Overview Response to Integrating Care – The next steps to building strong and effective integrated care systems across England [1]
Introduction
In the midst of a massive covid epidemic, NHS England (NHSE) is driving through a far-reaching top-down reorganisation of the NHS, based on proposals in the Long Term Plan (2019). They are consulting until January 8 on the details of new legislation which they expect the government to enact early this year to give legal legitimacy to changes which are already under way.
We are concerned that the implications of these changes for the accountability, availability and access to services and values underpinning the management of services have been barely noted within a tumultuous 2020.
Noting the serious concerns that have been raised by the Local Government Association and others, including NHS Providers, we are asking all politicians, from every party, to take a stand against these damaging proposals.
Restructuring of the NHS in England
At the core of the re-organisation are Integrated Care Systems (ICSs), bodies described by NHS England (NHSE) as NHS organisations that work in partnership with local councils and others to take collective responsibility for managing resources and delivering NHS care. ICSs have been driven from the top by NHS England, and in many areas resisted at local level by councils, GPs and campaigners. However a 39-page NHSE document “Integrating Care,” seeking new legislation allowing the whole of England’s NHS to be run through ICSs by 2022, claims they are “a bottom-up response.”
The proposals reduce the number of commissioning organisations from almost 200 to just 42 new “Integrated Care Systems” (ICSs). This has required merging (and eventually abolishing) local Clinical Commissioning Groups (established as public bodies by the Health & Social Care Act 2012), and replacing the 44 ‘Sustainability and Transformation Partnerships’ (STPs) set up in 2016.
The mergers inevitably result in larger bodies, more remote from the needs and concerns of any local community, and therefore a loss of local accountability. This point has been powerfully argued by the all-party Local Government Association (LGA), which represents the leaders of 335 of England’s 339 local authorities. Their response states:
“We are concerned that the changes may result in a delegation of functions within a tight framework determined at the national level, where ICSs effectively bypass or replace existing accountable, place-based partnerships for health and wellbeing….
“Calling this body an integrated care system is to us a misnomer because it is primarily an NHS body, integrating the local NHS, not the whole health, wellbeing and social care system.”
The Health Service Journal, aimed at NHS managers, has also shown how vague the proposals are:
“ICSs will be given a single pot of money from which to manage spending priorities. But there is no framework for how this will be spent that assures fairness, value for money and quality outcomes.”
29 of the proposed 42 ICSs have already been approved by NHS England – even though they lack any legal status, and almost all are functioning behind closed doors with no public accountability. The remaining 13 STPs [2] are required to become ICSs by April, or face the intervention of an “intensive recovery support programme.”
The LGA calls for the establishment of alternative structures involving genuine partnership with local authorities and, through them, links to local authority services and responsibilities that are vital components of the wider determinants of health.
Keep Our NHS Public (KONP) has issued a response to the lack of public accountability inherent in ICS structures, and set out proposals for developing genuine public accountability. See the report.
KONP also rejects the assumption, repeated frequently throughout ‘Integrating Care’, that social care might be managed through NHS ICS structures. KONP campaigns for a publicly provided national care and support service. At local level, we argue it is essential that social care continues to be managed by local authorities, retaining essential links to wider local authority responsibilities such as housing, education and leisure. KONP’s critique of the approach to social care set out in Integrating Care available at the end of this summary.
New legislative proposals
Integrating Care seeks new legislation that would provide the formal legal basis for ICSs that they currently lack, as well as changes to existing procurement requirements. KONP argues for the abolition of the commissioner-provider split, believing the NHS should be provided and managed directly as a public service, not through commercial contracts. However we argue that what is worse than a managed market in health is an unmanaged and unregulated market. The failed £multi-billion Covid-related contracts, including those for PPE or Test and Trace, dished out with no proper procurement procedures, have revealed what this can mean in reality.
NHSE wants to scrap Section 75 of the 2012 Health & Social Care Act which requires significant contracts to be put out to competitive tender, and to remove contracts from Public Contracts Regulations. The prospect of changing the law so that more and more large NHS contracts could be awarded without any due process or public scrutiny is seriously worrying.
KONP’s detailed response to the legislative proposals in Integrating Care is available here.
Values underpinning the management and direction of ICSs
Under proposals for ICSs, all providers will be bound by a plan written by the ICS Board and financial controls linked to that plan. Private companies may support the Board and potentially have a place on the Board, as well as being contracted for services.
NHS England has established a Health Systems Support Framework (HSSF) to facilitate easy contracting by ICSs. The Framework consists of organisations accredited by NHS England to support the development of internal structure and management of ICSs, and, potentially, also to play a long-term role in direct management of ICSs.
A quarter of the 83 organisations approved by NHSE to take on contracts with ICSs, and potentially also take seats on decision-making Boards of ICSs (as has happened in North East London) are American-based, offering expensive data-based systems designed to benefit US insurance companies and private hospital chains.
Research in the USA and experience in England has exposed the lack of evidence that data-led attempts at “population health management,” or targeting the small number of patients with complex medical and social needs, can either reduce demand or cut costs. However, such approaches do facilitate the development of private insurance pathways running alongside NHS care.
Digital technology and number-crunching are among the more lucrative areas in which private companies are seeking profitable NHS contracts, and this is a strong theme running through the HSSF. However digital and data are also areas of notorious recent private sector failures – including the Covid-tracking app, the privately-run test and trace system, Capita’s long delays in contacting professional staff offering to return to fight the pandemic, and the £10 billion saga of the NHS Programme for IT.
And while Integrating Care argues for the need to establish ICSs as “statutory bodies” with real powers, notably “the capacity to … direct resources to improve service provision,” there are real fears that NHS England sees ICSs and ‘system-wide’ policing of finances as a way of more ruthlessly enforcing cash limits and “control totals” limiting spending across each ICS, with growing lists of excluded “procedures of limited clinical value”.
These approaches to structure and management of ICSs pose a major threat to the NHS, distorting and undermining the core values and ethos of the NHS.
KONP has created a detailed critique of NHSE’s approach to organisation and management of ICSs as revealed through the Health Service Support Framework (HSSF).
Conclusion
Integrating Care raises serious concerns for the future of the NHS and social care services, concerns that we set out in detail in papers available on the KONP website, along with proposals for alternative structures and why social care should remain the responsibility of local authorities.
Our concerns, based on hard facts, are widely shared by councillors, senior NHS management, GPs and seasoned analysts. NHS England’s proposed changes threaten to make the NHS less locally responsive, less accountable, more dominated by US and other management consultants and contractors, and more focused on policing cash limits than meeting the needs of patients.
NHS England’s priorities should be on strengthening the NHS in alliance with local government and communities, not creating new remote bodies or adopting systems meant to maximise profits of private health insurance.
Keep Our NHS Public, January 2021
Read more
- Part 1: Corporate Agenda for Integrated Care
- Part 2. An alternative vision: achieving democratic accountability, by Keep Our NHS Public, January 2021
- Part 3. Social care: relationship to ICSs, by Keep Our NHS Public, January 2021
References
[1] https://www.england.nhs.uk/integratedcare/integrated-care-systems/
[2] Black Country and West Birmingham; Cambridge and Peterborough; Cheshire and Merseyside; Coventry and Warwickshire; Devon; Herefordshire and Worcestershire; Kent and Medway; Leicester, Leicestershire and Rutland; Lincolnshire; Mid and South Essex; Northamptonshire; Shropshire, Telford and Wrekin; Staffordshire and Stoke on Trent