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    The Equalities and Human Rights Commission has published a document setting out how independent living, as defined by the United Nations’ Convention on the Rights of Persons with Disabilities, can and should be written into domestic law. The document addresses the breadth of issues relevant to independent living, including recommendations relevant to such as transport and housing. As far as social care is concerned its recommendations describe a route to a newly envisioned but financially sustainable future built to deliver independent living.

    What is independent living?
    It is first important to understand what the UN means by independent living. It is firstly about living in the place of one’s own choosing, whether in one’s own home or communally, and secondly being able to make all the day to day choices that non disabled people take for granted. It applies to people of whatever age and whatever their impairment of body or mind. It applies as much to an older person wanting to choose the time they go to bed as to a younger person wanting to make their full contribution to society. In other words, it applies to every person in need of care and support.
    This is a different understanding from its original meaning created by the disabled people’s movement in the 1980’s. In relation to care and support, independent living was an alternative service model whereby the person managed their own support staff in their own home. Made possible by the 1996 Direct Payments Act, it has been a very successful model in the 25 years since for people with the skills, energy and time to make it work.

    Independent living and wellbeing

    The Commission notes the close relationship between the wellbeing principle of the Care Act and independent living. If a person can tick all nine of the wellbeing boxes of the Care Act – including as they do control over the person’s life and services, dignity and living in a home of their choosing – they will have independent living.
    How can it realistically happen?
    Resources are, of course, key. How can you reconcile such an ambitious vision with having to work within budgets settled in the hurly burly context of competing interests for limited public funds?
    The key is to acknowledge the simple and self evident truth that the adoption of any person centred ambition, whatever it might be, cannot be guaranteed to be affordable within existing resources. There will be a measure of unmet need. The test of society’s commitment to the vision will be the scale of unmet need.
    The UN approach to the resource challenge is straightforward. It does not expect states to make the resources required for independent living a legal right or in any other way guarantee all the funding required. What it does expect is that states adopt a strategy of progressively realising the resources that are required.
    The Equalities Commission accordingly reflects this approach. It believes the Secretary of State should periodically set out plans for how the resources required will be progressively realised.
    The start point for these plans must be knowing the true scale of unmet need.

    Making the plan a reality
    The first inescapable requirement must be real time information about the scale of unmet need at any point in time. That will require the wholesale transformation of the way needs are assessed, support planned and resources allocated.
    Whilst the law does not require it, policy in England, as in other parts of the UK, prohibits exposure of unmet need.
    An entirely new system of assessing need and allocating resources will be required. Assessments must start from the vision of what each person needs for independent living. Practitioners must identify and cost all such needs for every older and disabled person in need of care and support. Budget holders must control spending not by controlling the local eligibility threshold, but by making decisions about what they can afford. They must learn to secure the greatest degree of independent living for the greatest number of people their budgets allow. IT systems must capture information about needs met and unmet for strategic reporting.

    Political benefits
    Political leaders may not like being put on the spot in the way the Commission’s recommendation might suggest. However, it would be hard to mount an argument against its reasonableness. It does nothing more than expose political leaders to their responsibilities.
    But they can look forward to a silver lining – the banishment of the fear of social care as a bottomless pit of demand. The vision of independent living would create a positive, aspirational context for understanding ‘need’. Research has long shown that support plans built on the best that life can be for the persona and on their strengths, no matter how dire their circumstances, require less public resource than plans built on how bad life is and on their deficits which, it is widely acknowledged, is the hallmark of the current system. The need for, and existence, of stand alone ‘strengths based’ strategies testifies to as much. Swimming against a powerful tide, ‘strength based’ strategies are doomed to fail. The tide must be turned so that ‘need’ is routinely understood in the context of making life as good as it can be for the person. Support plans will be built on the person’s strengths as a matter of routine.

    Scotland
    Interestingly, as Peter Beresford and I previously pointed out, Scotland is ahead on this agenda. It is on the cusp of contemplating such a transformation. Its review of social care has recommended a new paradigm, one that will deliver on human rights with independent living at its core. Whether or not the Scottish government makes the leap is a matter of international as well as domestic interest.

    Conclusion
    This change can be achieved without legislation and instead through moral compulsion and pragmatic good sense. It can happen now. It will not require a single penny more for new services. The only ‘price’ is political courage and integrity.
    At the heart of the change is reversal of the dynamic between needs and resources. A founding principle of the NHS in 1948 was that need must always precede resource. If not always working perfectly, by and large it has survived. We expect clinicians to say what is wrong with us and what modern treatments can do to the best of their knowledge. Waiting times provide a safety valve if need exceeds resources.
    In social care, the reverse was applied. In passing responsibility for the care of older and disabled people from Poor Law Boards to local authorities, when pressed in Parliament on what local authorities would do, Nye Bevan as Minister for Health said they would do ‘as much as resources allow’. No doubt the best answer at the time, the surely unintended consequences were to put social care at the back of the queue for public resources and set it on the path of a resource led definition of need resulting in the tyranny of ‘eligibility criteria’.
    The Commission’s recommendation would require social care to be placed on the same footing as the NHS in how needs and resources are reconciled. It amounts to nothing less than the ‘1948 moment’ increasingly being heard by the likes of Nicola Sturgeon as being what social care requires.

    Colin Slasberg is a social care consultant

    This post makes an important contribution to the debate on the provision of social care in England and is not a reflection of the SHA’s policy.

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    The news that Sir Simon Stevens was standing down from his post as NHS England Chief Executive in July prompted some remarkable tributes from the Health Service Journal (HSJ), even by own standards. The editorial said that Stevens had managed to save the health service on no less than three occasions and has been the most important figure in NHS history since Aneurin Bevan. It also said that Stevens was “the greatest strategic health policy thinker of his generation”, and in this point at least the journal is accurate.

    STRATEGIC THINKING
    Back in May 2004 the Guardian’s John Carvel asked with regard to Stevens: “Why does a bright young man who has probably had more influence on NHS policy over the past seven years than anyone else in Britain decide to quit the public service to work for a $28bn US healthcare corporation intent on aggressive expansion into a new NHS market”? Indeed, Carvel thought that “If he had gone back into NHS management, he could have been running the whole shooting match after two or three more moves”.

    At the time Steven’s move did appear odd as UnitedHealth’s – his new employer and the largest health insurer in the world – anticipated role within the NHS was thought to be marginal at best. It only ran two GP practices in Derbyshire and a case management programme for elderly people. But by 2007 Stevens’ former colleagues had given the green light to 14 companies, including United and other US insurers, to bid for potentially much bigger contracts from primary care trusts providing data analysis and research, giving PCTs a clearer idea of how to manage patients with chronic condition.

    However, as the Guardian pointed out, “their role may be bigger than that. Companies may also be invited in to act as middlemen, negotiating with hospitals on the trusts’ behalf to reduce costs, ushering in the prospect that some patients may find their care plan managed not by a doctor but by an American insurance company”.

    While this programme – the FESC – proved a little premature, it offers much of the key to Stevens’ strategy. Transnational capital was in the early stages of creating a global market in healthcare and adopting standardized organizational formats from which the greatest profit could be extracted. As this process was US-led, it was inevitable that its dominant and most profitable format, that of Managed Care, would be adopted as the guiding template, and Stevens’ move to Minneapolis was in part to familiarize himself more fully with the working of this system and with its leading participants.

    It was also, as became evident, to locate himself as a major player within this wider market creation, and to bring English healthcare into its framework.

    US ‘REFORM’
    The focus of Stevens’ early work in the US was Managed Care’s applicability within public programmes, and in 2007 he became chief executive of Ovations, United’s division providing insurance packages for older patients, and which accounted for over 1/3 of its revenue. It also included Medicare Advantage, the private sector management of the state-funded programme for the over-sixties; a programme which had been heavily criticised for excessive administration costs, its evolution into a multibillion-dollar subsidy for private companies, as well as the insurer’s monopoly within certain states.

    Indeed, the scale of profiteering within Medicare Advantage, and within the US system in general, produced considerable clamour for reform. In 2007, Stevens told the Guardian, “For all its problems, there is often an ability in the States to innovate faster and really test new models of care. This is an exciting time in health reform in the US – there’s a real sense that there will be meaningful change here in the next few years”.

    But this was nonsense. Any sense of global market creation would be fatally undermined if Managed Care was to be replaced by single payer – a national system that would eradicate the need for insurers – on its home ground, and every effort was made to make sure this didn’t happen. Indeed, United, and Stevens himself, played significant roles not only in destroying single payer but ensuring that the position of the giant insurers was strengthened; in large achieved by taking greater control of Medicare, Medicaid and the new market exchanges, to the extent that within a few years these programmes had become the main artery of profits.

    GLOBAL CONCERNS
    With the home territory secured, United, and Stevens, began to apply themselves more fully to global market formation.

    In 2009 Stevens was also charged with managing United’s international operations, growth and M&A in 123 countries, including North America, Europe, and the Middle East. One of his first tasks was helping set up, in 2011, a high-level trade lobby group, the Alliance for Healthcare Competitiveness (AHC), which wanted “the Office of the US Trade Representative, acting through the World Trade Organisation, to force other nations to open up their national health systems to US for-profit insurers, hospitals, professionals, medical device makers, pharmaceutical firms, IT companies and other investor-owned firms”.

    However, it makes little sense to open up national systems unless these conform to standardized templates. A year later, Stevens was helping to pursue this aim, by acting as Project Steward within the World Economic Forum’s (WEF) year-long project on Sustainable Health Systems. Co-organized with the leading US consultancy, McKinsey, workshops held in New York, Berlin, Istanbul, Tianjin, Madrid, Basel, the Hague, and London were, according to the WEF, “remarkable in their consistency of vision”, advocating new care models with delivery from “capital-light settings” using “leveraged talent models” and “low-cost channels, such as home-based models”.

    In ‘Health Incorporated’, undoubtedly the WEF’s scenario of choice, the boundaries of the health industry would be redefined. “Corporations provide new products and services as markets liberalize, governments cut back on public services and a new sense of conditional solidarity emerges”. Further, “Health schemes and insurance markets boom as people seek to cover their health costs. Governments, meanwhile, focus on regulating large integrated health providers in a complex expanding global marketplace”.

    The final part of the jigsaw was applying these structures within the English NHS, and Stevens’ policy formation over the following years – the Five Year Forward View, the New Care Models Programme, the Sustainability and Transformation Partnerships, and, ultimately, the 42 regional-scale Integrated Care Systems – must be seen entirely within this context. With, for example, UnitedHealth “sitting within the ICS in Somerset and acting as the engine room” of transformation, and with Centene playing the same role in Nottingham, such relationships will be pursued in as many ICSs as possible. The bulk of the English policy community is firmly behind this and as yet the process only requires legal ratification.

    CONCLUSION
    This is Stevens’ legacy: that of helping to create a global regime of accumulation, and situating English healthcare within that. In this, and here we must agree with the HSJ, he has proved remarkably successful. Rather than viewing Stevens as unique, however, he should instead be seen as an exemplar of a widespread phenomenon, as throughout his tenure with NHSE, for example, he continued to work with the World Economic Forum on its Executive Board of the Value in Healthcare Coalition, alongside CEO’s from Humana, Kaiser Permanente, Takeda, and several others, to further the aims of transnational capitalism. But in terms of developing and promoting the central tenets of the NHS – those of universality, equity, and indeed ‘freedom from fear’ – he is as far removed from Aneurin Bevan as you can get.

    References

  • https://www.hsj.co.uk/policy-and-regulation/stevens-has-been-the-most-important-figure-in-nhs-history-since-bevan/7029999.article
  • https://www.theguardian.com/society/2004/may/26/nhs2000.health
  • https://www.theguardian.com/politics/2007/nov/11/uk.publicservices
  • The Framework for Procuring External Support for Commissioning. This was set up by Mark Britnell, then the Department of Health’s director general of commissioning and system management, and now short-listed to be Stevens’ successor as NHSE CEO. The policy community clearly
    expects some form of continuity.
  • See for example: https://pnhp.org/news/the-health-insurers-have-already-won/
  • Hellander, I. ‘Health firms’ proposal: Use trade rules to force other nations to import our failed “health ecosystem”’. Physicians For a National Health Program, 4 October 2011.
  • http://www3.weforum.org/docs/WEF_SustainableHealthSystems_Report_2013.pdf
  • http://www3.weforum.org/docs/WEF_Value_in_Healthcare_report_2018.pdf
  • Stewart Player is a political analyst with over 20 years experience of working in the field of healthcare policy. Research areas covered include primary care, ISTCs, US healthcare policy, and long-term strategic developments within the NHS. Most recently working on NHS estates policy, restructuring within the private healthcare sector, and the political theory of transnational class formation.

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    The recent buyout of a chain of London GP practices by the giant US insurer, Centene, prompted considerable media coverage last month with many Labour MPs and campaigning groups claiming the deal represented ‘privatization by stealth’. However, while this description may have been apt in 2005 it is now entirely outmoded as there is nothing covert nor slow about the process anymore. Instead, what is taking place – and has been for many years – is a full-blown, US-led takeover, by the same corporate interests, adopting the same instruments and organizational structures and effected by the deployment of key personnel within public office.

    In fact, primary care services are only a branch-line within Centene’s English ambitions; as in the US its core business will be managing as many of the regional-scale Integrated Care Systems (ICSs) as it can. And, as in the US, making huge profits from the role.

    Anyone doubting the speed and transparency of this takeover need only consider two recent headlines. On the 24th March the Health Service Journal (HSJ) reported that Timothy Ferris, the CEO of a leading US healthcare organization had been hired as NHS England’s new Director of Transformation and even, according to the journals’ editorial, a strong candidate to replace Sir Simon Stevens as head of the NHS in England. While undoubtedly the Director role is extremely important, it was thought that Ferris was unlikely to take such a pay loss unless something even bigger was in the offing. Even more tellingly, it was announced a week later that Boris Johnson’s new health ‘supremo’ was Centene’s UK Chief Executive Officer, Samantha Jones, and that she was entering government as expert adviser for NHS transformation and social care delivery.

    Having its UK CEO within the corridors of Number 10 is the culmination of several years of engagement with the NHS transformation agenda, and Centene’s business model also reveals a great deal about the nature of this agenda and its intended outcome.

    The corporation is unusual in that, unlike its main US competitors, UnitedHealth, Aetna, Anthem and Cigna, its revenues have been built almost entirely from public health programmes. While Centene’s annual accounts highlight its diversified portfolio of, among others, behavioral health management, correctional healthcare services, home-based primary care services, and telehealth, its core business is that of managing services for the poor and disabled, under what is known as Medicaid Managed Care (MMC).

    Collecting money from the state on a per-patient basis, the corporation promises to negotiate with healthcare providers for patient care. As it is allowed to keep any cost difference that may accrue, the incentive is to reduce such care to a minimum. While MMC existed before 2010, it was greatly expanded by the US Affordable Care Act – or Obamacare – in that year, and since then Centene has become the largest Medicaid insurer in the nation. Following its buyout of a major competitor, WellCare, in January 2020, it now commands 21% of this market and is the dominant presence in such key states as California, New York, Florida and Texas. Given the above-mentioned incentive to cut care, the company has inevitably left a trail of scandals, financial penalties and public outcry in almost every state it entered. (See attached examples)

    On the back of its rapidly growing wealth, in 2014, the company sought opportunities overseas, and whilst its first entry point was a 50% share in the Spanish Public Private Partnership company Ribera Salud, this was largely a stepping stone to the English NHS, where Managed Care was being pursued at a systemic level. Centene’s entry to the NHS in fact followed an event in October 2015 co-organized by NHS England’s New Care Model programme, led by Samantha Jones, and the NHS Confederation.

    At least 20 of these New Care Model vanguards – prototypes of the Integrated Care Systems (ICSs) – were introduced to Centene though it is not known how many engaged its services. They did include Nottingham and West Essex, and in the case of the former, the corporation designed the entire ICS over a two-year period beginning in early 2016. This involved an actuarial analysis – necessary for an insurance system – and 32 workstreams including those on patient pathways, population health management, social care integration, IT services, provider payment models, together with governance and contract design.

    Nottingham leaders were happy to boast of their affiliation with Centene and Ribera, saying they were now “standing of the shoulders of giants”. In subsequent events organized by the leading think thanks, the Kings Fund and Nuffield Trust, the corporation was described as a ‘system integrator’ or ‘transformation partner’ but little clarity was offered in terms of its future role.

    However, one presentation revealed far more than the policy community intended – and has since been removed – which described the corporation as an “impartial ICS manager, accountable for all services, data reporting, contracts, and other functions to manage the financial risk effectively”. It would also provide investment via capital and loan guarantees and risk-sharing would be involved. In other words, it would act as a middleman between public funding bodies and provider networks, be able to financially profit from the management of risk, and effectively be a Medicaid Managed Care Organization.

    It is clear that the US Managed Care model lies at the heart of the ICS Programme and of the entire NHS transformation process and is a model which systematically profits from the denial of care to patients, particularly the most vulnerable sections of the population. This is what the headlines should be saying, and this is the role that Centene is primarily seeking to replicate throughout as many ICSs as it can and why with Jones once again at the centre of government such ambitions will be rapidly realized. GP services, while very useful, will be small change in comparison.

    References

    1. https://leftfootforward.org/2021/04/privatisation-by-stealth-dozens-of-mps-slam-private-takeover-of-49-gp-practices/
    2. >https://www.hsj.co.uk/policy-and-regulation/the-leading-candidates-for-the-next-ceo-of-nhs-england/7029994.article
    3. It should also be pointed out that Centene has a large presence in both Medicare Advantage – the over 65’s equivalent of MMC – and in the Obamacare market exchanges.
    4. The list also includes: Arizona, Alaska, Georgia, Illinois, Kentucky, Michigan, and Mississippi.
    5. https://www.latimes.com/business/la-fi-medicaid-insurance-profits-20171101-story.html
    6. https://www.latimes.com/business/la-fi-medicaid-private-insurance-20181018-story.html
    7. https://eu.desmoinesregister.com/story/news/investigations/2018/07/01/iowa-new-private-medicaid-company-troubled-past-centene-millions-dollars-penalties/637740002/
    8. https://claudepeppercenter.fsu.edu/side-posts/dallas-morning-news-pain-and-profit-briefing-by-the-claude-pepper-center/
    9. Nottingham City Clinical Commissioning Group, ‘NHS Clinical Commissioners. Core Cities’, 6 December 2016.

    Stewart Player is a political analyst with over 20 years experience of working in the field of healthcare policy. Research areas covered include primary care, ISTCs, US healthcare policy, and long-term strategic developments within the NHS. Most recently working on NHS estates policy, restructuring within the private healthcare sector, and the political theory of transnational class formation.

    6 Comments

    A recent study by the Bevan Foundation has called for the establishment of a “ Welsh Benefits System”. It found that over £400 million in welfare type payments are distributed by devolved bodies but that the system  lacks coherence and does not operate in a strategically focused way.

    Just over half of all public expenditure in Wales is undertaken by devolved bodies e.g. Welsh Government, NHS, housing, and local government. The bulk of the remainder is through welfare payments which constitute over one third of all Welsh public expenditure. While the overwhelming bulk of these these payments are administered and delivered by the Westminster government a relatively small element is delivered by via devolved Welsh public bodies. However in terms of Welsh social protection payments, the sum is not insignificant and it operates to complement the main welfare benefit system.

    These payments cover twelve different schemes which were included in the study. They include Council Tax Reduction Scheme, Free School Meals, Disabled Facilities Grants, Education Maintenance Allowance and Discretionary Assistance Fund. They all operate under their own rules with varying eligible criteria and administered through a range of separate organisations who have their own way doing business.

    In view of this the Bevan Foundation calls on the Welsh Government to review all of these payments with purpose of establishing a new “Welsh Benefits System” which would have a clearer strategic focus, be less complex, easier to access and be more consistent in its operation across Wales.

    It sets out five principles on how the system should operate:-
    • It should focus on households on low incomes, defined as being eligible for Universal Credit, and use the same criterion across all schemes.
    • It should provide cash or in-kind help that is sufficient to make a real difference to household incomes
    • It has a single point of access for several benefits, using online, phone or postal methods.
    • It is based on eligibility for and an entitlement to assistance, not discretion.
    • Applicants are treated with dignity and respect.

    At a time when we are facing into a period of increased unemployment and financial hardship these proposals need serious consideration. In addition they provide an important stimulus to a wider debate on whether other social protection payments should be devolved to allow the Welsh Government and other devolved bodies to develop a more coherent anti-poverty strategy in Wales.


    https://www.bevanfoundation.org/publications/a-welsh-benefits-system/


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