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    NINE TESTS OF THE AUTHENTICITY OF HOLYROOD’S COMMITMENT TO HUMAN RIGHTS

    Joint authors:  Colin Slasberg and Peter Beresford

    We have previously set out why we believe the Feeley review of Adult Social Care in Scotland has the potential to be truly ground breaking. Its first and primary recommendation is that social care should be established on a human rights basis. Whilst it also makes recommendations about structural change, the report recognises that structural change without cultural change is no change at all.

    While the rhetoric of human rights has littered social care policy for at least two decades, Feeley is not the first to recognise it simply hasn’t happened. Whilst there are examples of excellence, they are not the norm. However, what makes the Feeley report different is that it goes further. It pinpoints the practical changes required. These focus on the process of assessment, support planning and resource allocation. Three recommendations are of particular importance;

    1. ‘People should understand better what their rights are to social care and support and “duty bearers”, primarily social workers, should be focused on realising those rights rather than being hampered in the first instance by considerations of eligibility and cost.
    2. A co-production and supportive process involving good conversations with people needing support should replace assessment processes that make decisions over people’s heads….that does not start from the basis of available funding. Giving people as much choice and control over their support and care is critical
    3. Where not all needs can be met that have been identified as part of a co-production process of developing a support plan, these must be recorded as unmet needs and fed into the strategic commissioning process’

    Delivery of these three recommendations alone would have far reaching consequences. They would amount to the abolition of eligibility criteria to identify ‘need’ and control spending. This would lead to the re-purposing of the entire system from its current protection of public resources to one that serves to promote the human rights of older and disabled people, whatever level of funding the democratic system happens to make available to it.

    The early responses

    The Feeley report was warmly welcomed by all parties in a debate in Holyrood on February 16. The Scottish Government committed to working toward a way forward ahead of the May elections.

    However, there remains deep scepticism amongst activists and academics. For some it is born of many years of national and local government talking the talk of rights whilst walking a very different walk. For others there is disappointment Feeley did not demand funding to meet all need as the precondition of a system based on human rights, or to the structural changes they favour, or to renationalisation of social care as the solution its ills.

    The following sets out nine key tests by which to judge the authenticity of the Government’s intentions in how they respond to Feeley. They set out the practical steps required if Scotland is to deliver the Feeley recommendations.

    Nine key tests

    1. Government will establish the principle that in social care, as in the NHS, need will precede resources. A founding principle of the NHS was that clinicians must be free to identify clinical need and the resource consequences must follow. People generally trust that NHS clinicians will indeed identify to the best of their knowledge what modern medicine can do to give them the best possible health. This is not the case in social care where decisions about ‘eligibility’ are made ‘above people’s heads’. If Government declares that social care will join health care in putting need before resource, social workers will be free in line with their professional ethic to identify what will give people the best quality of life their circumstances allow. This, in itself, is arguably the single most transformative change that will deliver for social care the ‘1948 moment’ Nicola Sturgeon says she is seeking. The following eight all rise from and are a consequence of this one change.
    1. Government will declare the end of the eligibility system. The eligibility system, whereby ‘need’ is defined against so-called ‘national’ criteria, ostensibly exists to deliver equity. The scale of the inequity in levels of provision between councils identified by the Feeley report is testament to its failure. What ‘critical and substantial’ means varies from council to council according to their resources. The durability of the eligibility system is owed therefore, not to the pursuit of equity, but to control of spending. Success in controlling spending in this way comes at the expense of the resource-led and controlling practices the Feeley report so roundly condemns.
    2. Government will declare a commitment to fund all needs for people to have a dignified quality of life to the best of its ability. The Feeley report does not recommend Government commits to funding all needs. No public service is guaranteed the funds to meet all its responsibilities, not even the NHS. However, the necessary process of prioritisation should not and need not lead to loss of vision and moral purpose. Government should lead the way in ensuring the needs of older and disabled people compete on a level playing field with all other public services, currently denied by the eligibility system.
    3. Government will require systems are established that aggregate and report unmet need. Unmet need is the inevitable consequence of adopting the principle of need preceding resources. The NHS equivalent is waiting times. At the operational level waiting times provide the safety valve when need exceeds resources. At the strategic level, they tell political leaders the level of funding they need to make available. In social care the eligibility system denies them such information. Unmet need must be seen as the social care equivalent of waiting times in the NHS. Information about unmet need must be in the public domain, easily accessible and able to hold political leaders to account.

    Councils have sometimes in the past experimented with boxes on assessment forms for social workers to record unmet need. The information languishes in filing systems, goes nowhere and quickly falls into disuse. Government must avoid repeating such a mistake.

    1. Government must acknowledge that regional equity depends on the level of resources available to local authorities and is a national responsibility. Whatever else a National Care Service may comprise, national government must accept responsibility both to ensure that resource levels minimise unmet need, and are fairly allocated regionally.
    2. Government must require councils to establish systems that control spending without compromising assessments. No matter how large or small the gap between needs and resources, it is a fact of life than spending will have to be contained within budgets. Case by case decisions to determine eligibility as the means to do so must be replaced with case by case decisions that determine This will require a complete re-engineering of the decision making infrastructure, including financial and IT supports. Whilst equitable allocation of resources at individual budget holder level will continue to be important, it will be joined by value for money as no less important a challenge. A budget holder’s task will be to achieve the greatest quality of life for the greatest number of people within their budgets. This will require significant re-skilling of budget holders
    3. Government must require councils to democratise their assessment process. Assessing for eligibility spawns a bureaucratic, obscure and professional-centric process. Such processes must be swept away. New processes will be required that are accessible to all service users to support them to think through and declare their own assessment of their needs and support requirements. The council only has to be concerned that such self-assessments make the best use of resources so the person can have the best quality of life their circumstances allows. The social work role will be to support people to achieve such a self-assessment, working to whatever depth is required. An open, democratised assessment process is key realising the Feeley recommendation that assessments must be ‘co-produced’ and for people to have authentic choice and control over their support.
    4. With the system fundamentally re-purposed, Government will need to ensure there is a workforce development strategy. The social work role will be transformed from the current ‘piggy in the middle’ role to being able to work in authentic partnership with service users. It should come naturally to those whose value base is person-centred and also to social workers who are professionally qualified.

    Re-skilling will also be needed at the most senior levels too. Directors of Social Work will no longer have the task of managing a system that makes ‘need’ fit within whatever resource their political masters give them. Their task will be firstly to get the best from the given resource, and then to inform their political leaders of the shortfall. Their relationships will change. They can truly become the champions of the community.

    1. A transition strategy for existing service users. Resource-led assessments for ‘eligibility’ and person centred assessments are as chalk and cheese. Whilst the former is a negative exchange to see how bad life can be, the latter is a positive one to see how good life can be. However, there will be overlap. Some needs previously deemed ‘eligible’ will continue to be needs within a human rights based approach. There is a clear moral argument that existing service users should not be penalised by the change. All needs previously considered ‘eligible’ that also meet needs within the reformed system should be subject to a guarantee of being met as long as the need remains.

    Conclusions

    For the above reasons, Feeley puts Scotland on the brink of becoming a world leading country in the delivery of social care. It would be one built upon the lived experience of each and every older and disabled person in need of state support. However, in the absence of pressure on Government to deliver the radicalism of the above agenda, the greater fear is that it won’t happen. Feeley’s plea for a system driven by human rights runs the real risk of being reduced to a pre-amble to the Government’s response that will amount to yet another reiteration of warm words and good intentions.

    Implications for England

    Whether or not Scotland does move forward, the lessons England could pick up are clear. England, whilst using different words, operates the same eligibility system as Scotland. England, too, has regional inequity of enormous proportions. Most service user groups will recognise the Feeley report’s description of the assessment and support planning process. It is bureaucratic, damaging and alienating.

    Debates in England are dominated by the funding issue. That takes the form either of focusing on the balance of public and private funding, sources of taxation or funding levels. There is, however, little debate about the vision for social care. Isolated Members of Parliament sometime raise the issue of a vision for social care, but those debates are not entering the mainstream. Yet without vision, how can the service know it is getting the best it can from the resources it has? And without vision, how can the public know what they are being asked to support, and how can political leaders know what they are being asked to fund?

    The issues Feeley is inviting Scotland to grapple with are issues England should grapple with too.

     

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    Something major happened in the NHS in February. No, not the new White Paper on rearranging the furniture; something else. This was the announcement, or lack of announcement, that a large number of GP Practices have been taken over by a US Health Insurance giant – Centene. AT Medics, a London based GP group, which runs 37 practices, has essentially been bought out by Centene. This means overnight hundreds of thousands of patients woke up with a new GP provider, without their consent. The acquisition makes Centene the largest provider of General Practice in England with 69 practices.

    The way this has happened follows a pattern seen in recent years. No consultation or public scrutiny; use of legal loopholes; and the use of the revolving door of ex-NHS leaders who know the system as gamekeepers turned poachers. It is possible by a sleight of hand similar to the methods of the cuckoo. The incoming company adds or replaces directors of the ‘host’ organisation, which technically still exists so keeps its NHS contracts, just as a cuckoo displaces the host’s chicks out of the original nest.

    The significance is twofold.

    Firstly, deep and comprehensive commercial involvement in our NHS is troubling. In this case the US health insurer is not only now the largest provider of GP services in the country, it also is providing contracts to NHS England and Integrated Care Systems to advise how they run the NHS – nationally and locally. This gives great insight into the decision makers and influence over how the money is spent. Combined with Centene having a major stake in private hospitals, it is not hard to join the dots- involvement in the design of systems, financing of services and the provision of services gives companies a great degree of involvement in our NHS.

    Secondly these developments are a logical conclusion to major changes for some years in the way family doctors services are organised and delivered. As a GP I have huge concerns and patients will do as well. Why does it matter?

    When invited in Parliament by his shadow, Jonathan Ashworth, to condemn the takeover, Secretary of State Matt Hancock declined, replying: ‘What matters for patients is the quality of patient care… what matters to people is the quality of care. That is what we should look out for’.

     Is he correct? Is the quality of care all that matters? Or do the people providing it, and their ethos, motivation, interests and agenda matter? Is it possible to disentangle ‘quality’, an abstract notion, from the specific people providing a service and their very non-abstract interests?

    One of the reasons I became a GP, and probably the major reason I have stayed in my practice working full time for nearly 15 years, is the deep-rooted feeling that I have of being part of something more than just a clinical service. Myself and my GP colleagues, similar to many across the country, both lead the service and work in it. Every day we see our patients and work in our communities, we know the people and the community. There is no escaping direct and sometimes blunt feedback. Our teams are small, if there is a problem, we are around to fix it. If something needs to change, we don’t need to enter into a large corporate machine for it to happen. We get the spanner out and make the adjustment.

    Can we really say the same for a company that has its eye on more than just providing a ‘good quality’ GP service for the 69 different sites it has control of? There are those who compare health care to supermarkets, or banks. The argument is that efficiency and scale are what is needed; the people who provide it can change and the patient-doctor relationship isn’t a problem, as long as the measurements prove ‘quality’. This may work for a simple transactional arrangement, such as buying some groceries or cashing a cheque, but healthcare – and especially holistic primary healthcare is a more complicated than that. It does matter who cares. It is all about the people, their motivations and their relationship with their patients and community. This is not to say that UK General Practice can’t be improved, but let’s at least keep the baby if we are changing some of the bathwater.

    If anything, General Practice feels more like farming than retail. When done well, looking after the health of the community well takes time, and deep commitment. When done badly it can result in destruction of the environment and soulless communities. Will this new huge, commercial type of model of healthcare care about this?

    I doubt it.

    https://www.theguardian.com/society/2021/feb/26/nhs-gp-practice-operator-with-500000-patients-passes-into-hands-of-us-health-insurer

    https://hansard.parliament.uk/commons/2021-02-23/debates/7CDE78FD-D275-41D3-B02E-D7690F054DB1/TopicalQuestions

     

    US Centene expands in the UK with increased stake in Circle Health

    3 Comments

    Joint Authors:

    Colin Slasberg Consultant in Social Care

    Peter Beresford visiting Professor University of East Anglia

    Last September, spurred into action by what the pandemic told her about the state of social care, Nicola Sturgeon announced an independent review of adult social care to ‘build a service fit for the future’ in Scotland. She invoked the spirit of 1948 for social care to experience the same transformation post Covid as the NHS did post war. The review was led by Derek Feeley, President and Chief Executive of the Institute for Healthcare Improvement.

    With remarkable speed, based on extensive public engagement the review has now reported. The headlines are likely to be dominated by calls for a National Care Service. Responsibility for funding will become centralised and new joint Boards with the NHS will be responsible for commissioning and procurement, not the local authorities. The latter will retain delivery of the ‘social work’ function, which means the great majority of current function given the infrastructure required to support and direct the field work role which identifies need and allocates resources to individuals.

    Cultural change must precede structural change.

    The report’s authors believe that structural change without cultural change does nothing more than re-arrange the furniture. This leads them to the view that it is their first recommendation, which transcends structural concerns to address cultural concerns, that is the real key to delivering what the First Minister wants. The report recommends a system is built from and driven by a ‘human rights approach’, such that ‘Human rights, equity and equality must be placed at the very heart of social care and be mainstreamed and embedded’. It would be ‘further enabled by incorporation of human rights conventions’ with particular reference to Independent Living.

    Facing up to the resource consequences

    It will not, of course, be the first time a review or commission has sought such high minded ideals. Nor would it be the first time a government has signed up to them, but without a serious plan to deliver. What is new in the Scotland review is that it has grappled with how those ideals engage with the question of resources. This raises genuine hope the ideals will for the first time get beyond ‘blue horizon’ managerial pleadings.

    The review makes the following three recommendations;

    1. ‘People should understand better what their rights are to social care and supports, and “duty bearers”, primarily social workers, should be focused on realising those rights rather than being hampered in the first instance by considerations of eligibility and cost.
    1. A co-production and supportive process involving good conversations with people needing support should replace assessment processes that make decisions over people’s heads….that does not start from the basis of available funding. Giving people as much choice and control over their support and care is critical
    1. Where not all needs can be met that have been identified as part of a co-production process of developing a support plan, these must be recorded as unmet needs and fed into the strategic commissioning process’

     The first two recommendation give practical expression to what a system built to deliver human rights looks like. The third offers a practical way forward to realising it.

    The transformation process – from what to what?

    The recommendations above also give expression to what a system not built to deliver human rights looks like. Neither the person nor the social worker has any power. Decisions are taken ‘above their heads’. The social worker is rendered merely piggy in the middle. They take information from the individual and give it to the decision maker and then feed the decision maker’s decisions back to the individual. The situation is further damaged by the social worker being ‘hampered’ by having to think first about resources, eligibility and cost.

    These first two recommendations make clear that a human rights based approach means that the individual and the social worker must be free to work in authentic partnership to work out the best way to give the individual the best quality of life their circumstances allows without regard to availability of resource.

    If these two recommendations were to be delivered, the role of the social worker would be transformed. They will, at long last, be the social care equivalent of the clinician in the NHS. People are generally confident that if they need a diagnosis and treatment from an NHS clinician that the clinician will make their best judgement as to what modern medicine will make possible.  Patients are aware, however, they may subsequently have a wait depending on availability of resources.

    Managing the resource consequence

    For such a positive practice process to ever become a reality in social care, the resource consequences have to be managed. To base a strategy on thinking otherwise, perhaps on the premise that society and their political leaders should fund all the needs of older and disabled people however much it costs, is very high risk. Social care would have to be delivered outside of a budget. Proponents will have to persuade political leaders and the public why social care should have a guarantee of all their responsibilities being funded while no other public service does, not even the NHS. Failure of such a strategy will mean the status quo will not change.

    The pragmatic approach is to accept that social care will continue to be delivered within a budget determined by the democratic process, national or local.

    The Feeley review addresses this reality in the third recommendation above. If need is to be identified without regard to resource availability, there is no arithmetic prospect that the resources required will coincide with the resources available with the precision required to match spend to budget. The system must allow for need to exceed resource.

    The political consequence

    The current, eligibility based system does the exact opposite – it does not allow for need to exceed resources. It actually forbids it. The system delivers the imperative to spend within budget by ensuring the flow of needs it meets is determined by the budget. This is made evident in Scotland by the scale of the post code lottery despite all councils ostensibly working to the same eligibility criteria. Because ‘need’ is determined by resources, it is a system that never recognises there is any unmet need. Whatever budget is provided is always enough.

    That, of course, is music to the ears of political leaders with other priorities on their minds. But if the Scottish government adopts the recommendations of this report, that comfort will have been given up. Councils will know the true cost of delivering on political leaders’ commitments to the human rights of their older and disabled citizens. The commissioners will have the information to tell them.

    Implications for England

    We have to wait and see how Holyrood responds. But however it does, perhaps this review’s thinking can influence the debate in England where the same eligibility based system is in place The debate in England has yet to get beyond the funding questions. Absent is any thought of vision. But only with vision can we know what we want for our money. And only with vision can we ensure we are spending our money well, achieving the results we want, and how far we are falling short.

    The Scotland review’s third recommendation as above is a remarkably simple idea. Eligibility of need must be replaced with affordability of need to control spending. Those responsible for the system will need to be prepared for transparency and honesty about any gap between needs and resources. Unmet need in social care should replicate the functions waiting times have in the NHS. Firstly they are a ‘safety valve’ at the front line when resources lag behind need. Secondly they act as a weather vane so political leaders know what way the wind is blowing when the time comes round to make political decisions about the funding requirements for social care.

    The Scottish review recommendations resonate powerfully with the view about the transformation change required in England set out by Barry Rawlings, leader of the Labour opposition in Barnet. Barry’s blog places the agenda in the English context.

    Whether or not the Scottish government lights this beacon, hopefully leaders in England will open their minds to the possibilities opened up.

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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

    John Lister (editor Health Campaigns Together, co-editor The Lowdown)

    This is an opinion piece – it is not SHA policy

    Despite all the other issues that might be expected to be priorities, it seems NHS England remains focused on driving through its plans for yet another reorganisation, to establish a network of 42 “Integrated Care Systems” (ICSs) to control services at local level – and possibly even fewer than that, with the possibility some smaller ICSs might also merge

    A new 39-page NHSE consultation document “Integrating Care” at the end of November follows on from a volley of instructions to local health chiefs in a circular on July 31, which appeared to be about rebuilding services after the first peak of Covid infection, but took the opportunity to drive forward the process of merging Clinical Commissioning Groups (CCGs) and establishing ICSs in a final page of instructions.

    The new document piles on pressure for prompt government action, setting an ambition of securing new legislation that would allow the whole of England’s NHS to be run through ICSs by 2022.

    It makes the extraordinary claim that the establishment of ICSs – driven relentlessly from the top by NHS England, and resisted at local level by local government bodies, GPs and campaigners – is in fact “a bottom-up response.”

    It rehearses the stock arguments for creating ICSs, with lofty, inflated and largely baseless claims that the handful of early ICSs “have improved health, developed better and more seamless services and ensured public resources are used where they can have the greatest impact.” In fact all the improvements that have been made along these lines have been made under existing legislation, with ICSs, lacking power or authority, having been able to do little or nothing.

    There are also multiple references to “digital” and “data” as ways of driving system working and improving outcomes, despite the lack of evidence for these claims. New “digital” technology and number-crunching for “population health management” are among the more lucrative areas in which private companies from the US and elsewhere are seeking to gain a profitable foothold, not least through the Health Systems Support Framework established by NHS England.

    Many campaigners remain justifiably suspicious of the extent to which ICSs, which have been set up and function largely in secret, would be in any way accountable to local communities if given statutory powers.

    And while Integrating Care argues for the need to establish ICSs as “statutory bodies” with real powers, notably “the capacity to … direct resources to improve service provision,” there are real fears that NHS England, facing more years of tight and inadequate budgets, sees ICSs and system-wide policing of finances as a way of more ruthlessly enforcing cash-cutting reductions or restrictions on availability of services through “control totals” limiting spending across each ICS, and growing lists of excluded “procedures of limited clinical value”.

    The HSJ, normally happy to go with the flow of NHS England, has pointed out how vague are the proposals in the new document, and raised questions over funding:

    “While the paper makes it clear the current system doesn’t work, it gives little indication of what a better solution will look like and how that efficiency drive will be maintained.

    “For example, it said ICSs will be given a ”single pot” of money from which to manage spending priorities. But there is no framework for how this will be spent that assures fairness, value for money and quality outcomes.”

    Integrating Care suggests two alternative routes to establishing a legal status for ICSs; one by setting them up as new “joint committees” once the remaining unmerged CCGs had been merged to leave one per ICS, with the resulting loss of local accountability. The joint committees would enable NHS “commissioners, providers and local authorities” to take decisions collectively, although NHSE admits that this leaves “many questions” about accountability and clarity of leadership unresolved.

    In the second option an ICS would effectively take the place of a CCG, replacing its governing body (along with its GP membership model) with a new board consisting of representatives from the “system partners” – including representatives of NHS providers, primary care and local government alongside a Chair, a Chief Executive and a Chief Financial Officer. In other words the CCGs, having been merged into bodies far larger in scope than the original 207 CCGs, would be abolished, with their commissioning role taken over by the ICSs.

    This second model is the one favoured by NHS England. But it has raised concerns amongst GPs, some of whom fear that they and primary care as a whole would once more be marginalised by new structures that could be dominated by bigger providers, and especially by large-scale acute hospital trusts.

    GP Online has highlighted “alarm” among GPs over the development of ICSs, and a recent motion adopted by Doctors in Unite which warns:

    “ICSs 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.”

    NHS Providers, representing trusts and foundation trusts, has also expressed some reservations, warning that:

    “It makes sense to collaborate and deliver different services at different levels of scale, but all of these partnerships will need appropriate resourcing and cannot necessarily continue operating from within the existing staff base. …

    “What we do know is that trust leaders – and partners from across the health and care system – are cautious about any top-down, inflexible reorganisation of the NHS, particularly in the middle of a pandemic.”

     

    Will ministers back NHSE plan?

    While NHS Providers expect an NHS Bill to be announced in the next Queen’s Speech and introduced in the late spring next year, this is up to ministers. In pushing hard and publicly now for legislation NHSE might be motivated by concern that the Johnson government (whose manifesto this time last year promised legislation to carry through NHS England’s Long Term Plan, which includes ICSs) may have since changed tack.

    Last month the Department of Health published outline plans for “Busting bureaucracy” which appeared to back the NHSE approach, and committed to “bring forward legislative reform to reduce bureaucracy and promote collaboration across the health and care system,” building on “previous NHS recommendations to remove the two current procurement regimes which apply to clinical healthcare services and replace them with a new procurement regime.”

    However revelations that Matt Hancock had been held back during the summer from plans to speed through the promised changes, and that  a secret Downing Street “task force” on health policy has been meeting over the summer and autumn – without inviting NHSE chief executive Sir Simon Stevens – suggest the PM may have been steered away by his advisors from what appeared to be a common agenda.

    The only legislation on the NHS since last December’s election gave Johnson a Commons majority of 80 was to lock in the government’s inadequate promise of an extra £20 billion in real terms (£33.9bn in cash terms) by 2024 – effectively limiting government health spending.

    And while the Covid pandemic has clearly preoccupied ministers and MPs since the early spring, the lack of any firm timetable or commitment for government action does raise the possibility that they have pulled back from the new legislation which NHSE argues is necessary to roll back key sections of the 2012 Health and Social Care Act – and pave the way for ICSs.

    However we should not confuse NHSE’s moves to limit the requirement to put services out to tender with rolling back privatisation. As we have seen with so many Covid contracts, awarding contracts without competitive tender does not by any means end privatisation – or the “market” in health care, separating purchasers (commissioners) from providers.

    The whole focus of NHS England’s proposals is on limiting contracting and competitive tendering …  to clear the way for even large-scale mergers of providers, which are free to involve the private sector as “partners” or as sub-contractors.

    The Lansley Act’s version of tendering has already to a large extent been supplanted by the proliferation of “Framework contracts” in which NHS England or its privatisation sub-division NHS Shared Business Services sets up a list of pre-approved providers including private companies, non-profits and some NHS-led organisations, which can be allocated contracts WITHOUT formal tendering or competition, or from which a small group can be selected for a ‘mini-competition’.

    Because no public process or advertisement is required, this type of contracting out/privatisation can take place with little or no public scrutiny.

    So far, regardless of the government’s obvious hesitancy, it appears that the consensus assumption within the NHS is that NHSE will get legislation along the lines it has requested.

    Even then there are many unknown factors. How far does Johnson’s clique of advisors really want to go with NHS reform? How fast?

    How much priority can they and will they give it as Brexit chaos breaks out from January?

    Do they really want now to marginalise Stevens and replace him with a more pliable Tory crony like Dido Harding – who would lack any credibility with NHS chiefs?

    What we do know is that whatever the organisational changes, without additional revenue and capital funding and a properly resourced workforce plan the NHS is headed for constant crisis.

    And for the Johnson government to assert greater central control over the NHS as it fails, or visibly attempt to privatise the most popular public service would be risking electoral disaster. We will have to wait to see which way they will go … and whether Johnson will – as rumoured – reshuffle his government, or even seek an early exit from Downing Street.

    Problems for campaigners

    There are also tough decisions for campaigners on how best to respond. The process of transition from CCGs towards ICSs is already well-advanced with the majority of CCGs already merged, and 29 of the target 42 ICSs now formally in place. This makes any nationally coordinated campaign extremely difficult.

    However the mergers have also served highlight the fact that defending the status quo against NHS England’s plans is also a non-starter, since merged CCGs are already showing themselves more than capable of implementing policies as bad as many fear from ICSs.

    In Nottingham, for example, the merged CCG covering the city and the whole county has embarked on a vicious combined attack on one of the best performing primary care practices in the area, putting the services up for tender while slashing the per capita funding by over 40% – with a subsidiary of the US-owned Centene corporation apparently lined up to snatch the contract.

    With CCGs as bad as this, and with as little accountability to local communities, ICSs could prove to be little worse.

    So while campaigners will continue to resist the forced mergers of more CCGs, the wider campaigning goal must not be limited to retention of the structures created by the 2012 Act.

    NHS England want to repeal only selective parts of the Act. But to create any chance of genuine local accountability it’s necessary to scrap the remaining elements of the Act and the competitive market and purchaser/provider split it entrenched, to roll back tendering and privatisation, and create unified local health boards.

    In other words the alternative would be genuine re-integration of health services split asunder since the days of Margaret Thatcher. However there’s no sign of any government appetite for such progressive reform, or of opposition pressure in this direction.

    So with the Johnson government still bolstered by a huge Commons majority it appears that for the time being genuine integration is an ambition that is largely limited to propaganda, while campaigning focuses on exposing the flaws in the current system and fighting every move that advances privatisation.

    (This article is adapted and updated  from an article in The Lowdown (December 6).

    Comments Off on NHS England pushes for “integration” … but not as we know it

    Joint authors:

    Colin Slasberg Consultant in Social Care

    Peter Beresford visiting Professor University of East Anglia

    In September, while the Health and Care Select Committee Inquiry into funding for social care was still sitting, we wrote an article highlighting the case of Anna Severight. The Committee played a clip of Anna’s testimony to Matt Hancock, Secretary of State. Anna is a 34 year old disabled woman who receives enough support to be ‘fed and watered’, but not enough to have a life ‘worth living’. Hancock noted this was a sad example of people not getting ‘all they would like’.  He thus failed to recognise that having a life worth living is something very much more than what people ‘would like’, a mere wish or want. Characterised by dignity, control over life and services and being able to engage in society a life worth living is a need recognised in the law by the Care Act.

    We had prepared a submission to the Inquiry to give them advanced notice of the issues and how councils, encouraged by central government, are ignoring what the Care Act requires. We wondered in September whether the Committee when it finally reported would correct Hancock and identify what needs to happen to address Anna’s plight.

    What the Select Committee says

    We now know. The Committee’s final report, encouragingly, opened with Anna’s story as powerful testimony of the system’s failings. It then proceeded to do nothing about it. The Committee concluded the system needed £7BN more to meet demand from demography and to pay care workers what they should; £5BN more to make personal care free; £3.1BN to introduce a care cap.

    Although not much more than government has recently found to fund its failing track and trace system, such increases would represent more than doubling of current spending on social care. Even so, the Committee’s proposals would not give a single penny toward giving Anna the support she needs. Indeed, if a care cap and free personal care are introduced and not fully funded – which on past precedent is a high risk – Anna’s chances of a normal life would reduce even further. The increased gap in funding would be made up through yet further restriction of eligibility.

    Here is the nub of the issue. The eligibility regime has long allowed councils to adjust ‘need’ to their budget. When NHS clinicians make their diagnoses, the essential ingredients are the patient and the clinician’s knowledge and judgement. If not always working perfectly, the founding NHS principle that need must precede resources provides the policy context. As need outstrips resources, so waiting times go up. Not so in social care, where the equivalent of the clinical diagnosis is assessment of need. Whilst social workers gather information about the person, it is managers with responsibility for budgets, often working through ‘panels’, who make the decision as to whether a need is ‘eligible’ and therefore will be met. This enables councils to control the flow of demand to ensure spend matches budget. Councils, unlike the NHS, are permitted neither overspends nor to leave any need unmet.

    In an almost absurd denial of the empirical evidence of this reality councils hotly deny it. They claim the eligibility decisions are the social worker’s, are entirely based on need and resources never come into it. That they are able to get away with this is due in no small part to political leaders having no interest in challenging them. It is a system that keeps the lid very firmly on demand, whilst silencing the voices of the older and disabled people within. It’s a system that suits those political leaders indifferent or even hostile to the needs of older and disabled people who want to keep the pot as small as they possibly can get away with. It also suits more liberal or more generous leaders who want to make the pot a little larger, but who don’t want the true limitations of their generosity exposed. They are able to secure virtue from comparison against the worst of their kind, not comparison with the best of what older and disabled people hope for.

    Can there be a different future?

    One view that is strongly pressed is for Independent Living to become a legal right. Independent Living as defined by the United Nations is indistinguishable from the Care Act’s vision of control, dignity and participation. At the moment, making independent living a legal right can seem a utopian ideal that no-one with the interests of older and disabled people at heart will disagree with. However, under our present politics, its prospects of happening in any foreseeable future are remote. The huge variability in individual costs will mean the service would have to be delivered on an ‘open cheque’ basis if councils will be under a legal obligation to meet every need for independent living. Given that service users’ quality of life doesn’t even make it into the top political priorities if the cross Party Select Committee report is anything to go by, the prospect of Parliament giving councils blank cheques to make independent living happen is very distant.

    We will continue to make the case for an end to the eligibility regime as the source of much that is rotten in the social care system. But we do so having accepted that spending will still have to be controlled given it must take place within budgets which have been democratically determined.

    Spending should be controlled in a very different way. Councils should assess and cost all needs as the Care Act requires – in effect all needs for independent living. Councils must be honest about which needs they can and which needs they cannot afford to meet. Political leaders should know how much funding they need to make available so that Anna and the many thousands like her have the life right for them. Political leaders should no longer be allowed hide behind their officers disappearing needs that the budget they have given officers is insufficient to meet. Political leaders must be held publicly and transparently accountable for the quality of the lives of their older and disabled citizens.

    2 Comments

    Issue: 111 – 10 November 2020

    Pfizer Covid-19 Vaccine

    This could be the only good Covid-19 news we have had in a very long time. Regulators have still not approved the vaccine though, but allegedly this will happen soon. According to DHSC guidelines issued in September 2020, the top priority list for those being given the vaccine is older adults resident in care homes and care home workers, 80 years of age and over and health and social care workers, 75+, 70+. 65+, and high risk adults under 65.

    The Government has an agreement with Pfizer to buy 30 million doses, with 10 million due by the end of December 2020.

    Very Steep Rise in Secondary School Covid-19 Infection Rates

    The National Education Union (NEU) has analysed Covid-19 infection data published by the Office for National Statistics. The NEU states that Infection rates in Secondary schools in England are an astonishing 50 times higher since September 2020. In Primary schools the rise is nine times. The NEU maintains these figures clearly show that schools are engines for virus transmission.

    The NEU recommends schools staying open only for children of key workers and for vulnerable children during Covid-19 lockdown. The NEU membership is 450,000 teachers, lecturers, educational support staff and leaders. More at:

    https://neu.org.uk

    As a postscript to this, when I researched infection rates across many Ealing neighbourhoods on 9 November 2020 the three highest rates were in neighbourhoods containing secondary schools – Northolt South (349 cases/100,000), Southall Green (310.1) and Cuckoo Park, Hanwell (280.9).

    Hospitals are Breeding Grounds for Covid-19 Infections

    On 9 November 2020, ‘ITV’ reported that of the 12,903 new Covid-19 cases between 18 September and 18 October 2020. 1,772 were acquired in hospital. Of the 700 new hospital cases in south east England, 23% were contracted in hospital.

    It seems for all kinds of reasons hospital staff and patients are not being tested on a regular basis. By 20 November 2020, allegedly, all patient-facing NHS staff will be asked to test themselves at home twice a week with results available before coming to work.

    Covid-19 Lockdowns Impacting the Mental and Emotional Health of Young People

    The NSPCC AND Childline are both reporting increasing telephone and counselling sessions. Young people are increasingly presenting with feelings of isolation, anxiety, insecurity and eating and body image disorders. More at:

    www.nspcc.org.uk

    www.childline.org.uk

    Is Covid-19 Population Testing (Mass-Screening of Asymptomatic People) in Liverpool Simply the Wrong Thing to Do?

    80 test centres and 2,000 troops involved. This sounds expensive. But will it ‘work’? Professor Allyson Pollock, a recognised Public Health expert, has her doubts. On 3 November 2020, as part of the Government’s £100 billion ‘Operation Moonshot’, population-wide Covid-19 testing of asymptomatic people in Liverpool was announced. Eight test centres opened on 6 November 2020.

    Professor Pollock has pointed out that this initiative is at odds with the SAGE advice of 10 September 2020 and with the current World Health Organisation (WHO) guidance. SAGE and WHO favour prioritising the rapid testing of symptomatic people, contact tracing and identification of infection clusters. Her concerns about the Liverpool pilot include:

    • a diversion of public money and resources. The OptiGene tests have cost £323 million.

    • the use of inadequately evaluated Covid-19 tests (direct LAMP test (OptiGene) and a lateral flow assay (Innova)

    • WHO evaluations of similar tests suggest between 1% and 5% of people without infection may get false positive readings. (With 392,000 adults in Liverpool these false positives could number anything between 3,920 to 19,600 adults)

    • there is no evidence demonstrating that Covid-19 mass screening can achieve benefit cost-efficiency

    • smaller pilot studies should have been carried out first before launching a massive pilot study of 498,000 people. (Allegedly a pilot was carried out in Manchester and it was found that half of the infections were missed).

    More at:

    https://allysonpollock.com

    The ‘Sunday Times‘ of 8 November 2020 leaked that three towns would be added to the mass-testing project. One is thought to be in The Midlands and one in the south of England. This would add another 100,000 people to be regularly tested.

    Reduced Support for the Homeless in Lockdown 2

    During Lockdown 1 many homeless people were put up in hotels, hostels and other forms of accommodation. This Government funded ‘Everyone In’ strategy was deemed to be successful in saving lives and reducing Covid-19 infections rates during Lockdown 1.

    Now it appears that money is running out to support the homeless and getting them off the street during Lockdown 2. Almost half of the night sleepers in London are foreign nationals and under the October 2020 post-Brexit legislation they could face deportation if found sleeping in the street.

    One week into Lockdown 2

    On day one of Covid-19 National Lockdown 2 (5 November 2020), I researched the following Ealing Covid-19 infection rates per 100,000 people. A week later I did this again:

    Southall Park: 265.3 became 244.1

    Ealing Broadway: 247.6 became 281.4

    Acton Central: 147.8 became 113.7

    West Ealing: 132.9 became 122.9

    A very small sample I know, but in three out of the four neighbourhoods the rate had fallen.

    Government’s Vaccine Taskforce Chair Spends £670,000 on Public Relations

    Kate Bingham, Chair of the Government’s Vaccine Taskforce, has allegedly hired eight Admiral Associates public relations consultants at £167,000/year each. Ms Bingham, a qualified biochemist and venture capitalist, was hired by the Government in May 2020. She is married to Jesse Norman MP. Bizarrely she reports directly to Prime Minister Johnson.

    Town/Hospital Based NHS Activist Groups Slowly Being Marginalised

    Three main factors at work here. Firstly the demolition of local CCGs. In 2018/19 there were 195 of them. By 1 April 2021 they will all have been closed down and ‘replaced’ be some 42 regional CCGs. Secondly, the Covid-19 response National Lockdown 2 has shifted commissioning from local, through regional, to a national undertaking. Thirdly, Covid-19 has allowed NHS bodies and Local Authorities to remove citizens from any effective, real time involvement in statutory body public meetings. In Ealing, for example, virtual, public Council care meetings employ MS-Teams software in a restricted, unhelpful fashion.

    NHS NWL EPIC

    On 17 December 2019 In NHS North West London (NWL) a public engagement initiative called ‘EPIC’ was launched at a workshop. 80 people attended of whom 34 were ‘patients’. EPIC is being used ‘to gather public opinion about local and NHS activities, involving ‘local residents in shaping and co-producing our services’. NHS NWL EPIC has built a ‘Citizen’s Panel’ of 4,000 north west London residents. The make up of the panel is allegedly representative of the 2.5 million residents in the region. I applied to join this panel but my application was ignored. Another EPIC Citizen’s panel meeting – this time a virtual one – was held 27 October 2020. In this meeting the idea of a ’Patient Forum in each borough’ was floated. The local Healthwatch, the local Council and the local voluntary sector would be invited. No timescale was set and it’s obvious that the forums would have no statutory significance whatsoever.

    Public Involvement Charter (PIC)

    EPIC is also developing its own ‘Public Involvement Charter’ (PIC). The PIC has admirable intentions and ‘core values’ – ‘the right to be involved, influence, improving outcomes, inclusion, engagement as residents want, information and transparency’. And all this as ‘we move more towards the (non-statutory) Integrated Core System (ICS)’.

    With all the generosity I can muster, I find the non-statutory EPIC, Citizen’s Panel and the Public Involvement Charter to be underwhelming, likely to be expensive and probably a complete waste of NHS and citizen’s time.

    Eric Leach

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    We  are  writing to you in response to the apparently hurried decision to begin population-wide testing in Liverpool, as part of the £100 + billion ‘Operation Moonshot’, in order to “find positive cases and to break chains of transmission” (Government Press Release, 3rd November 2020).

    This announcement is inconsistent with the SAGE advice at its 56th meeting on 10 September 2020 that it had “high confidence” that “Prioritising rapid testing of symptomatic people is likely to have a greater impact on identifying positive cases and reducing transmission than frequent testing of asymptomatic people in an outbreak area”. This chimes with WHO guidance to focus on contact tracing and identification of clusters, and which does not recommend mass screening.  Proposals for mass screening in their current form will undermine this priority.  

    Searching for symptomless yet infectious people is like searching for needles that appear transiently in haystacks. The potential for harmful diversion of resources and public money is vast. Also of concern are the potential vested interests of commercial companies supplying new and as yet inadequately evaluated tests. If the programme is to proceed, then the contracts awarded, or advertised, should be made public, including their cost to the public purse. (The government is already facing a judicial review for failing to publish covid-19 contracts, brought by your fellow MPs Debbie Abrahams, Layla Moran and Caroline Lucas with the Good Law Project.)

     There is currently no evidence demonstrating that SARS-CoV-2 screening can bring benefit cost-efficiently, and experience shows that unless screening is delivered as a systematic programme with quality assurance for every step of the pathway then any theoretical benefit will not be realised in practice, even where a benefit is possible.

    We would like to ask you what has been decided, and how were decisions reached, regarding the types of tests to be used, what exactly are they aiming to detect, and how has their accuracy been evaluated?  We understand that the Liverpool pilot is likely to use a direct LAMP test (Optigene) and a lateral flow assay (Innova). Currently there is little or no evidence of the accuracy of either of these tests from their use in presymptomatic and asymptomatic cases, or in field settings.  There is substantial uncertainty as to whether they can detect the lower viral loads that are likely in symptomless people, which appears to be the aim of this mass pilot.  If the tests fail to detect cases, then the programme will waste resources and time, and give people false reassurance which could increase transmission.   Similarly, the false positive rates of these tests have not been established in community use and neither have the implications for contact tracing services.  Evaluations of other similar tests by the WHO has suggested between 1% and 5% of people without infection may get false positive findings.  This means that if 1 in 100 people tested in the pilot have asymptomatic infections, as few as 1 in 5 of those getting positive results will actually have Covid-19 – and 4 out of 5 would be false positives and they and their contacts would unnecessarily be told to isolate.

    The accuracy of tests for identifying symptomless infection in a healthy population need to be evaluated in a pilot study with proper research design to assess the extent to which asymptomatic people contribute to overall case-loads, whether they play a significant role in transmission, and whether screening can help. We see no evidence that the Liverpool has such a research design.

    It appears unclear what will happen when people test positive, and negative, whether there will be clinical oversight in interpretation of the results and whether the results will be sent to patients’ GPs and integrated with medical records. What will people be offered? What will they be instructed to do? What support structures are in place to achieve this? It is also unclear how this programme will be integrated into, and affect, the track and trace system, which is already performing poorly.

    Are all the above considerations documented in a format suitable for the lay public to understand as part of an opt-in informed consent process? Is there an option to withdraw from the scheme at any stage, including freeing people of any study requirements? Are participants afforded the right to access their information, to know with whom it is being shared, and to request its deletion – in line with GDPR and the Data Protection Act?

    These are just some of the questions and issues that are concerning us and that need to be pursued, along with asking the government to explain why they are acting inconsistently with SAGE’s advice. We urge you to do so as soon as possible.

    If we can be of any assistance, please do not hesitate to contact us.

    Yours sincerely,

    Allyson Pollock

    Professor of Public Health, Newcastle University

    Anthony J. Brooks

    Professor of Genomics and Bioinformatics, Leicester University

    Louisa Harding-Edgar, General Practitioner and Academic Fellow in General Practice. Glasgow University

    Angela E. Raffle, Consultant in Public Health, Honorary Senior Lecturer in Public Health, Bristol Medical School Department of Population Health Sciences, University of Bristol

    Stuart Hogarth, Lecturer, Department of Sociology, University of Cambridge.

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    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

    Watching and reading the arguments Tory MPs put forward for voting against an extension of free school meals over the school holidays, there seems to be a common thread. Nearly all of them use the argument of dependency, that is relying on the state to provide for us rather than supporting ourselves through personal responsibility.

    These arguments are not new, “Booth and Rowntree found the greatest cause of poverty was not, as often believed, feckless shirking by the irresponsible lower classes, but low pay for full-time work, or inability to get regular work despite best efforts”. In other words dependency is invalid as an argument for poverty. The causes of poverty are well known. This research was conducted before 1914.

    What the Tories call dependency, Labour calls decency. Whatever defence the Conservative MPs type, say, shout or even belief is at odds with fundamental human rights. The right to water and food is part of our existence. The Tories commodify them through privatisation, e.g. the English water companies. Now, they are re-defining them – again – as dependency.

    The language of dependency is interesting yet alarming. From 1997 onwards, society was not focussed on this language, but on how to design policy around alleviating poverty. These alleviation measures while not focussing on the eradicating poverty, sadly, but they helped reduce child and pensioner poverty.

    Without the state focussing on alleviation and the eradication of poverty, we will go backwards in time rather forwards. I know, as I grew-up in poverty in the 1980s and received free school meals. I am very proud that Lewisham through the leadership of Damien Egan and Cllr Chris Barnham acted quickly in Lewisham to extend the free school meals entitlement over half-term.

    Finally, I suspect the dependency argument will continue to be spoken by Tory minsters and MPs. If they can use that past descriptor for free school meals then it won’t be long before it is extended to universal, free at the point of need, NHS healthcare. I have no doubt that a significant number of Tory MPs want us to follow the US system of healthcare. Such a system is the number one cause for bankruptcy among the American population.

    https://www.paulbell.org/

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    Yorkshire Socialist Health Association

    Command and Control Management:

    The Deadly Embodiment of Neo-Liberalism at work in the Public Sector

    John and Joe Carlisle, Mad Management[1]

    Although the Command and Control style of management is a fairly modern phenomenon, like all ideas, its roots go much further back, to a very dominant model of how to discipline and organise institutions. The philosopher Michael Foucault famously uses 18th Century Utilitarian philosopher Jeremy Bentham’s panopticon as a model for how a modern disciplinary society seeks to at all times to survey, or at least give the possibility of surveillance, its populace. The panopticon is a surveillance structure originally designed by Bentham for prisons but reproducible in any environment. The centre is occupied by a watchman who cannot be seen but who is surrounded in the round by the cells or workplaces of those he surveys. Each in their own compartmentalized sections the watchman, or manager, can see everything the prisoners do. As Foucault describes ‘[t]hey are like so many cages, so many small theatres, in which each actor is alone, perfectly individualized and constantly visible.’[2]

    Foucault rightly saw ‘panopticism’ as a paradigm through which individuals could be measured, assessed, marked and surveilled; it was not simply a design for a prison but a “how to” command and control for a whole variety of institutions from schools, hospitals and factories. It is worth quoting Foucault again, this time at length, as he describes the consequences of such a model:

    He is seen, but he does not see; he is the object of information, never a subject in communication… if they are workers, there are no disorders, no theft, no coalitions, none of those distractions that slow down the rate of work, make it less perfect or cause accidents. The crowd, a compact mass, a locus of multiple exchanges, individualities merging together, a collective effect, is abolished and replaced by a collection of separated individualities. From the point of view of the guardian, it is replaced by a multiplicity that can be numbered and supervised. 

    This top down model of designing the workplace was explicitly compatible with industrialization where work was broken down into small repetitive actions that can easily be measured and codified. What is harder to understand is why the model was placed upon all forms of work. Why do so many managers insist upon forcing this model onto industries, such as service, which it does not fit, and more tragically, why use it as the model for management in public services?

    It is now common for most people who work now to have a sense of being monitored. Whether through the ubiquitous CCTV camera, which now often can record audio, to electronic clock ins,’ recordings of all phone calls made in a call centres or on workphones, targets to be hit, milometers which time how long a delivery takes to go from A to B, to IPad’s whose programs must followed to the letter. What this produces is an abundance of data, a mountain of information which can be turned into charts, graphs, and reports. This gives the manager a great sense of control; to him nothing is hidden.

    Except of course a lot is hidden. Data by its very nature hides vast amounts of knowledge. The time it takes to get from A to B does not reveal that the final stage may add 20 mins because there is nowhere to park the lorry. The failure to reach the target may simply reveal the arbitrary nature of the target. In data the whole complexity of the human world is erased, flattened out into a spreadsheet, and the manager ends up mistaking the map for the terrain.

    Not only does it give the illusion of knowledge but command and control management style doesn’t work.  It makes waste rather than reducing it. This article will argue that it is an empirical fact that these modes of supervision fail to achieve what they claim to. Systems thinking is a far more effective way of improving organizations, and ironically, it has the data to back it up.

     Systems Thinking

     In 2003 Professor John Seddon published Freedom from Command and Control. [3] It caused quite a stir, demolishing most of the principles upon which the government had based its efficiency drive – which later morphed into wholly inappropriate and damaging austerity policies. It refuted the top down principle of leadership that is implicit in the New Public Management (NPM), which is a promoter of what Seddon calls ‘the management factory’: ‘The management factory manages inventories, scheduling, planning, reporting and so on. It sets the budgets and targets. It is a place that works with information that is abstracted from work. Because of that it can have a phenomenally negative impact on the sustainability of the enterprise.”

    The case studies gave irrefutable evidence of the damage caused by this neo-liberal mechanism in the public sector. Seddon’s solution was systems thinking as expanded in his next book, Systems Thinking in the Public Sector.[4] Here example after example illustrated the waste caused by NPM, especially as advocated by the likes of Barber (targets etc.) and Varney (shared services – see appendix)

    The research and analysis conducted by Professor John Seddon, which has looked at reasons for diseconomies of scale specifically in service organisations, fundamentally challenges the ‘Command and Control’ logics that underpin much of the public sector. Instead case study after case study confirms that concepts such as ‘designing against demand’, ‘removing failure demand’ deliver outstanding success  , while the typical drive to standardisation and specialisation of function results in inappropriate services being delivered, resulting in turn in escalating monitoring, management and correction costs.

    This, however, requires a change of thinking about how organisations work best in this the 21st century. Over a hundred years ago the workforce was only one generation removed from an industrial culture. Their understanding of industrial production and its organisation was very limited. Consequently even the best designers of organisations, e.g. Henry Ford, the Quakers, Cadburys, Rowntree’s and Clarks, were at best paternal, and at worst, reductionist pragmatists, i.e. treating workers as intelligent tools. However, even the latter did not mean not trusting them or attempting to look after them. After all, Henry Ford doubled the wages of his workforce overnight and refused to allow women to labour after 5pm so they could look after their families. He was also sued by his major shareholder for doubling his workers’ wages at the expense of dividends. The shareholder won.

    Today, we have a workforce that is literate and numerate and is at home with modern organisations, BUT are managed as those of 100 years ago. Why is this? The reason is the Command and Control style is more comfortable for those leaders whose upbringing (conditioning) and training at Business Schools has brainwashed them into feeling that being in charge means taking control. As they cannot be everywhere they therefore use measuring as a proxy for their physical presence. This usually translates into columns of comparative data or run charts, tick boxes compliance, and often targets to be reached as evidence of success of failure.

    So, who is the guardian in the panopticon? It is HR. In many public sector organisations HR has seized this opportunity to become the enforcer of compliance for the board. Rejoicing in their power they have abandoned their traditional role of looking after the workforce and now “guard” it.

    Politicians are entranced by these governance measures. They can conceive of nothing more confidence boosting than setting targets for, e.g. hospital waits, housing allocations, repairs completed. Their mental model is captured in the Table 1, below, in the left hand column. It is informed by their neo-liberal mindset, something they have imbibed from exposure to the right wing press; the fascination with material success, for example Peter Mandelson, playmaker of the Labour party said twenty years ago that he was “intensely relaxed about people getting filthy rich as long as they pay their taxes”; privatisation continues even though it is clearly an utter failure; and cost-cutting  and targets are the first knee jerk reactions to perceived public sector overspend.

    But there is another way. It comes in the form of a System of Profound Knowledge, first propounded by the great management philosopher, Dr W. Edwards Deming, whose principles are best presented in the work of Professor John Seddon, head of Vanguard.

    The Seddon Vanguard model, constructed from his research into effective organisations is the right hand column (Table 1).

    Table 1. The two conflicting models of management

    The question is why, in particular do UK politicians favour the Command and Control model? Our theory is that it is the “control” element that matters most – and, which has caused the most waste, and managers and politicians in particular are comforted by the illusion of control even when it clearly causes so much damage to people and resources as the examples below illustrate. [5]

    • Western Australia’s Department of Treasury and Finance Shared Service Centre promised savings of $56 million, but incurred costs of $401 million.
    • A National Audit Office report said that the UK Research Councils project was due to be completed by

    December 2009 at a cost of £79 million. But, in reality, it was not completed until March 2011, at a cost of £130 million.

    • The Department for Transport’s Shared Services, initially forecast to save £57m, is now estimated to cost the taxpayer £170m, a failure in management that the House of Commons Public Accounts Committee described as a display of ‘stupendous incompetence’

    Covid-19 has made the flaws are even more obvious. That greatest of all control freakery, the centralising state, has been shown for disaster that it is. The Health Secretary has kept control of all the testing and tracing administered from the centre, and it is failing at every level. The report from the Independent SAGE, a group of 12 leading scientists headed by former UK Government chief scientific advisor, David King, said the governments test, track and trace system is not “fit for purpose”.

    The government’s current approach to this system, including the contact-tracing app, is “severely constrained by lack of coordination, lack of trust, lack of evidence of utility and centralisation”, it adds. “The effective operation of this subsystem is also complicated by the apparent failure of the app that was designed to facilitate identification of contacts of those who have Covid-19” (Digital Health, June 16, 2020). We are talking here about thousands of British lives and further damage to a reeling economy.

    Dr W Edwards Deming summed it up perfectly: “Most people imagine that the present style of management has always existed and is a fixture. Actually, it is a modern invention – a prison created by the way in which people interact.”  He then asked the question:

     How do we achieve quality? Which of the following is the answer? Automation, new machinery, more computers, gadgets, hard work, best efforts, merit system with annual appraisal, make everybody accountable, management by objectives, management by results, rank people, rank teams, divisions, etc., reward the top performers, punish low performers, more statistical quality control, more inspection, establish an office of quality, appoint someone to be in charge of quality, incentive pay, work standards, zero defects, meet specifications, and motivate people.”[6]

    Answer: None of the above. (Will someone please tell our politicians.)

    All of the ideas above for achieving quality try to shift the responsibility from management. Quality is the responsibility of management. It cannot be delegated. What is needed is profound knowledge. A transformation of management is required, and to do that a transformation of thinking is required – actually the neo-liberal paradigm is so entrenched that that nothing less than metanoia (a total change of heart and mind) is needed.

    When this transformation happens almost miraculous levels of performance occur. For example, when left to the medical staff only, the level of delayed bed days fell from over 12,000 per month to under 6000 in a year (2017/2018) – an over 50% reduction! Much less command and control leads to much more economic and effective activity. It is time all the politicians learned to trust their public servants much more, and abandon the illusion of control foisted on them by neo-liberal ideologists from Labour and Conservatives. It is a political thing, not a party thing. The whole system of government must be overhauled.


    References

    [1] https://jcashbyblog.wordpress.com

    [2]Michel Foucault, Discipline and Punish, trans. A. Sheridan (Vintage books, New York, 1995) p. 200

    [3] Seddon 2003 ‘Freedom from Command and Control’ Vanguard Education

    [4] Seddon 2008 ‘Systems thinking in the Public Sector’ Triarchy: Axminster

    [5] John Seddon 2012 submission to the Local Government and Regeneration Committee – Public Sector reform and Local Government. 2012

    [6] Deming, W.E. (1993) Out of the Crisis, MIT: Cambridge

     

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