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    Author: B Fisher on behalf of Keep Our NHS Public

    The SHA asks you to support this great project if you can. Please spread the Crowdfunder with friends, families and in your networks – we need to know why so many deaths – why so many families, the NHS and social care were let down so very badly.

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    NHSE/I consultation on

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

    Response to the consultation by

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

    8 January 2021

    1. Overview

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

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

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

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

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

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

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

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

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

    In summary, the proposals:

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

    We discuss the details in the following two sections.

    1. ICSs during 2021/22 and before legislation

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

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

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

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

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

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

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

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

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

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

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

    • The single pot budget

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

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

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

    • Provider collaboratives

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

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

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

    • ICS membership

    There are two potential aspects in this regard.

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

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

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

    • Public accountability

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

    • Competition and contracting

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

    • Social care

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

    • Public health

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

    • Workforce planning

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

    • Moving staff and their terms and conditions

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

    1. ICSs after legislation

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

    The next steps document proposes two options for legislation.

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

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

    NHSE/I prefer Option 2.

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

    • Major reorganisation

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

    In September 2019, NHSE/I stated:

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

    • Competition and contracting

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

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

    • Fate of CCGs

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

    • ICS membership

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

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

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

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

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

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

    1. Conclusion

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

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

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

    END

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

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

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

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

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

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

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

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

     

    ICS Next steps Consultation Response 08Jan21

    2 Comments

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

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

     

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

    The 2012 Health and Social Care Act and Marketisation

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

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

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

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

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

    The Private Finance Initiative

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

    The promulgation of the Neoliberal Ethos in the NHS

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

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

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

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

    The Extent of Privatisation

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

    Consultation on Integrated Care Systems

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

     

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

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

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

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

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

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

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

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

    6 Comments

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

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

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

    WHAT SHA WANTS TO SEE

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

     SHA cannot support these proposals.

    RESPONSES TO QUESTIONS

    Q. Do you agree that giving ICSs a statutory footing from 2022, alongside other legislative proposals, provides the right foundation for the NHS over the next decade?
    SHA does not agree. Our many reasons are explained below.

    Q. Do you agree that option 2 offers a model that provides greater incentive for collaboration alongside clarity of accountability across systems, to Parliament and most importantly, to patients?
    SHA does not have a view on this.

    Q. Do you agree that, other than mandatory participation of NHS bodies and Local Authorities, membership should be sufficiently permissive to allow systems to shape their own governance arrangements to best suit their populations needs?
    There need to be national standards, locally delivered, matched to the needs of an area. Please see SHA’s thinking on NHS democracy.

    Q.Do you agree, subject to appropriate safeguards and where appropriate, that services currently commissioned by NHSE should be either transferred or delegated to ICS bodies?

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

     SHA’s REASONS FOR REJECTING THE PROPOSALS.

    Based around place

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

    Relationships with Local Authorities

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

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

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

    Devolution

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

    Governance

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

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

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

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

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

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

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

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

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

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

    Governance and PCNs

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

    Data

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

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

    Health Creation is not mentioned in this paper.

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

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

    Population health, but almost no mention of Health Inequalities

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

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

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

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

    of care to achieve maximum impact for the population.”

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

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

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

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

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

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

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

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

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

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

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

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

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

    Backroom functions will continue to be privatised.

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

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

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

    Staff

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

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

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

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

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

    Democracy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    SOCIALIST HEALTH ASSOCIATION RESPONSE TO ICS CONSULTATION 7 1 21

    2 Comments

    Please write to your MP to try and stop this deportation of up to 50 Black British residents to Jamaica on Wednesday 2nd December

    Please use the following template.

    Dear xxxxx MP,

    Please would you support this appeal.

    Many of those facing deportation have been criminalised through social exclusion and a police and justice system which is deeply prejudiced. Repeated investigation shows the consequences of their deportation are likely to be exceptionally severe.

     

    Socialist Health Association.

    Comments Off on Stop this deportation

    The Socialist Health Association is appalled by reports that Kate Bingham, who heads up Boris Johnson’s vaccine taskforce, has charged the government £670,000, for what is described as a ’team of boutique relations consultants.’ Each consultant is reportedly paid £167,000 a year – more than the Prime Minister. There appears to have been no formal process to appoint Bingham to chair Britain’s vaccine taskforce.

    This would appear to be a gross waste of public funds, which are desperately needed to fight the Covid pandemic.

    The Sunday Times reported that Bingham had shared government documents to investors at a $200-a-head virtual conference – an appearance that was not signed off by ministers. At the same time, she manages private investments in companies developing coronavirus drugs.

    We note that Ms Bingham, a venture capitalist, is married to Jesse Norman, a Tory Treasury minister, which only underlines the potential conflicts of interest.

    The SHA calls for the pandemic to be fought through the NHS and other public bodies, and not to be outsourced to private interests.

    https://www.thelondoneconomic.com/politics/kate-bingham-vaccine-tsar-runs-up-670000-taxpayer-funded-pr-bill/08/11/

    1 Comment

    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.

    Comments Off on Asymptomatic Covid-19 screening in Liverpool

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

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

    to launch our campaign to transform social care.

    Watch it here

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

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

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

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

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

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

    Speakers endorsed the 7 demands of our campaign:

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

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

    If you were unable to attend , watch the event here

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

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

    JOIN US!

    WE CALL ON SHA BRANCHES FOR SUPPORT

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

    Details will follow

     

     

     

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

    INTRODUCTION

    Branch chairs in England were phoned by BF and asked to help with two related issues:

    • A longstanding problem that branches have felt distant from CC with poor communication
    • The recent problems as a result of branches elected unconstitutionally no longer being represented on CC.

     What follows are the main themes people discussed. They include results from SHA London’s formal vote on the issue.

     INFORMATION FLOW THROUGH NATIONAL MEMBERS.

    Oxford: There is a channel to and from CC through national members. However, they are not delegated by the branch to vote on the national CC so cannot be a reliable channel – in either direction.

    Chester: Their national member keeps them informed about CC business.

    A BRANCH CHAIRS’ GROUP, BRINGING BRANCHES TOGETHER, SENDING MESSAGES TO CC

    Oxford: With no powers, may be useful, but is limited. It would need teeth – fitted into the governance arrangements.

    Yorkshire: A group of branch Chairs

    London: CC to set up a liaison group between branch chairs, and to include Wales and Scotland.

    West Midlands: There should maybe be a permanent chair plus secretary or nominated branch member WhatsApp group which would link all. Hopefully this might be a forum where co-operation could develop. Also a regular face to face meeting of branch Chairs and Secretaries.

    SHARING AND SUPPORTING BRANCHES’ ACTIVITY

    • Jean to write to branches to ask them to send her anything that your branch is doing.
    • Set up a branches section on website. (Oxford and Manchester)
    • National SHA will notify branches of work with Shadow teams and invite relevant expertise to input
    • SHA will formally notify SHAL and other branches in writing of any actions or decisions which directly impact on branch functions
    • To optimise on skills and avoid duplication, SHA will keep branches in the loop re work involving local CC members
    • Not formalized. Ad hoc. Or joint action, or supporting others’ action.
    • Branches could write blogs, as Vivien Walsh of Manchester has done. She had lots of very useful responses to her article on the fight for Manchester Royal Infirmary.

    CO-OPTION

    Oxford: W Mids has a lot of people on CC. Why can’t you co-opt others?

    London:

      • 67% of respondents support asking the CC to co-opt all of our 9 delegates to CC
      • keeping the current arrangement until next AGM and organising as many co options as possible – including ensuring those branches without CC reps of any kind are given space.

    DATE OF AGM

    Oxford: hold an early AGM

    London:

      • Hold an AGM in 2021, planning appropriately around public health needs, co-opting our delegates onto CC in the meantime.
      • In the event that Central Council does not agree to interim co-option, in the interests of inclusivity we would expect that the AGM is brought back to December 2020 and proper timely notification to branches in line with Clause 13 in either case.

    OTHER SUGGESTIONS:

    • Defer decisions till after AGM
    • One off rule change to co-opt previous delegates.
    • More listening to the branches. Before CC makes a decision – asking branches what do they think of this?
    • CC needs to base its decisions on what the membership thinks.
    • Branch chairs could be trained up to be national chairs.
    • Hold an SGM to reinstate delegates.

    CONCLUSIONS

    Probably the most popular and practical suggestions were:

    • Branches should use their national delegates to feed back on CC decisions
    • A process to bring together branch chairs and secretaries
      • A WA group
      • A regular or ad hoc meeting
    • Co-opt onto CC as many people as is constitutionally allowed from those branches with no CC delegates
    • Set up a branch section of the website where branches can announce their local activities
    • National SHA to notify branches of work with Shadow teams and invite relevant expertise to input
    • SHA will notify branches of any actions or decisions which directly impact on branch functions
    Comments Off on Suggestions For Improving Communication Between Branches And Central Council

    I am pleased to circulate the details of the launch of the joint SHA/KONP campaign to reshape social care in England. The launch will be at 1100 – 1300 on 10th October

    Register for the event here

    This is a major national campaign with a wide ranging support. Your support and involvement will be vital.

    More details are attached, including a MOTION that we would like you to discuss at wards and CLPs.

    We look forward to seeing you there.

    Yours,

    Brian and Jean

    A SUMMARY OF THE SOCIAL CARE CAMPAIGN

    Comments Off on Launch of the joint SHA/KONP campaign to reshape social care in England

    Dear SHA member,

    I stood for Chair of the SHA to progress a socialist approach to health and care. We have made great strides in a short time. After taking up the role, I found that I had inherited a range of difficulties that will take some time to sort out. In the meantime, I want to keep you up to date.

    Making Positive Change

    1. Social Care Campaign
      SHA has an agreed policy on Social Care and Carers. We have also agreed a campaign, jointly with KONP, for social care free at the point of use, supporting independent living, brought into the public sector and paid from taxation – like the NHS. We hope to launch in October. We have union support and support from other organisations, including John McDonnell’s https://claimthefuture.today/. John has said he will support us in any way he can. We have also talked to Liz Kendall, Shadow Minister for Social Care.
    2. Race policy
      The Black Lives Matter movement has spawned much. We intend to take a proposal to CC on developing policy on Racism, Race and Health. If that is accepted, then we shall be bringing people together to explore the topic. Tony Jewell will lead this.
    3. Work with the Shadow Team
      This has gone well over the last few weeks. We have produced briefings, mainly on public health issues related to Covid, but also on primary care and schools. A few weeks ago, we presented on inequalities to the Shadow Team which we understand was well received. We have followed up with more detailed analysis of workplace democracy and community development in health. The briefings are on the website.
    4. Branch activity
      Branches continue to be very active, fighting hospital closures, challenging racism, fighting to protect people and places from Covid. We need to reach out to branches and see how we can best keep in touch. We need to learn from each other as much as we can.
    5. The Covid blogs
      These 20 authoritative pieces, over 20 weeks of Covid, have increased the reputation of the SHA. They enabled us to see the progress of Covid from a global socialist perspective. They are all on the website. They have been paused now but may resume of there is an outcry for more!
    6. Feedback from the Frontline
      In response to a request from Jonathan Ashworth, we have been asking members to feedback their experiences and questions. You have done that in droves, and we have been able to help the Shadow Team confront the government more effectively with your questions and observations.
    7. Social Media
      Jean is doing two large pieces of work via our Twitter and Facebook feeds, one on the Tory attack on the humanity of refugees, and their rights, the other on A level results in England, and the unfairness to non-privately educated children the algorithm has produced.  Jean wants to hear more voices from experience, more human faces to put to the label “refugee”, or “immigrant”, more real lived experiences of living on no income at all. Do we have anyone dealing with such cases now, who could get us some human stories? Please read our Facebook and Twitter, and read, circulate and retweet.

    Overcoming Difficulties. Refer to SHA Debate for more detail

    1. Financial problems
      No-one is suggesting malfeasance, but there do appear to have been unconstitutional transactions over the last couple of years. We shall set up an independent investigation as soon as possible to understand and sort out the problems.
    2. Bringing us back to the constitution
      We found that the rules that bind the organisation had been bypassed.  It is essential that the SHA is, and is seen to be, a rules-based group that will fight relentlessly for socialism and health. That has required some hard changes.
    3. Special General Meeting
      Those hard changes have not been welcomed by many and there has been a request for an SGM which will aim to make Jean and myself resign. We shall call a Central Council meeting soon to decide on the practicalities of setting that up. All members need to be able to participate.

    I hope you can see that we are tackling the difficulties and moving forward. If there are aspects of the work that you would like to support – please let us know.

    All the best,

    Brian

    Comments Off on Debates in the SHA

    This week the Government is expected to announce that it will scrap the pandemic response function of Public Health England, and merge this with NHS Test and Trace to form an agency “similar to the German Robert Koch Institute”. It is also particularly distressing that the news was leaked to the press before PHE staff could be told.

    The SHA warns the reckless decision to restructure and defund public health services in the midst of a pandemic will result in further avoidable deaths. The public health service, nationally and locally has already been severely starved of funds as a result of austerity.

    The NHS Test and Trace Service (led by Baroness Dido Harding, and run by Deloitte, Serco, Sitel and other private sector outsourcing companies) has received strong criticism for its poor response to the COVID 19 pandemic.

    Dr Brian Fisher, SHA Chair, says “This is yet another example of the Government putting lives at risk by pursuing ideologically driven privatisation in a time of crisis.”

    Socialist Health Association members have told us that “this is another example of this government’s scapegoating, most especially since the man telling us the PHE response has been unacceptable was the man in charge, deliberately ignoring their expert recommendations and favouring sweet manufacturers and other non-expert businesses to deliver a service to the public. Public health has been underfunded, to the point it has required almost superhuman efforts from its staff to maintain a quality of service from the time of the so called Lansley Reforms. For that, our public health experts, like our nurses, are rewarded with a kick in the teeth.”

    SHA calls on the Government to reinvest funds from failing NHS Test and Trace private providers into the public sector pandemic response across the NHS, Public Health England and Local Authorities.

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