upon a local authority’s duty under the 2014 Act to have due regard to the United Nations Convention on the Rights of the Child, the United Nations Convention on the Rights of People with Disabilities, or the United Nations Principles for Older People?

    A.   This is a timely document and Welsh Government is to be commended in initiating this legislation. Not withstanding the attitude of the Westminster Government to international agreements the Welsh Government has always used best international standards to drive policy.

    A citizen focused, responsive, stable and caring service needs to be in place to meet international standards. This must include provision that is based on the needs and wishes of its users. The workforce must be well trained and valued.

    None of this will be possible if overall business model of care is not longer fit for purpose for the challenges of the 21 Century.

    Question 8 We would like to know your views on the effects that our proposals with regard to market stability reports would have on the Welsh language, specifically on opportunities for people to use Welsh and on treating the Welsh language no less favourably than English. What effects do you think there would be? How could positive effects be increased, or negative effects be mitigated?

    A.   This is particularly important. Bigger, footloose corporate bodies have a smaller footprint in Wales which is generally a good thing. Smaller, local providers with a local workforce are more likely to be culturally sensitive to their needs of citizens.

    In many parts of Wales the local population will include people who have spent most of their lives in an area and others who have moved in at various stages of their life cycle. Our providers must respond to this diversity.

    Many vulnerable users would wish to engage with services in their first language. The planning and service delivery process must be responsive to this need.

    The Welsh language is an important part of Welsh life. As well, individual communities have other cultural attributes which can provide support and comfort to local service users which should also be factored into a citizen centred service.

    Question 9 Please also explain how you believe the proposed policy around market stability reports could be formulated or changed so as to have positive effects or increased positive effects on opportunities for people to use the Welsh language and on treating the Welsh language no less favourably than the English language, and no adverse effects on opportunities for people to use the Welsh language and on treating the Welsh language no less favourably than the English language.

    A.   See Q8.

    Market stability reports should include a specific section demonstrating how the needs of Welsh speakers and other sensitive cultural dimensions are taken into account.


    Question 10 Under the Well-being of Future Generations (Wales) Act 2015, public bodies have a duty to consider the long-term impact of their decisions. We would like to know to what extent you think our proposals will support the principle of sustainable development set out in that Act. Further information on the Well-being of Future Generations (Wales) Act 2015 may be found here: https://www.futuregenerations.wales/about-us/futuregenerations-act/

    A.   Our health and care service is still too illness and crisis orientated. It needs to be more pro-active and enabling for all our citizens.

    Beyond the immediate pressures of Covid-19 and the longer term legacy we have inherited, the Welsh Government needs actively to promote a policy of prevention and early intervention to create a more equal and socially just society that is at ease with itself.

    This includes providing our young people with the best start in life, providing all citizens with the opportunity to live full and enjoyable lives and providing a healthy ageing strategy including tacking loneliness and social isolation for citizens as they progress through life.

    Question 11 We have asked a number of specific questions. If you have any related issues which we have not specifically addressed, please use this space to report them. Please enter here.

    A.   SHA Cymru welcomes this proposal to assess the inputs into service provision other than in crude quantitative ways. This approach could be extended to other field of policy e.g. to assess the scope and scale of service provision in different communities and localities.

    Our Chief Medical Officer has often pointed out that “one size does not fit all”. Different communities have different needs. If we are to address these varying needs at a community level we need to develop processes which could be informed by the lessons learned from implementing this legislation.

    Comments Off on ASSESSING THE VIABILITY OF THE SOCIAL CARE SECTOR — Response to Welsh Government Proposals


    The current business model for social care in Wales, like the rest of the UK, is under extreme pressure. This vulnerability has predated the present Covid-19 pandemic. Care Forum Wales, the main representative body for the private care sector, has claimed that Wales could lose half its care homes within a year unless urgent action is taken. A Care Forum Wales survey also reported that 84% of respondents said low pay made it difficult for the recruitment of staff. Responding to these long standing concerns the Welsh Government commissioned the Welsh Institute for Health and Social Care to study the variation in terms of employment in the social care sector in Wales.

    The study looked at the comparative experience of various social care sectors in Wales including local authorities, independent sector and the NHS. There were (2017) approximately 1350 providers in the independent sector with a workforce of 52,500 and 130 local authority services with a workforce of 11,000. While the study showed variation within sectors there were also important overall differences between the sectors which could account the differing sectoral work experiences.

    The median minimum basic pay for front line independent sector care workers was 18% less that for local authorities (£9.74/hr) and 9% for NHS. The differences for maximum basic pay were 32% less for independent sector workers compared to local authority staff (£11.88) and 18% less for NHS health care support workers. Independent sector care supervisors received 32% less in their median minimum basic pay compared to local authority supervisors (£13.37/hr) and 78% in their median maximum basic pay ( LA supervisors £18.03/hr) . In addition the public sector workers were much more likely to receive pay enhancements for pensions and activities such as weekend shifts, holiday cover and over-time.

    Compared to 55% of independent sector front-line workers about 25% of local authority staff were in permanent full-time employment while 23% in independent sector were permanent part-time posts compared to 51% in public sector. However there were less differences in more senior posts across the sectors. About 20% of front-line care workers across the independent, local authority and NHS had the equivalent of zero hours contracts. There was some evidence that not all staff were unhappy with the relative flexibility these contracts provided.

    The report confirmed that recruitment, retention and staff turnover is a problem for the sector as a whole. While all had concerns about the recruitment and retention of staff this was greatest in the independent sector. These problems were less in more senior staff positions and overall there was a greater problem in recruiting staff compared to retention. While the independent sector felt it was in competition with local authorities for staff, both felt under pressure from the NHS and outside sectors such as retail. As well there were geographical variations with rural areas having less problems that more urban ones.

    While pay was an important factor other issues such as the status of social care, work pressures and responsibilities were felt to barriers to recruitment and retention. On the other hand the caring and pastoral aspects of the work were valued by the staff and contributed to them staying in post in despite the poor levels of pay.

    The Welsh Government has responded to some of the problems in the sector with others more difficult to address due to ongoing austerity policies and the continuing failure of the Westminster Government to live up to its promised on producing a comprehensive set of proposals to deliver a quality, affordable social care service.
    In order to improve the skills and status all all staff care staff will be expected to be registered with Social Care Wales by 2022. Once they have been in employment for more than three months care staff will have the right to choose between a defined hours or “zero hours” contact. And last year (2019) the Welsh Government supported “We Care” a campaign and on-line portal to support social care recruitment.

    In the Covid-19 pandemic care staff were provided with a £500 grant in recognition of their work by the Welsh Government. However despite declaring its commitment to the workers in the sector, the Westminster Government refused to exempt the bonus from stoppages such as taxation and NI contributions.

    It is clear that most of those who work in the sector are committed to their job and value its humanitarian values even above pay. An unemployment fall-out from Covid-19 might provide some easing of recruitment and retention difficulties but this cannot be seen as a sustainable solution. More comprehensive measures are needed.

    For decades social care has been provided on the cheap with the cost, in the first instance, being borne by staff in terms of their pay, work conditions and their opportunities for career progression. This downward pressure was driven by the policies of out-sourcing and tendering and an under-valuing of the public sector. But this policy has more or less come to the end of the road.

    The Welsh Government realises this and has commenced a consultation process on legislation that will require local authorities and health boards to regularly assess the financial sustainability of the care sector in their catchment areas. This should provide important information to inform the future shaping of local social care services.

    But we need to do more. We must start looking for more radical solutions within the overall context of a National Care Service. As a first step domiciliary care services should be brought back into the public service as their contracts lapse. And we then need to see how this option can be extended to all other workers in the sector.

    2 Comments

    The Camden New Journal (CNJ) have published the sixth article about the NHS written by Susanna Mitchell and Roy Trevelion. You can see it on the CNJ website under ‘Forum’ published on 16 July 2020 here. Or you can read it below:

    Neglect and inadequate excuses lie at the heart of the government’s failures, argue Susanna Mitchell & Roy Trevelion

    It is understood that there will be a public inquiry into the UK’s handling of the coronavirus pandemic.

    This should begin now, and not when the current crisis is over. Criticisms will be focused on the government’s disastrous response:

    Its initial adoption of a “herd immunity” strategy.

    Its failure to provide health care workers and others in front-line positions with adequate personal protective equipment (PPE).

    The shambolic state of its belated testing and tracking operations, including the collapse of its much-heralded app.

    Its reliance on private contractors with no relevant experience to supply services and equipment that they were subsequently unable to deliver.

    Critically, it will be claimed that all the measures taken were put in place far too late. With the result that the UK now has the highest death toll in Europe. The proportion of care-home deaths is 13 times greater than that of Germany.

    All these accusations are currently being met with the excuse that the Covid-19 pandemic was unprecedented. The government claims it has worked to its utmost capacity to control and manage the outbreak.

    But this narrow focus on what was done once the virus had established itself in the country is completely inadequate.

    Rather, any inquiry must examine the long-standing reasons why the country was unable to deal with the situation in a more efficient way. Unless this is done, the necessary steps to improve our handling of future pandemics cannot begin.

    For a start, the argument that government was taken by surprise by a global viral attack is false.

    To the contrary, a research project called Exercise Cygnus was set up in 2016 to examine the question of preparedness for exactly this eventuality.

    Its report was delivered in July 2017 to all major government departments, NHS England, and the devolved administrations of Scotland, Wales and Northern Ireland.

    The report concluded that “…the UK’s preparedness and response, in terms of its plans, policies and capability” were insufficient to cope with such a situation.

    It recommended NHS England should conduct further work to prepare “surge capacity” in the health service and that money should be ring-fenced to provide extra capacity and support in the NHS.

    It also stated that the social care system needed to be able to expand if it were to cope with a “worst-case scenario pandemic”.

    These warnings, however, were effectively ignored.

    One government source is reported as saying that the results of the research were “too terrifying” to be revealed.

    And a senior academic directly involved in Cygnus and the current pandemic remarked: “These exercises are supposed to prepare government for something like this – but it appears they were aware of the problem but didn’t do much about it… basically [there is] a lack of attention to what would be needed to prevent a disease like this from overwhelming the system.

    “All the flexibility has been pared away so it’s difficult to react quickly. Nothing is ready to go.”

    But the reason that the system was too inflexible and unprepared lies squarely with the government’s actions during the last decade.

    The Health and Social Care Act of 2012 ruinously fragmented the system.

    The austerity and privatisation of these polices have lethally weakened both the NHS and the social care services.

    As a result, the NHS is under-staffed, under-equipped and critically short of beds, while the social care service is crippled by underfunding almost to the point of collapse. It is therefore vital that we do not allow any inquiry to be limited to an examination of recent mistakes.

    The government’s bungled handling of the present crisis was virtually inevitable within a public health system depleted and rendered inadequate by their long-term policies.

    No post mortem can achieve a productive conclusion unless it is understood that these policies were the root cause of the shambles.

    If we are to avoid another catastrophe, these policies must be radically changed with the minimum of delay, and public health put back into public hands.

    • Susanna Mitchell and Roy Trevelion are members of the Socialist Health Association.

    Other articles written by Susanna Mitchell and Roy Trevelion are:

    Don’t allow the price of drugs to soar: Drug pricing is still a critical issue for the NHS http://camdennewjournal.com/article/dont-allow-the-price-of-drugs-to-soar?sp=1&sq=Susanna%2520Mitchell

    Beware false prophets: Don’t be fooled by the Johnson government’s promise of new money. It masks a move to further privatise the NHS
    http://camdennewjournal.com/article/nhs-beware-false-prophets?sp=1&sq=Susanna%2520Mitchell

    Brexit and the spectre of NHS US sell-off: Americanised healthcare in the UK – after our exit from the EU – would only benefit global corporations
    http://camdennewjournal.com/article/brexit-and-spectre-of-nhs-us-sell-off?sp=1&sq=Susanna%2520Mitchell

    Deep cuts operation threatens the NHS: The sneaking privatisation of the NHS will lead to the closure of hospitals and the loss of jobs
    http://camdennewjournal.com/article/deep-cuts-operation-threatens-nhs-2?sp=1&sq=Susanna%2520Mitchell

    Phone app that could destroy our GP system: A private company being promoted by government to recruit patients to its doctor service spells ruin for the whole-person integrated care we need from our NHS
    http://camdennewjournal.com/article/phone-app-gp?sp=1&sq=Susanna%2520Mitchell

     

    Comments Off on Why the UK failed the pandemic test
    The damning report by MPs into hospital patients in England being discharged into care homes without a Covid-19 test reinforces the need for a public inquiry, sooner rather than later, into the government’s handling of the pandemic, Unite, Britain and Ireland’s largest union, said today (Wednesday 29 July).
    The influential cross-party Public Accounts Committee (PAC) accused ministers of being slow to support social care during the crisis. The initial decision to allow untested patients into care homes was an ‘appalling error’.
    Unite assistant general secretary Gail Cartmail said: “The committee’s findings are a welcome first step, but MPs need to dig deeper into the long-standing crisis in social care.
    “Covid-19 has heightened attention on the underlying shortcomings in the social care system that have been building up for decades.
    “The pain and distress of families whose elderly relatives died in care homes because of the government’s flawed policy will be forever etched in the nation’s memory.
    “We need swift government action on the broken business model, so prevalent in the world of privatised care, with measures to tackle the underpayment of the workforce and, what Unite members tell us, measures to address the inadequate training they receive in such areas as infection control.
    “The social care sector is predicated on an environment of insecure work leading to multiple work placements.
    “The workforce needs job security, decent pay that recognises their skills and assurances on the basics, such as adequate PPE and sanitation provisions.
    “There also needs to be a safeguarding structure for workers disproportionately at risk, such as those from the BAEM communities.
    “Today, Unite repeats its call for a public inquiry into the government’s handling of the pandemic.
    “This inquiry should happen, sooner rather than later, as we suspect that Boris Johnson wants to play for time before such an inquiry is set-up as it will expose the lamentable failings of his government during this national emergency which has seen more than 45,000 lives lost to Covid-19.”
    The PAC said about 25,000 patients were discharged into care homes in England between mid-March and mid-April to free up hospital beds. After initially saying a negative result was not required before discharging patients, the government then said in mid-April all patients would be tested.

    Unite senior communications officer Shaun Noble

    Comments Off on Unite renews call for pandemic public inquiry, following MPs’ report into untested patients discharged to care homes

    This is our twentieth weekly blog the series where we have commented on the course of the pandemic and the political context and implications from its impact on our country. The SHA has submitted our series of blogs to the All Party Parliamentary Group (APPG), Chaired by Layla Moran (LD, Oxford West and Abingdon), who are taking evidence to learn lessons from our handling of COVID-19 in time for the high risk winter ‘flu season’. The Labour MP Clive Lewis is on the group

    This is an edited version of the seven main points we have submitted:

    1. Austerity (2010-2020)

    This pandemic arrived when the public sector – NHS, Social Care, Local Government and the Public Health system had been weakened by disinvestment over 10 years. This was manifest by cuts to the Public Health England budgets, to the Local Authority public health grants and lack of capital and revenue into the NHS. In workforce terms there was staff shortages in Health and Social Care staffing exceeding 100,000.

    1. Emergency Planning but no investment in stocks (Cygnus 2016)

    The publication of the 2016 Operation Cygnus exercise has exposed the lack of follow on investment by the Conservative government which led to problems of PPE supplies, essential equipment such as ventilators and in ITU capacity. The 2016 exercise was a large-scale event with over 900 participants and occurred during Jeremy Hunt’s tenure as Secretary of State. There needed to be better preparation too on issues such as border controls as we note 190,000 people from China travelled through Heathrow between January-March 2020. Pandemics have been at the top of the UK risk register for years and the question is why were preparations not undertaken and stockpiles shown to be insufficient and sometimes time expired.

    1. Poor political leadership (PM and SoS Health)

    During the pandemic there has been a lack of clarity on what the overall strategy is and inconsistency in decision-making. The New Zealand government for example went for elimination, locked down early, controlled their borders and took the public with them successfully. We have had an over centralised approach from the Prime Minister and SoS for Health such as the NHS Test and Trace scheme and creating the Joint Biosecurity Unit. Contact tracing and engaging the Local Directors of Public Health was stopped on the 12th March and only in the past few weeks have their vital role been acknowledged. Ministers have been overpromising such as the digital apps, the antibody tests, the vaccine trials and novel drug treatments. Each time the phrases such as World Beating and Game Changers have been used prematurely. The Ministerial promises on numbers of tests has been shown to have become a target without an accompanying strategy and the statistics open to question from the UKSA.

    1. Social care

    From the early scientific reports from Wuhan it was clear that COVID-19 was particularly dangerous to older people who have a high mortality rate. A public health perspective would raise this risk factor and plan to protect institutions where older people live. Because of the distressing TV footage from Lombardy (Italy) the government’s main aim was to Protect the NHS. This was laudable and indeed the NHS stood up and had no call on the Nightingale Hospitals, which had a huge investment. The negative side of this mantra was that social care was ignored. As we have seen 40% of care homes have had outbreaks and about a third of COVID related mortality is from this sector. There have been serious ethical questions about policies in Care Homes as well as discharge procedures from the NHS that need teasing out. The private social care sector with 5,500 providers and 11,300 homes is in bad need of reform. Some of the financial transactions of the bigger groups such as HC One need investigation, especially the use of off shore investors who charge high interest on their loans. The SHA believes that the time is right to ‘rescue social care’ taking steps such as employing staff and moving towards a National Care Service.

    1. Inequalities

    It was said at the beginning of the pandemic in the UK that the virus did not respect social class as it affected Prince and Pauper. Prince Charles certainly got infected as did the Prime Minister. However we have seen that COVID-19 has exploited the inequalities in our society by differentially killing people who live in our more deprived communities as shown by ONS data. In addition to deprivation we have seen the additional risk in people of BAME background. The combination of deprivation and BAME populations put local authorities such as Newham, Hackney and Brent in London as having been affected badly. The ONS have also shown that BAME has an additional risk to the extent of being double for people of BAME heritage even taking statistical account for deprivation scores. Occupational risk has also been highlighted in the context of BAME status with the NHS having 40% of doctors of BAME heritage who accounted for 90% of NHS medical deaths. The equivalent proportions are 20% NHS nurses and BAME accounting for 75% deaths. The government tried to bury the Fenton Disparities report and we believe that this is further evidence of institutional racism.

    1. Privatisation

    The SHA is strongly committed to a publicly funded and provided NHS and are concerned about the Privatisation that we have witnessed over the last 10 years. We are concerned about the risks in the arrangement with Private Hospitals, the development of the Lighthouse Laboratories running parallel to NHS ones and the use of digital providers. In addition we feel that there needs to be a review of how contracts were given to private providers in the areas of Testing & Tracing, PPE supplies, Vaccine development and the digital applications. There are concerns about fraud and we note that some companies in the recent past have been convicted of fraud, following investigations by the Serious Fraud Office yet still received large contracts during the pandemic.

    1. Recovery Planning

    During the pandemic many of us have noticed the benefit of reduced traffic in terms of noise and air pollution. Different work patterns such as working from home has also had some benefits. The risk of overcrowded and poor housing has been manifest as well as how migrant workers are treated and housed. Green spaces and more active travel has been welcomed and the need for universal access to fast broadband as well as the digital divide between social class families. With the government having run up a £300bn deficit and who continue to mismanage the pandemic we worry about future jobs and economic prosperity. There is an opportunity to build a different society and having a green deal as part of that. The outcome of the APPG review should on the one hand be critical of the political leadership we have endured but also point to a new way forward that has elements of building a fairer society, creating a National Care Service, funding the NHS and Public Health system in the context of the global climate emergency and the opportunities for a green deal.

    Lets hope that the APPG can do a rapid review so we can learn lessons and not have to wait for years. The Grenfell Tower Inquiry remember was launched by Theresa May in June 2017, and we still await its key findings and justice for those whose lives were destroyed by the fire. The Prime Minister has been pointing the fingers of blame on others for our poor performance with COVID-19 but has accepted that mistakes were made and that an inquiry will be held in the future.

    However often these are mechanisms to kick an issue into the long grass (Bloody Sunday Inquiry) and even when completed can be delayed or not published in full such as the inquiry into Russian interference in our democratic processes. So let’s support the APPG inquiry and the Independent SAGE group who provide balance to the discredited way that scientific advice has been presented. As one commentator has pointed out there are similarities to the John Gummer moment when in 1990 he fed his 4yr old daughter a burger on camera during the BSE crisis. The public inquiry into the BSE scandal called for greater transparency in the production and use of scientific advice. During this crisis we have seen confusion whether on herd immunity, timing of lockdown, test and trace, border and travel controls and the use of facemasks.

    NHS and NIHR

    For the SHA we have been pleased with how the NHS has stood up to the challenge and not fallen over despite the huge strain that has been put under. Despite the expenditure on the Nightingale Hospitals and generous contracts with Private Hospitals these have not made a significant difference. These arrangements certainly helped to provide security in case the NHS intensive care facilities became overwhelmed and allowed some elective diagnostics and cancer care to be undertaken in cold hospital sites. However the lesson from this is the superiority of a national health system with mutual aid and a coherent public service approach to the challenge compared to those countries with privatised health care. The social care sector on the other hand, despite some examples of excellence, is a fragmented and broken system. The pandemic has shown the urgent need to ensure staff have adequate training, are paid against nationally agreed terms and conditions and we create an adequately resourced National Care Service as outlined in our policy of ‘Rescuing Social Care.

    Another area where a national approach has paid off is the leadership provided by the National Institute of Health Research (NIHR) which helps to integrate National R&D funding priorities and work alongside the Research Councils (MRC/ESRC) and Charitable Research funding such as from the Wellcome Trust and heart/cancer research funders. These strategic research networks use university researchers and NHS services to enable clinical trials to be undertaken and engage with patients and the public. It is through this mechanism that the UK has been able to contribute disproportionately to our knowledge about treatment for COVID-19 and in developing and testing novel vaccines.

    For example the Recovery trial programme has used these mechanisms to enlist patients across the UK in clinical trials. The dexamethasone (steroid) trial showed a reduction in deaths by a third in severely ill patients and is now used worldwide. On the other hand Donald Trump and Brazil’s Jair Bolsanaro’s hydroxychloroquine has been shown to be ineffective and this evidence will have saved unnecessary treatment and expense across the world.  Such randomised controlled trials are difficult to undertake at scale in fragmented and privatised health systems. The vaccine development and trials have also been built on pre-existing research groups linked to our Universities and Medical Schools. Finally while Hancock’s phone app hit the dust in the Isle of Wight, Professor Tim Spector’s COVID-19 symptom app has managed to enlist 4m users across the country providing useful data about symptoms and incidence of positive tests in real time. This is all from his Kings College London research base reaching out to collaborators in Europe. Ireland has launched the Apple and Google app created with the Irish software company NearForm successfully and it is thought that Northern Ireland is on the way to a similar launch within weeks too!

    A wealth tax?

    In earlier blogs we have drawn attention to the huge debt that the government have run up and we are already seeing the emerging economic damage to the economy and people’s livelihoods when the furloughing scheme is withdrawn in October. Already people are talking about up to 4m unemployed this winter and what this will mean in terms of the economy and funding public services like local government, education and health. The UK’s public finances are on an ‘unsustainable path’ says the Office for Budget Responsibility.

    There is a lot of chatter about the value of a wealth tax and there are some variations to the theme. It is estimated that there is £5.1 trillion of wealth linked to home equity. It is also said that the unearned gains on property are a better target for new taxes than workers earned income. Following this through a think tank has proposed – a property tax paid when a property is sold or an estate if the owner has died. A calculation could be made by taxing at 10% on the difference between the price paid for the property and the price at which it was sold. The % tax could be progressive and increase when the sum exceeds £1m for example. Assuming property rise in value by only 1% per annum this tax would raise £421bn over 25 years. If this sounds like an inheritance tax – that is true but for years now such taxes have become a voluntary tax for those with access to offshore funds and savvy accountants. In the USA, inheritances account for about 40% of household wealth. Fewer than 2 in 1000 estates paid the Federal estate tax even before Trump cut it in 2018. Trusts and other tax havens abound. Apparently Trump’s own Treasury Secretary has placed assets worth $32.9m into his ‘Dynasty Trust 1’

    Inherited wealth has been referred to in earlier blogs in relation to the Duke of Westminster family wealth. Another study which shows how this type of wealth transfer passes down the generations comes from Italy where in 2011 a study of high earners found many of the same families appeared as in the Florence of 1427!

    Populism and COVID

    In our blogs we have pointed to the fact that those countries, in different continents, which have had a bad pandemic experience are ones such as the UK, USA, Brazil, India and Russia. What unites them is a leadership of right wing populists. A recent study has started to analyse why this occurs and what the shared characteristics are:

    1. The leaders blame others – the Chinese virus/immigrants
    2. Deny scientific evidence – use ineffective drugs/resist face masks
    3. Denigrate organisations that promote evidence – CDC/PHE/WHO
    4. Claim to stand for the common people against an out of touch elite.

    What the authors found was that these leaders were successfully undermining an effective response to the pandemic. Sadly there is a risk that populist leaders perversely benefit from suffering and ill health.

    Taking lessons from history and the contemporary global situation we need to continue to speak out against these political forces and advocate for a better fairer recovery.

    27.7.2020

    Posted by Jean Hardiman Smith on behalf of the Officers and Vice-Chairs of the SHA.

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